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Cough worse in morning: The request could not be satisfied


What is that morning cough all about?

Waking up coughing? Here’s why.

A cough, no matter what time of day it occurs, is vital for clearing the airways of irritants.

However, if you’re not a regular smoker and keep on waking up with a cough, you might start wondering why. There are several conditions that can cause an early morning cough:

1. Postnasal drip

Postnasal drip is one of the most common causes of a persistent cough. Your nose serves as a gateway to your respiratory tract – and to protect it from irritants, the nose produces mucus that serves as a filter. But sometimes the body produces too much, which has to go somewhere – usually all the way down the respiratory tract, which will cause irritation and a cough. As mucus pools at the back of the throat while you are lying down, a cough associated with nasal drip can be especially bad at night and first thing in the morning.

What to do: Postnasal drip has various causes: it could be an allergy, sinusitis, a cold or flu. If the postnasal drip is persistent and causing a cough, especially first thing in the morning, you might want to address the underlying cause of the nasal drip by means of a decongestant or antihistamines.

2. Hay fever

There are various things inside the home that may cause an allergic reaction that triggers hay fever symptoms. It could be dust, pollen or pet dander. These allergens are present in many homes and can irritate your airways.

What to do: Make sure your house, especially your bedroom, is always free of dust. If pet dander is the issue, try to make your bedroom a pet-free zone. Make sure your bedroom is well-ventilated.

3. Bronchitis

If you cough up phlegm, especially in the morning, it might be a sign of bronchitis. Acute bronchitis is the most common form and occurs when the bronchi (the airways of the lungs) become inflamed. The cough tends to be worse in the morning as phlegm and fluids settle in the lungs during the night while you are sleeping.

What to do: Acute bronchitis is a common condition and is often mild enough not to require medical intervention. If, however, you experience a high fever, green or yellow sputum and are struggling to breathe, you should see your doctor as soon as possible. The cough will most likely last for up to three weeks and will resolve itself. Repeat courses of antibiotics might not have any effect and be pointless.

In conclusion, most coughs which are more persistent at night and first thing when you wake up tend to be caused by phlegm or mucus pooling in the throat or respiratory system. If you are treating the underlying condition, but your cough persists, you can take the following steps.

  • Keep the air in your bedroom moist by investing in a humidifier. Dry air can irritate the nasal passages, causing your body to produce even more mucus.
  • Drink plenty of fluids to keep the mucus thin.
  • Sleep with your head slightly elevated to keep mucus from pooling inside the throat.
  • Take half a teaspoon of honey before you go to bed – this can provide soothing relief from coughs.
  • Suck on a lozenge or take small sips of water to suppress your cough.
  • Take a mucolytic as this may help reduce your cough.

Image credit: iStock

Bronchitis Symptoms

Bronchitis is caused due to irritation, inflammation and infection of the airways in the lungs called the bronchi. There are basically two major types of bronchitis:-

  • Acute bronchitis – this lasts for 2 to 4 weeks and is usually responsive to therapy.
  • Chronic bronchitis – this is a different entity and leads to long term damage to the inner walls of the airways in the lungs. This is part of a group of lung diseases called chronic obstructive pulmonary disease or COPD. This is a progressively worsening condition that cannot be cured

Persistent cough

The common symptom for both types of bronchitis is a cough that is usually persistent and accompanied by expectoration of a yellowish green mucus or phlegm.

The cough may last long after the acute bronchitis is resolved. The continued cough may cause pain and soreness in the chest and stomach muscles as well.

Symptoms of bronchitis

  • Cough – the cough begins within two days of infection in 85 percent of patients. The cough in most people lasts for less than two weeks. In a quarter of patients however the cough may persist for six to eight weeks.

    The cough is worse and more noticeable in the morning because of pooling of secretions in the lying down position that get then mobilized with morning activities.

    Lying down at night may also result in cough because of the shifting or mobilization of the secretions.

  • Bringing up phlegm that may be clear, white, yellow, green, or even tinged with blood. This color is due to presence of the peroxidise enzyme released by the white blood cells in the sputum and is not indicative of a bacterial infection.
  • Tightness and pain in the chest
  • Shortness of breath
  • Soreness of throat
  • Hoarseness of voice
  • Runny or stuffy nose
  • Fever with chills especially seen in acute bronchitis
  • Wheezing and noisy breathing. On hearing with a stethoscope there are other sounds called rhonchi, and rales present along with breathing sounds. The breathing sounds raspy and harsh.
  • Blocked sinuses
  • Headaches
  • Soreness and body aches
  • Loss of appetite along with fatigue
  • Repeated flare ups or exacerbation of symptoms especially in winter months seen in chronic bronchitis.
  • In chronic bronchitis patients there may be a persistent lack of oxygen leading to features of cyanosis (blue lips and nails) and clubbing (enlargement of the tips of the fingers), swelling of the legs, or severe breathlessness.

Red flag symptoms

Some red flag symptoms that need medical attention immediately include:-

  • Very severe cough that lasts over three weeks
  • High fever for over three days
  • Chest pains and rapid breathing rates of over 30 per minute
  • Coughing up blood or sputum streaked with blood
  • Drowsiness and confusion
  • Recurrent bouts of bronchitis
  • Presence of underlying heart or lung disorders like asthma, emphysema, heart failure or COPD.
  • Very young (infants and babies) and very old patients with a lowered immunity

Further Reading

A dry cough that won’t go away? Don’t ignore it

General Health

Updated: 12/01/2021

When you’re really down with a cold or flu that affects your lungs, the accompanying cough usually sounds quite dramatic. A chesty, phlegm-rattling, mucus-producing cough is a sure sign that something is wrong. In comparison, a dry cough can be irritating and maybe even exhausting sometimes, but it doesn’t always feel like something serious that requires medical attention. This is also true for the cough that tends to accompany mild COVID-19.

Contrary to its presentation, however, a dry cough can have serious causes and can get worse. It is a protective reflex, in response to inflammation or irritants, and should not be ignored. Read on to find out what’s causing your dry cough, and when you need to see the doctor.


1. The Cough That Doesn’t Go Away: A cough that you’ve had for a long time is called a chronic cough (as opposed to an acute cough, which is sudden and short-term). It tends to be at its worst during the day, and may include coughing fits. These coughs are stubborn, and can be painful, even leading to pulled muscles or incontinence in older patients with severe cases. This could have a number of causes, including allergies, inflammation, or be a side effect of medication. This could also be caused by “long COVID-19” and post-viral asthma.

2. The Tickly Cough: What is that irritating, ticklish feeling at the back of the throat that causes relentless coughing? It is sometimes the result of inflammation from a cold or flu virus, or from atmospheric factors like pollution or climate. Post-nasal drip could also be a factor (where mucus drips down from the sinuses into the back of the throat).

3. The Barking Cough: Named for its similarity to the woof of your pup, this cough may occur at day or night, possibly with some wheezing. It is usually caused by inflammation, such as following a cold or flu, and it can be painful.

4. Plum Pit Cough: It feels like there’s a lump in your throat that won’t go away, no matter how much you swallow. When you cough, you might notice a slightly acidic taste. This is usually due to GORD, or acid reflux, where the stomach acid rises up the oesophagus, and can lead to more serious conditions.

5. Wheezy Cough: This cough is often worse at night or when you first wake up. It is accompanied by a wheezing sound – a high-pitched sound that is a bit like a whistle. The sound is caused by a tightening of the airways (bronchospasm), and is usually caused by asthma.



There are many common causes of cough. Some of these include:

  • Viruses, including COVID-19
  • Allergies / Hay fever (caused by pollen, dust, pollution, pet dander, second-hand smoke)
  • Climate (cold, dry climates, changes in temperature)
  • GORD / acid reflux
  • Post-nasal drip
  • Bronchitis, Tonsillitis, Sinusitis
  • Laryngitis (the larynx becomes inflamed and you “lose your voice”)
  • Medication (coughing is a side effect of ACE inhibitors)
  • Smoking
  • Asthma



It is thought that around 10% of people with asthma don’t actually have a diagnosis, so if you have been experiencing any type of chronic cough, it is worth having a check-up with a doctor to make sure that you aren’t asthmatic.

The asthmatic cough is usually accompanied by a wheezing sound, due to the effect that the condition has on the airways. Inflammation causes them to tighten and narrow, meaning that there is less space for the air to travel through. Whilst a dry, wheezy cough is one sign of this condition, it can become more serious, leading to difficulty breathing.

Some indications of asthma include a cough that gets worse with exercise or exertion, a feeling of tightness in the chest, difficulty catching your breath (or shortness of breath) or a general feeling of fatigue.

