A total of 22 chronic cough participants were included in the focus group discussions. Saturation, or the point at which no substantially new information continues to emerge, was reached for cough symptoms upon completion of the third focus group, thus three focus groups were conducted . The average age of study participants was 66.1 ± 12.9 years, and 72.7% of the sample was female. Among study participants, all were Caucasian and more than half the sample reported a household income greater than $60,000 per year. The most common etiologies of chronic cough as reported by patients were gastroesophageal reflux disease (GERD) (n = 7), asthma (n = 5), bronchitis (n = 4), and post-nasal drip syndrome (n = 4). Other causes of chronic cough reported by patients included irritant exposure, post-infectious cough, and mild chronic obstructive pulmonary disease (COPD). Most participants (86.7%) reported having completed diagnostic tests for their cough.
Descriptive statistics of the sociodemographic and clinical questionnaire showed that almost all of the participants reported coughing while performing daytime activities and all but three participants reported some coughing while trying to sleep at night. All participants had experienced their cough for greater than 8 weeks, and most of the participants (81.8%) reported experiencing their cough for greater than one year and 31.8% of participants rated their cough severity as "very severe;" 50% rated their cough severity as "moderate;" 13.6% considered their cough to be "mild;" and 4.6% considered their cough to be "very mild." With respect to treatment, most of the participants (n = 17) reported taking prescription medication, while others reported the use of over-the-counter treatments (n = 8) and/or herbal or other home remedies (n = 7).
Focus Group Discussion Results
Review of the focus group transcripts identified the emergence of three major themes which were used to develop the coding dictionary and used in qualitative analysis. First, participants in all groups discussed triggers of and treatments for cough at length. For example, participants discussed such triggers as spicy food, air conditioning, and perfumes, all of which were reported to provoke coughing. In addition, participants in each group were eager to discuss a variety of treatment options and homeopathic remedies, including prescription treatments, over-the-counter treatments, and behavioral modifications. While triggers and treatments were extensively discussed, this report does not summarize these topics in-depth as they do not pertain to the description of the attributes of cough severity. Secondly, participants described the attributes of cough and the characteristics of cough in terms of both intensity (e.g., deep cough) and frequency (e.g., constantly). Finally, in discussions about cough intensity and frequency, participants often discussed disruption of daily routines or activities and disruption to nighttime sleep. In the results sections that follow, attributes and characteristics of cough are discussed first. The final section discusses the quantity and quality of disruption to patients' daily routines and activities as well as disruption of nighttime sleep due to cough. It should be noted that in order to clearly present the information patients provided, major concept themes are discussed separately in the results sections that follow. During the focus groups, concepts and themes that we discuss in separate sections for clarity of presentation were often discussed jointly and were highly related for the participants.
Description of Cough Intensity
At the beginning of the focus group sessions, participants were asked to describe their cough. A variety of words were offered to describe the intensity of the cough: hacking, deep, strong, harsh, intense, deep, and barking.
When describing experiences with coughing, participants discussed physical discomfort and physical reactions such as pain or vomiting resulting from a particularly intense cough:
...I keep coughing, and that's when your throat starts to hurt.
I will cough, and cough, and cough, and cough until I basically have triggered, you know, trying to vomit in my stomach kind of thing.
I've gotten to that point where I'm coughing, I mean, the diaphragm, the rib cage, umm, is painful.
Participants also offered descriptions of other qualities of their cough, including whether the cough was productive or non-productive. The majority of participants in this sample described their cough as non-productive.
Mine is very hacking, and it's not intense or deep, and nothing comes up. It's not productive.... It's dry hacking.
