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Mootassim-Billah S, Schoentgen J, De Bodt M, Roper N, Digonnet A, Le Tensorer M, Van Nuffelen G, Van Gestel D. Acoustic Analysis of Voluntary Coughs, Throat Clearings, and Induced Reflexive Coughs in a Healthy Population. Dysphagia 2023; 38:1467-1486. [PMID: 37245187 PMCID: PMC10225042 DOI: 10.1007/s00455-023-10574-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 03/31/2023] [Indexed: 05/29/2023]
Abstract
Cough efficacy is considered a reliable predictor of the aspiration risk in head and neck cancer patients with radiation-associated dysphagia. Currently, coughing is assessed perceptually or aerodynamically. The goal of our research is to develop methods of acoustic cough analysis. In this study, we examined in a healthy population the acoustical differences between three protective maneuvers: voluntary cough, voluntary throat clearing, and induced reflexive cough. Forty healthy participants were included in this study. Voluntary cough, voluntary throat clearing, and reflexive cough samples were recorded and analyzed acoustically. Temporal acoustic features were the following: the slope and curvature of the amplitude contour, as well as the average, slope, and curvature of the sample entropy and kurtosis contours of the recorded signal. Spectral features were the relative energy in the frequency bands (0-400 Hz, 400-800 Hz, 800-1600 Hz, 1600 Hz-3200 Hz, > 3200 Hz) as well as the weighted spectral energy. Results showed that, compared to a voluntary cough, a throat clearing starts with a weaker onset pulse and involves oscillations from the onset to the offset (concave curvature of the amplitude contour, p < 0.05), lower average (p < 0.05), and slope (p < 0.05) as well as lower convex curvature (p < 0.05) of the kurtosis contour. An induced reflexive cough starts with a higher and briefer onset burst and includes higher frication noise (larger convexity of the curvature of the amplitude and kurtosis contours (p < 0.05)) compared to a voluntary cough. The conclusion is that voluntary coughs are acoustically significantly different from voluntary throat clearings and induced reflexive coughs.
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Affiliation(s)
- Sofiana Mootassim-Billah
- Department of Radiation Oncology, Speech Therapy, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium.
| | - Jean Schoentgen
- Department of Biomechatronics, Université Libre de Bruxelles, Brussels, Belgium
| | - Marc De Bodt
- Department of Otolaryngology and Head and Neck Surgery, University Rehabilitation Center for Communication Disorders, Antwerp University Hospital, Antwerp, Belgium
- Department of Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
- Department of Logopaedics and Audiological Sciences, Faculty of Medicine and Health Sciences, University of Ghent, Ghent, Belgium
| | - Nicolas Roper
- Department of Oto-Rhino-Laryngology and Head & Neck Surgery, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Antoine Digonnet
- Department of Surgical Oncology, Head and Neck Surgery Unit, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
| | - Mathilde Le Tensorer
- Speech Therapy Unit, Institut Jules Bordet, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
| | - Gwen Van Nuffelen
- Department of Otolaryngology and Head and Neck Surgery, University Rehabilitation Center for Communication Disorders, Antwerp University Hospital, Antwerp, Belgium
- Department of Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
- Department of Logopaedics and Audiological Sciences, Faculty of Medicine and Health Sciences, University of Ghent, Ghent, Belgium
| | - Dirk Van Gestel
- Department of Radiation Oncology, Head and Neck Unit, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
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Mootassim-Billah S, Van Nuffelen G, Schoentgen J, De Bodt M, Van Gestel D. Assessment of radio(chemo)therapy-related dysphagia in head and neck cancer patients based on cough-related acoustic features: a prospective phase II national clinical trial (ACCOUGH-P/A trial). Trials 2023; 24:619. [PMID: 37773172 PMCID: PMC10540417 DOI: 10.1186/s13063-023-07660-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 09/19/2023] [Indexed: 10/01/2023] Open
Abstract
BACKGROUND Radiation-associated dysphagia is defined as impaired swallowing efficiency/safety following (chemo)radiotherapy in head and neck cancer patients. In a dysphagia framework, impaired coughing may lead to lung aspiration and fatal lung infection. Although cough efficacy is a predictor of the risk of aspiration, cough investigation is minimal in patients with radiation-associated dysphagia. Because cough is a transient signal, existing software for speech analysis are not appropriate. The goal of our project is to develop an assessment method using acoustic features related to voluntary and reflexive coughs as biomarkers of the risk of penetration/aspiration in patients with radiation-associated dysphagia. METHODS Healthy subjects and head and neck cancer patients with and without dysphagia will produce voluntary coughs, throat clearings and reflexive coughs. Recordings will be made using an acoustic microphone and a throat microphone. The recorded signals will be manually segmented and subsequently analysed with a software under development. Automatic final segmentation enables to measure cough duration. The first method of analysis includes temporal features: the amplitude contour, the sample entropy and the kurtosis. These features report respectively the strength, the unpredictability (turbulence noise due to the air jet) and the impulsive quality (burst) of the signal. The second method of analysis consists of a spectral decomposition of the relative cough signal energy into several frequency bands (0-400 Hz, 400-800 Hz, 800-1600 Hz, 1600-3200 Hz, > 3200 Hz). The primary outcome of this exploratory research project is the identification of a set of descriptive acoustic cough features in healthy subjects as reference data (ACCOUGH). The secondary outcome of this research in head and neck cancer patients with radiation-associated dysphagia includes the identification of (1) a set of descriptive acoustic cough features as biomarkers of penetration-aspiration (ACCOUGH-P/A), (2) swallowing scores, (3) voice features and (4) aerodynamic cough features. DISCUSSION This study is expected to develop methods of acoustic cough analysis to enhance the assessment of radiation-associated dysphagia in head and neck cancer patients following (chemo)radiation. TRIAL REGISTRATION International Standard Randomized Controlled Trials Number (ISRCTN) registry ISRCTN16540497. Accepted on 23 June 2023.
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Affiliation(s)
- Sofiana Mootassim-Billah
- Department of Radiation Oncology, Speech Therapy, Institut Jules Bordet, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium.
| | - Gwen Van Nuffelen
- Department of Otolaryngology and Head and Neck Surgery, University Rehabilitation Center for Communication Disorders, Antwerp University Hospital, Antwerp, Belgium
- Department of Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
- Department of Logopaedics and Audiological Sciences, Faculty of Medicine and Health Sciences, University of Ghent, Ghent, Belgium
| | - Jean Schoentgen
- Department of Biomechatronics, Université Libre de Bruxelles, Brussels, Belgium
| | - Marc De Bodt
- Department of Otolaryngology and Head and Neck Surgery, University Rehabilitation Center for Communication Disorders, Antwerp University Hospital, Antwerp, Belgium
- Department of Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
- Department of Logopaedics and Audiological Sciences, Faculty of Medicine and Health Sciences, University of Ghent, Ghent, Belgium
| | - Dirk Van Gestel
- Department of Radiation Oncology, Head and Neck Unit, Institut Jules Bordet, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
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Varelas EA, Hwang C, Brown S, Chang J, Sataluri M, Kirke D, Courey M, Goldberg L. Standardized Behavioral Treatment Improves Chronic Cough. J Voice 2023:S0892-1997(22)00369-1. [PMID: 36642591 DOI: 10.1016/j.jvoice.2022.11.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 11/10/2022] [Accepted: 11/10/2022] [Indexed: 01/15/2023]
Abstract
OBJECTIVES Neurogenic Laryngeal Hypersensitivity (NLH) refers to a constellation of upper airway symptoms thought to be caused by a disturbance in afferent and/or efferent neural pathways creating an exaggerated hypersensitive laryngeal response. There is evidence to support behavioral therapy as treatment for improving symptoms from laryngeal motor dysfunction to sensory disturbance. This study aims to determine if there is significant symptomatic improvement in patients with NLH who received non-pharmacologic behavioral treatment performed by trained SLPs. STUDY DESIGN A retrospective review. METHODS A review of all patients with NLH from 2017 to 2020 was performed at a tertiary care voice and swallowing center. Subjects with persistent symptoms despite maximal medical management were considered for inclusion. Newcastle Laryngeal Hypersensitivity Questionnaire (NLHQ) was completed by patients before and after undergoing therapy by one of three trained SLPs. Posttherapy improvement was determined by utilizing the NLHQ's minimal clinically important difference of 1.7 points. RESULTS A total of 81 patients were included in this study. Study participants included 61 women and 20 men with an average age of 60.64±14.05 years. There was a statistically significant difference between the pre and post therapy scores amongst all patients when treated by each individual SLP and all three SLPs combined (P < 0.008). There was a clinically significant change in 66% of all patients, 76% of which presented with abnormal NLHQ scores, and 14% who presented with normal NLHQ scores. CONCLUSIONS A standardized behavioral treatment protocol for patients with symptoms consistent with NLH is effective in improving symptoms in a large majority of patients. When following a standardized protocol SLPs can obtain similar results for their patients.
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Affiliation(s)
- Eleni A Varelas
- Division of Laryngology, Department of Otolaryngology- Head and Neck Surgery, Mount Sinai Health System, New York, New York.
| | - Chaewon Hwang
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Sarah Brown
- Division of Laryngology, Department of Otolaryngology- Head and Neck Surgery, Mount Sinai Health System, New York, New York
| | - Joseph Chang
- The Permanente Medical Group, Department of Head and Neck Surgery, Kaiser Permanente Santa Clara, Santa Clara, California
| | - Medha Sataluri
- Northwestern Medicine, Department of Otolaryngology, Chicago, Illinois
| | - Diana Kirke
- Division of Laryngology, Department of Otolaryngology- Head and Neck Surgery, Mount Sinai Health System, New York, New York
| | - Mark Courey
- Division of Laryngology, Department of Otolaryngology- Head and Neck Surgery, Mount Sinai Health System, New York, New York
| | - Leanne Goldberg
- Division of Laryngology, Department of Otolaryngology- Head and Neck Surgery, Mount Sinai Health System, New York, New York
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Rouadi PW, Idriss SA, Bousquet J, Laidlaw TM, Azar CR, Al-Ahmad MS, Yañez A, Al-Nesf MAY, Nsouli TM, Bahna SL, Abou-Jaoude E, Zaitoun FH, Hadi UM, Hellings PW, Scadding GK, Smith PK, Morais-Almeida M, Maximiliano Gómez R, Gonzalez Diaz SN, Klimek L, Juvelekian GS, Riachy MA, Canonica GW, Peden D, Wong GW, Sublett J, Bernstein JA, Wang L, Tanno LK, Chikhladze M, Levin M, Chang YS, Martin BL, Caraballo L, Custovic A, Ortego-Martell JA, Lesslar OJ, Jensen-Jarolim E, Ebisawa M, Fiocchi A, Ansotegui IJ. WAO-ARIA consensus on chronic cough - Part III: Management strategies in primary and cough-specialty care. Updates in COVID-19. World Allergy Organ J 2022; 15:100649. [PMID: 35600836 PMCID: PMC9117692 DOI: 10.1016/j.waojou.2022.100649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 03/30/2022] [Accepted: 04/01/2022] [Indexed: 11/18/2022] Open
Abstract
Background Chronic cough management necessitates a clear integrated care pathway approach. Primary care physicians initially encounter the majority of chronic cough patients, yet their role in proper management can prove challenging due to limited access to advanced diagnostic testing. A multidisciplinary approach involving otolaryngologists and chest physicians, allergists, and gastroenterologists, among others, is central to the optimal diagnosis and treatment of conditions which underly or worsen cough. These include infectious and inflammatory, upper and lower airway pathologies, or gastro-esophageal reflux. Despite the wide armamentarium of ancillary testing conducted in cough multidisciplinary care, such management can improve cough but seldom resolves it completely. This can be due partly to the limited data on the role of tests (eg, spirometry, exhaled nitric oxide), as well as classical pharmacotherapy conducted in multidisciplinary specialties for chronic cough. Other important factors include presence of multiple concomitant cough trigger mechanisms and the central neuronal complexity of chronic cough. Subsequent management conducted by cough specialists aims at control of cough refractory to prior interventions and includes cough-specific behavioral counseling and pharmacotherapy with neuromodulators, among others. Preliminary data on the role of neuromodulators in a proof-of-concept manner are encouraging but lack strong evidence on efficacy and safety. Objectives The World Allergy Organization (WAO)/Allergic Rhinitis and its Impact on Asthma (ARIA) Joint Committee on Chronic Cough reviewed the recent literature on management of chronic cough in primary, multidisciplinary, and cough-specialty care. Knowledge gaps in diagnostic testing, classical and neuromodulator pharmacotherapy, in addition to behavioral therapy of chronic cough were also analyzed. Outcomes This third part of the WAO/ARIA consensus on chronic cough suggests a management algorithm of chronic cough in an integrated care pathway approach. Insights into the inherent limitations of multidisciplinary cough diagnostic testing, efficacy and safety of currently available antitussive pharmacotherapy, or the recently recognized behavioral therapy, can significantly improve the standards of care in patients with chronic cough.