Allergic Asthma:
Allergic asthma is very similar to normal asthma. The difference is that it is triggered by allergens (dust, mould, pet dander, or pollen are some of the most common allergic triggers for people with allergic asthma), which lead to inflammation in the airways of the lungs, causing coughing, difficulty breathing, or a full-blown asthma attack. For some people with the condition, it can be triggered by cold weather, inhaling smoke or fumes, or certain strong smells such as perfumes. With this condition, knowing your triggers and avoiding contact with them is an important aspect of managing the condition.

Post-Viral Asthma:
If you notice that your asthma symptoms are worse after you’ve had a cold (rhinovirus) or flu (influenza), or you’ve been ill recently and you’re now experiencing an ongoing cough that won’t go away, you may have post-viral asthma. This condition is partly caused by the immune system’s inflammatory response to infection, which, if it occurs in the lungs, can trigger the airways to swell. In those who have this condition, prevention is key. The doctor may recommend flu shots, and other preventative measures to ensure that you don’t get colds and flus in the first place.

People with “long COVID-19” have reported that their cough can continue for weeks or months and be accompanied with ongoing breathlessness and loss of stamina. We will be writing a new blog post about this soon.



In all cases, if you have a dry cough that isn’t going away, it is important to make an appointment with a GP. They can help you to find out the cause, and get you proper treatment. Early treatment is always preferable. Whether you have a minor illness, or are recovering from an infection, see a doctor to ensure that your condition doesn’t worsen.

In the case of dry cough, this is especially important. Although it is rare, a chronic dry cough can be caused by some serious and even fatal conditions, such as:

Heart Failure:
It may come as a surprise that a dry cough can be a sign of heart failure. This is caused by a build-up of fluid in the lungs. This can happen when the heart is not pumping as well as normal. A cough associated with fluid build-up tends to be worse first thing in the morning. It may even cause you to wake up out of breath.

Pulmonary Embolism:
A pulmonary embolism is a blood clot in an artery in the lungs. These clots usually form elsewhere in the body and then travel through the bloodstream to the lung. A pulmonary embolism can be fatal if it isn’t treated urgently. A cough is a symptom of this, although it is likely to be accompanied by blood and severe chest pain.

Lung Cancer:
In its early stages, lung cancer may not have any symptoms at all. As the condition develops, a cough is one of the earliest signs. This will be a new cough that doesn’t go away, and which is different to the types of cough you have had in the past. The cough may include a hoarse throat, wheezing, shortness of breath, or repeated lung infections or colds.



If you are feeling at all unwell, please don’t ignore your body’s signs. Make an appointment to see a GP as soon as possible, and get a diagnosis and appropriate treatment.



Why Your Cough Gets Worse at Night

The Science Behind a Cough That’s Worse at Night

Why do coughs get worse at night? There are a number of reasons why they do — or at least why they seem to.

Gravity The number one factor that makes your cough worse at night is simple: gravity. Mitchell Blass, MD, a physician with Georgia Infectious Diseases, says, “When we lie down, mucus automatically begins to pool.” The best way to counteract this gravitational pull is elevation. “Sleep with a pillow propping you up a little,” Dr. Blass suggests. “It will help keep the mucus from collecting in the back of the throat.”

A dry, indoor environment Dry air can aggravate an already irritated nose and throat, making your nighttime cough worse. To relieve a dry air cough, you can try a humidifier to put moisture back into the air and make it easier to breathe, but be sure to take proper care of the unit.

“Humidifiers are not always safe,” warns Blass. “If the water you put in it isn’t sterile, you run the risk of cycling the germs back into the air or breeding other diseases.” The last thing people with a cold or flu want is to experience complications, says Blass. “Bacterial infections can set in. Many flu-related deaths are caused by pneumonia that hits after people think they’re over the flu.” To ensure you use a humidifier safely, be sure to carefully follow all the directions that come with it.

How to Manage a Nighttime Cough

Most coughs associated with colds and flu are beneficial for clearing congestion from your lungs and airways, according to the Mayo Clinic. But sleep is also important for getting well — and it’s no fun tossing and turning all night.

How to Help a Cough at Night: Try These Tips

When it seems like you just can’t get any sleep, here’s how to stop coughing at night:

  • Suck on a cough drop. Before you go to sleep, suck on a cough drop or hard candy to ease a dry cough (one that doesn’t produce mucus) and soothe your throat, advises the Mayo Clinic.
  • Drink fluids. Be sure to drink plenty of fluids throughout the evening before bed — liquids help thin the mucus in your throat, and warm liquids are soothing, says the Mayo Clinic.
  • Have some honey. Adding honey to warm liquids like water or tea or just taking a spoonful or two has been shown to have modest benefits in reducing cough, says Stephen Russell, MD, a physician at the University of Alabama at Birmingham Department of Medicine and an expert in upper respiratory infections. A study published in JAMA Pediatrics found that honey had modest benefits in reducing nocturnal cough in children ages 2–18. Never give honey to children under age 1 though, says Dr. Russell, because in rare cases it can cause infant botulism.
  • Try cough medicine. Nighttime cough medicines typically contain an antihistamine that makes you feel sleepy, explains Russell. “Benadryl does a great job stopping allergies and postnasal drip with the side effect that it makes you sleepy,” says Russell, adding that it dries up the nose and helps stop the cough. But Benadryl may have some side effects for people over age 65, such as reducing stability in the middle of the night, he notes. Because of the risks of Benadryl and other over-the-counter cough medicines — some of which have not been proven to be more effective than placebos — Russell advises exploring natural remedies first, then using cough medicines with caution.

RELATED: Home Remedies to Stop a Bad Cough

When to See a Doctor About Your Cough

Acute or short-lived coughs — which often follow an upper respiratory tract infection such as the common cold — usually go away on their own without treatment, according to an article published in Thorax. But if your cough persists for more than a week, you should call your doctor, says Russell. If your cough is caused by an infection, your doctor may prescribe an antibiotic or antiviral medication, says the Cleveland Clinic.

A longer-lasting (chronic) cough could be the result of another health condition, such as allergies, gastroesophageal reflux disease (GERD), asthma, COPD (chronic obstructive pulmonary disease), or chronic sinusitis, according to the Mayo Clinic. Chronic bronchitis could also be the cause, according to the Cleveland Clinic, so make an appointment to see your doctor if your cough doesn’t get better.

Additional reporting by Jennifer D’Angelo Friedman.

A 43-year-old man with cough, expectoration and recurrent wheezing

Case presentation

A 43-year-old man was admitted to the Guangzhou Institute of Respiratory Disease (GIRD), the First Affiliated Hospital of Guangzhou Medical University because of recurrent episodes of coughing, expectoration and wheezing for 3 years with aggravation during the previous 6 months.

The patient began to cough with white phlegm after a cold in 2012. The cough was worse upon waking in the morning and laying down at night. He had no chills, fever, chest pain, chest tightness, palpitations, night sweats, hemoptysis or paroxysmal nocturnal dyspnea. He was diagnosed with ‘upper respiratory infection’ in a local hospital and received symptomatic treatment for several days that he could not recall clearly. His condition improved, but he still had occasional relapses. One month after the treatment, he suffered from an attack of wheezing during moderate activity and was admitted to a local hospital, in which he was diagnosed with ‘bronchial asthma’ and ‘type 2 respiratory failure’, from 1st December to 13th December 2012. Chest CT scan showed interstitial inflammation in the right middle and left upper lobe. Pulmonary function test suggested mild obstructive ventilatory dysfunction with FEV1 at 72.2% of predicted, FVC at 89.7% of predicted, and FEV1/FVC ratio at 66.81%. The bronchodilator reversibility test was positive: FEV1 increased >12% and >200 mL with inhaled Ventolin 400 µg (). No abnormalities were noted in echocardiogram. Inflammation was observed in both bronchial trees on bronchoscopy. After receiving symptomatic treatment, the patient’s condition improved but did not normalize. Upon referral, he was admitted to our hospital for further treatment. The treatment included Methylprednisolone at a daily dose of 40 mg intravenously and oral Theophylline 0.2 g once every 12 hours for 3 days. After that, his condition improved and he was subsequently discharged. He continued to take Singulair, Ketotifen and Theophylline, as well as Symbicort 320/9 µg bid and Foster 100/6 µg bid. His symptoms were under control.

Pulmonary function test (performed on Dec 25th, 2012 and May 26th, 2015, respectively).

The patient was re-admitted on May 25, 2015, 6 months before which, his symptoms recurred and were worse in cold weather. He began to wheeze after mild activity and coughed with increasing white phlegm. He received intravenous treatment with unknown regimen in a local hospital for a couple of days, but his condition was not improved. So he was referred to our hospital for further treatment. Since the onset of the disease, his appetite stayed the same with normal stool and urine. He lost 6 kilograms in 6 months.

