Complications of Cough

ACCP Evidence-Based Clinical Practice Guidelines

Richard S. Irwin, MD, FCCP

Objectives: To review the spectrum and frequency of complications associated with coughing.
Design/methodology: Ovid MEDLINE literature review (through March 2004) for all studies
published in the English language, including case series and case reports, since 1966 using the
MeSH terms “cough” and “complications.”
Results: The complications of cough appear to stem from physiologic events. The magnitude of
pressures, velocities, and energy that is generated during vigorous coughing allow coughing to be
an effective means of clearing the airways of excessive secretions and foreign material, and
providing cardiopulmonary resuscitation; however, they can also cause a variety of profound
physical and psychosocial complications. The adverse occurrences include cardiovascular, con-
stitutional, GI, genitourinary, musculoskeletal, neurologic, ophthalmologic, psychosocial, respi-
ratory, and skin complications, and a decrease in health-related quality of life.
Conclusions: Knowledge of the spectrum of complications should enable clinicians to appreciate
(1) the impact of cough on patients, (2) why it is imperative to exhaust all possible diagnostic and
therapeutic options to eliminate cough, and (3) why it is inappropriate to minimize a patient’s
complaint of cough and/or advise him/her to “live with it.” (CHEST 2006; 129:54S–58S)

Key words: cardiovascular; constitutional symptoms; GI; genitourinary; musculoskeletal; neurological; ophthalmologic;
psychosocial; quality of life; respiratory; skin

Abbreviation: CQLQ 5 cough-specific quality-of-life questionnaire

T he complications of cough stem from physiologic

events. It is thought that there are usually three
phases involved in the cough mechanism.1 The first
is an inspiratory phase, which ends before closure of
the glottis; the second is a compressive phase that is
characterized by contraction of thoracic and abdom-
inal musculature against a fixed diaphragm; and the
third is an expiratory phase, which consists of
the rapid expulsion of air when the glottis opens. The
result of these actions is the production of suffi-
ciently high expiratory velocity to dislodge and expel
secretions or foreign bodies.
During the compressive and expiratory phases,
cough can be described as a modified Valsalva
maneuver.2,3 Cough can also be accompanied by a
Reproduction of this article is prohibited without written permission
from the American College of Chest Physicians (www.chestjournal.
org/misc/reprints.shtml).
Correspondence to: Richard S. Irwin, MD, FCCP, University of
Massachusetts Medical School, Room S6-842, 55 Lake Ave North,
Worcester, MA 01655; e-mail: Irwinr@ummhc.org
reflex increase in vagal tone.4,5 Furthermore, during
vigorous coughing, intrathoracic pressures of up to
300 mm Hg6 and expiratory velocities of up to 28,000
cm/s, or 500 miles per hour (85% of the speed of
sound),7 may be generated. Coughing produces he-
modynamic changes that compare favorably to chest
compressions. During the expiratory phase of a
vigorous cough, systolic pressures approach 140 mm
Hg, compared with 75 mm Hg during chest com-
pressions.8 It has been estimated that a vigorous
cough can generate from 1 to 25 J of energy.9 While
the pressures, velocities, and energy of these magni-
tudes allow coughing to be an effective means of
clearing the airways of excessive secretions and
foreign material, and of providing cardiopulmonary
resuscitation, they also can cause a variety of pro-
found physically and psychosocially adverse occur-
rences that have the potential to lead to a significant
decrease in health-related quality of life.
Knowledge of these complications should help
clinicians to appreciate (1) the impact of cough on

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© 2006 American College of Chest Physicians
patients, (2) why it is imperative to exhaust all
possible diagnostic and therapeutic options to elim-
inate cough, and (3) why it is inappropriate to
minimize a patient’s complaint of cough and/or
advise him/her to “live with it.”
Spectrum of Complications
The adverse occurrences include cardiovascular,
constitutional, GI, genitourinary, musculoskeletal,
neurologic, ophthalmologic, psychosocial, respira-
tory, and skin complications, and a decrease in
health-related quality of life (Table 1). This spec-
trum of complications was determined with the aid
of an Ovid MEDLINE literature review (through
March 2004) for all studies published in the
English language, including case series and case
reports, since 1966 using the MeSH terms “cough”
and “complications.” With the exception of the
referenced literature on health-related quality of
life, the quality of evidence for the majority of
complications displayed in Table 1 consisted pri-

