How Can I Stop Coughing Up Mucus Each Day?

Are There Treatments To Reduce Mucus?

Dear Dr. Mahler:

I am tired of coughing up “junk” everyday and find it disgusting. It takes me a good hour or two in the morning to clear it out of my lungs and then I can breathe better. My PA has called it different names, including mucus, phlegm, and sputum. Do you have any suggestions for getting rid of it? A few years ago I was told that I had COPD with chronic bronchitis. I used to smoke, but quit soon after the diagnosis. I take Advair twice a day and ProAir a few times a day when needed. Thanks for your help.

Janice from Hagerstown, MD

Dear Janice:

Before reviewing possible treatments, let me start by describing how and why the lungs make this material.

What Is Mucus?

It is a liquid made by goblet glands located inside the breathing tubes

Goblet cells produce mucus

View of the lining of the breathing tubes from a microscope. The Goblet cells are dark blue and secrete mucus. Cillia are hair-like that carry mucus toward the throat.

(airways) (similar glands are also found in the intestines). Its purpose is to protect the lining inside the breathing tubes. The problem occurs when there is too much production. Cigarette smoking is a common cause of mucus being produced in the breathing tubes.

Other irritants can stimulate mucus production include dust, air pollution, chemicals, as well as bacteria and viruses. The purpose of the excess mucus is to capture these irritants and them get out of the lungs by coughing. However, too much mucus can cause a chronic cough that doesn’t go away.

Here is a picture of chronic bronchitis which is one of the types of COPD.

Chronic bronchitis with mucus

At the bottom is a breathing tube which has mucus inside. This is common in those with chronic bronchitis.

As you can see, thick yellow mucus is inside the breathing tube and narrows the opening causing shortness of breath.

Are There Treatments?

First, it is great that you quit smoking years ago. Second, it is important that you avoid inhaling irritants in the air including second-hand smoke, air pollution, and anything else in the air that makes you cough. And third, keep well hydrated by drinking water. This helps to thin the liquid material and make it easier to cough it out of the lungs.

The two major types of treatment are expectorants and mucolytics. An expectorant works by signaling the body to increase the amount of water in secretions. This results in clearer secretions and also lubricates the irritated lining of the breathing tubes. Guaifenesin is one of the most common expectorants and is available over-the-counter without a prescription required.

Mucolytics are medicines that thin mucus, making it less thick and sticky and easier to cough up. Acetylcysteine is a prescription medication that is used to thin mucus in people with certain lung conditions such as chronic bronchitis, cystic fibrosis, and bronchiectasis. It is liquid inhaled from a nebulizer machine. Your health care professional will decide whether to use the 10% solution (dose is 6 to 10 mLs) or 20% solution (dose is 3 to 5 mLs) usually 3 – 4 times a day.

How Effective Are Mucolytics?

In 2015, there was a review of all studies published in medical journals to determine whether treatment with mucolytics was helpful for chronic bronchitis or COPD (Cochrane Database Systematic Review July 29, 2015). The authors stated that, “We are moderately confident that treatment with mucolytics may produce a small reduction” in flare-ups and a small benefit on overall quality of life.

In 2017, Dr. Mario Cazzola performed an analysis (called a meta-analysis) of a mucolytic pill called erdosteine (published online in Pulmonary and Pharmacologic Therapeutics December 9, 2017). Based on 10 studies involving 1,278 patients, erdosteine improved the clinical score of those with chronic bronchitis and COPD and also reduced the chances of a flare-up (called an exacerbation). It also reduced how long the flare-up lasted. The usual dose is 300 mg twice a day.

Although erdosteine is approved for use as a treatment of COPD with chronic bronchitis in over 50 different countries, it is not currently approved for use in the United States.

Janice – I hope that this information is helpful to you. Please note, the advice provided is not a substitute for asking your health care professional about your specific situation.

Best wishes,

Donald A. Mahler, M.D.

Recurrent Chest Infections due to Acquired Immunodeficiency

Recurrent Chest Infections – Need to Test Immunoglobulin Levels

Background: Recurrent chest infections in those with COPD can cause coughing, chest congestion, shortness of breath, and “feeling sick all of the time.” These symptoms may improve with courses of antibiotics and prednisone, but may recur weeks after these medications are stopped.

One possible cause for repeated chest infections is a low level of antibodies.

Plasma cells, which are part of the body’s immune system, makes antibodies to fight off bacteria, viruses, and other invaders that could harm overall health.

The body makes several types of immunoglobulin antibodies called A, G, and M. They are abbreviated as IgA, IgG, and IgM. IgA is found at high levels in saliva, tears, and nasal secretions. IgG is found in blood and in tissue, while IgM is found in blood.

In some individuals, plasma cells do not produce normal levels of antibodies. This medical condition is called common variable immunodeficiency (abbreviated CVID). It is estimated that CVID occurs in one out of 50,000 individuals in North America.

Case Report: I recently saw a 69 year old female in my practice who was referred for repeated episodes of pneumonia. She reports five different times she was sick with pneumonia in the past 11 months. Main symptoms are cough which may or may not be productive of mucus, more shortness of breath, feeling tired, and low grade fever. Recent x-rays of the chest showed shadows in the right lower lung area. For each episode her primary care physician prescribed an antibiotic and higher doses of prednisone.

