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Wu M, Chen Z, Chen X, Wang G, Xu C, Zhu Y, Xie M. Altered functional connectivity of the nucleus tractus solitarii in patients with chronic cough after lung surgery: an rs-fMRI study. Thorac Cancer 2023; 14:3202-3207. [PMID: 37718475 PMCID: PMC10643787 DOI: 10.1111/1759-7714.15110] [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: 06/19/2023] [Revised: 08/29/2023] [Accepted: 08/31/2023] [Indexed: 09/19/2023] Open
Abstract
BACKGROUND To explore the altered functional connectivity (FC) of the nucleus tractus solitarii (NTS) in patients with chronic cough after lung surgery using resting-state functional magnetic resonance imaging (rs-fMRI), and the association between abnormal FC and clinical scale scores. METHODS A total of 22 patients with chronic cough after lung surgery and 22 healthy controls were included. Visual analog scale (VAS), Mandarin Chinese version of the Leicester Cough Questionnaire (LCQ-MC), and Hamilton anxiety rating scale (HAMA) scores were assessed, and rs-fMRI data were collected. The FC analysis was performed using the NTS as the seed point, and FC values with all voxels in the whole brain were calculated. A two-sample t-test was used to compare FC differences between the two groups. The FC values of brain regions with differences were extracted and correlated with clinical scale scores. RESULTS In comparison to healthy controls, FC values in the NTS and anterior cingulate cortex(ACC) were reduced in patients with chronic cough after lung surgery (GRF correction, p-voxel < 0.005, p-cluster < 0.05) which were positively correlated with LCQ-MC scores (r = 0.534, p = 0.011), but with VAS (r = -0.500, p = 0.018), HAMA (r = -0.713, p < 0.001) scores were negatively correlated. CONCLUSIONS Reduced FC of the NTS with ACC may be associated with cough hypersensitivity and may contribute to anxiety in patients with chronic cough after lung surgery.
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Affiliation(s)
- Ming‐sheng Wu
- Division of Life Sciences and MedicineUniversity of Science and Technology of ChinaHefeiChina
- Department of Thoracic Surgery, The First Affiliated Hospital of USTC, Division of Life Sciences and MedicineUniversity of Science and Technology of ChinaHefeiChina
| | - Zheng‐wei Chen
- Department of Thoracic Surgery, The First Affiliated Hospital of USTC, Division of Life Sciences and MedicineUniversity of Science and Technology of ChinaHefeiChina
| | - Xiao Chen
- Division of Life Sciences and MedicineUniversity of Science and Technology of ChinaHefeiChina
- Department of Thoracic Surgery, The First Affiliated Hospital of USTC, Division of Life Sciences and MedicineUniversity of Science and Technology of ChinaHefeiChina
| | - Gao‐xiang Wang
- Department of Thoracic Surgery, The First Affiliated Hospital of USTC, Division of Life Sciences and MedicineUniversity of Science and Technology of ChinaHefeiChina
| | - Chun‐sheng Xu
- Medical Imaging CenterThe First Affiliated Hospital of Anhui University of Chinese MedicineHefeiChina
| | - Yong‐fu Zhu
- The First Department of OncologyThe First Affiliated Hospital of Anhui University of Chinese MedicineHefeiChina
| | - Ming‐ran Xie
- Division of Life Sciences and MedicineUniversity of Science and Technology of ChinaHefeiChina
- Department of Thoracic Surgery, The First Affiliated Hospital of USTC, Division of Life Sciences and MedicineUniversity of Science and Technology of ChinaHefeiChina
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2
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Kunč P, Fábry J, Grendár M, Ferenc P, Strachan T, Ištvánková K, Hurtová T, Péčová R. Association of selected inflammatory biomarkers with cough reflex sensitivity in asthmatic children. Physiol Res 2023; 72:349-358. [PMID: 37449748 PMCID: PMC10668995 DOI: 10.33549/physiolres.935063] [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: 01/12/2023] [Accepted: 03/31/2023] [Indexed: 08/26/2023] Open
Abstract
Bronchial asthma is the most common chronic respiratory disease of childhood. Cough is one of its defining symptoms. This study investigated the associations between selected inflammatory biomarkers and cough reflex sensitivity after capsaicin inhalation in children with mild and moderate well-controlled type 2 endotype asthma compared with non-asthmatic probands. Sensitivity to the cough reflex was measured by recording the cough response after capsaicin inhalation. The sandwich ELISA method was used to measure serum concentrations of the investigated potential inflammatory biomarkers (interleukin 13, interleukin 1beta, eosinophil-derived neurotoxin). The acquired data were statistically evaluated according to descriptive analyses for summarization and comparison between cough reflex sensitivity parameters and individual biomarker values in the observed and control groups modeled by a simple linear regression model. Statistical significance was defined as p<0.05. We showed a statistically significant association (p-value 0.03) between cough reflex sensitivity - C2 value (capsaicin concentration required for two cough responses) and interleukin 1beta serum concentrations in the asthma group compared with the control group of non-asthmatic children. Our results support the possibility of interleukin 1beta as a potential additive inflammatory biomarker used in clinical practice in children with asthma because of its correlation with the activity of the afferent nerve endings in the airways.