Table 1—Complications of Cough

Variables Symptoms
Cardiovascular Arterial hypotension3,6,18–21
Bradyarrhythmias4,5 and tachyarrhythmias22,23
Dislodgement/malfunctioning of intravascular catheters24
Loss of consciousness3,6,18–21
Rupture of subconjunctival, nasal, and anal veins,6,25 and massive intraocular suprachoroidal
hemorrhage during pars plana vitrectomy26
Constitutional symptoms Excessive sweating, anorexia, exhaustion25,27
GI Gastroesophageal reflux events28
Gastric hemorrhage following percutaneous endoscopic gastrostomy29
Hepatic cyst rupture30
Herniations (eg, inguinal,31 through abdominal wall,32 small bowel through laparoscopic trocar
site33)
Malfunction of gastrostomy button34
Mallory-Weiss tear35
Splenic rupture36
Genitourinary Inversion of bladder through urethra37
Urinary incontinence11,27
Musculoskeletal From asymptomatic elevations of serum creatine phosphokinase to rupture of rectus abdominus
muscles25,38–44
Diaphragmatic rupture45,46
Rib fractures47–52
Sternal wound dehiscence53
Neurological Acute cervical radiculopathy54
Cerebral air embolism55
Cerebral spinal fluid rhinorrhea56,57
Cervical epidural hematoma associated with oral anticoagulation58
Cough syncope19–21,59–64
Dizziness27
Headache65–68
Malfunctioning ventriculoatrial shunts69
Seizures70
Stroke due to vertebral artery dissection71
Ophthalmologic Spontaneous compressive orbital emphysema of rhinogenic origin72
Others are listed under 9Cardiovascular9
Psychosocial Fear of serious disease10,12,27
Lifestyle changes10,12,27
Self-consciousness10,12,27
Quality of life Decreased10,12,13
Respiratory Exacerbation of asthma73
Herniations of the lung (eg, intercostal74–76 and supraclavicular77)
Hydrothorax in peritoneal dialysis78
Laryngeal trauma (eg, laryngeal edema79,80 and hoarseness10,12,27)
Pulmonary interstitial emphysema, with potential risk of pneumatosis intestinalis,
pneumomediastinum, pneumoperitoneum, pneumoretroperitoneum, pneumothorax,
subcutaneous emphysema81–84
Tracheobronchial trauma (eg, bronchitis25 and bronchial rupture85)
Skin Petechiae and purpura86
Disruption of surgical wounds25