He had no known allergies, but he had been suffering from cataract for about 1 year, gallbladder polyps and fatty liver for about 4 years. He was not exposed to an epidemic area before admission. He had smoked for 10 years, which was about 5 pack years, and ceased smoking 10 years ago. He got married at 25 and got along with his wife well. He had one son and one daughter, both of whom were healthy. No relevant family history was identified and no one in his family had similar symptoms.

On admission, vital signs were stable. The temperature was 36.8 °C, the pulse was 90 beats per minute and regular, the blood pressure was 120/73 mmHg and the respiratory rate was 20 breaths per minute. He was well developed and moderately nourished and free from skin eruption. Multiple flaky red macules, about 2 to 4 centimeters in diameter, were noted on both lower extremities without pruritus. He felt mild pain when pressing the red macules. There was no spider angioma. Superficial lymph nodes were not enlarged. The respiratory movement was bilaterally symmetric. Breath sounds from both lungs were coarse and wheezes were heard during expiration. Heart sounds and the remainder of physical examination were normal. His annual lab examination in May 2015 showed elevated serum total IgE (1,072 kU/L) and high percentage of eosinophils in peripheral blood (27.8%). Fractional exhaled nitric oxide (FeNO) was 37 ppb. The proportions of induced sputum cell counts were as follows: neutrophils 62.5%, macrophages 31%, eosinophils 2% and lymphocytes 4.5%. In bronchoalveolar lavage fluid (BALF), the proportions of cells were as follows: neutrophils 53.5%, macrophages 10.5%, eosinophils 35% and lymphocytes 1%. Eosinophils in peripheral blood were normal, although bone marrow puncture showed active eosinophil hyperplasia when he received treatment in our hospital for 3 days. Sputum smear tests for fungi and TB were all negative for 4 times. Fungal sputum culture and antigen test were also negative. The results were negative for mycoplasma pneumonia and HIV. Other test results are shown in .

Table 1

Laboratory data

Variables Reference ranges May 26, 2015 Jun 5, 2015 On current admission (Jul 20, 2015)
Completed blood count (CBC)
   White blood cell (WBC) (×109/L) 4.0–10.0 9.68 14.5 12.73
   Neutrophils (N) 40.0–70.0 36.3 66.1 60.8
   Eosinophils (E) 0.0–7.0 27.8 0 0.4
   Lymphocytes (L) 10.0–50.0 30.7
   Monocytes (M) 3.4–9.0 7.6
   Basophils (B) 0.0–1.5 0.5
Live function test (LFT)
   Total protein (TP) (g/L) 65–85 56.2
   Serum total bilirubin (STB) (ìmol/L) 1.7–22.2 2.5
   HDL-C (mmol/L) 1.17–2.00 1.59
   TG (mmol/L) 0.23–1.58 2.54
Hepatitis B test (HBV-test)
   Anti-HBs (mIU/mL) <10.00 10.99
   Anti-HBc (s/co) <1.00 2.53
MI test
   CK-MB (U/L) 3–25 14.0
   LDH (U/L) 109–255 223.4
   Troponin I (TnI) (ug/L) 0–0.04 0.01
Coagulation test
   Fibrinogen (Fg) (g/L) 4.3 2.79
   D-Dimer (ng/mL) 565 342
Blood gas test
   PO2 (mmHg) 83.0–108.0 77.7
   PCO2 (mmHg) 35.0–48.0 44.5
   PH 7.350–7.450 7.428
   HCO3 (mmol/L) 21.4–27.3 28.9
   SB (mmol/L) −2.3 to 3.0 −3.3 4.7
   ESR (mm/h) 0–20 25 7
   PCT (ng/mL) <0.05 <0.05
   PR3 (U/mL) 0–18 2.06 2.14 0.17
   MPO (U/mL) 0–18 8.58 9.21 5.57

Since admission to our hospital, nebulized compound ipratropium bromide solution 2.5 mL every 8 hours and budesonide 2 mL every 12 hours had been administered. The patient’s condition was not improved. On June 8th in the hospital, the patient was treated with intravenous cyclophosphamide (CTX) 0.2 g every other day for 3 days, and then with oral CTX as subsequent therapy () for 3 days, after which, his symptoms of wheezing and cough improved.

Table 2

Patient treatment with systemic corticosteroids and immunosuppressive agents

Methylprednisolone (intravenous drip, daily) (mg) Prednisone (orally, daily) (mg) Cyclophosphamide (intravenous drip, every other day) (mg) Cyclophosphamide (orally, twice a day) (mg)
May 27–May 31 40
Jun 1–Jun 4 80
Jun 4–Jun 7 160
Jun 8–Jun 10 200
Jun 11–Jun 11
Jun 11–Jun 12 80
Jun 12–Jun 25 (on discharge) 60 50
Jun 25–Jul 9 55 50
Jul 9– 40 50

On the second day in the hospital, chest CT scans revealed signs of bronchiolitis obliterans on bilateral lungs and nodules were noted in the right lower lobe (). Pulmonary function test suggested severe obstructive ventilatory dysfunction with FEV1 at 34.70% of predicted, FVC at 73.4% of predicted, and FEV1/FVC ratio at 38.58%. The bronchodilator reversibility test was positive: FEV1 increased >12% and >200 mL with inhaled Ventolin 400 µg. Diffusion capacity declined mildly and airway resistance was normal ().

CT scans of the chest (panel C, E performed on March 27th, 2013; panel D, F performed on May 26th, 2015) and sinus (panel A performed on April 11th, 2013, panel B performed on May 26th, 2015).

In turbinate mucosal tissue, basement membrane thickening, mucosal edema, scattered lymphocytes and few eosinophils was noted. Besides, the patient presented with focal epithelial squamous metaplasia, local thickening of basement membrane, submucosal edema, smooth muscle hyperplasia, increased lymphocytes and eosinophils on the mucous membrane of the lower right bronchus. Bronchiole wall was thickened on the right lower lobe, fibrous hyperplasia was noted, cellulose effused in alveolar cavities, focal lymphocytic infiltration was observed, bronchial wall and pulmonary interstitial presented with more eosinophil infiltration without vasculitis and granuloma.

Why is a grand round discussion warranted for this patient?

Dr. Qingling Zhang (Pulmonologist at GIRD):

After the treatment with a large dose of steroids and CTX for 3 days, the patient felt much better with no wheezing and only a bit of cough. The dose of CTX was reduced from 200 mg with intravenous drip every other day to 50 mg orally twice a day. With treatment, the patient’s condition further improved and the symptoms were relieved and his blood eosinophils count decreased. CT scans of chest and sinus showed milder inflammation in both lungs and sinus than before. In terms of lung function, spirometry on June 11 after high dose steroids treatment suggested mild obstructive ventilatory dysfunction, which was much better than his condition on admission in May before the steroids and CTX treatment. FEV1 increased to 77% of predicted. This patient was discharged on the 12th day (July 12). Then he was followed up in clinic, the systemic corticosteroid was gradually stepped down from a daily dose of prednisone 60 to 40 mg in 4 weeks and maintain CTX 50 mg orally twice a day. Recently, we re-examined his lung function. His spirometry results were a bit worse than the previous one in June and suggested moderate obstructive ventilatory dysfunction with FEV1 66% of predicted. Peak flow monitoring indicated that the values been improved greatly since June 8th when we started high dose steroids as well as CTX, and the values had been stable in the following outpatient clinic until now. This patient met four items of the diagnostic criteria of Eosinophilic Granulomatosis with Polyangiitis [EGPA, formerly known as Churg-Strauss syndrome (CSS)], including asthma, peripheral blood eosinophils greater than 10%, abnormalities in the paranasal sinus, and non-fixed pulmonary infiltrates. We were considering this patient might be with EGPA, which only affected the lung. Therefore, the purposes of today’s discussion are as follows: (I) could this patient be diagnosed with EGPA or chronic eosinophilic pneumonia (CEP)? Or has he suffered from a special phenotype of severe asthma? (II) how to prevent the side effects from using high dose steroids and CTX? (III) how to manage his further treatment including the steroids and immunosuppressive agent, as well as the side effects?

Prof. Nanshan Zhong (Grand round moderator, Pulmonologist at GIRD):

This case raised two questions. First, whether the patient could be diagnosed with EGPA, or just be diagnosed with very severe asthma (refractory asthma), or some other diseases like CEP? Secondly, how to manage the relatively large dose of corticosteroids and related side effects?

