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Hungin APS, Raghunath AS, Wiklund I. Beyond heartburn: a systematic review of the extra-oesophageal spectrum of reflux-induced disease. Fam Pract 2005; 22:591-603. [PMID: 16024554 DOI: 10.1093/fampra/cmi061] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Gastro-oesophageal reflux disease (GORD) is a chronic condition affecting up to one-quarter of the Western population. GORD is characterized by heartburn and acid regurgitation, but is reported to be associated with a spectrum of extra-oesophageal symptoms. OBJECTIVE The aim of this systematic review was to critically evaluate postulated extra-oesophageal symptoms of GORD. METHODS Extra-oesophageal symptoms were identified from population-based studies evaluating their association with GORD (either defined as heartburn and/or acid regurgitation, or diagnosed in general practice). The response of these symptoms to acid-suppressive therapy was investigated using randomized, double-blind, placebo-controlled studies. Pathogenic mechanisms were evaluated using clinical and preclinical studies. RESULTS An association between GORD and symptoms or a diagnosis of chest pain/angina, cough, sinusitis and gall-bladder disease was evident from three eligible population-based studies of GORD. Randomized placebo-controlled studies (n=20) showed that acid-suppressive therapy provides symptomatic relief of chest pain, asthma and, potentially, chronic cough and laryngitis. Mechanistic models, based on direct physical damage by refluxate or vagally mediated reflexes, support a causal role for GORD in chest pain and respiratory symptoms, but not in gall-bladder disease. CONCLUSION GORD is likely to play a causal role in chest pain and possibly asthma, chronic cough and laryngitis. Further investigation is desirable, particularly for other potential extra-oesophageal manifestations of GORD such as chronic obstructive pulmonary disease, sinusitis, bronchitis and otitis. Acid-suppressive therapy is likely to benefit patients with non-cardiac chest pain, but further placebo-controlled studies are needed for other symptoms comprising the extra-oesophageal spectrum of GORD.
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Affiliation(s)
- A Pali S Hungin
- Cetre for Integrated Health Care Research, University of Durham--Stockton Campus, Wolfson Research Institute, Stockton-on-Tees TS176BH, UK.
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102
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Abstract
The common cold and influenza (flu) are the most common syndromes of infection in human beings. These diseases are diagnosed on symptomatology, and treatments are mainly symptomatic, yet our understanding of the mechanisms that generate the familiar symptoms is poor compared with the amount of knowledge available on the molecular biology of the viruses involved. New knowledge of the effects of cytokines in human beings now helps to explain some of the symptoms of colds and flu that were previously in the realm of folklore rather than medicine-eg, fever, anorexia, malaise, chilliness, headache, and muscle aches and pains. The mechanisms of symptoms of sore throat, rhinorrhoea, sneezing, nasal congestion, cough, watery eyes, and sinus pain are discussed, since these mechanisms are not dealt with in any detail in standard medical textbooks.
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Affiliation(s)
- Ron Eccles
- Common Cold Centre, Cardiff School of Biosciences, Cardiff School of Biosciences, Cardiff University, Cardiff, UK.