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Affiliation(s)
- P Kunč
- Clinic of Pediatric Respiratory Diseases and Tuberculosis, Comenius University in Bratislava, Jessenius Faculty of Medicine in Martin, National Institute of Pediatric Tuberculosis and Respiratory Diseases, Dolny Smokovec, Slovak Republic, Department of Pathological Physiology, Comenius University in Bratislava, Jessenius Faculty of Medicine in Martin, Slovak Republic.
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Wei L, Hongping H, Chufang L, Cuomu M, Jintao L, Kaiyin C, Lvyi C, Weiwu C, Zuguang Y, Nanshan Z. Effects of Shiwei Longdanhua formula on LPS induced airway mucus hypersecretion, cough hypersensitivity, oxidative stress and pulmonary inflammation. Biomed Pharmacother 2023; 163:114793. [PMID: 37121151 DOI: 10.1016/j.biopha.2023.114793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 04/14/2023] [Accepted: 04/24/2023] [Indexed: 05/02/2023] Open
Abstract
Shiwei Longdanhua Granule (SWLDH) is a classic Tibetan medicine (TM) ranking in the top 20 Chinese patent medicines in prescription rate to treat respiratory diseases like pneumonia, acute and chronic tracheobronchitis, acute exacerbation of COPD and bronchial asthma in solution of inflammation, cough and phlegm obstruction in clinical practice. However, its systematic pharmacological mechanisms have not been elucidated yet. Here, we studied the therapeutic efficacy of SWLDH in treatment of acute respiratory diseases in BALB/c mice by comprehensive analysis of airway inflammation, oxidative stress, mucus hypersecretion, cough hypersensitivities and indicators associated with the development of chronic diseases. Our results show that SWLDH might exhibit its inhibitory effects on pulmonary inflammation by interference with arachidonic acid (AA) metabolism pathways. Oxidative stress that highly related to the degree of tissue injury could be alleviated by enhancing the reductive activities of glutathione redox system, thioredoxin system and the catalytic activities of catalase and superoxide dismutase (SOD) after SWLDH treatment. In addition, SWLDH could significantly abrogate the mucus hypersecretion induced bronchiole obstruction by inactivate the globlet cells and decrease the secretion of gel-forming mucins (MUC5AC and MUC5B) under pathological condition, demonstrating its mucoactive potency. SWLDH also showed reversed effects on the release of neuropeptides that are responsible for airway sensory hypersensitivity. Simultaneously observed inhibition of calcium influx, reduction in in vivo biosynthesis of acetylcholine and the recovery of the content of cyclic adenosine monophosphate (cAMP) might collaboratively contribute to cause airway smooth muscle cells (ASMCs) relexation. These findings indicated that SWLDH might exhibited antitussive potency via suppression of the urge to cough and ASMCs contraction. Moreover, SWLDH might affect airway remodeling. We found SWLDH could retard the elevation of TGF-β1 and α-SMA, which are important indicators for hyperplasia and contraction during the progression of the chronic airway inflammatory diseases like COPD and asthma.
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Affiliation(s)
- Liu Wei
- Guangzhou Laboratory, Guangzhou, China; State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou Medical University, Guangzhou, China
| | - Hou Hongping
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing, China
| | | | - Mingji Cuomu
- The University of Tibetan Medicine, Lhasa, China
| | - Li Jintao
- Beijing International Science and Technology Cooperation Base of Antivirus Drug, Beijing University of Technology, Beijing, China
| | - Cai Kaiyin
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou Medical University, Guangzhou, China; Tibet Cheezheng Tibet Medicine Co.,Ltd., Beijing, China
| | - Chen Lvyi
- School of Pharmaceutical Sciences, South-Central Minzu University, Wuhan, China
| | - Chen Weiwu
- Tibet Cheezheng Tibet Medicine Co.,Ltd., Beijing, China
| | - Ye Zuguang
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou Medical University, Guangzhou, China.
| | - Zhong Nanshan
- Guangzhou Laboratory, Guangzhou, China; State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou Medical University, Guangzhou, China.
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Slovarp LJ, Reynolds JE, Tolbert S, Campbell S, Welby S, Morkrid P. Cough desensitization treatment for patients with refractory chronic cough: results of a second pilot randomized control trial. BMC Pulm Med 2023; 23:148. [PMID: 37118696 PMCID: PMC10141869 DOI: 10.1186/s12890-023-02423-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 04/06/2023] [Indexed: 04/30/2023] Open
Abstract
OBJECTIVE The purpose of this study was to collect pilot efficacy data on a novel treatment for refractory chronic cough (RCC), which we call cough desensitization treatment (CDT). DESIGN AND METHODS In this parallel cohort, sham-controlled, randomized controlled trial, 21 adults with RCC were randomly assigned to 12 sessions of either CDT (progressive doses of aerosolized capsaicin while behaviorally suppressing cough; n = 11) or a sham treatment (repeated exposure to aerosolized saline; n = 9). The Leicester Cough Questionnaire (LCQ) was the primary outcome measure. Perceived cough severity with a visual analogue scale and cough challenge testing (for measuring cough-reflex sensitivity) were secondary outcome measures. Data were analyzed with mixed effects linear regression and follow-up contrasts. RESULTS Results on all measures favored CDT. Excluding one sham participant, whose baseline LCQ scores were deemed unreliable, mean change in LCQ at 3-weeks post treatment was 6.35 and 2.17 in the CDT and sham groups, respectively. There was moderate to strong evidence of a greater improvement in the CDT group in total LCQ score (p = .058) and LCQ Psychological domain (p = .026) and Physical domain (p = .045) scores. Strong evidence was found for a greater reduction in urge-to-cough during CCT in the CDT group (p = .037) and marginal for a reduction in the capsaicin cough-reflex sensitivity (p = .094). There was weak evidence of a greater reduction in cough severity in the CDT group (p = .103). DISCUSSION Although the study is limited due to the small sample size, the data provide additional evidence supporting further research on CDT. CDT resulted in a greater change in the primary efficacy measure (LCQ) than both pharmaceutical and behavioral treatments currently found in the literature. TRIAL REGISTRATION This trial (NCT05226299) was registered on Clinicaltrials.gov on 07/02/2022.
