Mr. Beeler, a fiftyish guy was perplexed and worried: “I just don’t get it. My mail box is maybe a hundred feet down the driveway. Used to be nothing to march down to it, grab the mail and hoof it back and never think about it. Then I started getting a bit winded on the uphill walk back. Now I’ve got to stop once on the way down and two or three times on the way back up to catch my breath. I’ve never even been a smoker; what’s the deal?”
Ok, this one is a bit more complicated, but common enough to be worth knowing something about. Pulmonary hypertension (PH), which is what Mr. Beeler ended up having, is where the blood pressure in the lung part of the circulation has become elevated. So, what does that do? That means the part of the heart that has to pump blood through that higher pressure system has to work harder. Over time the blood vessels change in ways that cause oxygen to be picked up more and more poorly by the lung’s circulation. Likewise the right side of the heart that serves as the pump for the lung circulation can get weaker and weaker.
A person developing PH may notice that it takes less and less effort to make them feel quite short of breath. They may also notice fatigue, chest pain with exertion or even passing out with exertion. Often they end up needing to be on oxygen to keep their blood oxygen level normal.
The causes of PH are quite varied — everything from heredity to COPD (chronic lung disease) to various heart conditions to a range of medicine and toxin side effects to a further laundry list of causes. While it is relatively rare in otherwise healthy folks, it can afflict up to 1/4th of people with COPD and one out of five with sleep apnea, just to name a couple of diagnoses.
It is often the shortness of breath that eventually brings people in to get checked by their doctor. The high pressure in the pulmonary (lung) circulation is often noted on an echocardiogram (an ultrasound of the heart). Other tests such as a heart cath, if needed, can be even more definitive.
Treatment for PH can be challenging. If there is some specific cause found for it then treating that underlying cause may help. If it is determined that the PH seems to have developed without some other trigger then there are a number of other treatments that are sometimes helpful in reducing the pressure and improving oxygen levels. One treatment even involves using the active ingredient in Viagra. At the far extreme of treatment, lung transplants are occasionally undertaken. Obviously along the way having a specialist involved can be vital.
So, worsening shortness of breath with exertion is never something to be ignored. And getting it checked sooner rather than later can sometimes make a significant difference in the success of treatment with several of the causes, including the complicated problem of PH.
It is doubtful that a day goes by in my office where no one coughs. It’s one of the most common symptoms we deal with day in and day out. Coughing is a protective reflex that helps to clear the lungs and upper airways. It is a symptom, and not a final diagnosis. There are dry coughs, wet coughs, deep coughs, light coughs, wheezing coughs, racking coughs, chronic coughs, and once in a while, whooping coughs, just to name some of the varieties. For many, it’s just a few days of a nuisance tickle. But for others, the cough just doesn’t seem to go away. Weeks or months go by, and still there is that nagging cough.
By definition, a chronic cough is typically defined as one that lasts for 8 weeks or more. What causes these persistent lingering coughs? In one study, almost half were found to have asthma and/or allergies as the cause. Often asthmatics, instead of, or in addition to, wheezing or getting short of breath, have a repetitive spasmy cough. For these folks, treating their asthma and allergies with appropriate inhalers, antihistamines, Singulair, or similar meds can bring their nagging cough under control. Likewise, allergy testing and immunotherapy can be highly effective in these situations.
Another 10% or more of persistent coughers have chronic postnasal drip (PND). This can be from chronic sinusitis or allergy as well. These folks tend to be constantly clearing their throats and “hawking up” mucous, especially first thing in the morning. Clearing these chronically inflamed or infected sinuses can be very challenging and often takes a great deal of persistence.
Chronic obstructive pulmonary disease (COPD) produces another 10% of the chronic coughers. This includes chronic bronchitis and emphysema and is most often brought about by smoking. One in twelve Americans has this disease and half don’t realize it. It can’t be cured, but can be managed. Still, the biggest help is putting down the cigarettes before the disease becomes advanced.
A trigger for yet another 10% of cough is gastroesophageal reflux disease (GERD). Here the acid from the stomach comes up the throat prompting a cough reflex. Treatment of the GERD with acid blockers and other measures will often yield substantial improvement in the cough.
Then there are medication side effects. The most common culprits are the ACE inhibitors, such as Lisinopril, a class of commonly-used blood pressure medications. They work well, but about 10% of folks on these meds develop a chronic cough or tickle in their throat that only goes away when the med is stopped.
Less common, but very important is whooping cough or pertussis. This has been called the 100 day cough, and this is no exaggeration. In infants and toddlers it can sometimes be fatal, and fully half of all infants who contract it are hospitalized. Unfortunately, by the time it has passed the “cold” stage of symptoms and shown itself for what it really is, antibiotics don’t change the course much (though they are vital to render the person non-infectious). Pertussis has been on the increase over the last couple of decades, partly due to laxity in immunization.
After certain more potent coughing illnesses there can be persistent airway inflammation that keeps the cough going after the other symptoms have passed. Air pollution or other irritant-exposure can also keep a chronic cough hanging on.
Besides these more common causes, there are rarer reasons for cough such as fungal infections, aspirated foreign bodies, cancers, cardiac asthma, habitual nervous coughs and so on.
So just saying we have a chronic cough is not enough. The real detective work comes in sifting out which of these many suspects is the actual culprit. Of course, sometimes two or more suspects are working together to allow an irritating cough to linger. At any rate, if you’ve got one of those long-running nagging coughs, get it checked out. You and everyone around you can benefit if the actual cause can be found and eliminated, or at least suppressed.
Andrew Smith, MD is board-certified in Family Medicine and practices at 1503 East Lamar Alexander Parkway, Maryville. Contact him at 982-0835