🫁 Understanding Chronic Cough in Aspergillosis

What the latest British Thoracic Society statement means for you

---

🌬️ Why This Matters

If you live with aspergillosis, Allergic Bronchopulmonary Aspergillosis (ABPA), or bronchiectasis, coughing can dominate your life. It’s tiring, painful, and socially awkward — especially when people assume it means infection.

Doctors used to see cough as just a symptom of another problem, but the British Thoracic Society (BTS) Clinical Statement on Chronic Cough in Adults (2023) recognises something new:

For many people, a cough can become a condition in its own right — caused by airway and nerve hypersensitivity, not just infection.

This matters for aspergillosis patients because fungal allergy and inflammation make the airways especially sensitive.

---

💡 What Is “Chronic Cough”?

A chronic cough is one lasting eight weeks or more.
It may be:

• Dry – little or no mucus

• Productive – thick sputum (common in bronchiectasis or chronic aspergillosis)

• Triggered by dust, cold air, perfume, or strong scents

For people with aspergillosis, several overlapping causes may exist:

• Fungal colonisation or infection

• Allergic inflammation (ABPA)

• Bronchiectasis and mucus retention

• Reflux or post-nasal drip

• Nerve hypersensitivity

This is why one treatment rarely fixes everything — different “treatable traits” must be addressed together.

---

🧬 Why It Happens

1️⃣ The Hypersensitive Cough Reflex

People with aspergillosis often develop overactive airway nerves — so normal irritants like dust, scent, or cold air trigger coughing fits.

This “cough reflex hypersensitivity” happens because:

• Ongoing inflammation damages the airway lining.

• Nerve endings in the throat and lungs become over-responsive.

• Even mild triggers set off powerful reflexes.

This is a real physiological process, not psychological.
It’s why cough can continue even when infection is under control.

---

2️⃣ Treatable Traits – Finding the Real Drivers

Identifying these traits helps your clinician personalise treatment.

---

💊 Medications That Can Cause or Worsen Cough

The BTS statement highlights that some medicines can trigger or amplify chronic cough — especially in people with already-sensitive lungs.

🔹 ACE Inhibitors (Blood pressure or heart disease)

Examples: Ramipril, Lisinopril, Enalapril, Perindopril

• Can cause a dry, tickly cough due to bradykinin build-up.

• Happens in ~1 in 5 users, sometimes months after starting.

• GP can switch to a similar drug (ARB – e.g., losartan) that doesn’t cause cough.

🔹 Beta Blockers (Heart or migraine medicines)

Examples: Atenolol, Propranolol, Bisoprolol

• May tighten airways, worsening wheeze or cough.

• Safer “lung-selective” versions exist but should still be monitored.

🔹 Inhalers

Examples: Fluticasone, Budesonide, Salbutamol

• Can irritate the throat if used without a spacer or if technique is poor.

• Always rinse or gargle after use, and ask your pharmacist to review inhaler technique.

🔹 Antifungal or Reflux Medicines

• Antifungals (itraconazole, voriconazole) don’t directly cause cough, but reflux or nausea can trigger coughing indirectly.

• PPIs (omeprazole, lansoprazole) usually help reflux-related cough, but long-term use should be reviewed regularly.

🔹 Other Drugs

• Amiodarone, methotrexate, and some biologics can rarely cause cough due to lung inflammation.

• Nasal sprays or lozenges with menthol/alcohol may irritate already-sensitive airways.

💬 If you suspect a medicine is contributing, don’t stop it suddenly — speak to your doctor or pharmacist first.
They can review interactions using the
👉 BNF Interactions Checker – NICE Medicines Guidance.

---

🔍 How Doctors Assess Chronic Cough

BTS recommends a structured pathway:

1. Basic tests: chest X-ray, spirometry, bloods (eosinophils, IgE), FeNO if available.

2. Further tests: CT scan, allergy or sputum studies if initial tests are abnormal.

3. Trait-based review: identifying overlapping issues — fungal, allergic, nerve-related, or reflux-related.

4. Specialist referral: to a Cough Clinic or Aspergillosis Centre if symptoms persist.

---

🧴 Pharmacists: Your Safety Specialists

Pharmacists — hospital or community — are crucial for managing long-term cough and medication safety:

• Check for cough-inducing drugs or interactions.

• Advise on best timing for antifungal and steroid doses.

• Help switch to fragrance-free personal or cleaning products.

• Liaise with your GP and consultant to fine-tune treatment.

🧭 Regular medication reviews every few months can prevent small problems becoming major triggers.

---

💬 How It Feels — and Why It’s Misunderstood

People with aspergillosis often describe:

“A tickle that turns into a spasm I can’t stop.”
“People think I’m ill, but it’s just the air or perfume.”

This happens because your airway nerves and immune cells are already primed.
Coughing doesn’t mean you’re infectious — it’s your body’s protective reflex in overdrive.

---

🩺 What Helps Most

• Optimise your aspergillosis and ABPA treatment.

• Cough-control physiotherapy or speech therapy for nerve-related cough.

• Airway clearance techniques for mucus.

• Identify and avoid irritants: perfume, smoke, strong detergents, cold air.

• Ask about biologics if inflammation remains active despite steroids.

• Use nerve-modulating medicines only under specialist advice.

---

🧘 Emotional Health Matters Too

Living with a chronic cough can cause anxiety, embarrassment, and isolation.
Support from counsellors, CBT therapists, or patient groups helps manage this stress — and can actually reduce cough frequency through better relaxation and breathing control.

---

🌱 Key Takeaway

Chronic cough in aspergillosis isn’t “just a symptom” — it’s often a mix of airway inflammation, fungal allergy, nerve hypersensitivity, and sometimes side effects of medicines.

The good news is that every contributing factor is treatable once identified — and cough can improve significantly with the right combination of medical, physical, and environmental care.

---

🔗 Trusted Resources

• BTS Clinical Statement on Chronic Cough in Adults (2023)

• WSH NHS Leaflet – Cough Hypersensitivity (PDF)

• BNF Interactions Checker – NICE Medicines Guidance

• Equality Act 2010 – Reasonable Adjustments (GOV.UK)