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103
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Abstract
BACKGROUND Cough is the most common symptom which presents to doctors. Chronic cough is reported in up to 9% of preschool aged children. American general practice guidelines suggest antimicrobial treatment may be indicated in children with cough lasting > 10 days. Questions concerning the benefits and harm of antibiotic treatment for prolonged cough in children need to be resolved. OBJECTIVES A Cochrane systematic review was undertaken to determine the efficacy of antibiotics in treating children with chronic moist cough (excluding those with bronchiectasis or other underlying respiratory illnesses). SEARCH STRATEGY The Cochrane Register of Controlled Trials (CENTRAL), the Cochrane Airways Group Specialised Register, MEDLINE, EMBASE, review articles and reference lists of relevant articles were searched. The latest searches were performed on 12th April 2004. SELECTION CRITERIA All randomised controlled trials (RCTs) comparing antibiotics with a placebo or a control group in children with chronic moist cough were considered. DATA COLLECTION AND ANALYSIS Results of searches were reviewed against pre-determined criteria for inclusion. Two independent reviewers selected, extracted and assessed the data for inclusion. Authors were contacted for further information. Data were analysed as 'intention to treat'. MAIN RESULTS Two studies were eligible for inclusion in the review. Neither study was high quality. Both studies failed to include a prospective analysis of cough quality in their inclusion criteria, although indicating >75% of children included had moist cough (Darelid 1993). A total of 140 patients, aged seven years or less, were included in meta-analysis. Treatment with antibiotics reduced the proportion of children not cured at follow-up (primary outcome measure) in both studies; pooled odds ratio (OR) was 0.13, 95% CI 0.06 to 0.32 (using intention to treat analysis), which translates to number needed to treat (NNT) of 3 (95% CI 2 to 4). No significant heterogeneity was found (fixed and random-effects model I(2) was 4%). However for this outcome measure, the overall estimate of effect and degree of statistical heterogeneity were sensitive to the model used for meta-analysis. Progression of illness, defined by requirement for further antibiotics, was significantly lower in the treatment group (OR 0.10, 95%CI 0.03 to 0.34), NNT was 4 (95% CI 3 to 5). Adverse events were not significantly increased in the treatment group. AUTHORS' CONCLUSIONS Antibiotics are likely to be beneficial in the treatment of children with chronic moist cough. This evidence is however limited by study quality, study design and sensitivity analysis data. The use of antibiotics however has to be balanced against their well known adverse events. Further well-designed RCTs using valid cough outcome measures are needed to answer this question conclusively.
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Affiliation(s)
- J M Marchant
- Royal Children's Hospital, Dept. of Respiratory Medicine, Herston Road, Brisbane, Qld, Australia 4006.
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104
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Abstract
Worldwide paediatricians advocate that children should be managed differently from adults. In this article, similarities and differences between children and adults related to cough are presented. Physiologically, the cough pathway is closely linked to the control of breathing (the central respiratory pattern generator). As respiratory control and associated reflexes undergo a maturation process, it is expected that the cough would likewise undergo developmental stages as well. Clinically, the 'big three' causes of chronic cough in adults (asthma, post-nasal drip and gastroesophageal reflux) are far less common causes of chronic cough in children. This has been repeatedly shown by different groups in both clinical and epidemiological studies. Therapeutically, some medications used empirically for cough in adults have little role in paediatrics. For example, anti-histamines (in particular H1 antagonists) recommended as a front-line empirical treatment of chronic cough in adults have no effect in paediatric cough. Instead it is associated with adverse reactions and toxicity. Similarly, codeine and its derivatives used widely for cough in adults are not efficacious in children and are contraindicated in young children. Corticosteroids, the other front-line empirical therapy recommended for adults, are also minimally (if at all) efficacious for treating non-specific cough in children. In summary, current data support that management guidelines for paediatric cough should be different to those in adults as the aetiological factors and treatment in children significantly differ to those in adults.
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Affiliation(s)
- Anne B Chang
- Dept of Respiratory Medicine, Royal Children's Hospital, Brisbane, Queensland 4029, Australia.
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105
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Abstract
STUDY OBJECTIVES Despite the success of specialist cough clinics, there is increasing recognition of a subgroup of chronic coughers in whom a diagnosis cannot be made even after thorough, systematic investigation. We call this condition chronic idiopathic cough (CIC). The aim of this study is to compare the clinical characteristics of CIC patients with those of coughers in whom a diagnosis has been established (non-CIC) to see if there is a recognizable clinical pattern that distinguishes CIC from non-CIC. DESIGN Retrospective analysis of the medical records of chronic cough patients. SETTING The Royal Brompton Hospital Chronic Cough Clinic, London. PATIENTS One hundred patients with chronic cough referred to the Royal Brompton Hospital Cough Clinic between October 2000 and February 2004. RESULTS Seventy-one percent of all patients were female. Median age was 57 years (range, 19 to 81 years), with a median duration of symptoms of 48 months (range, 2 to 384 months). The primary diagnoses were CIC (42%), postnasal drip syndromes (22%), gastroesophageal reflux disease (16%), asthma (7%), and others (13%). In CIC patients, the median age at referral, age at onset of cough, and proportion of females did not differ significantly from non-CIC patients. CIC patients had a longer median duration of cough (72 months vs 24 months, p = 0.002), were more likely to report an upper respiratory tract infection (URTI) as the initial trigger of their cough (48% vs 24%, p = 0.0014), and had a significantly lower cough threshold in response to capsaicin (log concentration of capsaicin required to induce five or more coughs, - 0.009 vs 0.592, p = 0.032) than non-CIC patients. CONCLUSIONS Patients with CIC commonly describe a URTI that initiates their cough, which then lasts for many years, and they demonstrate an exquisitely sensitive cough reflex. We believe that CIC may be a distinct clinical entity with an as-yet unidentified underlying pathology.