Before the discussion, we shall provide chest imaging data and pathologic data. First of all, I would like to invite Dr. Zeng to present the radiological information.

Images and pathological discussion

Dr. Qingsi Zeng (Radiologist at GIRD):

The first CT scan was performed in March 2013. It showed decreased attenuation of both lungs, air trapping, and diffuse thickening of bronchial walls. The second chest CT scan performed 7 months later (Oct 2013) revealed improvement of the thickening of bronchial wall and the recoiled pattern disappeared after treatment. The lesions included centrilobular nodules, tree-in-bud sign in the upper and lower lobe and the thickening of bronchial walls showed on May 2015 were more remarkable than that in 2013 (). The CT findings indicated the disease was progressing. But the latest CT scan after two months of treatment (July 2015) showed the infiltration disappeared and both lungs were clear. It’s confusing that the thickening of the bronchial wall still recurred this year even after effective treatment and improvement this month (July 2015). The dynamic CT series (July 2015) suggested the patient was recovering. All these findings indicate small airway diseases, mostly like a kind of untypical severe asthma. The sinus CT scan showed inflammation of bilateral maxillary sinus and ethmoidal sinus.

Prof. Nanshan Zhong:

Apart from the changes of bronchus, whether the patient had pneumonia when his symptoms recurred is extremely important for us to make diagnosis, for example, CEP or others, even CSS. May I ask Dr. Zeng, do you think this patient had pneumonia from the radiological point of view?

Dr. Qingsi Zeng:

We don’t think this patient had pneumonia because we cannot see any ground-glass opacity or consolidations. We just saw very tiny lesions with small centrilobular nodules and tree-in-bud. All evidence from CT scans is related to airway diseases.

Prof. Nanshan Zhong:

Are there any separate or tiny signs of pneumonia?

Dr. Qingsi Zeng:

No, we don’t think so.

Prof. Nanshan Zhong:

OK. This is very important for us to think about the diagnosis. Let’s move to the pathological information session. I would like to invite Dr. Gu to introduce the histological data.

Dr. Yingying Gu (Pathologist at GIRD):

Biopsies of the nasal mucosa, mucosa membrane of bronchus and lung were conducted on this patient. Let me introduce the biopsy of the nasal mucosa first. Sample of the nasal mucosa was obtained, covered by pseudostratified columnar ciliated epithelium predominantly. Widening of basement membrane was noted. Edema was seen under the mucosa and it looked pale. Scattering lymphocyte and a few eosinophils were infiltrated. A specimen of the bronchial mucosa revealed that pseudostratified columnar ciliated epithelium was predominant. Eosinophils infiltration and edema were observed under the mucosa. Another slice of the bronchial specimen also showed obvious edema on the mucosa with more eosinophils infiltration. There were no signs of vasculitis presented on the small vessels. The slice of transbronchial lung biopsy showed a lot of eosinophils and lymphocytes infiltration in the interstitial tissue, however, no eosinophilic angiitis was noted around the small vascular walls. A few eosinophils exudation were found in the alveolar space, while more eosinophils were infiltrated in the alveolar septum (). The first diagnosis we considered was EGPA. The second consideration was CEP, and the possibility of idiopathic hypereosinophilic syndrome (IHES) should be excluded. In terms of the diagnosis of EGPA for this patient, there were no typical pathological changes of angiitis and granulomatosis, but the clinical symptoms and presentations were systemic, including chronic gastritis, rashes on the skin. From the microscopy, eosinophils infiltrations were noted in nasal mucosa, bronchus, and the lung. In the early stage of EGPA, the pathological changes of vasculitis and granulomatosis may not be presented. Usually, it takes several years to show the changes of angiitis and granulomatosis with the development of the disease. Therefore, a possibility of EGPA was considered first, and the second differential diagnosis of CEP should be excluded. Eosinophilic infiltrations in the interstitial lung tissue may also be presented in the case of CEP, but the changes are mostly localized in the lung, not systemic. Compared to EGPA, the severity of eosinophilic infiltration of CEP is often milder. The third diagnosis we excluded was IHES because the clinical presentation of this patient was not supportive; meanwhile, the cell count of eosinophils in the peripheral blood was normal and the level of eosinophils in the bone marrow was a bit higher after the treatment.

Transbronchial biopsy of the lung. Panel A was presented by original magnification ×50. Panel B, C and D were presented by original magnification ×100. (Hematoxylin and eosin stain).

Overall, we tend to diagnose this case with EGPA according to the clinical presentation and pathological findings, as well as the comparison of three differential diagnoses.

Prof. Nanshan Zhong:

Dr. Gu, how do you think about the diagnosis of severe asthma based on the pathological findings?

Dr. Yingying Gu:

For severe asthma, the pathological changes usually are localized in the bronchial mucosa, smooth muscle hypertrophy accompanied with mucous gland hyperplasia should also be seen, and there are not many eosinophilic infiltrations in the lung. However, obvious eosinophilic infiltration was presented in the lung of this patient, so I prefer to a diagnosis of systemic disease.

Prof. Nanshan Zhong (in summary):

The pathologist has different opinions on the diagnosis. The radiologist’s diagnosis seems to be severe asthma based on the imaging findings. There is no much radiological clue showing the lung parenchymal infiltration. However, the histological examination showed eosinophilic infiltration in the bronchus and the alveoli, as well as in the lung interstitial space. The diagnosis of the patient is controversial.

Now, I would like to invite experts from the Firestone Institute for Respiratory Health (FIRH) to share their opinions.

Differential diagnosis

Dr. Paul O’Byrne (Pulmonologist at FIRH):

This gentleman, first of all, has had episodes of severe, variable airway obstruction. When he has been acutely ill, his lung function has been very severely impaired. When he is well, his lung function is not normal, but not far from normal. Secondly, he has atopy. He has an elevated total IgE over 1,000 kU/mL. However, we are not given any information about what he might be sensitized to. One of the tests that I think we’d consider here would be a very simple skin prick tests which might be helpful to provide evidence of some important allergens which he is sensitized to. If possible, avoiding these allergens might help to improve his clinical symptoms. The third component of this case is his eosinophilia. We can confidently exclude a diagnosis of eosinophilic pneumonia, as the radiologist indicated that there was no evidence of consolidation in the lungs with the extensive radiographic investigations. In my opinion, the diagnosis of EGPA requires pathological evidence of those changes. However, you have pathology which shows no evidence of angiitis, vasculitis or granulomatous. Therefore, at this moment, I am fairly confident that EGPA is probably not the reason why this man was so sick.

What he does have is, in my opinion, severe eosinophilic asthma. The asthma is documented by variable airway obstruction and the eosinophilia was being shown in his blood stream and BAL fluids, although the sputum eosinophils were very borderline and probably not elevated. He did respond very well when treated with intravenous and higher doses oral corticosteroids. So, the question, is whether there is anything else that could be causing the severe eosinophilia. Could this be, for example, allergic bronchopulmonary aspergillosis (ABPA), which can cause severe eosinophilia? However, the radiology makes that extremely unlikely. There are no characteristic upper lobe changes that we see with ABPA. The question becomes whether anything else can be done to establish the diagnosis. He was very thoroughly investigated, including lung tissue biopsy. The only additional test to do at this moment would be some skin prick testing (SPT) to identify the relevant environmental allergens. The immunological testing ANCA was negative, and ESR was not markedly elevated.

Another comment is that one of the biopsies we looked at was the airway mucosal biopsy. To me, it looked very much like an asthmatic airway biopsy, with a thickening of the submucosal basal membrane and a great deal of airway smooth muscle in that biopsy, much more than we see in a normal, non-asthmatic individual.

Altogether, I would not pursue the question of him having, at least at this moment, any evidence of vasculitis.

Dr. Gerard Cox (Pulmonologist at FIRH):

I don’t think EGPA is the most likely diagnosis, but if it was present, one might find it in the following way.

Firstly, the skin lesion that is referred to, we heard that was acne, which might be a side effect of prednisone possibly but not necessarily evidence of vasculitis. But if the patient had any rash that was unexpected, unusual and uncommon, I think it would be a good idea to biopsy that rash and see what tissue changes are present. Secondly, the pathologist made an excellent point about vasculitis presentation and the angiitis (EGPA), and why didn’t have a changing in presentation over time. If we see a patient at the very beginning of the presentation, they might not have the entire syndrome present. However, he has been sick for 3 years, which should be almost long enough for most things to come out. Nevertheless, it would be a good idea to recheck his ANCA levels sometime in the future. A number of our patients with CSS had a very low level of ANCA, usually just above the upper limit of normal range and they can certainly vary up and down.