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Affiliation(s)
- Philip W. Rouadi
- Department of Otolaryngology – Head and Neck Surgery, Eye and Ear University Hospital, Beirut, Lebanon
- Ear, Nose and Throat Department, Dar Al Shifa Hospital, Hawally, Kuwait
| | - Samar A. Idriss
- Department of Otolaryngology – Head and Neck Surgery, Eye and Ear University Hospital, Beirut, Lebanon
- Department of Audiology and Otoneurological Evaluation, Edouard Herriot Hospital, Lyon, France
| | - Jean Bousquet
- Hospital Charité, Universitätsmedizin Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
- Department of Dermatology and Allergy, Comprehensive Allergy Center, Berlin Institute of Health, Berlin, Germany
- Macvia France, Montpellier France
- Université Montpellier, Montpellier, France
| | - Tanya M. Laidlaw
- Department of Medicine, Harvard Medical School, Division of Allergy and Clinical Immunology, Brigham and Women's Hospital Boston, Massachusetts, USA
| | - Cecilio R. Azar
- Department of Gastroenterology, American University of Beirut Medical Center (AUBMC), Beirut, Lebanon
- Department of Gastroenterology, Middle East Institute of Health (MEIH), Beirut, Lebanon
- Department of Gastroenterology, Clemenceau Medical Center (CMC), Beirut, Lebanon
| | - Mona S. Al-Ahmad
- Department of Microbiology, Faculty of Medicine, Kuwait University, Kuwait
| | - Anahi Yañez
- INAER - Investigaciones en Alergia y Enfermedades Respiratorias, Buenos Aires, Argentina
| | - Maryam Ali Y. Al-Nesf
- Allergy and Immunology Section, Department of Medicine, Hamad Medical Corporation, P.O. Box 3050, Doha, Qatar
| | | | - Sami L. Bahna
- Allergy & Immunology Section, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | | | - Fares H. Zaitoun
- Department of Allergy Otolaryngology, LAU-RIZK Medical Center, Beirut, Lebanon
| | - Usamah M. Hadi
- Clinical Professor Department of Otolaryngology Head and Neck Surgery, American University of Beirut, Lebanon
| | - Peter W. Hellings
- KU Leuven Department of Microbiology, Immunology and Transplantation, Laboratory of Allergy and Clinical Immunology, Leuven, Belgium
- University Hospitals Leuven, Department of Otorhinolaryngology, Leuven, Belgium
- University Hospital Ghent, Department of Otorhinolaryngology, Laboratory of Upper Airways Research, Ghent, Belgium
- Academic Medical Center, University of Amsterdam, Department of Otorhinolaryngology, Amsterdam, the Netherlands
| | | | - Peter K. Smith
- Clinical Medicine Griffith University, Southport Qld, 4215, Australia
| | | | | | - Sandra N. Gonzalez Diaz
- Universidad Autónoma de Nuevo León, Hospital Universitario and Facultad de Medicina, Monterrey, Nuevo León, Mexico
| | - Ludger Klimek
- Center for Rhinology and Allergology, Wiesbaden, Germany
| | - Georges S. Juvelekian
- Department of Pulmonary, Critical Care and Sleep Medicine at Saint George Hospital University Medical Center, Beirut, Lebanon
| | - Moussa A. Riachy
- Department of Pulmonary and Critical Care, Hôtel-Dieu de France university Hospital, Beirut, Lebanon
| | - Giorgio Walter Canonica
- Humanitas University & Personalized Medicine Asthma & Allergy Clinic-Humanitas Research Hospital-IRCCS-Milano Italy
| | - David Peden
- UNC Center for Environmental Medicine, Asthma, and Lung Biology, Division of Allergy, Immunology and Rheumatology, Department of Pediatrics UNC School of Medicine, USA
| | - Gary W.K. Wong
- Department of Pediatrics, Chinese University of Hong Kong, Hong Kong, China
| | - James Sublett
- Department of Pediatrics, Section of Allergy and Immunology, University of Louisville School of Medicine, 9800 Shelbyville Rd, Louisville, KY, USA
| | - Jonathan A. Bernstein
- University of Cincinnati College of Medicine, Department of Internal Medicine, Division of Immunology/Allergy Section, Cincinnati, OH, USA
| | - Lianglu Wang
- Department of Allergy, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing Key Laboratory of Precision Medicine for Diagnosis and Treatment of Allergic Disease, State Key Laboratory of Complex Severe and Rare Diseases, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Beijing, 100730, China
| | - Luciana K. Tanno
- Université Montpellier, Montpellier, France
- Desbrest Institute of Epidemiology and Public Health, UMR UA-11, INSERM University of Montpellier, Montpellier, France
- WHO Collaborating Centre on Scientific Classification Support, Montpellier, France
| | - Manana Chikhladze
- Medical Faculty at Akaki Tsereteli State University, National Institute of Allergy, Asthma & Clinical Immunology, KuTaisi, Tskaltubo, Georgia
| | - Michael Levin
- Division of Paediatric Allergology, Department of Paediatrics, University of Cape Town, South Africa
| | - Yoon-Seok Chang
- Division of Allergy and Clinical Immunology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea
| | - Bryan L. Martin
- Department of Otolaryngology, Division of Allergy & Immunology, The Ohio State University, Columbus, OH, USA
| | - Luis Caraballo
- Institute for Immunological Research, University of Cartagena. Cartagena de Indias, Colombia
| | - Adnan Custovic
- National Heart and Lund Institute, Imperial College London, UK
| | | | | | - Erika Jensen-Jarolim
- Institute of Pathophysiology and Allergy Research, Center of Pathophysiology, Infectiology and Immunology, Medical University Vienna, Austria
- The interuniversity Messerli Research Institute, Medical University Vienna and University of Veterinary Medicine, Vienna, Austria
| | - Motohiro Ebisawa
- Clinical Research Center for Allergy and Rheumatology, National Hospital Organization Sagamihara National Hospital, Sagamihara, Japan
| | - Alessandro Fiocchi
- Translational Pediatric Research Area, Allergic Diseases Research Unit, Bambino Gesù Children's Hospital IRCCS, Rome, Holy See
| | - Ignacio J. Ansotegui
- Department of Allergy and Immunology, Hospital Quironsalud Bizkaia, Bilbao, Spain
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Mei H, Gu W, Ran L, Wen S, Yu L, Xu X. Evaluation methods and influencing factors of cough sensitivity. Ther Adv Respir Dis 2022; 16:17534666211070134. [PMID: 35114864 PMCID: PMC8819802 DOI: 10.1177/17534666211070134] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Increased cough sensitivity is an important mechanism of chronic cough, and the evaluation of cough sensitivity helps understand the mechanism of cough and explore better methods to reduce cough. Evaluation methods may be direct or indirect. Direct methods include mechanical stimulation and chemical stimulation, and indirect methods include laryngeal reflex test, questionnaires, and brain functional magnetic resonance imaging (fMRI). Chemical stimulation is the most common method, while the capsaicin cough challenge test is proven and widely used. In this article, we will compare evaluation methods and explore influencing factors of cough sensitivity.
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Affiliation(s)
- Hao Mei
- Department of Pulmonary and Critical Care Medicine, Tongji University School of Medicine, Tongji University, Shanghai, China
| | - Wenhua Gu
- Department of Pulmonary and Critical Care Medicine, Tongji University School of Medicine, Tongji University, Shanghai, China
| | - Linxin Ran
- Department of Pulmonary and Critical Care Medicine, Tongji University School of Medicine, Tongji University, Shanghai, China
| | - Siwan Wen
- Department of Pulmonary and Critical Care Medicine, Tongji University School of Medicine, Tongji University, Shanghai, China
| | - Li Yu
- Department of Pulmonary and Critical Care Medicine, Tongji University School of Medicine, Tongji University, No. 389 Xincun Road, Shanghai 200065, China
| | - Xianghuai Xu
- Department of Pulmonary and Critical Care Medicine, Tongji University School of Medicine, Tongji University, No. 389 Xincun Road, Shanghai 200065, China
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Rouadi PW, Idriss SA, Bousquet J, Laidlaw TM, Azar CR, Sulaiman AL-Ahmad M, Yáñez A, AL-Nesf MAY, Nsouli TM, Bahna SL, Abou-Jaoude E, Zaitoun FH, Hadi UM, Hellings PW, Scadding GK, Smith PK, Morais-Almeida M, Gómez RM, González Díaz SN, Klimek L, Juvelekian GS, Riachy MA, Canonica GW, Peden D, Wong GW, Sublett J, Bernstein JA, Wang L, Tanno LK, Chikhladze M, Levin M, Chang YS, Martin BL, Caraballo L, Custovic A, Ortega-Martell JA, Jensen-Jarolim E, Ebisawa M, Fiocchi A, Ansotegui IJ. WAO-ARIA consensus on chronic cough - Part 1: Role of TRP channels in neurogenic inflammation of cough neuronal pathways. World Allergy Organ J 2021; 14:100617. [PMID: 34934475 PMCID: PMC8654622 DOI: 10.1016/j.waojou.2021.100617] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 09/09/2021] [Accepted: 09/14/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Cough features a complex peripheral and central neuronal network. The function of the chemosensitive and stretch (afferent) cough receptors is well described but partly understood. It is speculated that chronic cough reflects a neurogenic inflammation of the cough reflex, which becomes hypersensitive. This is mediated by neuromediators, cytokines, inflammatory cells, and a differential expression of neuronal (chemo/stretch) receptors, such as transient receptor potential (TRP) and purinergic P2X ion channels; yet the overall interaction of these mediators in neurogenic inflammation of cough pathways remains unclear. OBJECTIVES The World Allergy Organization/Allergic Rhinitis and its Impact on Asthma (WAO/ARIA) Joint Committee on Chronic Cough reviewed the current literature on neuroanatomy and pathophysiology of chronic cough. The role of TRP ion channels in pathogenic mechanisms of the hypersensitive cough reflex was also examined. OUTCOMES Chemoreceptors are better studied in cough neuronal pathways compared to stretch receptors, likely due to their anatomical overabundance in the respiratory tract, but also their distinctive functional properties. Central pathways are important in suppressive mechanisms and behavioral/affective aspects of chronic cough. Current evidence strongly suggests neurogenic inflammation induces a hypersensitive cough reflex marked by increased expression of neuromediators, mast cells, and eosinophils, among others. TRP ion channels, mainly TRP V1/A1, are important in the pathogenesis of chronic cough due to their role in mediating chemosensitivity to various endogenous and exogenous triggers, as well as a crosstalk between neurogenic and inflammatory pathways in cough-associated airways diseases.