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Affiliation(s)
- Rubaiyat A Haque
- Airways Disease Section, National Heart & Lung Institute, Imperial College, Dovehouse St, London, SW3 6LY, UK.
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106
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Chang AB, Lasserson TJ, Gaffney J, Connor FL, Garske LA. Gastro-oesophageal reflux treatment for prolonged non-specific cough in children and adults. Cochrane Database Syst Rev 2005:CD004823. [PMID: 15846735 DOI: 10.1002/14651858.cd004823.pub2] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Cough is a very common symptom presenting to medical practitioners. Gastroesophageal reflux disease (GORD) is said to be the causative factor in up to 41% of adults with chronic cough. However cough and GORD are common ailments and their co-existence by chance is high. Also cough can induce reflux episodes. Treatment for GORD includes conservative measures (diet manipulation), pharmaceutical therapy (motility or prokinetic agents, H(2) antagonist and proton pump inhibitors (PPI)) and fundoplication. OBJECTIVES To evaluate the efficacy of GORD treatment on chronic cough in children and adults with GORD and prolonged cough that is not related to an underlying respiratory disease i.e. non-specific chronic cough. SEARCH STRATEGY The Cochrane Register of Controlled Trials (CENTRAL), the Cochrane Airways Group Specialised Register Collaboration and Cochrane Airways Group, MEDLINE and EMBASE databases, review articles and reference lists of relevant articles were searched. The date of last search was 4th April 2004. SELECTION CRITERIA All randomised controlled trials on GORD treatment for cough in children and adults without primary lung disease. DATA COLLECTION AND ANALYSIS Results of searches were reviewed against pre-determined criteria for inclusion. Two independent reviewers selected, extracted and assessed data for inclusion. Authors were contacted for further information. Data was analysed as "intention to treat" as well as "treatment received". Paediatric and adults data were considered separately. Sensitivity analyses were performed. MAIN RESULTS 11 studies (3 paediatric, 8 adults; 383 participants) were included. None of the paediatric studies could be included in meta-analysis. In adults, analysis on use of H(2) antagonist, motility agents and conservative treatment for GORD were not possible (from lack of data) and there were no controlled studies on fundoplication as an intervention. Five adult studies comparing PPI (2-3 months) to placebo were analysed for various outcomes in the meta-analysis. Enrollment of subjects for two studies were primarily from medical clinics and another three studies were otolaryngeal clinic patients. Using "intention to treat", pooled data from three studies resulted in no significant difference between treatment and placebo in total resolution of cough. Pooled data revealed no significant improvement in cough outcomes (end of trial or change in cough scores). Significant differences were only found in sensitivity analysis. A significant improvement in change of cough scores was found in end of intervention (2-3 months) in those receiving PPI with a standardised mean difference of -0.41 (95%CI -0.75, -0.07) using GIV analysis on cross over trials. Two studies reported improvement in cough after 5 days to 2 weeks of treatment. Significant heterogeneity was found between studies using omeprazole and other PPIs. AUTHORS' CONCLUSIONS There is insufficient evidence to definitely conclude that GORD treatment with PPI is beneficial for cough associated with GORD in adults. The beneficial effect was only seen in sub-analysis and its effect was small. The optimal duration of such a trial of therapy to evaluate response could not be ascertained in the meta-analysis although two RCTs reported significant change by two weeks of therapy. Clinicians should be cognisant of a period (natural resolution with time) and placebo effect in studies that utilise cough as an outcome measure. Data in children are inconclusive. Future paediatric and adult studies are needed whereby studies should be double blind, randomised controlled, parallel design, using treatments for at least two months, with validated subjective and objective cough outcomes and include ascertainment of time to respond as well as assessment of acid and/or non acid reflux whilst on therapy.
