2024 Health Academy Public Lecture Series - First Session

There are four sessions in this year's first half of the Health Academy Public Lecture Series. Today, June 1, 2024, is the first session, featuring Dr. Yu Chun-Hsiang, a thoracic specialist, presenting "Cough Cough Blue." The discussion and hosting will be done by Dr. Hong Yu-Shih.

Many patients have persistent coughs after contracting COVID-19 or for other reasons. Acute cough lasts about three weeks, subacute cough about three to eight weeks, and chronic cough over eight weeks. Cough sensitivity points and triggers are found throughout the respiratory system, from the upper to lower respiratory tract, esophagus, stomach, pericardium, and thyroid.

Coughing is the most common manifestation of respiratory infections. Its main function is to prevent us from inhaling foreign objects and to help expel inhaled substances, phlegm, and secretions.

Dr. Yu Chun-Hsiang: Good afternoon to all friends present and online. Sharing this topic is related to my profession as a thoracic specialist, so I have chosen an interesting topic called 'Cough Cough Blue.' Most of the cases I encounter now are not acute infections. Many patients were infected a year or two ago and have not stopped coughing since. I'm sure you've seen similar cases around you.

Coughing is very time-sensitive in medical terms. Acute cough is within three weeks, subacute cough is three to eight weeks, and chronic cough is over eight weeks.

Generally, there is a threshold for inducing cough. High or low sensitivity in the respiratory tract affects whether the patient will cough. Coughing is seen from a neurological perspective. There are different sensitivity points (receptors) in the upper and lower respiratory tracts. These receptors receive external stimuli, not only from the respiratory tract but also from the esophagus, stomach, pericardium, and thyroid. Stimuli are transmitted through nerves to the medulla oblongata, where the process is received, and then messages are sent to the medulla spinal nerves, diaphragm nerves, vagus nerves, intercostal muscles, diaphragm, and respiratory epithelium, producing a complete cough response.

Acute cough is mostly related to acute infections, including COVID-19 in the past three years and recent flu viruses. Some chronic conditions (chronic obstructive pulmonary disease, asthma) can also present acute cough during exacerbations. Tuberculosis and lung cancer can also trigger acute cough.

Subacute cough (3~8 weeks) is related to infections (COVID-19, Bordetella pertussis).

Chronic cough has many causes, most of which can be identified (75~90%). In chronic cough cases, 60~70% have a single cause, 20~30% have two causes, and 10% have three or more causes. Chronic idiopathic cough, with higher sensitivity than the general population, accounts for 10% of cases.

The five most common causes of chronic cough in adults are:

1. Non-asthmatic eosinophilic bronchitis

2. Asthma

3. Upper airway cough syndrome (postnasal drip)

4. Gastroesophageal reflux (heartburn)

5. Chronic conditions (bronchiectasis, chronic obstructive pulmonary disease, pulmonary fibrosis)

In the past three years, COVID-19 has become an increasingly common cause of chronic cough. Some blood pressure medications can also induce coughing. Past tuberculosis (6000~7000 cases), inhalation issues, cancer, heart failure, and stimuli to the vagus nerve from the stomach, esophagus, pericardium, or thyroid can cause chronic cough.

Lifestyle factors (environment, smoking) are also related. In children, asthma and postnasal drip are more common causes, with some cases related to protracted bronchitis.

Protracted bronchitis (Haemophilus influenzae, Streptococcus pneumoniae) involves incomplete eradication of bacteria, leading to chronic inflammation and infection in children's bronchi. In the past three years, COVID-19 has caused "long COVID" issues, with clinical manifestations including fatigue, breathing difficulties, chest discomfort, and about 30% of patients having chronic cough.

Why does COVID-19 infection cause chronic cough? First, rule out other causes of chronic cough to confirm if it's due to COVID-19 infection. COVID-19 infection differs from other viral infections, with more frequent inflammation, chest discomfort, and cough.

◎How to communicate with your doctor? (Information to provide when seeking medical attention)

1. How long has the cough lasted?

Clearly tell the doctor the duration of the cough, e.g., 1 month, 1 week, or several months.

2. When is the cough most severe?

Day or night? Early night (evening) or late night (early morning)? Coughing when lying down to sleep (rest), after exercise, during work, or constantly?

3. Dry cough or with phlegm?

Is the cough wet with phlegm or dry without phlegm?

4. Consistency and color of phlegm?

Is the phlegm white, yellow, or green? Any blood streaks?

5. How is the cough?

Is it throat-clearing style or short bursts? Any other symptoms?

◎Other accompanying symptoms (specific warnings) include: upper respiratory symptoms, nasal issues, chest discomfort, fever, weight loss, hoarseness, rib pain from excessive coughing, recurrent pneumonia, long-term smoking.

Supplement: The National Health Bureau currently promotes lung cancer screening, including screening for a smoking history. Smoking for over 15 years is a high-risk factor for lung cancer.

Medical history (family history, lifestyle), physical examination, empirical medication, lifestyle changes (avoiding overeating to prevent gastroesophageal reflux-induced cough), X-ray, lung function tests; if symptoms improve with these treatments, no further tests are needed: esophageal examination (gastroscopy), lung CT scan.

There are significant regional differences in cough. I (Dr. Yu Chun-Hsiang) have found some research to share with you.

This study involved over 900 participants in Guangdong who had coughed for over six months. It found that 70% of participants had dry cough symptoms, with no smoking history for 60% of men and 90% of women, ruling out smoking as a cause of chronic cough. The participants were aged 30-60 (working age group), mostly coughing during the day, with throat and nasal symptoms being most common.