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Affiliation(s)
- Philip W. Rouadi
- Department of Otolaryngology - Head and Neck Surgery, Eye and Ear University Hospital, Beirut, Lebanon
| | - Samar A. Idriss
- Department of Otolaryngology - Head and Neck Surgery, Eye and Ear University Hospital, Beirut, Lebanon
- Department of Audiology and Otoneurological Evaluation, Edouard Herriot Hospital, Lyon, France
| | - Jean Bousquet
- Hospital Charité, Universitätsmedizin Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
- Department of Dermatology and Allergy, Comprehensive Allergy Center, Berlin Institute of Health, Berlin, Germany
- Macvia France, Montpellier France
- Université Montpellier, Montpellier, France
| | - Tanya M. Laidlaw
- Department of Medicine, Harvard Medical School, Division of Allergy and Clinical Immunology, Brigham and Women's Hospital Boston, MA, USA
| | - Cecilio R. Azar
- Department of Gastroenterology, American University of Beirut Medical Center (AUBMC), Beirut, Lebanon
- Department of Gastroenterology, Middle East Institute of Health (MEIH), Beirut, Lebanon
- Department of Gastroenterology, Clemenceau Medical Center (CMC), Beirut, Lebanon
| | | | - Anahí Yáñez
- INAER - Investigaciones en Alergia y Enfermedades Respiratorias, Buenos Aires, Argentina
| | - Maryam Ali Y. AL-Nesf
- Allergy and Immunology Section, Department of Medicine, Hamad Medical Corporation, P.O. Box 3050, Doha, Qatar
| | | | - Sami L. Bahna
- Allergy & Immunology Section, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | | | - Fares H. Zaitoun
- Department of Allergy Otolaryngology, LAU-RIZK Medical Center, Beirut, Lebanon
| | - Usamah M. Hadi
- Clinical Professor Department of Otolaryngology Head and Neck Surgery, American University of Beirut, Lebanon
| | - Peter W. Hellings
- KU Leuven Department of Microbiology, Immunology and Transplantation, Laboratory of Allergy and Clinical Immunology, Leuven, Belgium
- University Hospitals Leuven, Department of Otorhinolaryngology, Leuven, Belgium
- University Hospital Ghent, Department of Otorhinolaryngology, Laboratory of Upper Airways Research, Ghent, Belgium
- Academic Medical Center, University of Amsterdam, Department of Otorhinolaryngology, Amsterdam, the Netherlands
| | | | - Peter K. Smith
- Clinical Medicine Griffith University, Southport Qld, 4215, Australia
| | | | | | - Sandra N. González Díaz
- Universidad Autónoma de Nuevo León, Hospital Universitario and Facultad de Medicina, Monterrey, Nuevo León, Mexico
| | - Ludger Klimek
- Center for Rhinology and Allergology, Wiesbaden, Germany
| | - Georges S. Juvelekian
- Department of Pulmonary, Critical Care and Sleep Medicine at Saint George Hospital University Medical Center, Beirut, Lebanon
| | - Moussa A. Riachy
- Department of Pulmonary and Critical Care, Hôtel-Dieu de France University Hospital, Beirut, Lebanon
| | - Giorgio Walter Canonica
- Humanitas University, Personalized Medicine Asthma & Allergy Clinic-Humanitas Research Hospital-IRCCS-Milano Italy
| | - David Peden
- UNC Center for Environmental Medicine, Asthma, and Lung Biology, Division of Allergy, Immunology and Rheumatology, Department of Pediatrics UNS School of Medicine, USA
| | - Gary W.K. Wong
- Department of Pediatrics, Chinese University of Hong Kong, Hong Kong, China
| | - James Sublett
- Department of Pediatrics, Section of Allergy and Immunology, University of Louisville School of Medicine, 9800 Shelbyville Rd, Louisville, KY, USA
| | - Jonathan A. Bernstein
- University of Cincinnati College of Medicine, Department of Internal Medicine, Division of Immunology/Allergy Section, Cincinnati
| | - Lianglu Wang
- Department of Allergy, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing Key Laboratory of Precision Medicine for Diagnosis and Treatment of Allergic Disease, State Key Laboratory of Complex Severe and Rare Diseases, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Beijing 100730, China
| | - Luciana Kase Tanno
- Université Montpellier, Montpellier, France
- Desbrest Institute of Epidemiology and Public Health, UMR UA-11, INSERM University of Montpellier, Montpellier, France
- WHO Collaborating Centre on Scientific Classification Support, Montpellier, France
| | - Manana Chikhladze
- Medical Faculty at Akaki Tsereteli State University, National Institute of Allergy, Asthma & Clinical Immunology, KuTaisi, Tskaltubo, Georgia
| | - Michael Levin
- Division of Paediatric Allergology, Department of Paediatrics, University of Cape Town, South Africa
| | - Yoon-Seok Chang
- Division of Allergy and Clinical Immunology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea
| | - Bryan L. Martin
- Department of Otolaryngology, Division of Allergy & Immunology, The Ohio State University, Columbus, OH, USA
| | - Luis Caraballo
- Institute for Immunological Research, University of Cartagena. Cartagena de Indias, Colombia
| | - Adnan Custovic
- National Heart and Lund Institute, Imperial College London, UK
| | | | - Erika Jensen-Jarolim
- Institute of Pathophysiology and Allergy Research, Center of Pathophysiology, Infectiology and Immunology, Medical University Vienna, Austria
- The Interuniversity Messerli Research Institute, Medical University Vienna and Univ, of Veterinary Medicine Vienna, Austria
| | - Motohiro Ebisawa
- Clinical Research Center for Allergy and Rheumatology,National Hospital Organization Sagamihara National Hospital, Sagamihara, Japan
| | - Alessandro Fiocchi
- Translational Pediatric Research Area, Allergic Diseases Research Unit, Bambino Gesù Children's Hospital IRCCS, Rome, Holy See
| | - Ignacio J. Ansotegui
- Department of Allergy and Immunology, Hospital Quironsalud Bizkaia, Bilbao, Spain
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7
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Mootassim‐Billah S, Van Nuffelen G, Schoentgen J, De Bodt M, Dragan T, Digonnet A, Roper N, Van Gestel D. Assessment of cough in head and neck cancer patients at risk for dysphagia-An overview. Cancer Rep (Hoboken) 2021; 4:e1395. [PMID: 33932152 PMCID: PMC8551981 DOI: 10.1002/cnr2.1395] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 02/22/2021] [Accepted: 03/26/2021] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND This literature review explores the terminology, the neurophysiology, and the assessment of cough in general, in the framework of dysphagia and regarding head and neck cancer patients at risk for dysphagia. In the dysphagic population, cough is currently assessed perceptually during a clinical swallowing evaluation or aerodynamically. RECENT FINDINGS Recent findings have shown intra and inter-rater disagreements regarding perceptual scoring of cough. Also, aerodynamic measurements are impractical in a routine bedside assessment. Coughing, however, is considered to be a clinically relevant sign of aspiration and dysphagia in head and cancer patients treated with concurrent chemoradiotherapy. CONCLUSION This article surveys the literature regarding the established cough assessment and stresses the need to implement innovative methods for assessing cough in head and neck cancer patients treated with concurrent chemoradiotherapy at risk for dysphagia.
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Affiliation(s)
- Sofiana Mootassim‐Billah
- Department of Radiation Oncology, Speech Therapy, Institut Jules BordetUniversité Libre de BruxellesBrusselsBelgium
| | - Gwen Van Nuffelen
- Department of Otolaryngology and Head and Neck Surgery, University Rehabilitation Center for Communication DisordersAntwerp University HospitalAntwerpBelgium
- Department of Translational Neurosciences, Faculty of Medicine and Health SciencesUniversity of AntwerpAntwerpBelgium
- Department of Logopaedics and Audiological Sciences, Faculty of Medicine and Health SciencesUniversity of GhentGhentBelgium
| | - Jean Schoentgen
- BEAMS (Bio‐, Electro‐ And Mechanical Systems)Université Libre de BruxellesBrusselsBelgium
| | - Marc De Bodt
- Department of Otolaryngology and Head and Neck Surgery, University Rehabilitation Center for Communication DisordersAntwerp University HospitalAntwerpBelgium
- Department of Translational Neurosciences, Faculty of Medicine and Health SciencesUniversity of AntwerpAntwerpBelgium
- Department of Logopaedics and Audiological Sciences, Faculty of Medicine and Health SciencesUniversity of GhentGhentBelgium
| | - Tatiana Dragan
- Department of Radiation Oncology, Head and Neck Unit, Institut Jules BordetUniversité Libre de BruxellesBrusselsBelgium
| | - Antoine Digonnet
- Department of Surgical Oncology, Head and Neck Surgery Unit, Institut Jules BordetUniversité Libre de BruxellesBrusselsBelgium
| | - Nicolas Roper
- Department of Oto‐Rhino‐Laryngology and Head & Neck Surgery, Erasme HospitalUniversité Libre de BruxellesBrusselsBelgium
| | - Dirk Van Gestel
- Department of Radiation Oncology, Head and Neck Unit, Institut Jules BordetUniversité Libre de BruxellesBrusselsBelgium
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8
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Kardos P, Blaiss M, Dicpinigaitis P. Addressing unmet needs for diagnosis and management of chronic cough in the primary care setting. Postgrad Med 2021; 133:481-488. [PMID: 33830846 DOI: 10.1080/00325481.2021.1914944] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Chronic cough (i.e. cough lasting >8 weeks) has a global prevalence of approximately 10% and is associated with substantial patient burden, including social, psychological, and physical impairments. This burden can be long-lasting, with some patients experiencing cough for many years. Although chronic cough is often a symptom of respiratory diseases (e.g. interstitial lung disease, chronic obstructive pulmonary disease) or is associated with comorbid conditions (e.g. asthma, gastroesophageal reflux disease) and may resolve after targeted treatment of these conditions, some patients continue to cough despite optimal treatment of associated conditions (refractory chronic cough (RCC)) or have no identifiable conditions presumed to be contributing to the cough (unexplained chronic cough (UCC)). As both RCC and UCC are diagnoses of exclusion, it is critical to perform a thorough initial patient assessment with adherence to diagnostic guidelines to accurately identify RCC and UCC and provide appropriate treatment. Primary care physicians may be in an important position to provide the initial diagnostic workup of patients with chronic cough as well as identify when referral to specialists (e.g. pulmonologists, allergists, otolaryngologists) is appropriate. In this narrative review, current diagnosis and management guidelines for chronic cough are summarized and recommendations for diagnostic workup in a primary care setting are provided. Increased appreciation of chronic cough as a distinct condition, rather than as only a symptom of other diseases, may help overcome current challenges in diagnosing and managing chronic cough and reduce patient burden.
