You know how we frequently leave the most important things for last? I think when I initially ask patients to keep a cough or symptom diary or a “trigger diary,” they are a little annoyed. I always hear people say that “I have thought about it, there is nothing that brings it on” or “I already told you what sets me off. There’s nothing else.” I get their annoyance- wait times for lung doctors can be months, and people are finally seeing the specialist for something that may have been bothering them for years and are being offered a very low-tech intervention. Many patients just prefer that I tell them what is causing their symptoms with their lung function test results or a chest CT. Having done this for a while, I find trigger diaries to be one of the most potent tools in evaluating the cause of a patient’s symptoms. It is also frequently done far too late in the evaluation, after thousands of dollars of testing, doctor visits and medications have been thrown at the problem, not to mention the patient’s own time.
There are one of two possible outcomes from using a trigger diary. The first is that it is not helpful, and it is hard to identify any other triggers besides the ones we have already discussed. You have then wasted the time it took to fill out the diary. And that’s not nothing. Your time is valuable. However, I have also seen the other end of it. People can have dramatic insights from the exercise of filling out a trigger diary. For example, a person can go from needing over $1000 of medications each month with frequent rescue inhaler use and nighttime symptoms, to needing only one medication and having excellent control with no nighttime symptoms after realizing that a neighbor’s lawn mowing is the main exacerbating trigger. Simply coordinating with the neighbor on when they’re planning to mow, making sure house windows are shut, and staying away until a few hours after the lawn mowing is completed, can really help. The particular mix of exhaust from an old mower and cut grass can be irritating, and avoiding the trigger entirely reduces airway inflammation. Frequently main triggers can identity other lesser triggers- for example, knowing that the lawnmower exhaust and cut grass combination bothers you can help you avoid running on the track when the nearby grass is being mowed or help you more carefully avoid traffic related air pollution, etc. Coughing worse in the morning after burying your face in a cat fur covered pillow might prompt you to consider having Crookshanks sleep in the living room.
Studies on how valuable a trigger diary may be are also somewhat mixed, and it’s hard to know in advance who will be helped by filling one out. However, when we’re thinking about a health intervention, we have to think about whether the intervention may be worth the side effects or risks. The only downside of filling out a trigger diary is that you might waste the time it took to sort out the cough that has been bothering you so much. However, the potential upside is enormous. If you fill out a trigger diary and it doesn’t end up being helpful to you, at most you’re out some ink and paper. If it is helpful, you can save yourself thousands of dollars in medications, doctor visits, missed sick days, etc. I recommend you do fill one out if you are coughing regularly or have episodes of trouble breathing. Potentially you and your primary care doctor, armed by your trigger diary, can figure out whether your cough is caused by post nasal drip from allergies, acid reflux, or whether it may actually be due to asthma, COPD, another lung disease or something else entirely. If you really are coughing with no triggers whatsoever, that is also helpful information and can help an evaluation move along further. If you do end up needing a referral to a lung doctor, fill out your Trigger Diary in advance. It will make your appointment much more worth your while.