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Affiliation(s)
- A B Chang
- Respiratory Medicine, Royal Children's Hospital, Herston Road, Herston, Brisbane, Queensland, Australia, 4029.
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107
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Niimi A, Chung KF. Airway inflammation and remodelling changes in patients with chronic cough: do they tell us about the cause of cough? Pulm Pharmacol Ther 2005; 17:441-6. [PMID: 15564089 DOI: 10.1016/j.pupt.2004.09.004] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2004] [Accepted: 09/13/2004] [Indexed: 11/19/2022]
Abstract
Airway mucosal changes have been reported in chronic cough. In cough variant asthma and in eosinophilic bronchitis, there is evidence of eosinophil infiltration and sub-basement membrane thickening. In non-asthmatic cough, an increase of bronchoalveolar mast cells, mucosal mononuclear cells, and epithelial shedding have been reported. In a more recent study, evidence of airway wall remodelling has been observed in both asthmatic and non-asthmatic cough, such as an increase in sub-basement membrane thickness, goblet cell area, vascularity and vessel size. Smooth muscle area was increased in non-asthmatic coughers. Heightened cough sensitivity in non-asthmatic coughers was related to the degree of goblet cell hyperplasia and epithelial shedding. Cough reflex may be heightened by increased production of growth factors that might be further enhanced by the physical effects of cough on the airways. Mast cells may participate in the cough pathophysiology through release of growth factors as well as tussive mediators. Changes in the airway wall mucosa and epithelium may be important in the pathogenesis of cough receptor sensitization.
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Affiliation(s)
- Akio Niimi
- Thoracic Medicine, National Heart and Lung Institute, Imperial College School of Medicine, Dovehouse Street, London SW3 6LY, UK
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108
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Morice AH. Post-nasal drip syndrome--a symptom to be sniffed at? Pulm Pharmacol Ther 2005; 17:343-5. [PMID: 15564073 DOI: 10.1016/j.pupt.2004.09.005] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2004] [Accepted: 09/13/2004] [Indexed: 10/26/2022]
Abstract
The syndrome or pseudo-syndrome of post-nasal drip (PNDS) represents a diagnostic label which is unhelpful in the understanding of chronic cough. There is no accepted definition of PNDS and no accepted method of measurement. The symptom of mucus dripping down the back of the throat occurs in normal subjects and is also reported by many patients in ENT clinics who do not have a cough. The lack of any clear pathological or biochemical tests makes the syndrome both a catch-all and a dustbin.
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Affiliation(s)
- Alyn H Morice
- University of Hull, Castle Hill Hospital, Castle Road, Cottingham, East Yorkshire HU16 5JQ, UK.
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109
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McLeod RL, Tulshian DB, Hey JA. Novel pharmacological targets and progression of new antitussive drugs. Expert Opin Ther Pat 2005. [DOI: 10.1517/13543776.13.10.1501] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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110
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&NA;. Consider the cause and severity of a case of acute cough before passing judgement on whether or not to treat. DRUGS & THERAPY PERSPECTIVES 2005. [DOI: 10.2165/00042310-200521030-00005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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111
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Chang AB, Gaffney JT, Eastburn MM, Faoagali J, Cox NC, Masters IB. Cough quality in children: a comparison of subjective vs. bronchoscopic findings. Respir Res 2005; 6:3. [PMID: 15638942 PMCID: PMC545936 DOI: 10.1186/1465-9921-6-3] [Citation(s) in RCA: 105] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2004] [Accepted: 01/08/2005] [Indexed: 12/04/2022] Open
Abstract