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Affiliation(s)
- Peter Kardos
- Group Practice and Centre for Allergy, Respiratory and Sleep Medicine, Red Cross Maingau Hospital, Frankfurt, Germany
| | - Michael Blaiss
- Medical College of Georgia at Augusta University, Augusta, GA, US
| | - Peter Dicpinigaitis
- Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, US
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9
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Abu-Zaid A, Aljaili AK, Althaqib A, Adem F, Alhalal DA, Almubarak AF, Aldughaither SM, Alghabban SA, Alfaraj G, Masoud AT, Alsuhaibani NA. Safety and efficacy of gefapixant, a novel drug for the treatment of chronic cough: A systematic review and meta-analysis of randomized controlled trials. Ann Thorac Med 2021; 16:127-140. [PMID: 34012479 PMCID: PMC8109686 DOI: 10.4103/atm.atm_417_20] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 09/06/2020] [Indexed: 11/23/2022] Open
Abstract
AIM We conducted this systematic review and meta-analysis to investigate the efficacy and safety of gefapixant, a novel P2X3 receptor antagonist, in patients with chronic cough. METHODS We searched four databases for randomized controlled trials (RCTs). We assessed the cough frequency, severity, total Leicester cough questionnaire (LCQ) score, and adverse events. We analyzed the data using Open Meta-Analyst and Review Manager Software. RESULTS We included four unique studies (comprising five stand-alone RCTs) with 439 patients. Compared to placebo, gefapixant had positive anti-tussive effects by improving awake cough frequency (mean difference [MD] = -5.27, 95% confidence interval [CI] [-6.12, -4.42], P < 0.00001), night cough frequency (MD = -3.71, 95% CI [-6.57, -0.85], P = 0. 01), 24 h cough frequency (MD = -4.18, 95% CI [-5.01, -3.36], P < 0.00001), cough severity using the Visual Analog Scale (MD = -13.36, 95% CI [-17.80, -8.92], P < 0.00001), cough severity diary (MD = -0.88, 95% CI [-1.25, -0.51], P < 0.00001), and total LCQ score (MD = 2.00, 95% CI [1.15, 2.86], P = 0. 00001). Meta-regression analyses showed a positive correlation between the gefapixant dose and the incidence of any adverse event (relative risk [RR] = 0.239, 95% CI [0.093, 1.839], P = 0.001) and incidence of adverse event related to treatment (RR = 0.520, 95% CI [0.117, 0.922], P = 0.011). CONCLUSIONS In patient with chronic cough, gefapixant exhibits favorable anti-tussive outcomes by improving the cough frequency, severity, and quality of life. While gefapixant is largely tolerable, its side effects (notably taste alteration) are dose dependent.
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Affiliation(s)
- Ahmed Abu-Zaid
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
- College of Graduate Health Sciences, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | | | - Amnah Althaqib
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Fatima Adem
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | | | | | | | | | - Ghaidaa Alfaraj
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
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10
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Lee KK, Davenport PW, Smith JA, Irwin RS, McGarvey L, Mazzone SB, Birring SS. Global Physiology and Pathophysiology of Cough: Part 1: Cough Phenomenology - CHEST Guideline and Expert Panel Report. Chest 2021; 159:282-293. [PMID: 32888932 PMCID: PMC8640837 DOI: 10.1016/j.chest.2020.08.2086] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 08/17/2020] [Accepted: 08/20/2020] [Indexed: 12/12/2022] Open
Abstract
The purpose of this state-of-the-art review is to update the American College of Chest Physicians 2006 guideline on global physiology and pathophysiology of cough. A review of the literature was conducted using PubMed and MEDLINE databases from 1951 to 2019 and using prespecified search terms. We describe the basic phenomenology of cough patterns, behaviors, and morphological features. We update the understanding of mechanical and physiological characteristics of cough, adding a contemporary view of the types of cough and their associated behaviors and sensations. New information about acoustic characteristics is presented, and recent insights into cough triggers and the patient cough hypersensitivity phenotype are explored. Lastly, because the clinical assessment of patients largely focuses on the duration rather than morphological features of cough, we review the morphological features of cough that can be measured in the clinic. This is the first of a two-part update to the American College of Chest Physicians 2006 cough guideline; it provides a more global consideration of cough phenomenology, beyond simply the mechanical aspects of a cough. A greater understanding of the typical features of cough, and their variations, may allow a more informed interpretation of cough measurements and the clinical relevance for patients.
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Affiliation(s)
- Kai K Lee
- School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, London, England
| | - Paul W Davenport
- Department of Physiological Sciences, University of Florida, Gainesville, FL
| | - Jaclyn A Smith
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, England
| | - Richard S Irwin
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, UMass Memorial Medical Center, Worcester, MA
| | - Lorcan McGarvey
- Centre for Experimental Medicine, Department of Medicine, Queen's University Belfast, Belfast, Northern Ireland.
| | - Stuart B Mazzone
- Department of Anatomy and Neuroscience, School of Biomedical Sciences, The University of Melbourne, Melbourne, VIC, Australia.
| | - Surinder S Birring
- Centre for Human and Applied Physiological Sciences, Faculty of Life Sciences and Medicine, King's College London, London, England
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11
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Sundar KM, Stark AC, Hu N, Barkmeier-Kraemer J. Is laryngeal hypersensitivity the basis of unexplained or refractory chronic cough? ERJ Open Res 2021; 7:00793-2020. [PMID: 33816599 PMCID: PMC8005678 DOI: 10.1183/23120541.00793-2020] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 12/22/2020] [Indexed: 01/10/2023] Open
Abstract
Refractory chronic cough (RCC) and unexplained chronic cough (UCC) are common problems seen in primary care and subspecialty clinics. The role of cough hypersensitivity and laryngeal dysfunction in contributing to the persistence of cough in RCC/UCC is not well recognised. Data of patients with RCC and UCC evaluated in 2019 by an interdisciplinary cough clinic led by a pulmonologist and speech-language pathology team was reviewed. Patients completed validated questionnaires including the Leicester cough questionnaire (LCQ), voice handicap index (VHI) and dyspnoea index (DI) questionnaire at initial encounter. Presence of cough hypersensitivity was based upon a history of allotussia and hypertussia. Laryngeal dysfunction was diagnosed in those with a history of laryngeal paresthesias, throat clearing, voice abnormalities, upper airway dyspnoea and documentation of functional or anatomic laryngeal abnormalities on nasoendoscopy. Of the 60 UCC/RCC patients analysed, 75% of patients were female and 85% were over 40 years of age. Cough hypersensitivity was documented in all patients and multiple cough triggers occurred in 75% of patients. 95%, 50% and 25% of patients reported laryngeal paresthesias, voice abnormalities and upper airway dyspnoea, respectively. Significant associations between LCQ and VHI and DI scores occurred when adjusting for age, sex, ethnicity and body mass index. Laryngeal functional abnormalities were documented on 44 out of 60 patients on nasoendoscopy. Hypertussia, allotussia and laryngeal dysfunction are common in patients with RCC and UCC. Evaluation of UCC and RCC can delineate laryngeal hypersensitivity and allows appropriate treatment to be directed at this phenotype.
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Affiliation(s)
- Krishna M. Sundar
- Dept of Internal Medicine, University of Utah, Salt Lake City, UT, USA
- These authors contributed equally
| | - Amanda Carole Stark
- National Center for Voice and Speech, University of Utah, Salt Lake City, UT, USA
- These authors contributed equally
| | - Nan Hu
- Dept of Biostatistics, Robert Stempel College of Public Health and Social Work and Division of Public Health, Florida International University, Miami, FL, USA
| | - Julie Barkmeier-Kraemer
- Division of Otolaryngology, University of Utah, Salt Lake City, UT, USA
- Dept of Communication Sciences and Disorders, University of Utah, Salt Lake City, UT, USA
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12
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Zeiger RS, Schatz M, Hong B, Li Q, Stern JA, Takhar HS, Weaver JP, Bali V, Schelfhout J, Chen W. Patient-Reported Burden of Chronic Cough in a Managed Care Organization. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 9:1624-1637.e10. [PMID: 33227523 DOI: 10.1016/j.jaip.2020.11.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 11/04/2020] [Accepted: 11/08/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND The burden of chronic cough (CC) requires better understanding. OBJECTIVE To determine the severity, health status, and health care resource utilization among patients with CC identified by electronic health records on 2 visits separated by ≥1 year. METHODS Information on cough-related burden was collected through survey from patients with CC, including validated questionnaires (the cough health status Leicester Cough Questionnaire [LCQ], the cough hypersensitivity Hull Airway Reflux Questionnaire [HARQ], and the Cough Quality of Life Questionnaire [CQLQ]), CC-associated respiratory and gastrointestinal comorbidities, and treatment responses. Spearman correlation coefficients were reported to examine the associations among the LCQ, HARQ, and CQLQ. Patient demographics and patient-reported CC features were compared between males and females, and among ethnic groups using Robust Poisson regression models. RESULTS The survey was completed by 565 patients who were 64.8 ± 12.6 years, 75.8% female, and 60.4% white. CC duration was 8.6 ± 10.5 years with an average weekly severity of 5.3 ± 2.3 (maximum 10). The LCQ score was 11.3 ± 3.9 (maximum 21). The HARQ score was 33.3 ± 13.6 (normal ≤13). The CQLQ score was 56.9 ± 17.5 (maximum 112, worse with higher scores). The Spearman rank correlations were high between the LCQ and HARQ (-0.65), the LCQ and CQLQ (-0.80), and the HARQ and CQLQ (0.69). Patients with CC-associated respiratory and gastrointestinal comorbidities generally showed similar results regarding the above questionnaires. Treatment responses were suboptimal. Women compared with men and non-whites compared with whites reported significantly worse cough severity and poorer LCQ, HARQ, and CQLQ scores. CONCLUSIONS CC is self-reported as a burdensome condition, particularly in women and non-white minorities, which markedly affects daily living with inadequate response to treatments.
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Affiliation(s)
- Robert S Zeiger
- Department of Allergy, Kaiser Permanente Southern California, San Diego, Calif; Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, Calif.
| | - Michael Schatz
- Department of Allergy, Kaiser Permanente Southern California, San Diego, Calif
| | - Benjamin Hong
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, Calif
| | - Qiaowu Li
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, Calif
| | - Julie A Stern
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, Calif
| | - Harpreet S Takhar
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, Calif
| | - Jessica P Weaver
- Center for Observational and Real-World Evidence (CORE), Merck & Co., Inc., Kenilworth, NJ
| | - Vishal Bali
- Center for Observational and Real-World Evidence (CORE), Merck & Co., Inc., Kenilworth, NJ
| | - Jonathan Schelfhout
- Center for Observational and Real-World Evidence (CORE), Merck & Co., Inc., Kenilworth, NJ
| | - Wansu Chen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, Calif
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13
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Barrett CM, Patel D, Vaezi MF. Laryngopharyngeal Reflux and Atypical Gastroesophageal Reflux Disease. Gastrointest Endosc Clin N Am 2020; 30:361-376. [PMID: 32146951 DOI: 10.1016/j.giec.2019.12.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Laryngopharyngeal reflux and atypical manifestations of gastroesophageal reflux disease have a high economic and social burden in the United States. There is increasing research supporting the reflex theory and hypersensitivity syndrome underlying this disease pathophysiology. Novel diagnostic biomarkers have gained more traction in the search for a more reliable diagnostic tool, but further research is needed. Current standard-of-care treatment relies on proton pump inhibitor therapy. Antireflux surgery is usually not recommended. Neuromodulators and treatments targeting specific neuronal receptors are discussed. A diagnostic algorithm is proposed for the evaluation of laryngeal symptoms suspected to be related to extraesophageal reflux disease.