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© 2006 American College of Chest Physicians
marily of nonrandomized, noncontrolled case re-
ports and small retrospective and prospective ob-
servational studies. Two studies published by
French and colleagues10,11 on the impact on
chronic cough on health-related quality of life
were prospective and controlled.
Cough and Health-Related Quality of
Life
The health-related quality of life of patients com-
plaining of acute and chronic cough is adversely af-
fected, and this is the most likely reason why these
patients seek medical attention. Four studies10 –13 have
prospectively shown that cough can adversely affect
health-related quality of life. In chronologic order, the
first study10 utilized the Sickness Impact Profile, a
non-illness-specific measure of health-related dysfunc-
tion that had been modified to measure the effects of
patients’ chronic cough on the performance of usual
daily activities. The health-related dysfunction of pa-
tients with chronic cough is most likely to be psychos-
ocial in nature. While the Sickness Impact Profile had
not been psychometrically tested to assess the effects of
cough, it revealed, in a before-and-after treatment
intervention trial, that chronic cough was associated
with a significant deterioration in patients’ quality of
life, and that the health-related dysfunction was most
likely due to psychosocial factors.12
The second study11 utilized a cough-specific qual-
ity-of-life questionnaire (CQLQ) that assessed the 28
most common reasons why patients seek medical
attention because of coughing. It has been shown to
be a reliable and valid tool for evaluating the impact
of acute and chronic cough on adult patients, and a
valid method by which to assess the efficacy of cough
therapies for chronic cough. A comparison of total
CQLQ scores of both chronic and acute coughers10
showed that, while the scores were similar to each
other, they were both significantly higher than those
for a control group of smokers who were not com-
plaining of cough. Compared to the control subjects,
patients with chronic cough complained significantly
more of physical complaints (eg, lost appetite, head-
aches, dizziness, sweating, hoarseness, hurts to
breathe, insomnia, ache all over, and exhaustion),
psychosocial issues (eg, family cannot tolerate it,
difficulty speaking on phone, embarrassment, upset
because others think I have something wrong, and
self-consciousness), functional ability impairments
(eg, prolonged absences from important activities,
cannot engage in important activities, cannot sing,
stopped going to social activities, and had to change
lifestyle), issues that adversely affected their emo-
tional well-being (eg, fear of tuberculosis or AIDS,
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soiled pants, and broke a rib), extreme physical
complaints (eg, sick to stomach and vomiting, retch-
ing, wet pants, and soil pants), and personal safety
fears (eg, concern about cancer, want to be reassured
that nothing is seriously wrong, and concern that
there is something seriously wrong).
The third study13 utilized the Leicester cough
questionnaire, which assessed 19 items that the
investigators found were troublesome to patients
with chronic cough. Psychometric testing revealed
the Leicester cough questionnaire to be a valid and
repeatable quality-of-life measure of chronic cough
that is responsive to change.13
The fourth study,14 utilizing the CQLQ in a study
with a control group of smokers not complaining of
cough to assess gender differences in health-related
quality of life in patients complaining of chronic
cough, determined that women with chronic cough
were probably more inclined to seek medical atten-
tion than men because their health-related quality of
life was significantly more adversely affected and
because they were more apt to experience physical
complaints such as stress urinary incontinence,
which provoked psychosocial issues such as becom-
ing embarrassed.11 Cough reflex sensitivity was not
measured in this health-related quality-of-life study11
(or in the other three studies10,12,13 just reviewed).
Consequently, while tussigenic inhalation challenges
have shown that healthy women14 and women with
chronic cough15 have lower cough thresholds than
healthy men and men with chronic cough, it is not
known whether this finding of higher cough reflex
sensitivity contributes to the greater adverse effect
on health-related quality of life. Women with chronic
cough are probably more inclined to seek medical
attention than men because their health-related
quality of life is more adversely affected and because
they are more apt to experience physical complaints
such as stress urinary incontinence, which provoke
psychosocial issues such as becoming embarrassed.
Recommendations
1. In patients complaining of cough, evaluate
for a variety of complications associated with
coughing (eg, cardiovascular, constitutional, GI,
genitourinary, musculoskeletal, neurologic, oph-
thalmologic, psychosocial, and skin complica-
tions), which can lead to a decrease in a patient’s
health-related quality of life. Level of evidence, low;
benefit, substantial; grade of recommendation, B
2. Patients with cough should have a thorough
diagnostic evaluation, according to the guidelines
set forth in this document, to mitigate or prevent
these complications. Level of evidence, low; net
benefit, substantial; strength of recommendation, B
Diagnosis and Management of Cough: ACCP Guidelines
 Cough and the Risk of Coronary Artery
Disease
Two large epidemiologic studies16,17 have pro-
vided evidence that chronic cough, as a clinical
manifestation of pulmonary infection or chronic
inflammation, is associated with an increased risk of
coronary artery disease or myocardial infarction. The
risks in both studies were independent of the known
major cardiovascular risk factors. The risk was found
to be increased in the Framingham Heart Study,
whether or not the cough was productive or unpro-
ductive. Whether the association is causal can only
be determined by additional and controlled studies.
Summary of Recommendations
1. In patients complaining of cough, evalu-
ate for a variety of complications associated
with coughing (eg, cardiovascular, constitu-
tional, GI, genitourinary, musculoskeletal,
neurologic, ophthalmologic, psychosocial,
and skin complications), which can lead to a
decrease in a patient’s health-related quality
of life. Level of evidence, low; benefit, substantial;
grade of recommendation, B
2. Patients with cough should have a thor-
ough diagnostic evaluation, according to the
guidelines set forth in this document, to
mitigate or prevent these complications.
Level of evidence, low; net benefit, substantial;
grade of recommendation, B
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