The Urge to Cough & the Coughing Episode
When describing their cough, participants also discussed two experiences that were related to coughing but differed from their description of an individual cough: the sensation of having the urge to cough and the experience of having coughing fits, episodes, or bouts. Urge to cough was generally discussed as the antecedent to a cough, and most often described as a tickling sensation in the throat. A coughing fit or episode was described as an uncontrollable bout of coughing lasting for more than one or two individual coughs. These two experiences were highly related to the experience of coughing for participants in these focus groups. Urge to cough was described in the following ways:
When I wake up in the morning, I can feel-if I feel a tickle back in the back of my throat I know ultimately I'll end up coughing during the day at some point or another.
I get this tickle and I have to cough, you know, and it's all day.
Many of the participants described having coughing paroxysms, which were termed fits, bouts, or episodes. These episodes were often described in terms of coughing uncontrollably for some duration of time. While there was perhaps some ability to control or fight off of the urge to cough or an individual cough, there was little control over the cough during an episode:
I have it under control with the medication, but I still get some fits that usually last five minutes, and they're rather intense, uh, in coughing.
...I had a coughing jag at work one day that was totally embarrassing. I couldn't stop. ...occasionally I'll have a real episode, but it's more just every once in a while.
...but normally during the day I'll have just attacks of four, five, or six coughs and then it will clear up...
Frequency of Urge, Cough, and Episode
In addition to discussing the qualities of the urge to cough, the cough, and the episode, participants also discussed the frequency of their urges to cough, coughing, and coughing episodes. For participants in these focus groups, the frequency of the urge, the amount of coughing, and the number of coughing fits or episodes that they experienced on any particular day was related to how 'bad' or severe their coughing was for that day. As one participant noted, "So frequency is an issue and so is how bad, how severe the cough is...so it does fall within some continuum." In addition, participants also discussed how often they experienced coughing during the night. Sample quotations representing this concept are as follows:
Mine's just all the time. I cough all the time.
For me it would be intermittent coughing throughout the day.
I will cough, you know, like occasionally, but not continuously unless I get something more severe.
Sometimes I can't sleep at all night. I have to get up and go get in a chair, because whatever is coming out of my head or my throat is sitting in this bronchial tube down there, and it's messing up everything. And it's continuous.
Umm, I pretty much cough all day and all night, but I've taken some medication.
Uh, yes, uh, I wake up at least by midnight and have a series of coughs and then about 3:00.
I'm not coughing at all and, you know, it could be months before I get another cough, but when I get a cough, the frequency is close to ten and how bad it is can be a ten.
While many people describe the frequency of their coughing during the day and at night with descriptive frequency terms (continuous, constantly, intermittent, occasional, a little), participants in all 3 focus groups reported that they could not accurately account for the exact number of coughs that they had over a given time period:
I don't really know how often I cough, 'cause I'm oblivious to it many times. My wife will tell me that I'm on the telephone coughing. So, that's part of probably just being not as aware sometimes as other people would be.
I don't think anyone can tell you how many times they cough a day. You're asking about frequency. I really don't.
And sometimes I'm coughing, I don't even realize it. You know.
Finally, participants also described the frequency of their urge to cough as well as the frequency of episodes:
...You should just stop coughing. Just stop. Don't do it. And I say but I get this tickle and I have to cough, you know, and it's all day.
Five, six, seven, eight [episodes]. I mean this is a really good time right now in here.
It's very infrequent episodes.
Variability in Frequency
Many participants reported that the amount of coughing that they experience varies both over the course of one day as well as from day to day. For example, some of the participants reported that they experience more frequent coughing in the morning, some reported more frequent coughing in the afternoon, and some reported that they cough more frequently at night or that the cough comes back at night. However, among this group of participants, there were no clear patterns in terms of when during the day participants were likely to experience more or less coughing. Participants discussed more variability in frequency from day to day than within one day. Participants said things like:
Some days are...much worse than others.
No, I think everyday, you know, everyday is different.
...Some days I don't have anything like that, and all of a sudden I might have one [episode].
