#5: To cough or turn it off?
#5: To cough or turn it off?
Q: Why is coughing bad for the throat? What to do about a cough? And will a cough really go away on its own? How can it be so wrong when clearing your throat just feels so right? What would Aaron say?
A: While it can feel like a beam of sunshine bursting through the clouds to finally get that piece of gunk off your cords, it can also be the very thing perpetuating the cough. The fact that coughing can be as gratifying as scratching an itch is due to the fact that both situations are related to histamine reactions and the nervous system. There is some disagreement about exactly why scratching/coughing feels good. Some researchers say it’s because it triggers pleasure centers in the brain, some say it reduces the nerve function in the region making it temporarily less sensitive. Either way, you have to pay attention to a few factors to know if your cough might affect your future vocal health in any permanent way. You may need to artificially stifle its progress, and you can’t always rely on how the cough feels to make that decision.
Before I get to the diagnostics, let’s answer the first question of “why is coughing bad for the throat?” The simple answer is that coughing is traumatic in the ER sense of that word; i.e. it’s blunt trauma due to impact. Coughing is literally slamming the cords together while air is thrust between them in the hopes that it will dislodge unwanted matter. This is great when you’re choking on a chicken bone, but when it’s just mucus, and when the mucus drags on and on, it can truly wreak havoc on the voice due to the swelling that results. Swollen cords are far more prone to injuries like hemorrhages and the lesions associated with bleeds, so it’s wisest to avoid singing on swollen cords. Nearly every vocal injury I’ve ever rehabbed began with someone singing through an illness. Now here I should insert...
THE MEDICAL DISCLAIMER: You must not rely on the information on this website as an alternative to medical advice from your doctor or other professional healthcare provider. If you are sick, see your doctor. If you have an emergency, go to the ER. If you just want information, read on.
Now about that swelling: All vocal cords/folds swell in response to singing. So the swelling itself isn’t the problem. It’s when you sing on that swelling that we get problems (micro-tears and bleeds and the resultant scarring and skin buildup). So if you rest when it’s time to rest, you’ll generally be safe. If you notice that your quiet sounds are cutting out on you, if your upper registers are scratchy or hissy, if you’re getting delayed onset (the air starts but the sound doesn’t start until a second later) you probably have swollen cords. (You may also have some muscle tension dysphonia but the cough must be resolved first and then you can rehab the muscle behaviors later. Have a good technician!) So assuming it’s swelling brought on by coughing during an illness, vocal rest should clear it up once the coughing subsides. Light swelling should improve in about three days. Do not observe strict vocal rest for longer than a week. It has not been shown to be any more effective, and the resulting atrophy/weakness isn’t worth the minuscule benefit of the extra quiet time. Even post-surgical cases are only on vocal rest for a week. If it’s not clearing up in three days or even a week, you need to see your voice doctor.
Now let’s face the fact that we can’t even begin voice rest until the cough is over. So that splits the topic into two questions. Should we stop the cough? And if we decide to, how? To know if we should stop the cough or not, you need to ask the big question:
If the cough IS productive, meaning there’s stuff coming up/out when you cough, then it’s best to let it continue (unless you feel you’re on the brink of catastrophic vocal injury, in which case run to your ENT). Your only real options are to cough as mildly as you can and treat your airways as kindly as you can, but the coughing has to happen. You can be extra nice to your cords in a couple of ways, and these are measures to be taken whether the cough is productive or not.
Use a Cool Mist Ultrasonic Humidifier. (Vicks makes one for about $60 that works the best for the price. I believe the new ones are labeled as “Ultraquiet.” Do NOT buy the invisible mist variety. They are pointless!) You want it humid enough to inhale briskly without it drying out your throat, but not so humid that the surfaces in the room feel damp. Do not put it by your bed right on your face. Try sitting it on a stool or something off the ground so that the water vapor has the maximum amount of time to get into the air and it will help to avoid making the floor wet. No breezes on the face! If the room is really cold, you can use a warm mist humidifier, but I recommend the cool mist variety because you can use it in the summer to combat the air conditioned dryness then as well.
If you really want to kick the infection’s ass, or just promote the restoration of your mucus membrane health, try the Vicks Personal Steam Inhaler (It’s around $30. Do not use the menthol pads that come with it. We’ll talk menthol in a second.) Use it two to three times a day and you’ll assist your immune system in battling the opportunistic organism that is attacking. The steam will help to kill whatever it is whether it’s viral or bacterial.
To make the cough the most productive it can be, make sure that the mucus is of the ideal viscosity for expulsion. Meaning, if the stuff isn’t budging, try Mucinex (guaifenesin) or another expectorant. Keep in mind that Mucinex does NOT change the amount of mucus you have, instead it merely alters the viscosity (i.e. it makes it runnier). So if you go too crazy with Mucinex, you can thin it so much that it’s like trying to kick water uphill. Not so easy. We want it wet and somewhat clumpy. That’s ideal. If it’s not coming out at all and you know it’s still in there, adjust the humidity levels in your life, make sure you’re drinking plenty of water, make sure you’re not drying yourself out too much with antihistamines and decongestants, and see if some Mucinex will get the mucus mobile again. If you’re on antibiotics, drink more water. If you have a fever, drink more water (one liter per day per degree above normal body temperature).
WHAT IF THE COUGH IS NOT PRODUCTIVE?
Consider these four categories of cough when looking at non-productive coughs.
If it is an unproductive cough that you are sure stems from a recent upper respiratory infection, jump to the “cough remedies” section below.