We heard about a few other symptoms including gastritis. Obviously, if eosinophilic gastritis or eosinophilic esophagitis was present, that would make a diagnosis of EGPA much more solid. The biopsies of the airway (nose, bronchus and lung) showing eosinophils, according to Dr. O’Byrne’s argument about all that eosinophilic inflammation, supposed to be a track for allergic asthma and allergic rhinitis. Therefore, I think we have to find the eosinophilic infiltration outside the respiratory tract. In my opinion, stomach or esophagus given the symptoms of reflux and gastritis would be a good place to look for eosinophilic inflammation. I heard something about eye symptoms, and I wonder if he has got any evidence of vasculitis affecting his eyes. In our situation, we will ask for a specialist to see the patient when we worry about that because we don’t feel confident at the bedside excluding vasculitis of various levels of his eye. That would strengthen the argument that this is a vasculitis syndrome if it was found.

Moreover, there were some tests done showing a possible involvement of the heart because some of the enzymes were raised in the blood. We would repeat that assessment with an ECG to look for any problems there, as well as echocardiogram as a minimum. At the ATS meeting this spring in Denver, there was a presentation on EGPA with cardiac involvement where they showed with PET scanning. They found involvement of the myocardium in their patients with EGPA more often than expected. So if you want to find evidence of another organ involved to prove and make the case for EGPA, I think the heart would be a good place to look at if PET scanning is available. The last, mononeuritis has such different symptoms from allergy and asthma, so if the patient has anything suggests mononeuritis syndrome, that might change Dr. O’Byrne’s opinion away from this being severe, allergic asthma affecting all the respiratory tract.

Discussion about management

Dr. Paul O’Byrne:

Another comment is in relation to his treatment since he is being treated with cyclophosphamide. Of all the medications he’s on, cyclophosphamide is the one I have the most concern about side effects. I would stop cyclophosphamide due to the absence of pathological evidence of vasculitis. I would manage him with systemic corticosteroids. Then I think about what else may be additional useful treatment. One thing that might be available and could be a value is anti-IgE, omalizumab. There is evidence that omalizumab can be helpful in reducing the risk of severe exacerbations in patients with severe refractory asthma. A recent study (1) supported that this approach is the most likely to work in patients who had an elevated eosinophilia at least in the airways. That is one possibility. The second issue is optimizing his inhaled medications (dose of the inhaled corticosteroids). I would certainly treat him with a combination inhaler of ICS and LABA because the patient has variable airway obstruction and inflammation, both of those are appropriate. I personally would introduce the combination budesonide/formoterol in this treatment plan because it can be useful as a maintenance treatment and as a rescue. We did not hear about how much rescue medicine the patient is taking but I suspect from his history that it is probably several times a day. So if this is true, then he should get a rescue treatment containing corticosteroid, as well as a bronchodilator. We often also consider whether using higher doses of additional ICS, such as budesonide or fluticasone given in addition to budesonide/formoterol and try to optimize the inhaled medication doses.

Dr. Andrew McIvor (Pulmonologist at FIRH):

I fully agree with Dr. O’Byrne about what he said, but I would like to make a small comment. One thing that I noticed is that the patient was on montelukast. There have been reported a black box warning about montelukast perhaps a potentiation of CSS. There are two ways this syndrome may present. Sometimes, people with severe asthma are on steroids, and if montelukast is added in, they seem to get a little bit better. But when the oral steroids are dropped, then the patients seem to develop full-blown CSS. Perhaps it wasn’t related to the drug whatsoever, but it was related to change in treatment. Churg-Strauss can also present in people with quite mild asthma associated with allergic rhinitis, who then go on to develop lower vasculitic symptoms and the montelukast could be added in because it was presumed to be mild asthma. To these patients, we should always look at the benefits that can occur from increasing treatment, and this is just one thing that I think we should bring up for teaching aspect.

Dr. Gerard Cox:

Regarding to the management, I think he’s already having trouble with prednisone side effects since he’s mentioned having cataracts, gastritis, acne and fatty liver. So, these are already showing that he is at risk for more complications from steroids. Therefore we will be very interested in a drug other than prednisone to help control his disease. You have heard about a very good suggestion from Prof. O’Byrne about anti-IgE therapy. If that isn’t available to you and if intensive inhaled therapy isn’t sufficient, when we give somebody in this situation with difficult asthma, lung eosinophilia, or maybe another syndrome, we might often use methotrexate before we used cyclophosphamide, particularly for young patients. He is only 43, and we would worry about longer-term consequences of malignancy with somebody who was treated with oral cyclophosphamide for a long period of time. If you have to give him a nonsteroid drug to get away from prednisone and you don’t get biologic one available to you, methotrexate might be a cheap and economic way to get in there.

Night Cough – Symptoms, Causes, Treatments

Night cough is a cough, or tussis, that occurs primarily at night, typically when you are lying down (postural cough). Physiologically, coughing is a rapid expulsion of air from the lungs that happens reflexively to keep the airways clear. Night cough may be a symptom of conditions specifically affecting the lungs and throat or a more generalized condition, such as a cold or the flu.

Inflammation of the lungs or throat, due to smoking, colds, or flu, is a common cause of night cough. Smokers produce excess mucus in their airways and the lung struggles constantly to clear these passages. Remarkably, this symptom is one of the first to improve, even completely disappear, with smoking cessation.

In rare cases, night cough can be a symptom of a serious infection of the lungs, bronchial tubes, or throat. Night cough can also be a symptom of congestive heart failure if it occurs together with pink frothy mucus in the mouth, severe shortness of breath, wheezing, and rapid heartbeat. Night cough can also be a sign of lung cancer, especially if it is accompanied by hemoptysis (coughing up blood).

Depending on the cause, night cough may occur only while you are lying down or also while you are sitting up, and it may be accompanied by sputum production, sneezing, shortness of breath, wheezing, or gastric contents moving upward into the mouth.

In some cases, night cough can be a sign of a life-threatening condition, such as congestive heart failure, pulmonary edema, or a severe respiratory infection. If you, or someone you are with, have night cough that is accompanied by serious symptoms, such as chest pain, a high fever (higher than 101 degrees Fahrenheit), or severe breathing problems,
seek immediate medical care (call 911).

If your night cough is persistent or causes you concern,
prompt medical care.

Cough – Lung Health A-Z

About Cough

Key facts about Cough

  • Coughing is an important human reflex that helps protect your airway and lungs.
  • Occasional coughing is normal. Coughing helps clear your throat and airway from bugs, mucus, and dust. Persistent cough with other symptoms, such as shortness of breath, mucus production, or bloody phlegm, could be a sign of a more serious medical problem.
  • Persistent cough is a common symptom of a problem in your lungs, but it can also point to disease of the heart, stomach, or nervous system.

Coughing is a natural body response. When mucus, germs, and dust irritate your throat and airway, your body responds by coughing. Similar to other reflexes, such as sneezing or blinking, coughing helps protect your body.

Your throat and airways are equipped with nerves that sense irritants. When these nerves are stimulated, they send a signal to your brain. The brain then sends a signal back to the muscles of your chest wall and abdomen to rapidly and forcefully take a deep breath in and breathe out really fast, trying to remove the irritation. This response is immediate and effective. Coughing can propel air and particles out of your lungs and throat at speeds close to 50 miles per hour.

How cough affects your body

Occasional cough is a normal, healthy response. Our throats and lungs produce a small amount of mucus to keep the airways moist and to have a thin covering layer that helps protect against irritants we may breathe in.

Cough also helps us remove any toxins we accidentally breathe in. As we grow older, the muscles we use to cough tend to lose power, and our cough may not be as effective as it once was. Mucus starts to accumulate, and our cough is less effective at removing toxins and irritants from our throat and airways, putting us at higher risk of lung infections.

Occasional cough is normal, but a cough that persists is not. If you have a persistent cough, you should tell your health care provider. Cough associated with other symptoms, such as runny nose, acid reflux, shortness of breath, chest pain, increased mucus production, or colored or bloody mucus, is most likely a sign of an ongoing disease.

How serious is cough?

Cough affects 10% of the world’s population. Illnesses such as the common cold can cause it. It’s also important to know that very serious diseases, such as pneumonia, collapsed lung, blood clots in the lung, and fluid in your lung, can also cause cough.

People who have a history of smoking, chronic lung diseases such as COPD, asthma, seasonal allergies, acid reflux disease (called gastroesophageal reflux disease), lung cancer, and chronic infections such as tuberculosis, have chronic cough.

How serious cough is depends on the disease that causes it.

What causes short-term cough?