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Affiliation(s)
- Laurie J Slovarp
- University of Montana, School of Speech, Language, Hearing, & Occupational Sciences, Missoula, MT, USA.
| | - Jane E Reynolds
- University of Montana, School of Speech, Language, Hearing, & Occupational Sciences, Missoula, MT, USA
| | - Sophia Tolbert
- University of Montana, School of Speech, Language, Hearing, & Occupational Sciences, Missoula, MT, USA
| | - Sarah Campbell
- University of Montana, School of Speech, Language, Hearing, & Occupational Sciences, Missoula, MT, USA
| | - Shannon Welby
- University of Montana, School of Speech, Language, Hearing, & Occupational Sciences, Missoula, MT, USA
| | - Paige Morkrid
- University of Montana, School of Speech, Language, Hearing, & Occupational Sciences, Missoula, MT, USA
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Lavorini F, Bernacchi G, Fumagalli C, Noale M, Maggi S, Mutolo D, Cinelli E, Fontana GA. Somatically evoked cough responses help to identify patients with difficult-to-treat chronic cough: a six-month observational cohort study. EClinicalMedicine 2023; 57:101869. [PMID: 36874394 PMCID: PMC9975680 DOI: 10.1016/j.eclinm.2023.101869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 01/23/2023] [Accepted: 01/30/2023] [Indexed: 02/22/2023] Open
Abstract
BACKGROUND Recently we identified in patients with chronic cough a sensory dysregulation via which the urge-to-cough (UTC) or coughing are evoked mechanically from "somatic points for cough" (SPCs) in the neck and upper trunk. We investigated the prevalence and the clinical relevance of SPCs in an unselected population of patients with chronic cough. METHODS From 2018 to 2021, symptoms of 317 consecutive patients with chronic cough (233 females) were collected on four visits (V1-V4) 2 months apart at the Cough Clinic of the University Hospital in Florence (I). Participants rated the disturbance caused by the cough (0-9 modified Borg Scale). We attempted to evoke coughing and/or UTC using mechanical actions in all participants who were subsequently categorised as responsive (somatic point for cough positive, SPC+) or unresponsive (SPC-) to these actions. An association was established between chronic cough and its commonest causes; treatments were administered accordingly. FINDINGS 169 patients were SPC+ and had a higher baseline cough score (p < 0.01). In most of the patients, the treatments reduced (p < 0.01) cough-associated symptoms. All patients reported a decrease (p < 0.01) in cough score at V2 (from 5.70 ± 1.4 to 3.43 ± 1.9 and from 5.01 ± 1.5 to 2.74 ± 1.7 for SPC+ and SPC- patients respectively). However, whilst in SPC- patients the cough score continued to decrease indicating virtually complete cough disappearance at V4 (0.97 ± 0.8), in SPC+ patients this variable remained close to V2 values during the entire follow-up. INTERPRETATION Our study suggests that the assessment of SPCs may identify patients whose cough is unresponsive and are eligible for specific treatments. FUNDING This work was funded by an unrestricted grant from Merck (Italy).
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Affiliation(s)
- Federico Lavorini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Corresponding author. Department of Experimental and Clinical Medicine, Largo Brambilla 3, Florence 50134, Italy.
| | - Guja Bernacchi
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Carlo Fumagalli
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Marianna Noale
- Italian National Research Council (CNR), Neuroscience Institute, Aging Branch, Padua, Italy
| | - Stefania Maggi
- Italian National Research Council (CNR), Neuroscience Institute, Aging Branch, Padua, Italy
| | - Donatella Mutolo
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Eliana Cinelli
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Giovanni A. Fontana
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
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Naqvi KF, Mazzone SB, Shiloh MU. Infectious and Inflammatory Pathways to Cough. Annu Rev Physiol 2023; 85:71-91. [PMID: 36170660 PMCID: PMC9918720 DOI: 10.1146/annurev-physiol-031422-092315] [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] [Indexed: 01/07/2023]
Abstract
Coughing is a dynamic physiological process resulting from input of vagal sensory neurons innervating the airways and perceived airway irritation. Although cough serves to protect and clear the airways, it can also be exploited by respiratory pathogens to facilitate disease transmission. Microbial components or infection-induced inflammatory mediators can directly interact with sensory nerve receptors to induce a cough response. Analysis of cough-generated aerosols and transmission studies have further demonstrated how infectious disease is spread through coughing. This review summarizes the neurophysiology of cough, cough induction by respiratory pathogens and inflammation, and cough-mediated disease transmission.
