Bethan Galliers was excited to be at the theater with friends for a play she’d been wanting to see for ages. But within minutes, her enjoyment was rudely interrupted by a violent coughing fit—hers.
‘The more I tried to suppress it, the worse it got,’ says Bethan, 56, from Manchester. ‘I was embarrassed about it, so I would go down to the hall to get my cough under control, before coming back five minutes later.’
In fact, this experience in the theatre in Salford a few weeks ago was nothing new. Bethan has been living with a chronic persistent cough, the medical term for a condition with no apparent cause, for over ten years. It is a common complaint that is thought to affect one in ten people.
“I cough every day,” says Bethan, mother of two adopted teenage children.
‘Some days are worse than others, depending on the cause: from eating crusty bread to switching between a hot and cold environment.
Bethan Galliers, 56, has lived with a chronic persistent cough, the medical term for a condition with no clear cause, for more than a decade.
‘Strong cooking smells can also cause coughing. I once coughed for six hours straight when foreign students staying with us cooked a delicious Sri Lankan meal.’
Another time she coughed uncontrollably after sitting next to a woman who was wearing very strong perfume.
A chronic cough is defined as a persistent cough that lasts eight weeks or longer. It affects more than twice as many women as men (possibly due to hormonal fluctuations) and in some it can last for decades.
Some people cough almost constantly, day and night; for others, it can occur in sudden bursts. In extreme cases, patients experience blackouts (due to difficulty breathing), incontinence, or even a broken rib. Although common, it can often be misdiagnosed as a symptom of asthma or acid reflux, and thus incorrectly treated.
Experts from the University of Manchester and Imperial College London are among the researchers currently investigating chronic cough. For example, Jacky Smith, professor of pulmonology at Manchester, is leading a £3 million research project, Let’s Talk About Cough, which aims to increase knowledge and awareness of the condition.
Professor Smith told Good Health: ‘Chronic cough is a condition that has only recently been recognised. Often people were told it was nothing serious and that they would just have to learn to live with it.’
As Bethan did until recently.
Although she has suffered from hay fever since she was a teenager and is allergic to dust, neither of these factors explain the cough that started more than ten years ago and has never gone away.
“At first it was just a bit of a nuisance, but I didn’t think it was anything serious,” says Bethan, community health coordinator.
‘I’ve talked to my GP about it from time to time since 2012, because it wasn’t getting better. At first I was given antibiotics, but the cough persisted. My GP couldn’t find a reason for it, so I thought I’d just have to learn to live with it.’
But it wasn’t easy, she says: ‘During meetings I often had to cough a lot, especially when I walked from one room to another or when I came in from outside, because of the temperature fluctuations.
‘I was constantly apologizing for it and colleagues would always give me a glass of water or offer me a pat on the shoulder. Since the pandemic, people assume it’s Covid, so if I start coughing in a shop, for example, everyone runs away.’
A chronic cough is defined as a persistent cough that lasts eight weeks or longer. It affects more than twice as many women as men, and for some it can last for decades.
There are few effective treatments for persistent cough
New research suggests the condition is caused by ‘the sensitivity of the nerves that control our cough reflex’, Professor Smith said.
This explains why those affected often experience coughing fits in response to temperature changes or airborne irritants such as air fresheners or perfumes. These activate nerves in the throat, which send an electrical signal to the brain, causing a cough.
Normally, this mechanism is there to prevent you from inhaling dangerous chemicals, for example.
Professor Smith said: ‘For example, when you eat dry, crumbly food, it stimulates nerves in the throat that respond to mechanical stimuli. This mechanism causes us to cough, which prevents us from choking.
“But in patients with chronic cough, these nerves become super sensitive, so they’re reacting all the time, even to things that aren’t threatening. Patients often come to us because their cough is ruining their lives. They’ve usually had it for five or six years, sometimes longer.”
Dr Samuel Kemp, a consultant respiratory specialist at Nottingham University Hospitals NHS Trust, sees a lot of patients with chronic coughs — often because their partner has it worse than they do. ‘One patient had a cough for 16 years,’ he says.
The constant pressure associated with coughing can have negative consequences, such as incontinence (especially in women), chest pain, abdominal pain and hernia.
For years, doctors had few effective treatments for the problem.
Professor Smith explains: ‘We should be saying to patients: ‘I know this is awful, but you just have to get on with it.”
But one treatment that has recently emerged is the painkiller morphine – more specifically morphine sulfate tablets that slowly release 5 mg (the smallest dose available) of the drug over 12 hours.
Although it is not clear how it works, one theory is that it acts on the nerves that connect the brain to the throat and airways. ‘It was first shown to have an effect on chronic cough in 2007, but it is not licensed for this specific condition, so the doctor has to take responsibility for prescribing it as an off-licence medicine,’ Professor Smith explains.
‘It helps about 50 percent of patients, but the dosage has to be kept very low and you have to monitor it closely because it can be addictive, even in small doses.’
Late last year, a new drug, gefapixant, was approved for use in the UK.
This blocks a receptor called P2X3 on the vagus nerve, one of the main nerves that causes coughing.
Studies of 2,044 people with chronic cough that lasted an average of 11 years found that the drug (taken daily) reduced cough frequency by 18.5 percent, The Lancet reported in 2022.
Professor Smith explains that the drug blocks receptors in the throat that are sensitive to chemicals and temperature changes. This stops them from responding to a chemical, ATP, which we all have naturally in our airways, but levels of which are elevated in people with chronic cough.
She says: ‘The drug effectively stops the activation of ATP from those sensitive nerves. This reduces the number of times the cough is triggered.’
However, it still needs to be approved by the National Institute for Health and Care Excellence, the NHS spending regulator, before it can be rolled out on a large scale.
A second generation, called camlipixant, is now being tested because gefapixant can have unwanted side effects, such as a reduced sense of taste.
Meanwhile, Bethan’s condition improved after her GP finally referred her to a pulmonologist in late 2021.
After tests were carried out to rule out other conditions, Bethan was started on the slow-release morphine tablets last September.
It significantly reduced her coughing fits, by about 40 percent, especially at night.
And earlier this year, a tiny camera was inserted into her nose and throat, revealing the most likely cause of her persistent cough: inducible laryngeal obstruction, a rare throat condition that causes the vocal cords to briefly close in response to inhaled irritants. This can cause and be triggered by coughing.
“The diagnosis made perfect sense because I always felt like my cough was coming from my throat rather than my chest,” says Bethan.
Since then, she has been seeing a speech therapist who recommended exercises to relax her vocal cords, which reduced the impact of the cough.
Bethan hopes to one day be prescribed one of the new medications being developed to help control her cough even better. As she explains: ‘I’d like to be able to go to places like the theatre and cinema without having to worry so much about coughing.’