Common causes of acute (short-term) cough include:

  • Infections, such as the common cold
  • Allergies, such as hay fever
  • Breathing irritants and exposure to fumes and vapors
  • Asthma

More serious conditions that can cause short-term cough include:

What causes long-term cough?

Some causes of long-term cough, also called chronic cough, include:

  • COPD
  • Asthma
  • Medications (Some medications can cause dry cough.)
  • Chronic lung infections
  • Lung cancer

Chronic bronchitis – MC “LOTOS”

Bubnova Valeria Sergeevna

Pulmonologist, general practitioner

Chronic bronchitis is an inflammation of the mucous membrane of the bronchi, which often leads to narrowing of their lumen, difficulty breathing and the appearance of a cough with phlegm. In Russia, chronic bronchitis occurs in 10-20% of the population.More often men and elderly people suffer from chronic bronchitis.

Chronic bronchitis begins gradually. The damaged mucous membrane secretes more and more phlegm, while taking it out worse. This causes a cough in the morning. Over time, the cough occurs both at night and during the day, and worse in cold and damp weather. Over the years, the cough becomes constant. During periods of exacerbation, the sputum becomes mucopurulent or purulent, cloudy, yellowish or greenish, with an unpleasant odor.

Chronic bronchitis is characterized by a cough with phlegm that lasts most of the month, at least three months a year and for two consecutive years, unless there is another cause that could cause the cough.

What are the main causes of chronic bronchitis?

The main cause of chronic bronchitis is smoking, which leads to irritation of the mucous membrane, its thickening, hyperproduction of sputum, a change in its viscosity and elasticity, the appearance of cough, especially in the morning.

In addition to smokers, chronic bronchitis often develops in people who inhale long-term polluted air containing dust, chemical reagents (for example, miners, construction workers, workers in factories that produce chemicals).

Exacerbation of chronic bronchitis in 1 / 2-2 / 3 of cases is caused by a bacterial or viral infection. Other causes of exacerbation of the disease can be allergens, air pollutants, etc.

What are the main symptoms of chronic bronchitis?

The main symptom of the disease is a chronic cough observed for at least 3 months over two consecutive years. Often the cough is accompanied by sputum production.

With exacerbation of chronic bronchitis observed:

– Increased dyspnea
-Increased cough
-Increase in the volume of secreted sputum
– Purulent sputum
– Increased body temperature

Diagnostics and treatment

The diagnosis of chronic bronchitis is established by a physician or pulmonologist. The compulsory examination plan includes: X-ray of the lungs, general and biochemical blood tests, sputum examination with bacteriological culture and antibiotic sensitivity test, examination of the function of external respiration with drugs.

In some cases, bronchoscopy is performed.

During the period of exacerbation of chronic bronchitis, the doctor prescribes antibiotics, expectorants and anti-inflammatory drugs.

Special breathing exercises, physiotherapeutic treatment (inhalation, electrical procedures) are also used.

Prevention of exacerbations of chronic bronchitis

-To give up smoking.

-Try to avoid prolonged contact with dust and cigarette smoke.

-If you stay in rooms with polluted air for a long time, wear a respirator.

– Adequate rest and nutrition plays an important role in reducing the frequency of exacerbations.

– Air conditioning in the room helps cough up and remove phlegm. The air should be warm and humid.

-Therapeutic exercise promotes sputum discharge and improves the course of the disease.

Bubnova Valeria Sergeevna, Candidate of Medical Sciences, pulmonologist at the LOTOS Medical Center

What is a cough

Since the world became sealed due to coronavirus infection, under the influence of external circumstances, attitudes towards seemingly familiar things began to change.Increasingly, people have become fearful and shy of those who cough or sneeze. However, before experiencing stress from the fact that someone is spreading a dangerous infection, do not forget that, according to doctors’ observations, the coronavirus is often not accompanied by this symptom at all. How to define a cough?

Swjournal offers to understand the common types of cough, the exacerbation of which can be easily provoked even by the coming seasonal cold snap.

Be healthy, don’t cough!

Recently it became known that artificial intelligence can be instructed to diagnose cough from COVID-19.Such a system for assessing the presence of a person’s cough disease may appear at Russian airports. To do this, the developers of the program had to create a database of coughs of several thousand people who were diagnosed with the infection.

So far, no worse than modern technologies, the person himself copes with the assessment of diseases: an experienced specialist is able to determine the cause of a cough from the patient’s medical history and using modern diagnostic tools. And although it is not entirely customary in society to talk about coughing, every year it manifests itself in an increasing number of defenseless citizens.

Remember that you should not diagnose yourself on your own, and, moreover, if you find any of the symptoms in yourself, do not postpone a visit to the doctor!

1. Allergic reaction

Allergic cough occurs in the respiratory system as a reaction to an irritant – an allergen. This type of cough can be caused by such everyday human companions as house dust, the smell of cigarette smoke, household chemicals, animal hair, food, cosmetics, etc.When the allergen gets on the mucous membranes of the respiratory system, it causes irritation and a reflex cough. At the same time, it is rather difficult to determine the source of the allergen without special tests – it is necessary to exclude many factors.

On your own, you can only distinguish an allergic cough from a cold – it is not accompanied by a temperature, its attacks occur suddenly and depend on the degree of exposure to the allergen. If you have been exposed to an irritant for a short time, then the cough will quickly subside.However, if this effect is prolonged, then the cough will develop incrementally.

Such a cough is not dangerous for others, since it is not associated with exposure to viruses or bacteria. If you find an allergic cough, seek treatment from an allergist. A specialist will develop for you a course of treatment aimed at removing sensitivity to allergens and restoring the general condition of the body.

As a rule, antihistamines, sorbents, or inhaled glucocorticoids can help to cope with this annoying type of cough.

2. Asthmatic cough

An asthmatic cough may seem like a typical manifestation of respiratory problems. However, there are features that allow specialists to establish the nature of the problem with the subsequent selection of the correct treatment regimens.

The cough that occurs in asthmatics is usually sudden – the symptomatology, as with an allergic cough, develops after exposure to a provoking factor. Bronchodilators in the form of aerosols for inhalation use, prescribed by specialists, can quickly stop seizures.

Asthma attacks are characterized by an unproductive, paroxysmal cough. Most often, attacks occur at night or in the morning.

The characteristic signs of asthmatic cough are the occurrence of frequent breaths, followed by a long and difficult exhalation. Patients have a fear of suffocation, provoking panic, which is accompanied by motor restlessness.

3. Cough – ARVI agent

Cough is a typical symptom of ARVI along with a runny nose, pain, sore throat, fever.In the early stages of the development of the disease, as a rule, it is dry and without phlegm. With him, you must immediately refuse to visit public places and consult a doctor.

At the onset of the disease, there is a dry cough, which, with proper treatment, develops into a wet cough, which helps to cleanse the respiratory system and further recovery.

Treatment of ARVI and cough can be accelerated thanks to cough syrups with a complex anti-inflammatory and antitussive effect (Stodal – for children from birth, when taken in the first 2-3 days of illness, subsequent cough treatment can be reduced from 3 to 1 week) , mucolytic (expectorant) drugs, as well as inhalation using a special device – a nebulizer.Nebulizers are now available in pharmacies.

4. Smoker’s cough

If you smoke, a cough may be a sign of bronchitis (inflammation of the bronchi). Smokers are usually worried about a paroxysmal cough with phlegm, mainly in the morning. An alarming signal is shortness of breath when walking or exercising.

A long-term cough from smoking can signal a serious injury, such as chronic obstructive pulmonary disease (COPD).The majority of patients with COPD are heavy smokers.

Be sure to consult a doctor and diagnose the focus of the disease for its further treatment.

Expert Opinion: Irina Farber, Ph.D., Assistant at the Department of Pediatric Diseases of the First Moscow State Medical University named after I.M. Sechenov Russian Ministry of Health : “In the current conditions, most people began to perceive cough painful, but rather at a psychological or even psychosomatic level.Do not be afraid of cough as such: there are many ways to diagnose and treat it. As soon as this unpleasant symptom began to bother you, see your doctor. An effective method of protection against various infections is wearing masks in transport and public places, distancing, and constant hand hygiene. ”

Publication link:

90,000 The doctor told why in the morning you want to clear your throat

The doctor explained why for some people the morning begins with a cough.

An unpleasant habit

Each person has their own traditional morning. For some, it starts with a cup of coffee. Others do exercises immediately after waking up, while others drink coffee. But there are people among us who, barely waking up and getting out of bed, begin to cough hysterically.

What is the reason for this behavior, said the therapist Andrey Zvonkov .

According to him, inflammation of the respiratory tract, smoking and allergies are not all the reasons that make a person cough immediately after waking up. Moreover, accompanying symptoms (for example, dry and irritated throat) can warn of a person having serious health problems, up to and including cancer.