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Affiliation(s)
- Kubra F Naqvi
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA;
| | - Stuart B Mazzone
- Department of Anatomy and Physiology, University of Melbourne, Victoria, Australia
| | - Michael U Shiloh
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA;
- Department of Microbiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Ahmad SR, Iyer VN. The Evolving Clinical Practice of Chronic Cough. Mayo Clin Proc 2022; 97:1164-1175. [PMID: 35483988 DOI: 10.1016/j.mayocp.2022.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 12/13/2021] [Accepted: 02/09/2022] [Indexed: 11/24/2022]
Abstract
Chronic cough, defined as a cough lasting for greater than 8 weeks, accounts for a substantial number of primary care and specialist consultations in the United States. Although cough can arise from a myriad number of serious respiratory diseases, attention has traditionally focused on diagnosing and treating gastroesophageal reflux, upper airway cough syndrome, and eosinophilic airway inflammation (asthma and nonasthmatic eosinophilic bronchitis) in patients with normal chest imaging. The newly described paradigm and entity of cough hypersensitivity syndrome (CHS) becomes useful when the etiology of cough remains elusive or when the cough remains refractory despite appropriate therapy for underlying causes. We present an update on the evolving understanding of refractory chronic cough and/or unexplained chronic cough as manifestations of laryngeal hypersensitivity and CHS. This includes a focus on understanding the pathophysiology underlying current and novel therapeutics for CHS, while also ensuring that common causes of chronic cough continue to be evaluated and treated in a systematic multidisciplinary manner.
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Affiliation(s)
- Sumera R Ahmad
- Division of Pulmonary and Critical Care, Mayo Clinic, Rochester, MN, USA.
| | - Vivek N Iyer
- Division of Pulmonary and Critical Care, Mayo Clinic, Rochester, MN, USA
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Structural and Functional Correlates of Higher Cortical Brain Regions in Chronic Refractory Cough. Chest 2022; 162:851-860. [DOI: 10.1016/j.chest.2022.04.141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 04/05/2022] [Accepted: 04/22/2022] [Indexed: 01/10/2023] Open
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Liang H, Zhi H, Ye W, Wang Z, Liang J, Yi F, Kong X, Jiang M, Chen R, Lai K. Risk factors of chronic cough in China: a systematic review and meta-analysis. Expert Rev Respir Med 2022; 16:575-586. [PMID: 35271782 DOI: 10.1080/17476348.2022.2049759] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Risk factors of chronic cough in China have not been systematically analyzed and we hypothesized that risk factors of chronic cough might have distinct characteristics in China. Hence, we performed this meta-analysis focusing on the potential risk factors of chronic cough in China. METHODS We searched 7 databases for studies published before May 8, 2021. This systematic review was performed in accordance with the PRISMA checklist. RESULTS A total of 33 eligible articles were identified and included in this systematic review, and 28 studies were included in the meta-analysis. Our results showed that allergy (OR: 3.72; 95% CI: 1.85-7.47), nasal/sinusitis diseases (OR: 3.56; 95% CI: 2.02-6.29), family history of allergy (OR = 1.74; 95% CI: 1.59-1.90), family history of chronic respiratory diseases (OR = 1.67; 95% CI: 1.47-1.91), exposure to pollutants (OR = 1.60; 95% CI: 1.26-2.04), passive smoking (OR = 1.44; 95% CI: 1.32-1.57), and exposure to pets (OR = 1.37; 95% CI: 1.18-1.58) were risk factors for chronic cough in China. CONCLUSIONS Our study indicated some potential risk factors of chronic cough in China, which provides useful epidemiological information for managing chronic cough in China and is worthy as a reference for future global investigations.
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Affiliation(s)
- Hanwen Liang
- National Clinical Research Center for Respiratory Disease, State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou Medical University, Guangzhou, Guangdong, 510120, China.,Guangzhou Blood Center, Guangzhou, Guangdong, 510095, China
| | - Haopeng Zhi
- National Clinical Research Center for Respiratory Disease, State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou Medical University, Guangzhou, Guangdong, 510120, China
| | - Weiyan Ye
- National Clinical Research Center for Respiratory Disease, State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou Medical University, Guangzhou, Guangdong, 510120, China
| | - Zhufeng Wang
- National Clinical Research Center for Respiratory Disease, State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou Medical University, Guangzhou, Guangdong, 510120, China
| | - Jingyi Liang
- National Clinical Research Center for Respiratory Disease, State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou Medical University, Guangzhou, Guangdong, 510120, China
| | - Fang Yi
- National Clinical Research Center for Respiratory Disease, State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou Medical University, Guangzhou, Guangdong, 510120, China
| | - Xuetao Kong
- National Clinical Research Center for Respiratory Disease, State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou Medical University, Guangzhou, Guangdong, 510120, China
| | - Mei Jiang
- National Clinical Research Center for Respiratory Disease, State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou Medical University, Guangzhou, Guangdong, 510120, China
| | - Ruchong Chen
- National Clinical Research Center for Respiratory Disease, State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou Medical University, Guangzhou, Guangdong, 510120, China
| | - Kefang Lai
- National Clinical Research Center for Respiratory Disease, State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou Medical University, Guangzhou, Guangdong, 510120, China
