Severe Cough and Coughing Fits

What makes a cough severe

A cough is a protective reflex that clears mucus and irritants from the airways. It becomes severe when:

• coughing comes in uncontrollable fits (paroxysms)
• it causes vomiting, chest or rib pain, headache or leaking urine
• you cannot catch your breath between coughs
• it prevents sleep or work

Repeated violent coughing can rarely crack a rib, cause a hernia, or make you faint.

Common causes of a severe cough

Viral chest infections and acute bronchitis

Colds, flu, RSV and COVID-19 inflame the airways. Acute bronchitis causes a chest cough, often with mucus, that can be intense and last 2 to 3 weeks, sometimes longer. Antibiotics do not help viral bronchitis.

Whooping cough (pertussis)

Whooping cough is a bacterial infection that starts like a cold, then after 1 to 2 weeks causes violent coughing fits: many rapid coughs on one breath, followed by a high-pitched "whoop" as air is sucked in, often with vomiting and exhaustion. Between fits the person may seem well. It can last 10 weeks or more, earning the name "100-day cough". Babies may not whoop but can stop breathing and turn blue, and are at high risk of serious illness. Vaccination in pregnancy protects newborns.

Asthma

Asthma causes coughing, wheezing, chest tightness and breathlessness, often worse at night, with exercise, cold air or after a cold. In cough-variant asthma, a dry cough is the main symptom.

Pneumonia

Pneumonia is infection in the lung tissue. It causes a cough with colored mucus, fever, chills, fast breathing, sharp chest pain on breathing in and feeling very unwell. Older adults may have confusion and little fever.

COPD flare-ups

People with COPD may have worsening cough, more mucus that changes color, and more breathlessness, often triggered by infections.

Croup and bronchiolitis in children

• Croup: a barking, seal-like cough and hoarse voice in young children, worse at night, sometimes with noisy breathing.
• Bronchiolitis: in babies under 2, usually from RSV, with cough, wheezing, fast breathing and feeding problems.

Other causes

• Post-viral cough: airways stay sensitive for weeks after an infection.
• Post-nasal drip and GERD: can cause persistent, sometimes severe coughing.
• Inhaled foreign body: sudden choking and coughing, especially in toddlers.
• Smoke, dust or chemical exposure.
• ACE inhibitor blood pressure medicines (such as lisinopril): a dry, tickly cough.
• Pulmonary embolism, lung cancer, tuberculosis and heart failure: less common but important, especially with blood in the mucus, weight loss or breathlessness.

Clues to the cause

How doctors assess a severe cough

A clinician will ask how long the cough has lasted, what it sounds like, whether you bring up mucus or blood, about fever, breathlessness, wheeze, vaccinations, contacts with whooping cough, smoking and medicines. They listen to your chest, check oxygen levels with a finger probe, and check breathing rate and temperature.

Tests may include a chest X-ray, a nose or throat swab for pertussis, flu or COVID-19, blood tests, spirometry for asthma or COPD, and CT scans for persistent or unexplained cough.

Treatment

• Whooping cough: antibiotics (usually a macrolide such as azithromycin) given early reduce spread and may shorten illness. Close contacts, especially babies and pregnant women, may also need antibiotics.
• Asthma: reliever and preventer inhalers; a short course of oral steroids for flare-ups.
• Pneumonia: antibiotics, and hospital care if oxygen is low or you are very unwell.
• COPD flare-up: inhalers, steroids and antibiotics if infection is likely.
• Croup: a single dose of oral steroid.
• Viral cough: rest, fluids and time.

Home care

• Drink warm fluids. Honey in warm water eases cough in adults and children over 1 year. Never give honey to babies under 12 months.
• Use a humidifier or breathe steam from a shower.
• Sleep with your head raised.
• Avoid smoke and other irritants.
• Cough suppressants may help a dry cough at night in adults. Do not give cough and cold medicines to children under 6 unless a doctor advises.
• Acetaminophen (paracetamol) or ibuprofen for fever and chest wall pain; follow the label dose.

Prevention

Keep up to date with whooping cough (Tdap, including in every pregnancy), flu, COVID-19, pneumococcal and RSV vaccines as recommended. Stop smoking, wash hands often and avoid close contact with people who are coughing.

Frequently asked questions

What causes severe coughing fits?

Severe coughing fits are often caused by whooping cough, asthma, a viral chest infection, pneumonia or a flare-up of COPD. Post-viral airway sensitivity, GERD and post-nasal drip can also trigger intense fits. Fits ending in vomiting or a whoop strongly suggest whooping cough.

When should I worry about a severe cough?

Seek emergency care for trouble breathing, blue lips, coughing up blood, choking, or a baby with pauses in breathing. See a doctor promptly for high fever, chest pain, wheezing not helped by an inhaler, coughing fits with vomiting, or a cough lasting more than 3 weeks.

Why do I vomit when I cough?

Forceful coughing raises pressure in the abdomen and can trigger the gag reflex, leading to vomiting. Coughing until you vomit is a classic sign of whooping cough, but it can also happen with asthma, bronchitis and post-nasal drip, especially in children.

How can I calm a severe cough at night?

Raise your head with extra pillows, sip warm water with honey (not for babies under 1), use a humidifier, and avoid lying flat after meals if reflux is a factor. Take your preventer inhaler if you have asthma. Persistent night-time coughing should be checked.

How long does a severe cough last?

A cough from a cold or bronchitis usually improves within 3 weeks, though some last up to 8 weeks. Whooping cough can last 10 weeks or more. A cough lasting longer than 3 weeks, or one that is getting worse, should be checked by a doctor.