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Month: February 2020

New Treatments for Chronic Cough

Why do we cough? Coughing is a natural defense mechanism to expel excessive mucus, microbes, and irritant substances from our airways which acts to protect our lungs from the potential damage caused by them. Coughing, however, can also be a bothersome symptom and is one of the most common reasons why patients consult their doctors.
The sound of a cough is produced after forcible expiration (i.e., breathing out) against a closed glottis (i.e., voice box) as the air flows out when the glottis suddenly opens. A cough is defined as “acute” when it persists for less than 3 weeks, subacute when the duration is between 3 and 8 weeks, and chronic if it continues to be present for longer than 8 weeks.

Approximately 12% of U.S. population experiences a chronic cough at some point in their lives. It is more common in women than in men and generally peaks between the 5th and 6th decades of life. A chronic cough can be very bothersome which may negatively impact one’s quality of life. A severe cough may lead to vomiting, broken ribs, bleeding, incontinence, sleep disturbance, social distress, and/or depression.

Common causes of a chronic cough:

  • Asthma
  • Medications such as ACE (angiotensin converting enzyme) inhibitors and some diabetes mellitus medications
  • Upper airway cough syndrome (e.g., post-nasal drip)
  • GERD (i.e., gastroesophageal reflux disease) – Also known as acid reflux.
  • Environmental irritants
  • Tobacco use
  • Eosinophilic bronchitis
  • Tumors

Initial evaluation begins with obtaining a comprehensive history, which includes:

  • Duration of the condition
  • Characteristics of the cough
  • Triggers for the cough (e.g., environmental, dietary)
  • Medications taken (e.g., over-the-counter, herbal, prescriptions)

“Red flags” in the history suggesting a serious illness may include:

  • Coughing up blood (i.e., hemoptysis)
  • Chronic smoking with a new cough
  • Difficulty in breathing
  • Persistent hoarseness
  • Difficulty in swallowing
  • Vomiting
  • Fever
  • Weight less
  • Swollen hands and/or feet
  • Abnormal examination
  • Abnormal chest X-ray


  • Upper airway cough syndrome: Post-nasal drip is usually a result of inflammation of the nose and throat either from allergens or irritants. This condition frequently responds to either antihistamines or nasal sprays or the combination of both antihistamines and nasal sprays.
  • Asthma: Cough may be the only symptom of asthma (e.g., cough variant asthma) and can be controlled with inhaled corticosteroids and/or oral leukotriene modifiers (e.g., Singulair, Accolate, Zyflo)
  • Non-asthmatic eosinophilic bronchitis: A trial of oral corticosteroids such as prednisone for 1 to 2 weeks is usually helpful in relieving the cough.
  • GERD: Approximately 10% of the population report frequent “heartburn” from acid reflux. Lifestyle modifications and medications to reduce acid secretion (e.g., Prilosec, Nexium, Prevacid) for 4 to 8 weeks will usually result in a substantial improvement of the cough.
  • Speech evaluation and speech therapy may be useful in certain situations.

If the cough does not respond to the above treatments at the correct dosage for a sufficiently long duration, it is termed a chronic refractory cough.
New medications which target the neurological pathways and block the cough reflex are actively being investigated and are as follows:

  • Sodium channel blockers: Similar to local anesthetics such as lidocaine.
  • Neurokin-1 (NK-1) receptor antagonists (e.g., Orvepitant, Aprepitant)
  • Purinergic receptor antagonists: Gefapixant is the name of one of the most promising drugs currently in development which exhibited significant efficacy in controlling a refractory cough. It is undergoing phase 3 clinical trials at this time. It is given by mouth twice a day. Side effects reported so far include taste disturbances.

The board certified allergists at Black & Kletz Allergy have been treating coughs in adults and children in the Washington, DC, Northern Virginia, and Maryland metropolitan area for more than 50 years.  Black & Kletz Allergy provides on-site parking at all of their convenient locations in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  The Washington, DC and McLean, VA locations are Metro accessible and there is a complementary shuttle that runs between our McLean office and the Spring Hill metro station on the silver line.  Please call any one of our offices to schedule an appointment for your allergy, asthma, or immunology needs. Alternatively, please click Request an Appointment and we will respond within 24 hours on the next business day.