Background Cough is the most common symptom presenting to doctors. The quality of cough (productive or wet vs dry) is used clinically as well as in epidemiology and clinical research. There is however no data on the validity of cough quality descriptors. The study aims were to compare (1) cough quality (wet/dry and brassy/non-brassy) to bronchoscopic findings of secretions and tracheomalacia respectively and, (2) parent's vs clinician's evaluation of the cough quality (wet/dry). Methods Cough quality of children (without a known underlying respiratory disease) undergoing elective bronchoscopy was independently evaluated by clinicians and parents. A 'blinded' clinician scored the secretions seen at bronchoscopy on pre-determined criteria and graded (1 to 6). Kappa (K) statistics was used for agreement, and inter-rater and intra-rater agreement examined on digitally recorded cough. A receiver operating characteristic (ROC) curve was used to determine if cough quality related to amount of airway secretions present at bronchoscopy. Results Median age of the 106 children (62 boys, 44 girls) enrolled was 2.6 years (IQR 5.7). Parent's assessment of cough quality (wet/dry) agreed with clinicians' (K = 0.75, 95%CI 0.58–0.93). When compared to bronchoscopy (bronchoscopic secretion grade 4), clinicians' cough assessment had the highest sensitivity (0.75) and specificity (0.79) and were marginally better than parent(s). The area under the ROC curve was 0.85 (95%CI 0.77–0.92). Intra-observer (K = 1.0) and inter-clinician agreement for wet/dry cough (K = 0.88, 95%CI 0.82–0.94) was very good. Weighted K for inter-rater agreement for bronchoscopic secretion grades was 0.95 (95%CI 0.87–1). Sensitivity and specificity for brassy cough (for tracheomalacia) were 0.57 and 0.81 respectively. K for both intra and inter-observer clinician agreement for brassy cough was 0.79 (95%CI 0.73–0.86). Conclusions Dry and wet cough in children, as determined by clinicians and parents has good clinical validity. Clinicians should however be cognisant that children with dry cough may have minimal to mild airway secretions. Brassy cough determined by respiratory physicians is highly specific for tracheomalacia.
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Affiliation(s)
- Anne Bernadette Chang
- Dept of Paediatrics & Child Health, University of Queensland; Dept Respiratory Medicine, Royal Children's Hospital, Brisbane, Qld 4029, Australia
| | - Justin Thomas Gaffney
- Department of Respiratory Medicine, Royal Children's Hospital,, Herston Rd, Brisbane, Qld 4029, Australia
| | - Matthew Michael Eastburn
- School of Information Technology and Electrical Engineering, University of Queensland, St Lucia, Qld, Australia
| | - Joan Faoagali
- Department of Microbiology, Queensland Health Pathology Service, Royal Brisbane Hospital, Herston, Qld 4029, Australia
| | - Nancy C Cox
- Department of Cytology, Queensland Health Pathology Service, Royal Brisbane Hospital, Herston, Qld 4029, Australia
| | - Ian Brent Masters
- Dept Respiratory Medicine, Royal Children's Hospital, Herston Rd, Brisbane, Qld 4029, Australia
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112
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Niimi A, Nguyen LT, Usmani O, Mann B, Chung KF. Reduced pH and chloride levels in exhaled breath condensate of patients with chronic cough. Thorax 2004; 59:608-12. [PMID: 15223872 PMCID: PMC1747079 DOI: 10.1136/thx.2003.012906] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Increased hydrogen and reduced chloride ionic environments of the airways are conducive to the stimulation of cough. However, the constituents of the local milieu of the airways of patients with chronic cough are unknown. METHODS The pH and chloride levels in exhaled breath condensate and capsaicin cough threshold (C5) were measured in 50 patients with chronic cough and in 16 healthy controls. pH and chloride measurements were repeated after capsaicin challenge in those with cough. The cause of cough was asthma (n = 13), postnasal drip/rhinitis (n = 7), gastro-oesophageal reflux (n = 5), bronchiectasis (n = 5), but remained unidentified in 20. RESULTS Compared with controls, patients with chronic cough had lower pH (mean 7.9 v 8.3, 95% CI of difference -0.5 to -0.2, p<0.0001), chloride levels (median 4 v 6 mmol/l, 95% CI -3.1 to -0.2, p = 0.007), and C5 (median 3.9 v 125 micro M, 95% CI -270.0 to -17.6, p = 0.002). The pH levels were different in the six subgroups including controls, and were reduced in all diagnostic subgroups of patients with cough compared with controls but did not differ between them. Chloride levels were significantly different in the six subgroups but were lower than controls in only the gastro-oesophageal reflux subgroup. There was a weak but significant correlation between chloride levels and C5 when all participants were analysed together, but not between pH and C5 or chloride levels. pH and chloride levels did not change after capsaicin challenge. CONCLUSIONS The epithelial lining fluid of patients with chronic cough has a reduced pH and reduced chloride levels which could contribute to the enhanced cough reflex.