What does a cough “warn” about?

– If a person is not a smoker, is not allergic and does not suffer from chronic bronchitis and inflammatory processes, the cause of the morning cough may be problems with the thyroid gland, with the gastrointestinal tract.It can be chronic gastritis, because acidity, excess gastric juice, causes a feeling of dryness and sore throat. This may be due to diabetes, because due to high sugar, the mucous membranes dry out, a cough appears, – said Andrey Zvonkov.

It turns out that in some cases, an unexpectedly appeared cough may turn out to be an individual allergic reaction of a person to a certain food. For example, sushi. Cases have been recorded when the desire to cough appeared after drinking alcohol.

– A dry cough can occur, for example, from too dry rice: it irritates the throat, like emery, leaving a feeling of irritation and perspiration. Alcohol, drunk the day before, as a rule, in the morning also dries out in the throat, and dry cough, tickling and nausea appear, – he noted.

And you, split?

Surprisingly, even a regular air conditioner can lead to breathing problems. There are two main reasons: either it has not been cleaned for a long time and the person develops an allergy to dust and other dirt stuck to the iron box.And the second – the operating unit dries the air too much and because of this, a strong cough may develop.

How I am sick with coronavirus – Vedomosti

I was one of the first victims of the newfangled coronavirus. I was in Courchevel, then in Dubai, and I still can’t say where I got it from. I think that a large number of sick people who descended from the mountains is explained by the thinness of the air, the openness of the bronchi and therefore the deep penetration of the virus, which in this case does not pass the classical path through the nasopharynx, but enters the lungs immediately and proceeds to its plan.

Frankly, I lay in January with a fever and a cough, so I vaguely suspected that I had already dealt with this virus: well, it cannot be that, with an abundance of contacts with China and with such virulence, someone did not deliver it by the end of December to us. Like, he was ill, he will carry it.

But what happened happened. Just now I felt a strong chill combined with a cold sweat and could not get warm in any way. In the morning, the temperature jumped to 38.5, my throat sore. Having adopted all the popular methods, I somehow felt relief, but the disease did not recede, although the temperature subsided and a cough appeared.I went to the hospital and got tested for coronavirus. I didn’t get the results personally, but someone kindly provided them to the scandalous Internet publication, where it was reported that I was with my eldest son in Kommunarka and that this was a payback for Courchevel’s debauchery. (At that time I was lying at home … well, at least I found out that way.)

I went to the hospital again, and I was found to have bilateral pneumonia. Since I was in touch with my medical friends, and I myself understood the vagueness of what was happening, I followed the already existing protocol, which involved the combination of azithromycin, hydrochloroquinyl, and kaletra (a combined antiviral drug).Plus, large doses of vitamins C, D, A and zinc, coupled with a host of immunostimulants. Well, taking into account the cough – lazolvan.

I decided to undergo medical treatment at home, considering that I did not need a ventilator: the oxygen saturation of the blood was normal.

And here I come to a very important part of the symptomatology of this creature. I understand for sure that in addition to focusing on the lungs, the coronavirus carries a pronounced psychotropic component. At night, when coughing attacks occur, panic attacks also occur.The general background as a whole is extremely depressive and does not resemble the usual flu. External informational accompaniment sounds like a requiem, and consciousness paints terrifying pictures.

I once tried sessions of shamanic special techniques of altered consciousness several times. It seemed to me that the coronavirus affects the same structures, causing extremely unpleasant experiences. I began to feel the virus by a special sensation in my mouth. Every time there was a deterioration, this strange, as if “buzzing” taste appeared; it is no coincidence that one of the characteristic symptoms is the loss of smell and taste, which I also experienced myself.Imagine the sensation when the head of garlic under the nose does not smell at all, and the taste of pure lemon juice is indistinguishable from drinking water! Therefore, it seems to me that sufficiently deep structures of the brain are affected, and this can aggravate respiratory disorders in a critical situation.

It became clear to me that it is dangerous to be alone in such a state – the condition can deteriorate sharply, and a ventilator and a resuscitator are needed next to him.

The next day I moved to the hospital in Lapino, where I was already under observation, for my pneumonia was flourishing and required control.And thanks to Mark Kurtser and Natalya Petrovskaya for their professionalism: we jointly debugged the psychotropic protocol, which must include anxiolytics, tranquilizers, sleeping pills.

Sleep is an essential component, especially in asthenia caused by pneumonia.

Pneumonia in any form, even typical, requires a very long recovery. Your biofield is punctured and will recover for a long time. Now I am at home and I am doing just that. It is pleasant to feel smells and tastes, and most importantly – appetite.Fortunately, they prepared a lot of food.

The main thing I want to say is more optimism. Try not to get sick – this is not an ordinary flu, but if it happens, do not lose heart, get treated: the treatment has already been debugged, everything will be fine. In three to four months, a cure will be found, and we will return to normal life.

Author – financier, medic

Trump has a fever and cough

American leader Donald Trump, who became ill with COVID-19, has a fever and cough, Vanity Fair reported, citing two sources in the White House.According to various sources, the wife of the President, Melania, also has moderate symptoms.

On Friday morning, it became known that the American leader had contracted the virus – presumably from the adviser Hope Hicks, who accompanied the president at the debate on September 29 and at the rally in Minnesota on September 30.

“We will immediately begin quarantine and treatment. We will overcome this together! ” – wrote Trump on Twitter this morning.

Tonight, @FLOTUS and I tested positive for COVID-19.We will begin our quarantine and recovery process immediately. We will get through this TOGETHER!

– Donald J. Trump (@realDonaldTrump) October 2, 2020

“No one knows where this will lead,” a source said about the health of the president and the first lady, noting that their condition is worse than it was in the morning.

It also became known that Republican Senator Mike Lee, who met Trump a couple of days ago, tested positive for coronavirus. He himself reported this on Twitter.


– Mike Lee (@SenMikeLee) October 2, 2020

And here is Joe Biden, who participated in the debate with Trump on September 29, passed a negative test.

I’m happy to report that Jill and I have tested negative for COVID. Thank you to everyone for your messages of concern. I hope this serves as a reminder: wear a mask, keep social distance, and wash your hands.

– Joe Biden (@JoeBiden) October 2, 2020

We treat sore throat with effective methods

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Unpleasant sore throat causes severe discomfort.But much worse is that it can indicate serious illnesses that lead to serious complications. We will tell you why it scratches in the throat, why it is dangerous, and how to get rid of this feeling.

Symptoms and types of sore throat

Perspiration manifests itself as a feeling of unpleasant itching, burning, tickling, sometimes accompanied by a sore throat and cough. Also, the clinical picture can be supplemented by general symptoms: fever, weakness, headache, etc.

With a cough

In most cases, sore throat and cough appear together.Because of discomfort in the throat or larynx, a person intuitively wants to cough. In this case, the cough can be dry or wet. Most often it is provoked by inflammatory diseases of the respiratory tract.

No coughing

If the throat is sore and you don’t want to cough, this may indicate chronic diseases. Such conditions are dangerous and threaten with dangerous complications. In any case, in case of perspiration, you need to seek advice from an ENT doctor – regardless of whether there are accompanying symptoms or not.

Causes of a sore throat

When discomfort is felt in the throat, most people think they have a cold. But not everything is as simple as it seems. If you feel a sore throat, the causes can be varied: from a simple allergy or cold to malignant tumors.

Inflammatory pathologies

The symptom often manifests itself in infectious diseases of bacterial, fungal or viral origin:

  • ARVI;
  • influenza;
  • scarlet fever;
  • rhinovirus;
  • measles;
  • angina;
  • pharyngitis;
  • whooping cough;
  • laryngitis;
  • pharyngomycosis.

At the same time, the temperature often rises, the throat hurts, and a cough appears.


Often, discomfort in the throat is a manifestation of allergic reactions to dust, pollen, animal hair and other irritants. In this case, it occurs suddenly, accompanied by severe swelling of the throat, cough, shortness of breath and shortness of breath.


Sore throat at night or at any other time of the day is a symptom of neoplasms: cysts of the tonsils, papillomas, fibromas, angiomas and other tumors of the pharynx or larynx.Quite often, they are benign, but under certain circumstances they can degenerate into cancer. Therefore, at the first sign of discomfort in the throat, you need to contact an otolaryngologist. Tumors in the early stages are removed easily and without consequences for the body.

Other reasons:

  • neurosis of the pharynx;
  • laryngeal paresis;
  • thyroid pathology;
  • lesions of the esophagus;
  • poisoning;
  • overload or pathology of the vocal cords.