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Slovarp LJ, Reynolds JE, Emma BD, Sarah P, Sarah C, Paige M. Cough desensitization treatment: A randomized, sham-controlled pilot trial for patients with refractory chronic cough. Respir Med 2022; 193:106739. [PMID: 35091204 PMCID: PMC8881373 DOI: 10.1016/j.rmed.2022.106739] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 01/05/2022] [Accepted: 01/09/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND The purpose of this study was to determine feasibility of treating refractory chronic cough (RCC) with progressive doses of capsaicin paired with cough suppression. METHODS In this sham-controlled, parallel RCT, 14 adults with RCC were randomly assigned to either behavioral cough suppression therapy (BCST) plus 6 treatment sessions involving exposure to nebulized capsaicin in progressively larger concentrations while actively suppressing cough (n = 8), or BCST plus 6 sessions of exposure to a single subthreshold dose of capsaicin (sham; n = 6). The Leicester Cough Questionnaire (LCQ) was the primary outcome measure. Urge-to-cough (UTC) testing, measuring both UTC and cough frequency, served as secondary outcome measures. Data was analyzed with mixed effects linear regression and follow-up contrasts. RESULTS Results on all measures favored the treatment group; however, there was only strong evidence of a difference in treatment effect on cough frequency during UTC testing. Mean change in LCQ at 3-weeks post treatment was 2.95 and 1.75 (p = .23), in the treatment and sham groups, respectively. Cough frequency during UTC testing reduced by 97% and 56% (p < .0001) at three weeks post, respectively. Within-group comparisons revealed strong evidence of change in the treatment group (p < .001) and moderate evidence of a change in the sham group (p = .08) in LCQ. CONCLUSIONS Conclusions from this study are limited due to the very small sample size; however, the study provides feasibility and proof-of-concept evidence to support further investigation of treating RCC with repeated exposure to nebulized capsaicin paired with BCST.
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Affiliation(s)
| | - Jane E. Reynolds
- School of Speech, Language, Hearing, & Occupational Sciences,
University of Montana, 32 Campus Dr., Missoula, MT, USA
| | - Bozarth-Dailey Emma
- School of Speech, Language, Hearing, & Occupational Sciences,
University of Montana, 32 Campus Dr., Missoula, MT, USA
| | - Popp Sarah
- School of Speech, Language, Hearing, & Occupational Sciences,
University of University of Montana, 32 Campus Dr., Missoula, MT, USA
| | - Campbell Sarah
- School of Speech, Language, Hearing, & Occupational Sciences,
University of Montana, 32 Campus Dr., Missoula, MT, USA
| | - Morkrid Paige
- School of Speech, Language, Hearing, & Occupational Sciences,
University of Montana, 32 Campus Dr., Missoula, MT, USA
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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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Al-Kandery ASA, Rao MS, El-Hashim AZ. Prostaglandin E 2 sensitizes the cough reflex centrally via EP3 receptor-dependent activation of NaV 1.8 channels. Respir Res 2021; 22:296. [PMID: 34794450 PMCID: PMC8603488 DOI: 10.1186/s12931-021-01889-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 11/05/2021] [Indexed: 11/29/2022] Open
Abstract
Background Cough hypersensitivity is a major characteristic feature associated with several types of cough, including chronic cough, but its underlying mechanisms remain to be fully understood. Inflammatory mediators, such as prostaglandin E2 (PGE2), have been implicated in both peripheral induction and sensitization of the cough reflex. In this study, using a conscious guinea pig model of cough, we investigated whether PGE2 can sensitize the cough reflex via central actions and, if so, via which mechanisms. Methods All drugs were administered by intracerebroventricular (i.c.v.) route and whole-body plethysmograph set-up was used for both induction, using aerosolized citric acid (0.2 M), and recording of cough. Immunohistochemistry was performed to confirm the expression of NaV 1.8 channels in the nucleus tractus solitarius (nTS). Results We show that both PGE2 and the non-selective EP1/EP3 agonist, sulprostone, dose-dependently enhanced the citric acid-induced cough (P ≤ 0.001, P ≤ 0.01, respectively). Pretreatment with the EP1 antagonist, ONO-8130, did not affect the sulprostone-induced cough sensitization, whilst the EP3 antagonist, L-798,106, dose-dependently inhibited this effect (P ≤ 0.05). Furthermore, treatment with either the EP2 agonist, butaprost or the EP4 agonist, L-902,688, had no effect on cough sensitization. Additionally, pretreatment with either the TRPV1 antagonist, JNJ-17203212 or the TRPA1 antagonist, HC-030031, alone or in combination, nor with the NaV 1.1, 1.2, 1.3, 1.4, 1.6 and 1.7 channel blocker, tetrodotoxin, had any effect on the cough. In contrast, pretreatment with the NaV 1.8 antagonist, A-803467, dose-dependently inhibited this effect (P ≤ 0.05). Furthermore, NaV 1.8 channels were shown to be expressed in the nTS. Conclusion Collectively, our findings show that PGE2 sensitizes the cough reflex centrally via EP3 receptor-dependent activation of NaV 1.8 but independently of TRPV1,TRPA1 and TTX-sensitive sodium channel activation. These results indicate that PGE2 plays an important role in central sensitization of the cough reflex and suggest that central EP3 receptors and/or NaVv 1.8 channels may represent novel antitussive molecular targets. Graphical Abstract ![]()
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Affiliation(s)
- Al-Shaimaa A Al-Kandery
- Department of Pharmacology & Therapeutics, Faculty of Pharmacy, Kuwait University, Kuwait City, Kuwait
| | - Muddanna S Rao
- Department of Anatomy, Faculty of Medicine, Kuwait University, Kuwait City, Kuwait
| | - Ahmed Z El-Hashim
- Department of Pharmacology & Therapeutics, Faculty of Pharmacy, Kuwait University, Kuwait City, Kuwait.
