Hello, I'm Dr. Robert Bastian of Laryngopedia
and Bastian Voice Institute (BVI). Our subject is coughing in the context of Covid-19. Covid-19
has intruded into our lives in innumerable ways. We've lost a lot of our fellow citizens. Others
contracted the virus and were very ill from it, including with pneumonia or bronchitis, and
hard coughing was a part of the fight to recover completely, and they are now fully recovered. A
second group has recovered in general, and they're weeks or months passed the acute infection, but
they are experiencing a lingering and somewhat productive cough. For this second group, it is as
though a viral hurricane hit weeks or months ago, and now for some, the high winds have been- are
gone—the acute infection is gone—but there's a lot of damage and debris. It's like the limbs and
the roof shingles that have been blown off by the hurricane, even though the sun is
out—those things have to be cleared away. So for some of these people, there is coughing
that continues for a time even after they're relatively well, as inflammation resolves.
So it still has a purpose; (the cough) it's cleaning up after the storm. A third group—the
illness is gone and the lungs are tidied up. They're healed and clean, there's nothing being
produced, but the person continues to cough. It isn't a cough like during the hurricane or
immediately after clearing out debris. It's just a cough that serves no purpose. It no longer
is solving a problem of clearing things away but the cough is the problem—it's
interfering with quality of life. So what's the explanation if there's no active
infection and there's no debris to clean up? This third group may have damaged or sensitized
sensory nerve endings in the larynx. Here's the vocal cords in the trachea. So the trachea here,
the larynx here, and in the pharynx. Those areas may have damaged sensory nerve endings. So these
traumatized, damaged nerve endings are irritable and twitchy. They go zing for no apparent reason
and demand that you cough. Such persons with Covid-19 nerve ending damage may have a specific
cough diagnosis called Sensory Neuropathic Cough that not a lot of people still know about. Now
I have described sensory neuropathic cough in detail in prior videos and on my teaching website
Laryngopedia. I've also published on the subject, and I've worked with general post-viral sensory
neuropathic cough for 25 years, and I believe the Covid-19 infection has simply taken its place
along some of those earlier viruses as a cause of sensory neuropathic cough. Well to review
what I've described previously, key features of sensory neuropathic cough are that each episode of
coughing is initiated by a stereotype sensation; a zing. People say it's a tickle, a dry patch,
an itch, a pinprick, a dripping sensation. It's like it happens again and again. The commonest
location is at the sternal notch. The sternal notch is right here. It's right at the base of
the neck. The sternal notch, right there. That's the most common. A second would be at the level
of the larynx itself, and then there's some where it's higher up here in the throat. And there are a
few where it's kind of central chest down in here. Now when that zing happens, it can initiate
a single cough so a person could go <cough> and they're just doing that
dozens or hundreds of times a day. Or it could be a few seconds of coughing, they
get that zing and they kind of go <cough> <cough> and then they're done. Or, unfortunately,
sometimes it will trigger a violent and protracted episode of talk- coughing that could go on
for 30 seconds, a minute, and even longer. So stereotype sensory disturbance, that's kind
of this tickle, or itch, or something. Number two is that the cough is out of proportion to
anything produced by that cough. The cough is dry or it produces mucus only after hard coughing,
and I'm not sick at all I haven't been sick, but if I sit here and force myself to cough really
hard I will produce a surprising amount of mucus. So the person asks in exhaustion, "Who coughs
this much to produce that little amount of mucus, or coughs that long before the mucus comes up?"
The person may even cough hundreds of times a day, mostly briefly, but they also can have
those agonizing protracted and exhausting episodes several times a day, to the point of
embarrassment in public or even humiliation. And that's not overlooked that some have it
also interrupting their sleep a time or two, and sometimes many times people are awakened at night,
fortunately not all. So sensory disturbance, cough out of proportion to anything you produce,
and trigger phenomena. While coughing spells can occur spontaneously, certain actions make that
"zing!" more likely to happen. So people say things like, "You know, I have a big laugh and I don't
dare laugh in my usual way because every time I do that it makes me cough." Or "If I talk a while
on the phone," or "If I go outside in the cold and I breathe in that first breath of cold air,"
or "I smell something really strong, a cleaning solution," or "I swallow." Change your position.
"I get in bed at night," or "When I get up at night to use the bathroom I- it makes me cough."
Or they'll say "If I touch right there it makes me cough." Those are trigger phenomena. Fourth is
the seeming futility of usual treatments. Taking an expression from the film Casablanca, remember
the french chief of police says to his underlings at one point, "Go round up the usual suspects."
Well those are allergy, acid reflux and asthma, when people have this kind of chronic cough,
and the treatment for those things does nothing. Steroids may help but only while you're on them,
and narcotic cough suppressants may provide some relief, but that's not a good long-term treatment
if the cough is going to go on and on and on for months and months. Well what is the best approach?
It's to target the irritable nerve endings. Medications like Amitriptyline or Desipramine,
Gabapentin, Citalopram, Mirtazapine, Venlafaxine, Capsaicin spray, all of these have been
described, I think most of them are on my website, Laryngopedia. Usually one of the
first two, if you're under 65, it would be Amitriptyline or Gabapentin, usually one of those
is effective. May not abolish the cough totally but it's usually much much better. Persons with
resistant cases may need to work their way down a longer list beyond the first two, and so,
you have to be patient to just work your way through this series of medications. Occasionally
injection of a long-acting local anesthetic—I use Mepivacaine or Bupivacaine—combined
with a locally acting steroid—the same kind of thing you would have in a sore
shoulder, or injected into your knee, or that kind of thing—that is injected into a
sensitized area and sometimes that can help. Well what are the practicalities of finding help
for sensory neuropathic cough after Covid-19? Well first, if you're still very early after the
infection and you're congested and bringing up mucus and material, stay the course
with the normal treatments of hydration, cough suppressants and so forth. If the infection
was weeks ago and you're feeling reasonably well, but the main impediment to recovery and
return of quality of life is your cough, it seems like it's a cough that's the problem; not
solving anything. Then educate yourself more fully about sensory neuropathic cough. Laryngopedia has
many articles, videos, patient interviews that you can find by typing "COUGH" into the search
window. Or, you can read an article—I'll link here below—on the subject. It's a peer-reviewed article
found in an open source medical journal—that is, it's not behind a paywall because
I wanted people to be able to to get it anywhere around the world. And then
raise the question with your personal physician, "Is it possible I have sensory
neuropathic cough?" and hand the article. Consider that article because your doctor may
not have encountered this diagnosis before. And in that article, the treatment
protocol is clearly outlined. Think about doing advanced work before you go see
a doctor. Call the group ENT or pulmonary and ask to speak to the triage nurse. Say "I need that
conversation before I decide whether or not I'm going to come." And then ask him or her, "So any
of your doctors treat sensory neuropathic cough?" If the answer is no, or you get this kind of
awkward response that lets you know they don't, then call the next group with the same question.
If you exhaust all local sources of help, consider a teleconversation with an expert who
lives far away from you. There are a number of physicians across the country who are now
aware of this diagnosis, but you may have to do a little work to find them. Do your internet
search and find people like us at Laryngopedia or you are welcome to work with any of our doctors at
Bastian Voice Institute in the suburbs of Chicago. Now doctors at BVI would also be glad to
help you in person if you live near Chicago. Well here is wishing you a speedy resolution
of your cough and hoping, along with you, that it is only a brief aftermath of Covid-19.
If, on the other hand, you are struggling with coughing that won't go away, and after many
weeks and despite many tests and treatments, then I hope this discussion has helped give
you a direction. Thank you for listening!