She also has severe COPD based on results of breathing tests. She smoked one and one-half packs of cigarettes per day for 35 years, but quit 9 years ago. She did not report any heartburn symptoms to suggest possible acid reflux.

As part of her evaluation, I ordered blood tests to measure levels of immunoglobulins. Her IgG level was below normal, while IgA and IgM levels were in the normal range. I made the diagnosis of  common variable immunodeficiency and ordered: a CT scan of the chest to look for bronchiectasis; and replacement therapy with IVIG (immunoglobulin G).

Discussion: CVID was reviewed recently in the November-December 2016 issue of the Journal of Allergy and Clinical Immunology: In Practice (volume 4, pages 1039-1052). Usually, the person has recurrent sinus and/or chest infections. In the lungs, these repeated infections can cause thickening of the walls of breathing tubes and damage air sacs which creates a reservoir for bacteria (bronchiectasis) as shown in the figure below.

Figure C (bottom right) shows bronchiectasis with mucus inside the breathing tube and thickening of the wall.

Figure C (bottom right) shows bronchiectasis with mucus inside the breathing tube and thickening of the wall.

To diagnose CVID, your health care provider should measure levels of immunoglobulins (IgA, IgG, and IgM) in blood.

Replacement therapy is available if a person has a low level of IgG. The goal is to increase blood levels of IgG to normal to prevent future sinus and respiratory infections. Treatment is given intravenously (through an arm vein) every 4 weeks. This can be done at home or in an infusion center at the hospital. Studies confirm that IgG replacement reduces infections in those with CVID.

Cystic changes in the lungs due to bronchiectasis.

CT scan of the chest shows cystic changes in the lungs due to bronchiectasis.

If the person also has bronchiectasis, it is important to obtain a sample of sputum to identify the specific type of infection. Antibiotic therapy may be necessary for weeks to months.

Frequent Exacerbations of COPD and Bronchiectasis on CT Scan

Why Am I Having Frequent Exacerbations?

Dear Dr. Mahler:

I recently had a CT scan without contrast which shows no increase in several bullae, but now shows bronchiectasis.  My doctor said this was common with copd (emphysema FEV1 = 26% predicted), but not what classification. 

I have never had a cough or sputum even with exacerbations, which I have every 4 – 6 weeks for 3 years.  Should I ask for further clarification of this?  My doctor prescribed azithromycin every other day, but after several weeks always get diarrhea.  Thank you for your input.

Marie from Saco, ME

Dear Marie,

It sounds like your doctor ordered the CT scan of your chest to look for a reason for your frequent exacerbations. As I sure that you know, it is unusual to have flare-ups every 4 – 6 weeks as you are experiencing. It is important to figure out the reason.

On October 28, 2016, I posted the findings presented at the 2016 CHEST meeting that bronchiectasis was a risk factor for frequent exacerbations. If you have not read it, I encourage you to review the information (under the heading COPD News).

Bronchiectasis is a chronic condition in which the walls of the breathing tubes are thickened from long-term inflammation and scarring. It usually develops as a result of pneumonia which can damage the lungs and provide a reservoir, or space, for bacteria or mycobacteria. Over time, the number of bacteria increase in number leading to symptoms such as cough, yellow-green mucus, chest congestion, and difficulty breathing.

CT scan shows cystic bronchiectasis which can cause frequent exacerbations

A slice of the chest on a high-resolution CT scan in a 62 year old with cystic bronchiectasis. The cysts are seen on the lower portions of both lungs.

Bronchiectasis is common in those with COPD. In one study, bronchiectasis was found in 29% of 110 patients from 40 – 80 years old who were diagnosed as having COPD by their primary care physician (O’Brien. Thorax. year 2000; volume 55; pages 635-642).

Even though you are not coughing up any phlegm, I suggest that you ask your doctor to see if it possible to try to obtain a sample of mucus from your lungs. The reason is to find out if you have a chronic lung infection that is causing repeated exacerbations. The sample should be sent to the microbiology laboratory at the hospital for culture of bacteria, mycobacteria, and fungi.

The easiest approach is to breathe a solution of saline (salt water) from a nebulizer to see if this can cause you to cough something up. A respiratory therapist can help with this.

If this is not successful, you may want to ask your doctor about

Diagram of scope passed thru mouth into the lungs (called bronchoscopy)

Diagram of scope passed thru mouth into the lungs (called bronchoscopy)

bronchoscopy. This is an out-patient procedure in which a tube is placed through your mouth and then passed into the breathing tubes. Sterile water can be passed through a channel in the scope; the water can “capture” possible infectious organisms. The fluid is then suctioned back into a container for culture. I have done this in some individuals to successfully identify whether a bacteria, mycobacteria, or fungus is contributing to repeated flare-ups.

Finally, have you been tested for alpha-1 antitrypsin deficiency? Bronchiectasis is common in those with this hereditary type of emphysema. A simple blood test is used to test for this condition.

Also, I suggest that your doctor consider measuring immunoglobulin levels (A, G, and M) in your blood to evaluate for acquired immunodeficiency. Immunoglobulins are proteins in the blood that fight infection. Low levels may make it more likely for infections to occur. Replacement therapy is available for low Immunoglobulin G (abbreviated IgG) levels which can help the body fight or prevent infections.

Best wishes on finding an answer.

Donald A. Mahler, M.D.