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Affiliation(s)
- Caroline M Barrett
- Department of Internal Medicine, Vanderbilt University Medical Center, 719 Thompson Lane, Suite 20400, Nashville, TN 37204, USA
| | - Dhyanesh Patel
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, 1301 Medical Center Drive, TVC # 1660, Nashville, TN 37232, USA.
| | - Michael F Vaezi
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, 1301 Medical Center Drive, TVC # 1660, Nashville, TN 37232, USA
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14
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Vertigan AE. Chronic cough: prevention is better than cure. THE LANCET. CHILD & ADOLESCENT HEALTH 2019; 3:840-842. [PMID: 31635951 DOI: 10.1016/s2352-4642(19)30322-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 10/02/2019] [Indexed: 06/10/2023]
Affiliation(s)
- Anne E Vertigan
- John Hunter Hospital, Hunter Region Mail Centre, NSW 2310, Australia.
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15
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Mazzone SB, Chung KF, McGarvey L. The heterogeneity of chronic cough: a case for endotypes of cough hypersensitivity. THE LANCET RESPIRATORY MEDICINE 2018; 6:636-646. [DOI: 10.1016/s2213-2600(18)30150-4] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 03/31/2018] [Accepted: 04/04/2018] [Indexed: 12/15/2022]
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16
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Risks and Cough-Aggravating Factors in Prolonged Cough. Epidemiological Observations from the Nagahama Cohort Study. Ann Am Thorac Soc 2018; 14:698-705. [PMID: 28186843 DOI: 10.1513/annalsats.201608-616bc] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
RATIONALE Chronic cough hypersensitivity, a potentially important concept of chronic or prolonged cough, is featured by heightened cough response to low-intensity stimuli, which may be generated in the absence of airflow limitations or allergic conditions. However, there is little epidemiological evidence to support this. OBJECTIVES In this large-scale community survey, we aimed to determine risks and cough-aggravating factors of prolonged cough while focusing on serum IgE levels. METHODS Prevalence of prolonged cough, defined as cough lasting 3 weeks or longer, was determined in 9,804 residents from a baseline measurement of the Nagahama Cohort Study, conducted from 2008 to 2010. Risk assessment of prolonged cough was confined to subjects without asthma (n = 9,402). A follow-up measurement of the Nagahama Study was successively conducted from 2013 to 2015, recruiting the same residents living in Nagahama City, Japan (n = 8,292). Validation analysis was performed in the follow-up measurement. RESULTS In a baseline measurement, prolonged cough was reported by 9.5% of subjects without asthma and 32.3% of subjects with asthma. In subjects without asthma, various cough-aggravating factors were associated with prolonged cough. On the multivariate analysis, several cough-aggravating factors, including nighttime or early morning, weather, pollen season, and common cold, were associated with prolonged cough, independent of female sex, younger age, chronic obstructive pulmonary disease, postnasal drip, daytime sputum, and lower serum total IgE. Serum-specific IgE levels against Japanese cedar pollen were significantly higher in subjects who responded "yes" to "cough in the pollen season" than in those who did not respond, whereas, among subjects who responded "yes" to "cough in the pollen season," prolonged coughers showed lower serum IgE levels against Japanese cedar pollen than temporal coughers. Validation analysis in a follow-up measurement confirmed the associations between prolonged cough and cough-aggravating factors observed in the baseline measurement. CONCLUSIONS The presence of several cough-aggravating factors in the absence of severe allergic conditions may support the presence of cough hypersensitivity.
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17
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Cough management in primary, secondary and tertiary settings. Pulm Pharmacol Ther 2017; 47:93-98. [DOI: 10.1016/j.pupt.2017.05.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 04/10/2017] [Accepted: 05/01/2017] [Indexed: 11/21/2022]
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18
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Belvisi MG, Birrell MA, Wortley MA, Maher SA, Satia I, Badri H, Holt K, Round P, McGarvey L, Ford J, Smith JA. XEN-D0501, a Novel Transient Receptor Potential Vanilloid 1 Antagonist, Does Not Reduce Cough in Patients with Refractory Cough. Am J Respir Crit Care Med 2017. [DOI: 10.1164/rccm.201704-0769oc] [Citation(s) in RCA: 93] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Maria G. Belvisi
- Respiratory Pharmacology Group, Division of Airway Disease, National Heart and Lung Institute, Imperial College London, United Kingdom
- Innovative Medicines and Early Development, IMED RIA, AstraZeneca, Mölndal, Sweden
| | - Mark A. Birrell
- Respiratory Pharmacology Group, Division of Airway Disease, National Heart and Lung Institute, Imperial College London, United Kingdom
| | - Michael A. Wortley
- Respiratory Pharmacology Group, Division of Airway Disease, National Heart and Lung Institute, Imperial College London, United Kingdom
| | - Sarah A. Maher
- Respiratory Pharmacology Group, Division of Airway Disease, National Heart and Lung Institute, Imperial College London, United Kingdom
| | - Imran Satia
- Division of Infection, Immunity, and Respiratory Medicine, University of Manchester, University Hospital of South Manchester, Manchester Academic Health Sciences Centre, Manchester, United Kingdom
| | - Huda Badri
- Division of Infection, Immunity, and Respiratory Medicine, University of Manchester, University Hospital of South Manchester, Manchester Academic Health Sciences Centre, Manchester, United Kingdom
| | - Kimberley Holt
- Division of Infection, Immunity, and Respiratory Medicine, University of Manchester, University Hospital of South Manchester, Manchester Academic Health Sciences Centre, Manchester, United Kingdom
| | - Patrick Round
- Ario Pharma Ltd., Cambridgeshire, United Kingdom; and
| | - Lorcan McGarvey
- Centre for Experimental Medicine, Queen’s University Belfast, Belfast, United Kingdom
| | - John Ford
- Ario Pharma Ltd., Cambridgeshire, United Kingdom; and
| | - Jaclyn A. Smith
- Division of Infection, Immunity, and Respiratory Medicine, University of Manchester, University Hospital of South Manchester, Manchester Academic Health Sciences Centre, Manchester, United Kingdom
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19
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Hull JH, Backer V, Gibson PG, Fowler SJ. Laryngeal Dysfunction: Assessment and Management for the Clinician. Am J Respir Crit Care Med 2017; 194:1062-1072. [PMID: 27575803 DOI: 10.1164/rccm.201606-1249ci] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
The larynx is one of the most highly innervated organs in humans and serves a number of vitally important, complex, and highly evolved biological functions. On a day-to-day basis, the larynx functions autonomously, addressing several roles including airway protection, swallowing, and phonation. In some situations the larynx appears to adopt a functional state that could be considered maladaptive or "dysfunctional." This laryngeal dysfunction can underpin and account for a number of respiratory symptoms that otherwise appear incongruous with a clinical disease state and/or contribute to the development of symptoms that appear "refractory" to treatment. These include conditions associated with a heightened tendency for inappropriate laryngeal closure (e.g., inducible laryngeal obstruction), voice disturbance, and chronic cough. Recognition of laryngeal dysfunction is important to deliver targeted treatment and failure to recognize the condition can lead to repeated use of inappropriate treatment. Diagnosis is not straightforward, however, and many patients appear to present with symptoms attributable to laryngeal dysfunction, but in whom the diagnosis has been overlooked in clinical work-up for some time. This review provides an overview of the current state of knowledge in the field of laryngeal dysfunction, with a focus on pragmatic clinical assessment and management.
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Affiliation(s)
- James H Hull
- 1 Department of Respiratory Medicine, Respiratory Biomedical Research Unit, Royal Brompton & Harefield National Health Service Foundation Trust, London, United Kingdom
| | - Vibeke Backer
- 2 Department of Respiratory Medicine, Bispebjerg Hospital, Copenhagen, Denmark
| | - Peter G Gibson
- 3 Centre for Healthy Lungs, University of Newcastle, Newcastle, United Kingdom.,4 Department of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle, United Kingdom.,5 Hunter Medical Research Institute, Newcastle, Australia
| | - Stephen J Fowler
- 6 Centre for Respiratory Medicine and Allergy, University of Manchester, Manchester, United Kingdom; and.,7 Manchester Academic Health Science Centre, Manchester, United Kingdom
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20
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Affiliation(s)
- Ahmed Z. El-Hashim
- Department of Pharmacology and Therapeutics, Faculty of Pharmacy, Kuwait University, Kuwait City, Kuwait
| | - Sahar M. Jaffal
- Department of Pharmacology and Therapeutics, Faculty of Pharmacy, Kuwait University, Kuwait City, Kuwait
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21
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Abstract
Chronic cough is a common and troublesome condition affecting approximately 12% of the general population. It is associated with poor quality of life with psychological, social and physical consequences. Patients typically complain of a dry irritating cough, driven by a strong urge to cough associated with a sensation or irritation located in the throat. Treatment of potential 'causes', ie asthma, gastro-oesophageal reflux disease and rhino-sinusitis, may produce a complete or partial response, but the response of some patients to opiates and alpha-2-delta ligand antagonists (gabapentin and pregabalin) supports the concept that this is primarily a neurological disorder, characterised by hyper-responsiveness of the nerves. Novel and highly effective neuronal treatments are in development and offer hope of better symptom control with fewer side effects within a few years. This review focuses on understanding the mechanism of chronic cough, current management approaches and research that may lead to novel therapies.
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Affiliation(s)
- Imran Satia
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, and Manchester Academic Health Sciences Centre. University Hospital of South Manchester NHS Foundation Trust, Manchester, UK
| | - Huda Badri
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, and Manchester Academic Health Sciences Centre. University Hospital of South Manchester NHS Foundation Trust, Manchester, UK
| | - Bashar Al-Sheklly
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, and Manchester Academic Health Sciences Centre. University Hospital of South Manchester NHS Foundation Trust, Manchester, UK
| | - Jaclyn Ann Smith
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, and Manchester Academic Health Sciences Centre. University Hospital of South Manchester NHS Foundation Trust, Manchester, UK
| | - Ashley A Woodcock
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, and Manchester Academic Health Sciences Centre. University Hospital of South Manchester NHS Foundation Trust, Manchester, UK
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Affiliation(s)
- Jaclyn A Smith
- From the University of Manchester, University Hospital of South Manchester, Manchester Academic Health Sciences Centre, Manchester, United Kingdom
| | - Ashley Woodcock
- From the University of Manchester, University Hospital of South Manchester, Manchester Academic Health Sciences Centre, Manchester, United Kingdom
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"Cold air" and/or "talking" as cough triggers, a sign for the diagnosis of cough variant asthma. Respir Investig 2016; 54:413-418. [PMID: 27886852 DOI: 10.1016/j.resinv.2016.07.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 06/27/2016] [Accepted: 07/10/2016] [Indexed: 01/08/2023]
Abstract
BACKGROUND Fractional exhaled nitric oxide (FeNO) is considered an alternative marker of eosinophilic airway inflammation and is sometimes incorporated in the diagnosis of asthma. However, many patients with cough variant asthma (CVA) demonstrate an FeNO in the normal range. Therefore, additional information is needed to confirm the diagnosis of CVA, particularly in patients with low FeNO levels. We aimed to investigate the feasibility of using cough triggers to help diagnose CVA. METHODS We studied 163 patients presenting with prolonged/chronic cough alone (including 104 CVA patients) who underwent FeNO measurements and an airway responsiveness test, and answered a questionnaire listing 18 cough triggers. The sensitivity and specificity of FeNO levels and cough triggers for the diagnosis of CVA were determined. RESULTS CVA patients showed higher FeNO levels than non-CVA patients. When the cut-off value of FeNO levels for the diagnosis of CVA was set at 22ppb, its sensitivity was 57%. CVA patients more frequently responded to "cold air" and "talking" as cough triggers than non-CVA patients. When the analysis was confined to those with a low FeNO (<22ppb) group, the sensitivity and positive predictive values of "cold air" and "talking" for the diagnosis of CVA were 36% and 70% for "cold air", and 44% and 74% for "talking", respectively. Their specificity was 81%. "Cold air" was associated with airway hyperresponsiveness in all patients with an emphasis on those with low FeNO levels. CONCLUSION "Cold air" and/or "talking" as cough triggers could be signs for the diagnosis of CVA, particularly when FeNO levels are low.