If the cough is due to a longterm chronic illness like emphysema or COPD, then only your doctor can address the cough because it may require some serious medications like steroids.
If you’re clearing your throat because you feel like there’s something on your cords but it never comes off, it’s possible you’re dealing with a vocal lesion (even mild nodules sometimes feel like something is on the cords), and you might be misreading what you’re feeling; i.e. you are trying to cough that extra skin off and that just isn’t going to happen. In that case you need to see an ENT who is a vocologist and get a scope to see if there really is something on your cords that needs to be addressed. (I recommend finding an ENT who can provide a DVD of the stroboscopy as a record for future reference.) A skilled voice technician can usually identify this problem as well (Is the head voice scratchy? Is there a rasp at quiet volumes? Has there been a recent change in vocal quality prior to the cough?), but the exact course of treatment will depend on the particular problem. Some require surgery. Some respond to rehab. Some just need vocal rest. But vocal rest doesn’t fix all problems. There’s a little dictum that useful to remember: You SING your way out of nodules, you REST your way out of swelling. I prefer to say that you EDUCATE your way out of nodules. Nodes are areas of skin which require reconditioning, swelling is fluid that needs to drain.
If you’re clearing your throat for no reason other than habit, it’s likely this is just a holdover from a previous illness and frankly, the only way to break this is to become hyper-conscious of it (possibly even enlisting friends and family to help police it) and develop an alternate behavior (e.g. take a sip of water, swallow instead, blow out all your air, or take a deep breath) which will in time lessen the psychophysical need to clear the throat.
If you are coughing and there is clearly nothing left to expel, then it’s definitely time to intervene. Make sure you’ve already run through the checklists above and have tried the humidifier and/or steam inhaler. And if that hasn’t soothed the throat enough to stop the cough, medicate. Dextromethorphan (the DM in Robitussin DM and Mucinex DM) is your best bet. It will make you loopy, but it should limit the urge to cough. It is important to buy a product that has ONLY the medication you require. Products that combine many active ingredients will likely include something you don't need. So for pure DM, get the "Robitusssin Lingering Cold Long-acting Coughgels" or similar since they contain ONLY dextromethorphan. Ask the pharmacist if you aren't sure. Don't take more medications than you need. The only other over-the-counter solution is menthol cough drops. Ricola is typically fine. Even Halls. But the heavy-duty ones like Fisherman’s Friend can have as much as 10mg of menthol and that’s simply too much. It will likely upset your stomach, but more importantly menthol will dry you out! So aim for a menthol content of around 5mg or less. That usually does the trick. It’s a big tradeoff between the drying of the menthol versus the damage from the coughing. That’s why if there’s mucus actually coming up, let it run its course, but if there isn’t any “product” then the coughing is just damage with no benefit at all. Codeine is the next step up and will usually require a prescription (though I hear tales that in some states you can request codeine from the pharmacist directly and they’ll give it to you, though it will be plain rather than in a formulation). Or your ENT may decide to go with a prescription non-narcotic cough suppressant like Benzonatate (Tessalon Perles). Either way, you’re at the doctor now, so a plan for resolution should be in place before you go.
If you’re in that in-between state where the cough is sort of productive and sort of not, here’s the rule:
ONLY COUGH/CLEAR YOUR THROAT IF YOU’RE GOING TO SPIT SOMETHING OUT!
Do not clear your throat to move the mucus out of the way and then leave it there. In a few moments it will slide down onto the cords again and you’ll clear it again. In this scenario you’re paying over and over again for the same piece of mucus. So if you’re going to bother to clear your throat, decide to make it productive. This will mean less trauma in the long run albeit probably grosser for those around you. Another good tip is to avoid just breaking directly into a cough, but instead expel some air forcefully on something like an “h” sound to gather up the mucus on your cords and THEN cough it up. That way you’re saving the cords at least some of the trauma.
While I’m at it, I’d like to mention three more kinds of NON-infection-related coughing situations which stem from NON-infection-related mucus production.
If you are coughing/clearing your throat because you typically wake up with mucus on your cords, but it isn’t from a postnasal drip and you aren’t sick, it could be that you’re having acid reflux while you sleep and your throat is producing the mucus in response to the acid irritating the region. See your ENT for that one but in the meantime stop eating within three hours of bedtime. (You’ll likely also notice that high notes are scratchy and quiet notes sound hissy while the bottom notes seem normalish.)
Another likely cause for excessive morning mucus (not due to illness) is that the sleeping environment is too dry. Get thee to a CVS and get a humidifier (see links above). If that clears it up, then you know it was dryness. As a rule: If it’s dry enough for your lips and skin to be chapped, you should be using a humidifier.
If you are on medications that are drying out your skin in general (like acne medications in pill form), you can expect the cords to also suffer from the dryness, and you may find a cough results. Try the humidifier fixes there too. Also an aloe & glycerin throat spray like Entertainer’s Secret can help until you’re off the meds. Don’t use it when you have mucus, however, because you will just make soup back there.
Cough if it’s productive, and if it isn’t productive, employ the fixes listed above to stop coughing. If you feel like you want to see your doctor, then you probably should. If voice rest doesn’t clean it up after the cough is done, see your doctor. It is good to keep in mind that typically your body will do exactly the right thing. Help it out by giving it good food, plenty of rest, and less stress. That will do more for you than most medicine can. (Though codeine can be fun.)
-Aaron Hagan, voice technician extraordinaire
