Deep Breathing Causing Cough: Evaluation and Management
If deep breathing consistently provokes coughing, this suggests cough reflex arc hypersensitivity and warrants systematic evaluation for underlying respiratory conditions, particularly asthma, upper airway cough syndrome (UACS), or eosinophilic bronchitis. 1
Understanding the Mechanism
Deep inspiration-provoked cough (DIPC) is a form of allotussia—an abnormal cough response to normally non-tussive stimuli—and represents objective evidence of cough reflex arc hypersensitivity. 1 This phenomenon occurs when the cough receptors and afferent nervous pathways become sensitized, causing coughing in response to mechanical stimulation from deep breathing. 2
Initial Assessment Steps
Obtain a focused medical history specifically targeting:
Medication review: Immediately ask about ACE inhibitor use, as this is a common and reversible cause that should be addressed by switching to another drug class. 3, 4
β-blocker use: These medications may exacerbate underlying asthma. 3
Smoking status: Active smoking is a critical factor requiring cessation counseling. 4
Duration of symptoms: Determine if this is acute (<3 weeks), subacute (3-8 weeks), or chronic (>8 weeks). 3, 5
Associated symptoms: Ask about wheezing, shortness of breath, postnasal drip, heartburn, or nocturnal symptoms that suggest specific etiologies. 4
Mandatory Initial Testing
All patients with cough provoked by deep breathing require:
Chest radiograph to rule out pneumonia, malignancy, structural abnormalities, or infiltrates. 3, 6, 4
Spirometry with bronchodilator testing to assess for asthma or obstructive lung disease, as cough-variant asthma commonly presents with normal baseline spirometry. 3, 6
Systematic Treatment Approach
The American College of Chest Physicians recommends sequential and additive empiric treatment targeting the most common causes: 4
First-Line: Upper Airway Cough Syndrome (UACS)
Begin with an oral first-generation antihistamine/decongestant combination, as UACS (formerly postnasal drip) is the most common cause of chronic cough. 4
This addresses allergic or irritant-induced rhinitis that may sensitize cough receptors. 4
Second-Line: Asthma Evaluation
If cough persists after UACS treatment:
Bronchoprovocation challenge testing should ideally be performed if spirometry shows no reversible airflow obstruction, as this directly assesses airway hyperresponsiveness. 4, 6
In the absence of bronchoprovocation testing availability, initiate an empiric trial of combination therapy with inhaled corticosteroids, inhaled β-agonists, or oral leukotriene inhibitors. 4
Consider a limited trial of oral corticosteroids before eliminating asthma from consideration. 4
Third-Line: Eosinophilic Bronchitis
If UACS and asthma have been eliminated or treated without resolution:
Request induced sputum testing for eosinophils (>3% eosinophil count indicates eosinophilic bronchitis). 4
If properly performed induced sputum testing cannot be done, an empiric trial of corticosteroids should be the next step. 4
A two-week trial of oral corticosteroids can help diagnose eosinophilic airway inflammation; lack of response effectively rules it out. 6
Fourth-Line: Gastroesophageal Reflux Disease (GERD)
If cough responds only partially or not at all to interventions for UACS, asthma, or eosinophilic bronchitis:
Institute treatment for GERD, as reflux-associated cough may occur without typical gastrointestinal symptoms. 4, 6
GERD treatment requires at least 3 months of intensive acid suppression for proper evaluation. 6
Critical Pitfalls to Avoid
Do not rely solely on spirometry to diagnose asthma, as cough-variant asthma frequently presents with normal spirometry but positive bronchoprovocation testing. 6
Do not overlook GERD even in the absence of heartburn or regurgitation symptoms. 6
Do not provide inadequate trial periods for empiric therapy—each intervention requires sufficient time to assess efficacy. 6
Do not dismiss the significance of deep inspiration-provoked cough, as it correlates with heightened cough reflex sensitivity and predicts response to treatment. 1
When to Refer to Specialist
Referral to a cough specialist is indicated when:
The condition remains undiagnosed after systematic evaluation of UACS, asthma, eosinophilic bronchitis, and GERD. 4
Chronic cough should only be labeled as idiopathic after thorough assessment at a specialist cough clinic. 6
Special Considerations
Research demonstrates that patients with deep inspiration-provoked cough show significantly heightened sensitivity to chemical cough challenges, with lower concentrations of citric acid required to provoke coughing compared to those without this phenomenon. 1 This objective finding validates the clinical significance of this symptom and supports aggressive evaluation for underlying airway disease.