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Ando A, Smallwood D, McMahon M, Irving L, Mazzone SB, Farrell MJ. Neural correlates of cough hypersensitivity in humans: evidence for central sensitisation and dysfunctional inhibitory control. Thorax 2016; 71:323-9. [DOI: 10.1136/thoraxjnl-2015-207425] [Citation(s) in RCA: 94] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 01/07/2016] [Indexed: 12/17/2022]
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Chung KF, Canning B, McGarvey L. Eight International London Cough Symposium 2014: Cough hypersensitivity syndrome as the basis for chronic cough. Pulm Pharmacol Ther 2015; 35:76-80. [PMID: 26341666 DOI: 10.1016/j.pupt.2015.08.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Accepted: 08/31/2015] [Indexed: 02/01/2023]
Abstract
At the Eighth International London Cough Conference held in London in July 2014, the focus was on the relatively novel concept of cough hypersensitivity syndrome (CHS) as forming the basis of chronic cough. This concept has been formulated following understanding of the neuronal pathways for cough and a realisation that not all chronic cough is usually associated with a cause. The CHS is defined by troublesome coughing triggered by low level of thermal, mechanical or chemical exposure. It also encompasses other symptoms or sensations such as laryngeal hypersensitivity, nasal hypersensitivity and possibly also symptoms related to gastrooesopahgeal reflux. The pathophysiologic basis of the CHS is now being increasingly linked to an enhancement of the afferent pathways of the cough reflex both at the peripheral and central levels. Mechanisms involved include the interactions of inflammatory mechanisms with cough sensors in the upper airways and with neuronal pathways of cough, associated with a central component. Tools for assessing CHS in the clinic need to be developed. New drugs may be developed to control CHS. A roadmap is suggested from the inception of the CHS concept towards the development of newer antitussives at the Symposium.
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Affiliation(s)
- Kian Fan Chung
- Experimental Studies, National Heart and Lung Institute, Imperial College London, UK; Royal Brompton NIHR Biomedical Research Unit, London, UK.
| | - Brendan Canning
- The Johns Hopkins Asthma and Allergy Center, Baltimore, MD 21224, USA
| | - Lorcan McGarvey
- Department of Respiratory Medicine, Centre for Infection and Immunity, Queen's University Belfast, UK
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26
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Undem BJ, Zaccone E, McGarvey L, Mazzone SB. Neural dysfunction following respiratory viral infection as a cause of chronic cough hypersensitivity. Pulm Pharmacol Ther 2015; 33:52-6. [PMID: 26141017 DOI: 10.1016/j.pupt.2015.06.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Revised: 06/16/2015] [Accepted: 06/26/2015] [Indexed: 02/03/2023]
Abstract
Respiratory viral infections are a common cause of acute coughing, an irritating symptom for the patient and an important mechanism of transmission for the virus. Although poorly described, the inflammatory consequences of infection likely induce coughing by chemical (inflammatory mediator) or mechanical (mucous) activation of the cough-evoking sensory nerves that innervate the airway wall. For some individuals, acute cough can evolve into a chronic condition, in which cough and aberrant airway sensations long outlast the initial viral infection. This suggests that some viruses have the capacity to induce persistent plasticity in the neural pathways mediating cough. In this brief review we present the clinical evidence of acute and chronic neural dysfunction following viral respiratory tract infections and explore possible mechanisms by which the nervous system may undergo activation, sensitization and plasticity.
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Affiliation(s)
- Bradley J Undem
- Department of Medicine, Johns Hopkins Asthma and Allergy Center, 5501 Hopkins Bayview Circle, Baltimore, MD, 21224, USA.
| | - Eric Zaccone
- Department of Medicine, Johns Hopkins Asthma and Allergy Center, 5501 Hopkins Bayview Circle, Baltimore, MD, 21224, USA
| | - Lorcan McGarvey
- Centre of Infection and Immunity, The Queen's University of Belfast, Belfast, Northern Ireland, BT12 6BJ, UK.
| | - Stuart B Mazzone
- School of Biomedical Sciences, The University of Queensland, St Lucia, Brisbane, QLD, 4072, Australia.
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27
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Clinical features of the urge-to-cough in patients with chronic cough. Respir Med 2015; 109:701-7. [DOI: 10.1016/j.rmed.2015.03.011] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Revised: 03/22/2015] [Accepted: 03/27/2015] [Indexed: 11/20/2022]
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Millqvist E. TRP channels and temperature in airway disease-clinical significance. Temperature (Austin) 2015; 2:172-7. [PMID: 27227021 PMCID: PMC4843868 DOI: 10.1080/23328940.2015.1012979] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2014] [Revised: 01/24/2015] [Accepted: 01/26/2015] [Indexed: 11/16/2022] Open
Abstract
Temperatures above and below what is generally regarded as "comfortable" for the human being have long been known to induce various airway symptoms, especially in combination with exercise in cold climate with temperatures below 0°C, which is naturally since exercise is followed by enhanced ventilation and thus greater amounts of inhaled cold air. The aim was to highlight the knowledge we have today on symptoms from the airways (here also including the eyes) arisen from various temperatures; the mechanisms, the pathophysiology and their clinical significance. The most common eye and airway conditions related to temperature changes are dry eye disease, rhinitis, laryngeal dysfunction, asthma, chronic obstructive pulmonary disease and chronic cough. Transient receptor potential (TRP) ion channels are probably involved in all temperature induced airway symptoms but via different pathways, which are now beginning to be mapped out. In asthma, the most persuasive hypothesis today is that cold-induced asthmatic bronchoconstriction is induced by dehydration of the airway mucosa, from which it follows that provocations with osmotic stimuli like hypertonic saline and mannitol can be used as a surrogate for exercise provocation as well as dry air inhalation. In chronic unexplained cough there seems to be a direct influence of cold air on the TRP ion channels followed by coughing and increased cough sensitivity to inhaled capsaicin. Revelations in the last decades of the ability of several airway TRP ion channels to sense and react to ambient air temperature have opened new windows for the understanding of the pathogenesis in a diversity of airway reactions appearing in many common respiratory diseases.
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Affiliation(s)
- Eva Millqvist
- Department of Internal Medicine/Respiratory Medicine and Allergology; The Sahlgrenska Academy; University of Gothenburg; Gothenburg, Sweden
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29
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Abdulqawi R, Dockry R, Holt K, Layton G, McCarthy BG, Ford AP, Smith JA. P2X3 receptor antagonist (AF-219) in refractory chronic cough: a randomised, double-blind, placebo-controlled phase 2 study. Lancet 2015; 385:1198-205. [PMID: 25467586 DOI: 10.1016/s0140-6736(14)61255-1] [Citation(s) in RCA: 339] [Impact Index Per Article: 37.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Preclinical studies suggest that P2X3 receptors are expressed by airway vagal afferent nerves and contribute to the hypersensitisation of sensory neurons. P2X3 receptors could mediate sensitisation of the cough reflex, leading to chronic cough. We aimed to investigate the efficacy of a first-in-class oral P2X3 antagonist, AF-219, to reduce cough frequency in patients with refractory chronic cough. METHODS We did a double-blind, placebo-controlled, two-period, crossover study at one UK centre. With a computer-generated sequence, we randomly assigned patients with refractory chronic cough to AF-219, 600 mg twice a day, or to placebo (1:1), and then, after a 2 week washout, assigned patients to receive the other treatment. Patients, health-care providers, and investigators were masked to sequence assignment. We assessed daytime cough frequency (primary endpoint) at baseline and after 2 weeks of treatment using 24 h ambulatory cough recordings. The primary analysis used a mixed effects model with the intention-to-treat population. This study was registered at ClinicalTrials.gov, number NCT01432730. FINDINGS Of 34 individuals assessed between Sept 22, 2011, and Nov 29, 2012, we randomly assigned 24 patients (mean age 54·5 years; SD 11·1). In the observed case analysis, cough frequency was reduced by 75% when patients were allocated to AF-219 compared when allocated to placebo (p=0·0003). Daytime cough frequency fell from a mean 37 coughs per h (SD 32) to 11 (8) coughs per h after AF-219 treatment versus 65 (163) coughs per h to 44 (51) coughs per h after placebo. Six patients withdrew before the end of the study because of taste disturbances, which were reported by all patients taking AF-219. INTERPRETATION P2X3 receptors seem to have a key role in mediation of cough neuronal hypersensitivity. Antagonists of P2X3 receptors such as AF-219 are a promising new group of antitussives. FUNDING Afferent Pharmaceuticals.
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Affiliation(s)
- Rayid Abdulqawi
- Centre for Respiratory Medicine and Allergy, Institute of Inflammation and Repair, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK; University Hospital of South Manchester, Education and Research Centre, University Hospital of South Manchester, Manchester, UK
| | - Rachel Dockry
- Centre for Respiratory Medicine and Allergy, Institute of Inflammation and Repair, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK; University Hospital of South Manchester, Education and Research Centre, University Hospital of South Manchester, Manchester, UK
| | - Kimberley Holt
- Centre for Respiratory Medicine and Allergy, Institute of Inflammation and Repair, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK; University Hospital of South Manchester, Education and Research Centre, University Hospital of South Manchester, Manchester, UK
| | | | | | | | - Jaclyn A Smith
- Centre for Respiratory Medicine and Allergy, Institute of Inflammation and Repair, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK; University Hospital of South Manchester, Education and Research Centre, University Hospital of South Manchester, Manchester, UK.
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Canning BJ, Chang AB, Bolser DC, Smith JA, Mazzone SB, McGarvey L. Anatomy and neurophysiology of cough: CHEST Guideline and Expert Panel report. Chest 2014; 146:1633-1648. [PMID: 25188530 PMCID: PMC4251621 DOI: 10.1378/chest.14-1481] [Citation(s) in RCA: 168] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Accepted: 07/21/2014] [Indexed: 12/11/2022] Open
Abstract
Bronchopulmonary C-fibers and a subset of mechanically sensitive, acid-sensitive myelinated sensory nerves play essential roles in regulating cough. These vagal sensory nerves terminate primarily in the larynx, trachea, carina, and large intrapulmonary bronchi. Other bronchopulmonary sensory nerves, sensory nerves innervating other viscera, as well as somatosensory nerves innervating the chest wall, diaphragm, and abdominal musculature regulate cough patterning and cough sensitivity. The responsiveness and morphology of the airway vagal sensory nerve subtypes and the extrapulmonary sensory nerves that regulate coughing are described. The brainstem and higher brain control systems that process this sensory information are complex, but our current understanding of them is considerable and increasing. The relevance of these neural systems to clinical phenomena, such as urge to cough and psychologic methods for treatment of dystussia, is high, and modern imaging methods have revealed potential neural substrates for some features of cough in the human.