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Rodríguez-Torres J, López-López L, Cabrera-Martos I, Torres-Sánchez I, Prados-Román E, Ortíz-Rubio A, Valenza MC. Symptom severity is associated with signs of central sensitization in patients with asthma. CLINICAL RESPIRATORY JOURNAL 2021; 15:1219-1226. [PMID: 34328269 DOI: 10.1111/crj.13429] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 07/22/2021] [Accepted: 07/22/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Asthma is characterized by recurrent episodes of wheezing, dyspnoea, chest tightness and cough. In addition to respiratory symptoms, previous studies have reported the presence of pain. OBJECTIVE To analyse the nociceptive processing of young adults with well-controlled asthma. METHODS A cross-sectional case-control study was performed. Patients diagnosed with persistent well-controlled asthma were recruited from the 'Complejo Hospitalario Universitario' (Granada). Main outcomes included pain processing, measured by the pressure-pain thresholds (PPTs) and temporal summation and latency of pain; symptoms, including cough (Leicester Cough Questionnaire) and dyspnoea (Borg scale); and catastrophic cognitions about breathlessness, assessed by the Breathlessness Catastrophizing Scale (BCS). RESULTS Seven-two participants were finally recruited in our study. Patients with asthma presented lower pressure thresholds (p < 0.05) and significant differences in latency and summation tests. These patients also presented a greater cough level, with significant differences in all subscales (p < 0.05). Significant differences were also found in the BCS between groups (p < 0.001). CONCLUSION Our results show a decrease of PPTs and a greater pain intensity in latency and summation tests, suggesting an abnormal pain processing in patients with asthma.
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Affiliation(s)
- Janet Rodríguez-Torres
- Department of Physical Therapy, Faculty of Health Sciences, University of Granada, Granada, Spain
| | - Laura López-López
- Department of Physical Therapy, Faculty of Health Sciences, University of Granada, Granada, Spain
| | - Irene Cabrera-Martos
- Department of Physical Therapy, Faculty of Health Sciences, University of Granada, Granada, Spain
| | - Irene Torres-Sánchez
- Department of Physical Therapy, Faculty of Health Sciences, University of Granada, Granada, Spain
| | - Esther Prados-Román
- Department of Physical Therapy, Faculty of Health Sciences, University of Granada, Granada, Spain
| | - Araceli Ortíz-Rubio
- Department of Physical Therapy, Faculty of Health Sciences, University of Granada, Granada, Spain
| | - Marie C Valenza
- Department of Physical Therapy, Faculty of Health Sciences, University of Granada, Granada, Spain
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Satia I, Cusack R, Stevens C, Schlatman A, Wattie J, Mian F, Killian KJ, O'Byrne PM, Bienenstock J, Forsythe P, Gauvreau GM. Limosilactobacillus reuteri DSM-17938 for preventing cough in adults with mild allergic asthma: A double-blind randomized placebo-controlled cross-over study. Clin Exp Allergy 2021; 51:1133-1143. [PMID: 34192396 DOI: 10.1111/cea.13976] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 06/27/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Cough is a common troublesome symptom in asthma which is neuronally mediated. Limosilactobacillus reuteri DSM-17938 (L. reuteri DSM-17938) is a probiotic shown to be effective in pre-clinical models at suppressing neuronal responses to capsaicin, a transient receptor potential vanilloid agonist (TRPV1). OBJECTIVE Investigate the effects of DSM-17938 versus matched placebo on capsaicin-evoked coughs in mild allergic asthmatics. METHODS We performed a 4-visit, randomized, double-blind, placebo-controlled, two-way cross-over study comparing full dose cough responses with inhaled capsaicin in mild allergic asthmatics after 1 month of treatment with DSM-17938 compared with matched placebo. Randomization and allocation to trial group were carried out by a central computer system. Histamine skin prick testing, airway hyper-responsiveness and inflammatory cells in induced sputum were measured at every visit. Blood was collected to extract PBMCs and stimulated with CD3/CD28 to ascertain the effects of DSM-17938 /placebo on T-cell cytokine responses. RESULTS Seventeen subjects were recruited and 15 completed the study (8 females, mean age 27.3 years). There was no difference in the change in maximum capsaicin-evoked coughs (Emax) after treatment with L. reuteri DSM-17938 compared with placebo [mean difference 2.07 coughs (95% CI -2.77 to 6.91, p = .38) or relative changes in geometric mean ratios for the dose evoking at least half the Emax (ED50) [1.05 (95% CI 0.31-3.58, p = .94)], concentration evoking 2 coughs (C2) [0.63 (0.26-1.53), p = .28] and 5 coughs (C5) [0.79 (0.25-2.50), p = .67]. There was no effect on histamine skin prick wheal size, intensity of itch sensation, methacholine PC20, airway inflammation or T-cell responses after stimulation with CD3/CD28. There were no serious adverse events. One subject developed a mild upper respiratory tract infection and another mild transient nausea whilst on DSM-17938. CONCLUSION In this small study in adults with mild allergic asthma, we found no evidence that L. reuteri DSM-17938 has any systemic effects on airway nerves, smooth muscle, sputum inflammatory cells, skin responses or T-cell responses after oral consumption. TRIAL REGISTRATION Clinicaltrials.gov Identifier: NCT03603522.