Daytime Activity Disruption
Participants anchored the severity of their cough to the disruption it caused, including social disruption that they experience due to their frequent cough, which included reports of being embarrassed in public situations and having concerns that their coughing disturbs others around them. In addition, participants discussed the impact of cough on their emotional state, including feelings of annoyance, irritation, frustration and worry about the implications of the intensity of their cough on their health. Participants also discussed the ways in which their cough disrupted their work, causing them to regularly have to step out of the room during meetings or having difficulty when talking with colleagues. Finally, participants discussed other activity disruption including intense coughing occurring when driving a car, having an episode at a restaurant or while eating, and having to cancel plans because of coughing. Participants had comments such as:
It's embarrassing sometimes, too. I mean, either you're-if I'm standing in a grocery line and start coughing, people are looking at me like I'm contagious with something.
But, like I said, I live in fear of that cough and that cough has come back.
I don't cough all the time, but it is embarrassing. You will be in a restaurant, when you start coughing. Really, it's embarrassing.
I was talking to the person that was reporting to me and giving her direction or what to do, that I could not complete the sentence without coughing. And that was so annoying and embarrassing.
Nighttime Sleep Disruption
For participants who experienced coughing at night or when lying down, disrupted sleep had a particularly debilitating effect on daytime functioning. Participants discussed experiencing sleep disruption due to coughing as well as daytime impacts of this sleep disturbance:
I've also learned to sleep sitting up, so basically sitting up like [inaudible]. I mean, I don't have this every night, but when I'm going through a period where I'm having that, expecting it, I just try to sleep sitting up as much as I can, uh, to avoid getting any – I mean, you move, so you're-then I slide down and I start coughing and then I wake up. So, like you, I often find I don't get a good night's sleep.
...I cough a lot when I go to bed. I lay down, and I find that makes me cough a lot.
I'll cough. Sometimes I can't sleep at all night.
Overlap in Discussion of Severity Concepts
While the concepts of cough severity identified in the data have been presented separately for clarity, the concepts of frequency, intensity, and disruption were often interconnected for participants. In one utterance, for example, participants could have discussed how their intense cough disrupted their meetings at work or how their frequent nighttime coughing disrupted sleep. Several quotes are presented below to illustrate the interconnectedness of cough severity concepts.
For some, intensity and frequency were interconnected:
But what's intense about it is it keeps on in the-on and on, the days that I'm coughing. Not the amount, er, or the physical thing, and it just exhausts me, and I just get sick to death when one starts and I think, Here we go. And then, you know-but it's, it's mostly the, the pattern of it during the day, versus what some people are describing as you know, it's, it's, like, I'm not gonna break a rib or anything. It's-but it's hacking.
And when I have a cough on those occasions, it's probably close to a ten. I mean, it will just – I mean, it will just continue and it's painful, the rib cage, the diaphragm, and it'll be all day, all night.
For others, intensity and disruption to activities were interconnected:
To me that strikes me as always a very serious bout of coughing, because obviously, oxygen wasn't getting where it was supposed to be getting. Um, and I find this is freaky, especially if you're driving, you know, and your coughing, and all of a sudden you're dizzy.
For others, frequency and disruption to activities were interconnected:
I had one on a job interview, and by the time I was done trying to speak, I sounded like Minnie Mouse on speed. I was so squeaky. But it [the cough] wouldn't stop, just would not stop.
Are you coughing less, are you feeling better, are you sleeping through the night.
For me it's not being able to sleep, you know, just waking up coughing, coughing, and coughing.
Finally, intensity, frequency and disruption can all be interconnected:
And that then trickles down here, and then I cough like the devil... I get-it sticks here, great big chunks of it will stick here-can't get it out. And I cough, and cough, and cough, and then if you go to a restaurant and start coughing, they throw you out.
The final cough was absolutely – absolutely retched and, ugh, I think was XXXXX who mentioned embarrassed. Ugh, I had a lot of – I had a number of meetings that I – that I had to go to and, uh, I couldn't stop coughing in those things.