Spring Allergies

Historically, March is the month that many trees begin pollinating in the Washington, DC metropolitan area. This year, trees have begun to pollinate in February, as the temperatures in the metro area have been higher than normal for a typical Winter. We will begin to see tree pollen marked by a yellowish coating on our automobiles soon. For many allergic individuals, this represents a tumultuous time for those who are sensitized to tree pollen. Birch, cedar, ash, oak, elm, cottonwood, hickory, and maple are the predominant trees producing pollen in our area during the Spring.  This time of the year is the reproductive season for the trees. As a result, the tree pollen grains are released into the atmosphere in order to fertilize the ovules of other trees.  This process is called pollination. Pollen is produced and then dispersed by the wind throughout the day, however, the tree pollen counts are highest during the morning hours.

Pollen grains are not harmful or noxious when inhaled, unless an individual’s immune system mistakes the pollen as potentially hazardous and subsequently mounts a defensive attack on them.  This process is called allergic sensitization and results in the release of certain chemical mediators such as histamine and leukotrienes, which are mediators of the annoying symptoms of allergic rhinitis (i.e., hay fever) and allergic conjunctivitis (i.e., eye allergies).

Over the past decade, several scientists have noticed a steady increase in the tree pollen counts across the country.  Many scientific researchers believe, although controversial, that climate change is contributing in part to this trend of increasing pollen counts.  Carbon dioxide is the primary gas needed for the growth and development of trees, (along with sunlight, water, and nutrients), and increasing levels of carbon dioxide are being documented every year.  These changes in the climate may impact the pollen season of not only trees, but in addition, may affect the pollination of both grasses and weeds. Climate change may cause an increase in the amount of pollen produced as well as cause an extension of the duration of the pollen seasons.

What are the symptoms of Spring allergies?
The most common symptoms of Spring allergies may include sneezing, clear runny nose, nasal congestion, post-nasal drip, itchy nose, itchy throat, itchy eyes, watery eyes, red eyes, puffy eyes, cough, itchy ears, clogged ears, sinus headaches, sinus congestion, sinus pressure, snoring, and/or fatigue.  In asthmatics, the pollen can also trigger chest tightness, coughing, wheezing, and/or shortness of breath.

How are Spring allergies diagnosed?
Spring allergies are diagnosed by board certified allergists such as the allergy specialists at Black & Kletz Allergy who first take a comprehensive history and perform a detailed physical examination.  Allergy testing is often done either by skin testing or occasionally via blood testing in order to identify the offending allergen.  Once the allergens are known, preventive measures are recommended in order to reduce exposure to the allergens.
Some preventive measures to reduce exposure to pollen and to minimize symptoms may include the following:

  • Track the local pollen counts on the homepage on our website, www.bkallergy.com by clicking Today’s Pollen Count and avoid outdoor activities on days where the pollen count is high, especially in early morning hours.
  • Go outdoors shortly after it rains, as the water keeps the pollen from blowing from place to place.
  • Change and clothes after wearing them worn outside.
  • Leave shoes outdoors in order to help prevent bringing pollen into the home.
  • Wipe down a pet’s fur and/or wash the pet before he/she comes indoors.
  • Shower off the pollen from skin and hair before going to bed.
  • Close the windows in automobiles and at home to keep the pollen out.
  • Run the air conditioner in automobiles and at home.

How are Spring allergies treated?
Begin using antihistamines and nasal corticosteroid sprays early in the season. They are more effective if begun before the onset of symptoms and if taken daily throughout the season. Other common types of prescription medications may include decongestants, leukotriene antagonists, nasal antihistamines, nasal anticholinergic agents, eye drops, inhaled corticosteroids, and inhaled beta-agonists. In cases of persistent or severe symptoms, consider allergy desensitization (i.e. allergy shots, allergy immunotherapy, allergy injections, allergy hyposensitization) to the pollen, which usually provides a long-term benefit and reduces the need for medications. They are effective in 80-85% of patients. They are generally taken for 3-5 years.

The board certified allergists at Black & Kletz Allergy have 3 locations in the Washington, Northern Virginia, and Maryland metropolitan area.  We have offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  Our 3 office locations have on-site parking and the Washington, DC and McLean, VA offices are Metro accessible.  Our McLean office has a free shuttle that runs between our office and the Spring Hill metro station on the silver line.  The allergy specialists at Black & Kletz Allergy diagnose and treat both adult and pediatric patients.  To schedule an appointment, please call our office directly or alternatively, you can click Request an Appointment and we will respond within 24 hours by the next business day.  The allergy doctors at Black & Kletz Allergy have been serving patients with hay fever, asthma, sinus disease, hives, eczema, insect sting allergies, food allergies, medication allergies, and immunological disorders for more than 50 years.  If you are bothered from allergies, it is our mission to improve your quality of life by reducing or preventing your undesirable and annoying allergy symptoms.