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Affiliation(s)
- Imran Satia
- Division of Respirology, Department of Medicine, McMaster University, Hamilton, ON, Canada.,Firestone Institute for Respiratory Health, St Joseph's Healthcare, Hamilton, ON, Canada
| | - Ruth Cusack
- Division of Respirology, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Catie Stevens
- Division of Respirology, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Abbey Schlatman
- Division of Respirology, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Jennifer Wattie
- Division of Respirology, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Firoz Mian
- Division of Respirology, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Kieran J Killian
- Division of Respirology, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Paul M O'Byrne
- Division of Respirology, Department of Medicine, McMaster University, Hamilton, ON, Canada.,Firestone Institute for Respiratory Health, St Joseph's Healthcare, Hamilton, ON, Canada
| | - John Bienenstock
- Division of Respirology, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Paul Forsythe
- Division of Respirology, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Gail M Gauvreau
- Division of Respirology, Department of Medicine, McMaster University, Hamilton, ON, Canada
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Song WJ, Hui CKM, Hull JH, Birring SS, McGarvey L, Mazzone SB, Chung KF. Confronting COVID-19-associated cough and the post-COVID syndrome: role of viral neurotropism, neuroinflammation, and neuroimmune responses. THE LANCET. RESPIRATORY MEDICINE 2021; 9:533-544. [PMID: 33857435 PMCID: PMC8041436 DOI: 10.1016/s2213-2600(21)00125-9] [Citation(s) in RCA: 154] [Impact Index Per Article: 51.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 02/15/2021] [Accepted: 02/21/2021] [Indexed: 01/08/2023]
Abstract
Cough is one of the most common presenting symptoms of COVID-19, along with fever and loss of taste and smell. Cough can persist for weeks or months after SARS-CoV-2 infection, often accompanied by chronic fatigue, cognitive impairment, dyspnoea, or pain-a collection of long-term effects referred to as the post-COVID syndrome or long COVID. We hypothesise that the pathways of neurotropism, neuroinflammation, and neuroimmunomodulation through the vagal sensory nerves, which are implicated in SARS-CoV-2 infection, lead to a cough hypersensitivity state. The post-COVID syndrome might also result from neuroinflammatory events in the brain. We highlight gaps in understanding of the mechanisms of acute and chronic COVID-19-associated cough and post-COVID syndrome, consider potential ways to reduce the effect of COVID-19 by controlling cough, and suggest future directions for research and clinical practice. Although neuromodulators such as gabapentin or opioids might be considered for acute and chronic COVID-19 cough, we discuss the possible mechanisms of COVID-19-associated cough and the promise of new anti-inflammatories or neuromodulators that might successfully target both the cough of COVID-19 and the post-COVID syndrome.
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Affiliation(s)
- Woo-Jung Song
- Department of Allergy and Clinical Immunology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | | | - James H Hull
- Department of Respiratory Medicine, Royal Brompton and Harefield NHS Trust, London, UK
| | - Surinder S Birring
- Centre for Human & Applied Physiological Sciences, School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Lorcan McGarvey
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Stuart B Mazzone
- Department of Anatomy and Physiology, University of Melbourne, VIC, Australia
| | - Kian Fan Chung
- Department of Respiratory Medicine, Royal Brompton and Harefield NHS Trust, London, UK; Experimental Studies Unit, National Heart & Lung Institute, Imperial College London, UK.
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Kunc P, Fabry J, Lucanska M, Zatko T, Grendar M, Pecova R. Cough Reflex Sensitivity in Asthmatic Children. Physiol Res 2021; 69:S147-S150. [PMID: 32228020 DOI: 10.33549/physiolres.934399] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
New knowledge about the neural aspects of cough has revealed a complex network of pathways that initiate cough. The effect of inflammation on cough neural processing occurs at multiple peripheral and central sites within the nervous system. Evidence exists that direct or indirect neuroimmune interaction induces a complex response, which can be altered by mediators released by the sensory or parasympathetic neurons and vice versa. The aim of this study was to clarify changes of cough reflex sensitivity - the activity of airway afferent nerve endings - in asthmatic children.25 children with asthma and 15 controls were submitted to cough reflex sensitivity measurement - capsaicin aerosol in doubling concentrations (from 0.61 to 1250 µmol/l) was inhaled by a single breath method. Concentrations of capsaicin causing two (C2) and five coughs (C5) were reported. Asthmatic children' (11 boys and 14 girls, mean age 9 ± 1 yrs) cough reflex sensitivity (geometric mean, with the 95 % CI) for C2 was 4.25 (2.25-8.03) µmol/l vs. control C2 (6 boys and 9 girls, mean age 8 ± 1 yrs) was 10.61 (5.28-21.32) µmol/l (p=0.024). Asthmatic children' C5 was 100.27 (49.30-203.93) µmol/l vs. control C5 56.53 (19.69-162.35) µmol/l (p=0.348). There was a statistically significant decrease of C2 (cough threshold) in the asthmatic patients relative to controls (p-value for the two-sample t-test of log(C2) for the one-sided alternative, p-value = 0.024). The 95 % confidence interval for the difference of the mean C2 in asthma vs. control, [1.004, 6.207]. For C5, the difference was not statistically significant (p-value = 0.348). There was a statistically significant decrease of cough reflex sensitivity (the activity of airway afferent nerve endings) - C2 value in the asthmatic children relative to controls.