To find out the cause of the problem, you need to contact the ENT. He will conduct a survey and then examine you using modern endoscopic equipment. Also, in case of inflammatory pathologies, crops are taken from the patient to determine the type of pathogen.

“I feel a sore throat – what to do”?

Make an appointment with an otolaryngologist. Only a doctor can understand the cause of this symptom and prescribe the correct treatment.Trying to relieve discomfort with the help of pills, sprays and other means, you only exacerbate the problem.

Sore throat

The symptom manifests itself in different ways, depending on the age and general condition of the body.

In children

Small children often cannot express what is bothering them. A sore throat in a child can be suspected by a cough and a capricious mood. Also, sometimes babies touch their throats, try to scratch it. In such cases, you need to quickly contact a pediatric ENT.

In adults

Adults often ignore this symptom, especially if it is not severe. It is very dangerous. For any discomfort in the throat, see a doctor.

During pregnancy

The expectant mother needs to listen carefully to her body. If your throat is blocked during pregnancy, you should not take emollients uncontrollably. They may be contraindicated for you. It is better to immediately make an appointment with the doctor – he will prescribe harmless remedies that will help get rid of the unpleasant symptom.

How to treat a sore throat

For patients complaining of a sore throat, treatment is selected based on the diagnosis. In inflammatory diseases, the necessary medications and procedures are prescribed to eliminate infection and inflammation. For allergies, antihistamines and immunotherapy are used. If a tumor is found, it must be removed.

Where to go for help?

The doctors of our center know how to remove a sore throat. They tailor the therapy to the individual patient.At the same time, modern effective methods of treatment are used.

Possible complications

Feeling of perspiration is not as harmless as it seems. The pathologies that cause it can cause serious complications. For example, the inflammatory process spreads to neighboring organs and structures, tumors are especially dangerous. They can degenerate into cancer that progresses rapidly. As a result, a person has to remove the larynx and other important structures. But even if it happened, our center will help you with voice restoration and other important steps in rehabilitation after surgery.


To prevent sore throat, it is recommended to maintain oral hygiene, treat ENT diseases in time and lead a healthy lifestyle. Wearing a mask in public places will also help, especially during epidemics.

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Why is it hard to breathe lying down

The onset of breathing difficulties, or shortness of breath, is a fairly common symptom that can occur in healthy people, for example, after exercise.However, if the problem appears at rest, while lying down, it can be caused by a number of diseases, including serious ones. Why is it hard to breathe while lying down? There may be many reasons for this.

For example, shortness of breath can occur with a rare hereditary pathology – Pompe disease. Pompe disease refers to the so-called storage diseases. In this disease, due to a gene mutation, there is a deficiency of the enzyme acidic glucosidase, which breaks down glycogen. It builds up and progressive muscle weakness develops.

Usually, the muscles of the legs are weak at first, the muscles of the arms, the muscles involved in the breathing process are gradually affected, which leads to shortness of breath 1.2 . Pompe disease occurs rarely and is classified as an orphan disease. More often, shortness of breath in the supine position is due to other pathologies. What diseases can cause it and what to do in such cases?

Mechanism of dyspnea in the supine position

Supine dyspnea, or orthopnea, occurs due to increased pressure in the blood vessels of the lungs.In the supine position, blood flows from the lower extremities to the heart and then to the lungs. In healthy people, this distribution of blood does not cause any difficulty. But with a number of diseases, the ability of the heart to pump out excess blood from the heart may be reduced. As a result, blood accumulates in the pulmonary circulation passing through the lungs 3 .

An increase in blood pressure in the pulmonary artery can contribute to the secretion of fluid into the alveoli and the development of pulmonary edema. This makes breathing even more difficult while lying down 3 .

Orthopnea is not a disease, but a symptom that occurs only in a horizontal position. An attack can develop at night when a person wakes up due to lack of air. This phenomenon is called nocturnal paroxysmal (sudden) shortness of breath. In a sitting or reclining position, breathing, as a rule, is facilitated or completely normalized 3 .

Why does orthopnea develop?

Lying dyspnoea can occur with various disorders, primarily with diseases of the lungs.The predisposing factors are impaired ventilation and gas exchange in the lungs and changes in their blood circulation 4 . Let’s consider some of the most common reasons.

Chronic obstructive pulmonary disease (COPD) is a common disease in which inflammation develops in the airways, often accompanied by an infectious process. Due to the narrowing or complete blockage of the airways and the loss of the elastic force of the lungs, air flow is restricted.There is constant shortness of breath, including in a horizontal position, which becomes stronger over time. Along with it, there is a chronic wet cough 5 .

Pulmonary edema is a condition that occurs with the rapid movement of plasma from the capillaries of the lungs to the alveoli. It can develop against the background of heart disease – rhythm disturbances, arterial hypertension, heart failure and other pathologies. With pulmonary edema, there is a lack of air, orthopnea, anxiety, often – a cough with bloody sputum, pallor.Patient needs immediate medical attention 6 .

Other causes of dyspnea

Orthopnea may indicate a number of other diseases, primarily – damage to the heart and blood vessels. “Heart” shortness of breath develops against the background of impaired outflow of blood from the pulmonary circulation and left ventricular failure due to damage to the heart muscle (myocardium), heart valves and / or coronary vessels 4 .

Heart failure is a common cause of orthopnea.This is a syndrome that develops as a result of various diseases of the cardiovascular system associated with a decrease in the pumping function of the heart. At the same time, the heart is not able to pump as much blood as the body needs for the proper functioning of all organs and systems. Blood can accumulate (stagnate) in veins, lungs and other tissues, and the load on the heart becomes even higher 7 .

Heart failure can be asymptomatic for many years.As the disease progresses, signs of the disease appear. The most common are shortness of breath, including when lying down, palpitations, fatigue, chest discomfort 7 .

In addition, orthopnea can develop at 3.8 :

  • Large accumulation of fluid in the abdominal cavity – ascites. Its causes can be severe liver damage, malignant neoplasms, heart failure.
  • Bilateral paralysis of the diaphragm on the background of trauma to the chest, upper spines and a number of diseases.
  • Pompe Disease. According to the American Association of Neuromuscular and Electrodiagnostic Medicine, a complex of symptoms can indicate it: weakness of the lumbar girdle, especially the pelvis, pterygoid scapula, orthopnea and weakness of the back muscles, weakness of the respiratory muscles.
  • Severe obesity.
  • Severe pneumonia (pneumonia).

But osteochondrosis can cause shortness of breath during exertion and in an upright position, which is associated with damage to the thoracic spine 9 .

When to see a doctor?

If it becomes difficult to breathe while lying down, this is an alarming symptom, and you cannot delay with consulting a doctor. In order to diagnose the disease on time and start treatment, it is important to contact a specialist pulmonologist, cardiologist or therapist as early as possible. The doctor conducts an examination and, if necessary, refers to other narrow specialists. Based on the diagnostic data, a treatment regimen is drawn up.


  1. Klyushnikov S.A. et al. Clinical case of Pompe disease with late onset // Nervous diseases, 2015. No. 2.
  2. Sukhorukov V.S. et al. Diagnosis of Pompe disease // Russian Bulletin of Perinatology and Pediatrics, 2010. V. 55. No. 6.
  3. McGee S. Evidence-based physical diagnosis e-book. – Elsevier Health Sciences, 2012; p. 145-155.
  4. Radiation methods for diagnosing heart disease / Manfred Thelen, Raimund Erbel, Karl-Friedrich Kreitner, Jörg Barkhausen; per. with him. ; under total. ed. prof.V.E. Sinitsyna. – M.: MEDpress-inform, 2011 .– 408 p. : ill.
  5. Belovol A. N., Knyazkova I. I., Gridasova L. N. Diagnosis of chronic heart failure in patients with chronic obstructive pulmonary disease // Scientific Bulletin of Belgorod State University. Series: Medicine. Pharmacy, 2014. T. 28. No. 24 (195).
  6. Chuchalin A.G. Pulmonary edema: treatment programs // Practical Pulmonology, 2005. No. 4.
  7. Frolova E. B., Yaushev M. F. Modern understanding of chronic heart failure // Bulletin of modern clinical medicine, 2013.T. 6.No. 2.
  8. Pompe Disease More Common Than Previously Believed, Experts Say. Pompe Disease News. URL: https://pompediseasenews.com/ 2019/05/08/ pompe-disease-more-common-than-previously-believed-experts-say / (date of access 13.09.2019).
  9. Shchukina S. V. et al. The frequency and degree of dyspnea in patients with ankylosing spondylitis // Siberian Medical Journal (Irkutsk), 2007.