When cough ‘goes to your chest’ it doesn’t mean you need a doctor

WHEN I was on a hospital respiratory ward earlier in my career I worked briefly with a respiratory consultant who had developed a rather awkward phobia.

I was told she was morbidly afraid of phlegm. To me, that’s a bit like Michael Flatley being afraid of dancing or Lionel Messi harbouring an unwavering fear of footballs.

To be fair though, phlegm is pretty gross. Even the word, in all of its onomatopoeic glory, sounds unsavoury.

Its origin lies in the ancient Greek words for heat or inflammation. As it turns out, this was quite an apt association. It’s a shame then that they diverged from that promising start by inventing the theory of the four humours, a theory which became the accepted norm for the next 2,000 years or so.

I often refer to this idea of the four humours — the supposed balance of yellow bile, black bile, phlegm and blood being vital to one’s health.

An excess of phlegm in the classical sense meant one would become apathetic and indifferent. This is something that lives on in the adjective “phlegmatic” to describe someone who has an unemotional demeanour.

But in no way was it the tangible phlegm that we know and love today.

Mucus and phlegm are often used interchangeably but there is a slight difference speaking technically. While mucus is the clear gel-like substance that lines and protects the cells and surfaces that line the entrances and exits of our bodies, phlegm adds to it all the debris produced when these surfaces become inflamed, alongside breakdown products of viruses or bacteria and the white blood cells that are fighting them.

In other words, it tends to come into existence when there is infection.

There’s a lot of that going around at the moment. Over the past month or two, GP surgeries have noted a sharp increase in the number of people presenting with coughs, colds and sore throats.

Public Health estimates that the acute cough costs the UK economy around £979 million annually. About £104 million of this is due to the burden it places on our healthcare system.

I wasn’t around 100 years ago but I get the sense that people then would just get on with things and allow these mostly viral infections to pass.

That was in the days before antibiotics. More recently, a worrying culture has developed in which we have little patience for these infections and so, in this society of immediacy, we expect these illnesses to be cured with antibiotics.

Every year I am surprised at how quickly people seek help from doctors due to their coughs and colds.

There are a few classic lines we hear almost every day. One common one is, “I’ve had a cough for a week and now I think it’s gone to my chest.” Another is the declaration that “my phlegm has turned green.”

There seems to be some unwritten rule that this therefore means we need antibiotics from the doctor. It doesn’t.

I have written about antibiotic resistance before so I won’t labour things too much.

One public health survey found that 40 per cent of the general public believed antibiotics would help a cough with green phlegm get better more quickly than that with white phlegm.

The green phlegm thing, however, is a myth. The green colour is present in infections due to a certain product produced by the white blood cells that fights infection.

Infections can of course also be caused by bacteria, which are susceptible to antibiotics. But the vast majority of the illnesses circulating are caused by viruses and are therefore not susceptible to antibiotics (as I hope readers already knew).

What’s more, it is not unusual for them to last three to four weeks. I admit, having a nasty upper respiratory tract infection is not very nice but we must gain some perspective on when we should and shouldn’t be intervening with scarce medical resources for something that will get better on its own.

An antibiotic may work against a mild bacterial infection but even this only by knocking perhaps 12 hours off the symptoms.

At the other end of the scale, a serious pneumonia can kill someone unless an antibiotic is used. It’s no use, however, if that antibiotic has been used so much within a community that the bug causing the pneumonia is resistant to it.

The natural course of an infection often involves a sore throat, runny nose, headache, body aches and temperatures. This can last a week or so.

Initially the cough may be dry and the airways may feel all bunged up. However, when things loosen, the cough can sound wetter, you may start to produce phlegm (classed as sputum when expectorated) and it may sound lower down on the chest.

That tends to be around the time people phone in concerned that it has “gone to my chest”.

In reality, it just means it has gone on to the next phase of infection and the body is responding appropriately with its natural immune system.

People are also often concerned their cough has turned into a “chest infection”. This is a bit of an umbrella term that could encompass a bad pneumonia or a viral bronchitis. It is therefore not in itself a reason to push the antibiotic button either.

At the end of the day, coughing gets the phlegm out of the body, either into the air or via the stomach where all the viruses or bacteria are killed.

Patients should consider all these issues when considering seeking help for these illnesses.

Furthermore, GPs must also prescribe responsibly. It is easy for a physician to just give someone antibiotics even when not really required, thereby validating often inappropriate requests for GP review.

In reality, rest, fluids and time is the best course of action.

There is a difficult balance here because some people can become really quite ill with respiratory infections.

Signs that they may require treatment include feeling very short of breath, producing consistently red sputum (as opposed to flecks of blood from a burst vessel due to forceful coughing), confusion, or signs of deoxygenation such as blue lips.

A lot of people will have oxygen saturation probes lying around since covid and these can be used to check how well the blood is being oxygenated. Anything above 92 per cent is okay but below that, it is important to get checked.

Anyone with chronic obstructive pulmonary disease, or who has other significant long-term health issues, or is a child under five years of age should have a lower threshold to get checked.

If you don’t have any of these more serious indicators, you really shouldn’t be contacting the GP.

It is no secret that the health service is creaking. We are lucky in this area to have well-staffed and efficient surgeries. Some other areas are not so lucky. GP appointment waits are often the butt of jokes and there are stories of some surgeries not being able to offer appointments in any form for several weeks even before cough and cold season begins.

In order to maintain the high standards that our local surgeries set themselves, I’m sure that I speak for other colleagues when asking people whose cough has “gone to their chest” or whose phlegm has turned green, to consider carefully whether there really is a role to play for a GP.