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Affiliation(s)
- A Niimi
- Department of Thoracic Medicine, National Heart and Lung Institute, Imperial College and Royal Brompton Hospital, Dovehouse Street, London SW3 6LY, UK
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113
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Paul IM, Yoder KE, Crowell KR, Shaffer ML, McMillan HS, Carlson LC, Dilworth DA, Berlin CM. Effect of dextromethorphan, diphenhydramine, and placebo on nocturnal cough and sleep quality for coughing children and their parents. Pediatrics 2004; 114:e85-90. [PMID: 15231978 DOI: 10.1542/peds.114.1.e85] [Citation(s) in RCA: 103] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To determine whether the commonly used over-the-counter medications dextromethorphan and diphenhydramine are superior to placebo for the treatment of nocturnal cough and sleep difficulty associated with upper respiratory infections and to determine whether parents have improved sleep quality when their children receive the medications when compared with placebo. METHODS Parents of 100 children with upper respiratory infections were questioned to assess the frequency, severity, and bothersome nature of the nocturnal cough. Their answers were recorded on 2 consecutive days, initially on the day of presentation, when no medication had been given the previous evening, and then again on the subsequent day, when either medication or placebo was given before bedtime. Sleep quality for both the child and the parent were also assessed for both nights. RESULTS For the entire cohort, all outcomes were significantly improved on the second night of the study when either medication or placebo was given. However, neither diphenhydramine nor dextromethorphan produced a superior benefit when compared with placebo for any of the outcomes studied. Insomnia was reported more frequently in those who were given dextromethorphan, and drowsiness was reported more commonly in those who were given diphenhydramine. CONCLUSIONS Diphenhydramine and dextromethorphan are not superior to placebo in providing nocturnal symptom relief for children with cough and sleep difficulty as a result of an upper respiratory infection. Furthermore, the medications given to children do not result in improved quality of sleep for their parents when compared with placebo. Each clinician should consider these findings, the potential for adverse effects, and the individual and cumulative costs of the drugs before recommending them to families.
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Affiliation(s)
- Ian M Paul
- Department of Pediatrics, Division of General Pediatrics, Pennsylvania State College of Medicine, Hershey, Pennsylvania 17033-0850, USA.
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114
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Abstract
Although the frequency of physician consultations and the sale of over-the-counter remedies establish the high prevalence of acute cough in the elderly, epidemiological studies have tended to be imprecise. However, respiratory tract infections in nose, larynx and/or bronchi, either viral or bacterial or both, are by far the commonest cause of acute cough. These are especially frequent and hazardous in the elderly, and community living and institutionalisation may aggravate this problem. A variety of viruses and bacteria have been incriminated, with rhinovirus, influenza and respiratory syncytial viruses, and Streptococcus pneumoniae, Haemophilus influenza and Bordetella pertussis being especially important. Viral infections can readily lead to community-acquired pneumonia. Successful diagnosis should point to successful treatment, and in this respect clinical examination and patient history are paramount, supplemented by chest X-ray, viral and bacterial culture and serological testing. Depending on the results of these tests, specific antibacterial therapy may be called for, although there is dispute as to the merits of antibacterial therapy in cases of uncertain diagnosis. Prevention and prophylaxis for influenza and S. pneumoniae infections are now commendably routine in the elderly, especially those in communities. Treatment, as well as the use of antibacterials, may also be directed against the inflammatory and infective processes in the airways. Non-specific antitussive therapy is common and usually highly desirable to prevent the adverse effects of repeated coughing. There have been few advances in antitussive therapy in recent years, opioids and dextromethorphan being the most commonly used agents; they act centrally on the brainstem, but also have a large placebo effect. However they work, they are much appreciated by patients and their partners. Moreover, striking advances in our understanding of the peripheral sensory and central nervous pathways of the cough reflex in recent years should soon lead to a new and more specific choice of agents to inhibit cough.
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115
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Affiliation(s)
- Josephine C Ojoo
- Academic Department of Medicine, University of Hull, Castle Hill Hospital, Cottingham, HU16 5JQ, Hull, UK.
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