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Affiliation(s)
| | - Anne B Chang
- Queensland Children's Respiratory Centre, Royal Children's Hospital, Brisbane, QLD, Australia, Child Health Division, Menzies School of Health, Darwin, NT, Australia
| | - Donald C Bolser
- Department of Physiological Sciences, University of Florida, Gainesville, FL
| | - Jaclyn A Smith
- Centre for Respiratory and Allergy, University of Manchester, Manchester, England
| | - Stuart B Mazzone
- School of Biomedical Sciences, University of Queensland, Brisbane, QLD, Australia
| | - Lorcan McGarvey
- Centre for Infection and Immunity, The Queen's University of Belfast, Belfast, Northern Ireland.
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31
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Ando A, Farrell MJ, Mazzone SB. Cough-related neural processing in the brain: A roadmap for cough dysfunction? Neurosci Biobehav Rev 2014; 47:457-68. [DOI: 10.1016/j.neubiorev.2014.09.018] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2013] [Revised: 06/29/2014] [Accepted: 09/25/2014] [Indexed: 01/05/2023]
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32
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McGarvey L. Update: the search for the human cough receptor. Lung 2014; 192:459-65. [PMID: 24770379 DOI: 10.1007/s00408-014-9581-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Accepted: 03/29/2014] [Indexed: 10/25/2022]
Abstract
Despite the best efforts of basic and applied science, the identity of the human "cough receptor" remains elusive. The attraction of identifying a single "catch all" cough receptor is obvious, although such an objective is unlikely to be realised given the concept of "cough hypersensitivity," which is now considered the most clinically relevant description of what underlies problem coughing. One means of progressing this area is to join the thinking and experimental effort of basic science and clinical research in an effective manner. Some of the best examples of cooperative and translational research over the years together with an update on the most recent work will be discussed in this article.
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Affiliation(s)
- Lorcan McGarvey
- Centre for Infection and Immunity, Queens University Belfast, Health Sciences Building, Lisburn Road, Belfast, BT9 7BL, Northern Ireland,
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33
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Dicpinigaitis PV, Morice AH, Birring SS, McGarvey L, Smith JA, Canning BJ, Page CP. Antitussive drugs--past, present, and future. Pharmacol Rev 2014; 66:468-512. [PMID: 24671376 PMCID: PMC11060423 DOI: 10.1124/pr.111.005116] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Cough remains a serious unmet clinical problem, both as a symptom of a range of other conditions such as asthma, chronic obstructive pulmonary disease, gastroesophageal reflux, and as a problem in its own right in patients with chronic cough of unknown origin. This article reviews our current understanding of the pathogenesis of cough and the hypertussive state characterizing a number of diseases as well as reviewing the evidence for the different classes of antitussive drug currently in clinical use. For completeness, the review also discusses a number of major drug classes often clinically used to treat cough but that are not generally classified as antitussive drugs. We also reviewed a number of drug classes in various stages of development as antitussive drugs. Perhaps surprising for drugs used to treat such a common symptom, there is a paucity of well-controlled clinical studies documenting evidence for the use of many of the drug classes in use today, particularly those available over the counter. Nonetheless, there has been a considerable increase in our understanding of the cough reflex over the last decade that has led to a number of promising new targets for antitussive drugs being identified and thus giving some hope of new drugs being available in the not too distant future for the treatment of this often debilitating symptom.
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Affiliation(s)
- P V Dicpinigaitis
- King's College London, Franklin Wilkins Building, 100 Stamford St., London, SE1 9NH, UK.
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Khalid S, Murdoch R, Newlands A, Smart K, Kelsall A, Holt K, Dockry R, Woodcock A, Smith JA. Transient receptor potential vanilloid 1 (TRPV1) antagonism in patients with refractory chronic cough: a double-blind randomized controlled trial. J Allergy Clin Immunol 2014; 134:56-62. [PMID: 24666696 DOI: 10.1016/j.jaci.2014.01.038] [Citation(s) in RCA: 130] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2013] [Revised: 12/29/2013] [Accepted: 01/16/2014] [Indexed: 12/27/2022]
Abstract
BACKGROUND Inhalation of capsaicin, the extract of hot chili peppers, induces coughing in both animals and human subjects through activation of transient receptor potential vanilloid 1 (TRPV1) on airway sensory nerves. Therefore the TRPV1 receptor is an attractive target for the development of antitussive agents. OBJECTIVE We sought to assess the antitussive effect of TRPV1 antagonism in patients with refractory chronic cough. METHODS Twenty-one subjects with refractory chronic cough (>8 weeks) attending a specialist clinic were recruited to a randomized, double-blind, placebo-controlled crossover trial assessing a TRPV1 antagonist (SB-705498). Cough reflex sensitivity to capsaicin (concentration of capsaicin inducing at least 5 coughs) and 24-hour cough frequency were coprimary end points assessed after a single dose of SB-705498 (600 mg) and matched placebo. Cough severity and urge to cough were reported on visual analog scales, and cough-specific quality of life data were also collected. RESULTS Treatment with SB-705498 produced a significant improvement in cough reflex sensitivity to capsaicin at 2 hours and a borderline significant improvement at 24 hours compared with placebo (adjusted mean difference of +1.3 doubling doses at 2 hours [95% CI, +0.3 to +2.2; P = .0049] and +0.7 doubling doses at 24 hours [95% CI, +0.0 to +1.5; P = .0259]). However, 24-hour objective cough frequency was not improved compared with placebo. Patient-reported cough severity, urge to cough, and cough-specific quality of life similarly suggested no effect of SB-705498. CONCLUSION This study raises important questions about both the role of TRVP1-mediated mechanisms in patients with refractory chronic cough and also the predictive value of capsaicin challenge testing in the assessment of novel antitussive agents.
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Affiliation(s)
- Saifudin Khalid
- Centre for Respiratory and Allergy, University of Manchester, University Hospital of South Manchester, Manchester, United Kingdom
| | | | | | | | - Angela Kelsall
- Centre for Respiratory and Allergy, University of Manchester, University Hospital of South Manchester, Manchester, United Kingdom
| | - Kimberley Holt
- Centre for Respiratory and Allergy, University of Manchester, University Hospital of South Manchester, Manchester, United Kingdom
| | - Rachel Dockry
- Centre for Respiratory and Allergy, University of Manchester, University Hospital of South Manchester, Manchester, United Kingdom
| | - Ashley Woodcock
- Centre for Respiratory and Allergy, University of Manchester, University Hospital of South Manchester, Manchester, United Kingdom
| | - Jaclyn A Smith
- Centre for Respiratory and Allergy, University of Manchester, University Hospital of South Manchester, Manchester, United Kingdom.
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Ferner RE, Aronson JK. Laughter and MIRTH (Methodical Investigation of Risibility, Therapeutic and Harmful): narrative synthesis. BMJ 2013; 347:f7274. [PMID: 24336308 PMCID: PMC3898427 DOI: 10.1136/bmj.f7274] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
OBJECTIVE To review the beneficial and harmful effects of laughter. DESIGN Narrative synthesis. DATA SOURCES AND REVIEW METHODS We searched Medline (1946 to June 2013) and Embase (1974 to June 2013) for reports of benefits or harms from laughter in humans, and counted the number of papers in each category. RESULTS Benefits of laughter include reduced anger, anxiety, depression, and stress; reduced tension (psychological and cardiovascular); increased pain threshold; reduced risk of myocardial infarction (presumably requiring hearty laughter); improved lung function; increased energy expenditure; and reduced blood glucose concentration. However, laughter is no joke-dangers include syncope, cardiac and oesophageal rupture, and protrusion of abdominal hernias (from side splitting laughter or laughing fit to burst), asthma attacks, interlobular emphysema, cataplexy, headaches, jaw dislocation, and stress incontinence (from laughing like a drain). Infectious laughter can disseminate real infection, which is potentially preventable by laughing up your sleeve. As a side effect of our search for side effects, we also list pathological causes of laughter, among them epilepsy (gelastic seizures), cerebral tumours, Angelman's syndrome, strokes, multiple sclerosis, and amyotrophic lateral sclerosis or motor neuron disease. CONCLUSIONS Laughter is not purely beneficial. The harms it can cause are immediate and dose related, the risks being highest for Homeric (uncontrollable) laughter. The benefit-harm balance is probably favourable. It remains to be seen whether sick jokes make you ill or jokes in bad taste cause dysgeusia, and whether our views on comedians stand up to further scrutiny.
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Affiliation(s)
- R E Ferner
- West Midlands Centre for Adverse Drug Reactions, City Hospital, Birmingham B18 7QH, UK
- School of Clinical and Experimental Medicine, University of Birmingham, Birmingham B15 2TT, UK
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Abstract
Cough persisting beyond 8 weeks (ie, chronic cough) is one of the most common reasons for an outpatient visit. A protracted cough can negatively affect one's quality of life by causing anxiety, physical discomfort, social isolation, and personal embarrassment. Herein, the anatomy and physiology of the cough reflex are reviewed. Upper airway cough syndrome, asthma, eosinophilic bronchitis, and gastroesophageal reflux disease account for most chronic cough after excluding smoking, angiotensin-converting enzyme inhibitor use, and chronic bronchitis. Many patients have more than one reason for chronic cough. Treating the underlying cause(s) resolves cough in most instances. There are some coughs that seem refractory despite an extensive work-up. The possibility of a hypersensitive cough reflex response has been proposed to explain these cases. Several clinical algorithms to evaluate chronic cough are presented.
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Affiliation(s)
- Vivek N Iyer
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
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O'Neill J, McMahon SB, Undem BJ. Chronic cough and pain: Janus faces in sensory neurobiology? Pulm Pharmacol Ther 2013; 26:476-85. [PMID: 23831712 DOI: 10.1016/j.pupt.2013.06.010] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2013] [Revised: 06/20/2013] [Accepted: 06/26/2013] [Indexed: 10/26/2022]
Abstract
Both chronic cough and chronic pain are critical clinical issues in which a large number of patients remain unsatisfied with available treatments. These conditions have considerable effects on sufferers' quality of life, who often show co-morbidities such as anxiety and depression. There is therefore a pressing need to find new effective therapies. The basic neurobiological mechanisms and pathologies of these two conditions show substantial homologies. However, whilst chronic pain has received a great deal of attention over the last few decades, the same cannot be said for the neurological underpinnings of chronic cough. There is a substantial literature around mechanisms of chronic pain which is likely to be useful in advancing knowledge about the pathologies of chronic cough. Here we compare the basic pain and cough pathways, in addition to the clinical features and possible pathophysiologies of each; including mechanisms of peripheral and central sensitisation which may underlie symptoms such as hyperalgesia and allodynia, and hypertussitvity and allotussivity. Due to the substantial overlap that emerges, it is likely that therapies may be effective over both areas.
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Affiliation(s)
- Jessica O'Neill
- Neuroscience, Physiology and Pharmacology, University College London, UK. Jessica.o'
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Abstract
Chronic cough has been variably defined as a cough lasting longer than 3, 4 or 8 weeks. Many post viral or pertussis like illnesses are associated with prolonged coughing that resolves over time. Management involves first trying to make a diagnosis and identify the presence of any underlying condition. Targeted treatments can then be employed. Trials of treatments are often used to make a diagnosis. Because natural resolution of cough is so common any trial of treatment to confirm a diagnosis should be time limited and the treatment only restarted if the coughing returns. Only a small proportion of children with an isolated non-specific dry cough have asthma and care is needed not to over diagnose asthma. Children with chronic wet cough may have protracted bacterial bronchitis (PBB) that responds to a full course of antibiotics. Children with PBB failing to respond to treatment or with specific pointers should be investigated for specific causes of suppurative lung disease.
