In a patient with costochondritis whose workup has excluded acute coronary syndrome (normal electrocardiogram, negative D‑dimer, troponin 13 ng/L) and pulmonary embolism, what is the most likely cause of an urge to cough when talking or breathing deeply and how should it be managed?

Urge to Cough with Talking or Deep Breathing in Costochondritis Patient

This patient most likely has laryngeal hypersensitivity syndrome (also called chronic refractory cough or neurogenic cough), which manifests as an urge to cough triggered by non-tussive stimuli like talking and deep breathing, and should be managed with speech therapy techniques focused on cough suppression and desensitization. 1, 2

Understanding the Urge-to-Cough Phenomenon

The urge to cough when talking or breathing deeply represents a sensory neuronal dysfunction of vagal afferents rather than a reflex response to airway irritation 2. This is a consciously perceived compulsion that engages behavioral coughing rather than true reflex cough 1.

Key characteristics that define this condition:

• The urge-to-cough is encoded in brain networks including the primary sensory cortex, insula, prefrontal cortex, and posterior parietal cortices, representing higher brain control of this visceral reflex 1
• Patients experience throat irritation or tickle sensation (typically localized in the neck) that precedes the cough 2
• Talking is a common trigger reported by 72% of chronic cough patients, along with cold temperatures (67%) and dry atmospheres (66%) 2
• The severity of urge-to-cough is rated highly (84.5 mm on visual analog scale) by patients, and 91% always cough in response to this urge 2

Why This Diagnosis Fits Your Patient

Given that acute coronary syndrome and pulmonary embolism have been excluded with normal ECG, negative D-dimer, and troponin of 13 ng/L 1, and the patient has costochondritis (a musculoskeletal chest wall condition), the urge to cough with specific triggers like talking and deep breathing indicates:

• Laryngeal hypersensitivity where the airways have become hypersensitive to mechanical stimuli (talking, deep breathing) 1, 2
• This is not psychogenic cough - it represents reversible changes in function or aberrant involuntary learned behaviors rather than psychological distress 1
• The costochondritis itself is not causing the cough but may have heightened awareness of chest sensations 1

Management Algorithm

First-Line Treatment: Speech and Language Therapy

Speech therapy is the primary evidence-based treatment for this pattern of dysfunctional cough 1. The approach includes:

• Cough suppression techniques to help patients recognize triggers and modify their behavioral response to the urge-to-cough 1
• Desensitization strategies to reduce the hypersensitivity of laryngeal receptors 1
• Breathing pattern retraining to avoid the deep breathing that triggers the urge 1

Assessment Process

Before initiating speech therapy, ensure:

• Respiratory physician assessment has been completed including spirometry to rule out asthma or airway hyperresponsiveness 1, 3
• The diagnosis is clearly established - this appears to be either persistent habitual cough or intermittent hypersensitive pattern cough occurring in response to salient stimuli (talking, deep breathing) 1
• Common causes of chronic cough have been addressed: upper airway cough syndrome, asthma, gastroesophageal reflux disease 1, 3

If Speech Therapy Access Is Limited

While awaiting speech therapy referral:

• Educate the patient that the urge-to-cough represents a learned hypersensitivity response rather than dangerous pathology 1, 4
• Identify and document specific triggers (talking duration, depth of breathing, environmental factors) to help the patient recognize patterns 2
• Teach temporary cough suppression: sipping water, swallowing, or controlled breathing when the urge arises 1, 2

Critical Pitfalls to Avoid

• Do not prescribe cough suppressants as the primary treatment - this condition requires behavioral modification, not pharmacologic suppression 1, 4
• Do not label as psychogenic without proper assessment, as this can be stigmatizing and inaccurate; psychiatric comorbidity is often secondary rather than causal 1
• Do not ignore the patient's distress - 42% of patients report that nothing provides relief from their urge-to-cough, and many develop anxiety and sleep disturbance 1, 2
• Do not assume the costochondritis is causing the cough - these are likely separate conditions, though the chest wall pain may increase awareness of respiratory sensations 1

When to Reconsider the Diagnosis

Re-evaluate if:

• Foul-smelling sputum develops - this would indicate lung abscess or anaerobic infection requiring urgent CT imaging 5, 6
• Hemoptysis occurs - this requires bronchoscopy even with normal chest radiograph 5
• Systemic symptoms emerge (fever, weight loss, night sweats) - this necessitates chest imaging and broader workup 1, 3
• Cough persists beyond 8 weeks despite speech therapy - consider high-resolution CT to evaluate for bronchiectasis or interstitial lung disease 1