1. Seasonal dry cough: 60% of South Korean participants were more prone to dry cough in certain seasons (pollen season), compared to 40% in Taiwan.

2. Cough with phlegm: 70% of South Korean participants had phlegm, compared to 50% in Taiwan.

3. Cough due to infection: 30% of participants in both South Korea and Taiwan experienced this.

4. Stress incontinence caused by coughing: 40% of South Korean participants and 17% of Taiwanese participants experienced this.

5. Postnasal drip (related to upper respiratory symptoms): 60% of South Korean participants and 70% of Taiwanese participants experienced this.

6. Seeking medical advice: 70% of South Korean participants sought medical advice, compared to 50% in Taiwan.

7. Department consulted: 30-40% of participants in both regions consulted ENT specialists, with fewer seeing thoracic specialists.

8. Cause of cough: Most participants in both regions had upper respiratory infections (related to the nose, defined as the nasal cavity, sinuses, pharynx, and larynx).

1. Receiving strange looks in public.

2. Inconvenience in life, worrying about coughing in trains, living spaces, or airplanes.

3. Feeling desperate due to the inability to control coughing, suffering for a long time.

4. Trying many methods without success, resorting to home remedies and medicines, becoming a financial burden.

5. Excessive concern from friends and family causing psychological stress.

6. Impact on quality of life.

7. Reduced work efficiency.

8. Affecting sleep, even causing anxiety.

9. Pseudoattendance in 30% of cases.

◎Leicester Cough Questionnaire Research

This research involved 19 questions for chronic cough patients to answer, finding that severe coughing caused incontinence, postnasal drip, and reduced quality of life.

Most medications are steroids, with severe cases using opioid-based medications, inhaled steroids.

◎Cough Treatment and Research:

Rehabilitation therapy, speech and language therapy, psychological therapy, education, voice care (speaking too loudly or softly can trigger coughing), cough suppression strategies, psychological counseling (psychogenic cough, e.g., chronic idiopathic cough).

◎Research on chronic cough due to COVID-19:

1. Some studies suggest that Tai Chi or other exercises are effective for cough.

2. Traditional Chinese medicine for cough:

Ginger (effective for phlegm cough), honey, licorice, apricot kernel, ginseng, schisandra, fritillaria, etc. Combining Chinese and Western medicine is effective for chronic cough.

◎Impact of Chronic Cough

1. Reduced quality of life and socioeconomic burden, fear of going to work or public places, psychological stress.

2. Effective treatment and diagnosis remain unmet clinical needs, with many chronic cough patients reluctant to seek medical attention.

3. Despite detailed evaluation and treatment for some patients, coughing may remain unexplained or persist for years or decades.

4. New effective treatments are needed to alleviate this disease burden, but due to the heterogeneity of chronic cough, a one-size-fits-all approach is impossible.

5. Some coughs are caused by lifestyle, gastroesophageal reflux, or cancer metastasis.

1. There is no conclusive evidence that sugar triggers coughing, but excessive sweets should be avoided if they cause gastroesophageal reflux.

2. Those who have asthma triggered by seafood and proteins should avoid excessive seafood.

3. Is chronic cough the same as chronic bronchitis?

Chronic cough is not necessarily chronic bronchitis. Diagnosis is based on the doctor's experience and X-ray examination. Many smokers in Taiwan have chronic bronchitis, with smoking being the cause of 80% of chronic obstructive pulmonary disease cases. A small proportion is related to infection, with bacteria causing chronic inflammation and damage, leading to bronchiectasis. Medically, chronic bronchitis is long-term bronchial inflammation, characterized by induced phlegm in the airways, with thickening and damage of the bronchial walls. Chronic bronchitis is a cause of chronic obstructive pulmonary disease.

There are formal diagnostic procedures for chronic bronchitis in clinical practice.

Lung Cancer:

‧ Female lung adenocarcinoma is not significantly related to oil fumes.

‧ Male lung adenocarcinoma is related to smoking.

‧ Air pollution is also an important risk factor for lung cancer, with higher incidence in western Taiwan.

‧ High-risk groups for lung cancer:

1. Age (50-74 years for men or 45-74 years for women)

2. Smoking history (long-term smokers)

3. Family history (relatives with lung cancer)

Lung cancer screening is effective, with past detection mostly at stages 3 and 4, now detected at stage 1.

Many patients switch doctors frequently, taking medications without seeing improvement, creating a cycle of constant change. Be patient when consulting a doctor. If new symptoms arise, the original doctor will pay special attention and arrange further tests to identify the cause of chronic cough. Avoid excessive anxiety, self-diagnosis through Google or home remedies, and seek proper medical channels.

1. Lieque Point: Extend both hands with thumbs and index fingers crossing each other, locate the inner side of the arm where the index fingers intersect.

2. Tanzhong Point: Central point of the chest, aligned with the nipples.

3. Chize Point: Palm up, located on the outer side of the elbow crease.

4. Fenglong Point: Locate the midpoint between the outer depression below the kneecap and the outer ankle, gently press or use a hairdryer to warm the area, or moxibustion to remove phlegm. Herbal balls can also be used for gentle acupressure.

This health lecture provided a wonderful afternoon for everyone, discussing health promotion topics. Special thanks to Dr. Yu Chun-Hsiang for sharing, Yinyi Academy for the venue, co-organizers Taiwan Local Creation Association and Green Dining Guide, and sponsors Fusen Purifying Ecological Wellness Village and Volando Hotel Series. We hope this lecture was beneficial to everyone.