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Pacheco A, Cobeta I. Refractory chronic cough, or the need to focus on the relationship between the larynx and the esophagus. Cough 2013; 9:10. [PMID: 23552099 PMCID: PMC3687571 DOI: 10.1186/1745-9974-9-10] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2012] [Accepted: 03/11/2013] [Indexed: 12/14/2022] Open
Abstract
In this review we question the current way of handling tackle a problem of chronic cough, especially by the excessive number of patients who can not find complete relief from your cough by anatomical diagnosis of universal use. From the field of Otolaryngology new perspectives arise now considering the larynx as a preferential afferent stimuli cough reflex arc. Also the constitution laryngopharyngeal reflux gas and new approaches to non-acid reflux and the local action of pepsin in laryngeal deserving of a joint review, which can illuminate new ways to handle the problem of chronic refractory cough. We believe that the chronic cough syndrome hpersensitivity as more precise label for chronic cough, should place particular emphasis on laryngeal sensory neuropathy as cough and reflux the influence that may have on their maintenance, and thereby causes definitely wide related to the syndrome if the larynx is incorporated, place greater number of afferent nerves of chronic cough, which are sure to cover much of the case of refractory cough remain without a satisfactory solution. The close collaboration between Otolaryngology, Gastroenterology and Pneumology in a patient with refractory chronic cough seems now an unavoidable necessity.
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Affiliation(s)
- Adalberto Pacheco
- Chronic Cough Unit, Pneumology Service, Hospital Ramón y Cajal, Madrid, Spain
- Otolaryngology Department, Hospital Ramón y Cajal, Madrid, Spain
| | - Ignacio Cobeta
- Otolaryngology Department, Hospital Ramón y Cajal, Madrid, Spain
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40
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Pacheco A, Cobeta I, Wagner C. Refractory Chronic Cough: New Perspectives in Diagnosis and Treatment. ACTA ACUST UNITED AC 2013. [DOI: 10.1016/j.arbr.2013.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Millqvist E, Ternesten-Hasséus E, Bende M. Inhalation of menthol reduces capsaicin cough sensitivity and influences inspiratory flows in chronic cough. Respir Med 2012; 107:433-8. [PMID: 23266255 DOI: 10.1016/j.rmed.2012.11.017] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Revised: 11/13/2012] [Accepted: 11/16/2012] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Chronic cough is a common clinical problem and there is a shortage of effective treatments for it. Within the group of transient receptor potential ion channels a receptor for the cooling substance menthol has been identified. This study aimed to assess whether pre-inhalation of dissolved, nebulised menthol could increase capsaicin cough thresholds and influence spirometric values. METHODS Fourteen patients with chronic cough and airway sensitivity to environmental irritants and 15 control subjects were tested on three occasions. Each one inhaled a 1 mL of nebulised menthol solution of 0.5% or 1% or placebo (saline with 0.05% menthol) at each visit in a randomized and double-blind order. They were then provoked by capsaicin inhalation. RESULTS Patients' cough thresholds differed significantly from the controls' on all three provocations (P < 0.0001). After inhalation of 1% menthol, the patients' cough thresholds were significantly higher (P < 0.02) compared to after placebo inhalation and to after 0.5% menthol inhalation (P < 0.05). The patients' peak inspiratory flows were significantly reduced after inhalation of the placebo (saline) (P < 0.05) but not after inhalation of 0.5% or 1% menthol. Forced inspiratory flows 50% were lowered after inhalation of placebo and of 0.5% menthol (P < 0.05) but not after 1% menthol. Among the controls, forced inspiratory flows 50% were lowered after only placebo inhalation (P < 0.05). CONCLUSIONS In patients with chronic cough, pre-inhalation of menthol reduces cough sensitivity to inhaled capsaicin and influences inspiratory flows. The findings may provide scientific support for the common practice of using menthol as a reliever for variant airway discomfort. The use of menthol in different cigarette brands could be questioned since it could conceal the natural irritation following smoking.
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Affiliation(s)
- Eva Millqvist
- Department of Internal Medicine/Respiratory Medicine and Allergology, The Sahlgrenska Academy at University of Gothenburg, Sweden.
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Refractory chronic cough: new perspectives in diagnosis and treatment. Arch Bronconeumol 2012; 49:151-7. [PMID: 23165122 DOI: 10.1016/j.arbres.2012.09.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2012] [Revised: 09/14/2012] [Accepted: 09/26/2012] [Indexed: 02/01/2023]
Abstract
In patients with chronic cough, nearly 40% of the population does not experience definitive improvement of their cough despite correctly applying the anatomic diagnosis. In many of these patients with refractory cough, laryngeal symptoms are frequent. The region of the larynx/pharynx is configured as a bridge between the esophagus and the upper and lower respiratory tract. The association of reflux in patients with chronic cough and symptoms such as globus pharyngis, itchiness or the need to clear one's throat have recently been given attention due to the possibility of joint therapeutic intervention of the gastroesophageal reflux and larynx, both with new medications as well as with laryngeal rehabilitation therapies, with observed benefits in the disappearance of chronic cough in cases that had been previously labeled as refractory.
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McGarvey L. A 54 year-old man with a chronic cough — Following referral: a secondary care perspective from the UK. PRIMARY CARE RESPIRATORY JOURNAL : JOURNAL OF THE GENERAL PRACTICE AIRWAYS GROUP 2012; 21:345-7. [DOI: 10.4104/pcrj.2012.00077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Iida S, Omoto K, Kanemitsu I, Setoguchi K, Ishida H, Tanabe K, Suzuki T, Tashiro Y, Kishimoto H, Abe R. Interleukin-6 receptor signaling disruption prevents cardiac allograft deterioration in mice. EXP CLIN TRANSPLANT 2012; 10:375-85. [PMID: 22758208 DOI: 10.6002/ect.2011.0159] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Interleukin-6, a pleiotropic cytokine that functions in both innate and adaptive immune responses, has been implicated in allograft rejection. We analyzed the efficacy of anti interleukin-6 receptor monoclonal antibody in delaying allograft rejection in a murine model of a heart. MATERIALS AND METHODS To investigate the role of interleukin-6 receptor signal transduction in acute and chronic allograft rejection, we blocked interleukin-6 receptor signaling to suppress the alloimmune response in C57BL/6 recipients of BALB/c cardiac allografts. RESULTS Administration of a high-dose α-interleukin-6 receptor monoclonal antibody prevented the intragraft infiltration of inflammatory cells and lymphocytes and prolonged allograft survival during the peritransplant period. However, all allografts were rejected by 23.5 days after transplant. In contrast, cardiac allograft recipients treated with a cytotoxic T-lymphocyte antigen 4-immunoglobulin plus continued administration of low-dose α-interleukin-6 receptor monoclonal antibody showed long-term graft survival compared with cytotoxic T-lymphocyte antigen 4-immunoglobulin monotherapy. A histologic analysis revealed that graft fibrosis was prevented in cytotoxic T-lymphocyte antigen 4-immunoglobulin plus high-dose α-interleukin-6 receptor monoclonal antibody group, but not in the cytotoxic T-lymphocyte antigen 4-immunoglobulin alone group. This suggests that deterioration of graft function associated with chronic rejection could be prevented by blocking interleukin-6 receptor signaling. CONCLUSIONS Disruption of interleukin-6 receptor signaling is an effective strategy for modulating proinflammatory immune responses and preventing chronic rejection.
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Affiliation(s)
- Shoichi Iida
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan.
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Neural correlates coding stimulus level and perception of capsaicin-evoked urge-to-cough in humans. Neuroimage 2012; 61:1324-35. [DOI: 10.1016/j.neuroimage.2012.03.030] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2011] [Revised: 03/05/2012] [Accepted: 03/06/2012] [Indexed: 12/28/2022] Open
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Pacheco A, Faro V, Cobeta I, Royuela A. Chronic Cough With Limited Response to Treatment and Incidence of Gastroesophageal Reflux. ACTA ACUST UNITED AC 2012. [DOI: 10.1016/j.arbr.2012.03.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Tos crónica de escasa respuesta al tratamiento e incidencia de reflujo gastroesofágico. Arch Bronconeumol 2012; 48:197-201. [DOI: 10.1016/j.arbres.2012.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2011] [Revised: 02/01/2012] [Accepted: 02/01/2012] [Indexed: 01/10/2023]
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Abstract
Chronic cough is defined as cough lasting more than 2 months. Common causes for chronic cough in nonsmokers with normal chest radiographs and pulmonary functions include gastroesophageal reflux disease (GERD), cough-variant asthma (CVA), and upper airway cough syndrome (UACS). Current guidelines recommend diagnosing the etiology of chronic cough based upon the results of therapy for suspected GERD, CVA, and UACS. Despite following current recommendations for diagnosis and treatment, the cause for a significant proportion of chronic cough remains unexplained.Recent reports indicate the resolution of chronic cough following treatment of concomitantly diagnosed obstructive sleep apnea (OSA). Whether this represents a co-occurrence of two commonly prevalent disorders or a pathophysiologic relationship between OSA and cough remains unknown. This review offers insights into a pathophysiologic link between OSA and the commonly purported etiologies for cough, namely, GERD, UACS, and CVA. In addition, evidence for a relationship between airway inflammation that can trigger or perpetuate cough and OSA is discussed. This review explores mechanisms by which nocturnal continuous positive airway therapy resolves cough by improving underlying airway inflammation secondary to OSA and impacts upon GERD, CVA, and UACS.
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Affiliation(s)
- Krishna M Sundar
- Department of Medicine, Utah Valley Pulmonary Clinic, Provo, UT 84604, USA.
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Pacheco A. Tos crónica: nuevas perspectivas en diagnóstico y tratamiento. Arch Bronconeumol 2012; 48:104. [DOI: 10.1016/j.arbres.2011.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2011] [Accepted: 11/17/2011] [Indexed: 10/14/2022]
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Molassiotis A, Lowe M, Ellis J, Wagland R, Bailey C, Lloyd-Williams M, Tishelman C, Smith J. The experience of cough in patients diagnosed with lung cancer. Support Care Cancer 2011; 19:1997-2004. [PMID: 21107612 DOI: 10.1007/s00520-010-1050-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2010] [Accepted: 11/11/2010] [Indexed: 01/18/2023]
Abstract
PURPOSE The aim of this study was to explore the patient experience of cough in a population of patients with lung cancer. METHODS A qualitative exploratory study design was developed and elicited the views of 26 patients with lung cancer who had current or past experience with cough. RESULTS The data's four themes highlight the complex and distressing nature of cough, including its interaction with other symptoms, such as breathlessness, fatigue and sleep disturbance. A theme around descriptions of cough suggests typically a dry tickly cough and highlights mechanical and environmental triggers for cough. The theme around the effects of cough in daily life shows the impact of cough in socialising, the embarrassment from cough and the psychological effects experienced by patients. The last theme focuses on strategies for coping with and managing cough, showing the perceived ineffectiveness of current antitussives and the patients' use of a variety of approaches on an ad hoc basis to try to manage their cough often unsuccessfully. CONCLUSION Cough has not received the same attention as other cancer symptoms, which means that patients' experience of a distressing and difficult symptom is often unnoticed by health care professionals. More clinical and research attention in this debilitating symptom is necessary.
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Affiliation(s)
- Alex Molassiotis
- School of Nursing, Midwifery and Social Work, University of Manchester, University Place, Block 3, Manchester M13 9PL, UK.
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