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Affiliation(s)
- P Kunc
- Department of Pathological Physiology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak
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Behrens R, McGovern AE, Farrell MJ, Moe AAK, Mazzone SB. Mini Review: Central Organization of Airway Afferent Nerve Circuits. Neurosci Lett 2020; 744:135604. [PMID: 33387662 DOI: 10.1016/j.neulet.2020.135604] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 12/16/2020] [Accepted: 12/21/2020] [Indexed: 10/22/2022]
Abstract
Airway afferents monitor the local chemical and physical micro-environments in the airway wall and lungs and send this information centrally to regulate neural circuits involved in setting autonomic tone, evoking reflex and volitional respiratory motor outflows, encoding perceivable sensations and contributing to higher order cognitive processing. In this mini-review we present a current overview of the central wiring of airway afferent circuits in the brainstem and brain, highlighting recent discoveries that augment our understanding of airway sensory processing. We additionally explore how advances in describing the molecular diversity of airway afferents may influence future research efforts aimed at defining central mesoscale connectivity of airway afferent pathways. A refined understanding of how functionally distinct airway afferent pathways are organized in the brain will provide deeper insight into the physiology of airway afferent-evoked responses and may foster opportunities for targeted modulation of specific pathways involved in disease.
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Affiliation(s)
- Robert Behrens
- Department of Anatomy and Neuroscience, School of Biomedical Science, The University of Melbourne, Parkville, Australia
| | - Alice E McGovern
- Department of Anatomy and Neuroscience, School of Biomedical Science, The University of Melbourne, Parkville, Australia
| | - Michael J Farrell
- Department of Medical Imaging and Radiation Sciences, Monash University, Clayton, Australia; Monash Biomedical Imaging, Monash University, Clayton, Australia
| | - Aung Aung Kywe Moe
- Department of Anatomy and Neuroscience, School of Biomedical Science, The University of Melbourne, Parkville, Australia
| | - Stuart B Mazzone
- Department of Anatomy and Neuroscience, School of Biomedical Science, The University of Melbourne, Parkville, Australia.
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Pain Perception, Brain Connectivity, and Neurochemistry in Healthy, Capsaicin-Sensitive Subjects. Neural Plast 2020; 2020:9125913. [PMID: 33178262 PMCID: PMC7644335 DOI: 10.1155/2020/9125913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 09/29/2020] [Accepted: 10/16/2020] [Indexed: 11/17/2022] Open
Abstract
Most of the occupational exposure limits (OELs) are based on local irritants. However, exposure to much lower concentrations of irritant substances can also lead to health complaints from workers. Exposure to irritants is often accompanied by strong unpleasant odors, and strong odors might have distracting effects and hence pose a safety risk. The findings obtained in human exposure studies with chemically sensitive, stressed, or anxious persons suggest that their ability to direct attention away from the odorous exposure and to focus on a cognitive task is reduced. In addition, after repeated odor exposure, these persons show signs of sensitization, i.e., difficulties in ignoring or getting used to the exposure. The question arises as to whether certain health conditions are accompanied by a change in sensitivity to odors and irritants, so that these persons are potentially more distracted by odors and irritants and therefore more challenged in working memory tasks than nonsusceptible persons. In our study, susceptible persons with sensory airway hyperreactivity ("capsaicin-sensitive") respond more strongly to mechanical skin stimuli than controls and show altered network connectivity. Capsaicin-sensitive subjects have a lower pain threshold and thus are more sensitive to mechanical skin stimuli. The intrinsic functional connectivity of their saliency network is higher, and the lower the GABAergic tone of the thalamus, the higher their pain sensitivity to mechanical stimuli. It seems that the increased communication between resting-state networks promotes a stronger perception of the sensory input signal. The results can be used to inform about actual risks (i.e., attention diversion and increased risk of accidents) and "pseudo" risks such as odor perception without a negative impact on one's well-being. This way, uncertainties that still prevail in the health assessment of odorous and sensory irritating chemicals could be reduced.
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Grabczak EM, Dabrowska M, Birring SS, Krenke R. Looking ahead to novel therapies for chronic cough. Part 1 - peripheral sensory nerve targeted treatments. Expert Rev Respir Med 2020; 14:1217-1233. [PMID: 32804594 DOI: 10.1080/17476348.2020.1811686] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Due to a relatively high prevalence and negative impact on quality of life chronic cough (CC) is a challenge for both patients and clinicians. There is ongoing research to address the unmet need and develop more effective antitussive treatment options. This is the first part of a series of two reviews of new antitussive medications. Medical databases (Medline, Embase and SCOPUS) and trial registries (ClinicalTrials.gov and EudraCT) were searched for studies on antitussive drugs targeting peripheral sensory nerves. AREAS COVERED This review presents current knowledge of peripheral receptors that are not only involved in evoking the cough reflex, but are also potentially responsible for more sustained neural alterations. Blockage of the receptors and ion channels is discussed in terms of its potential antitussive effect. EXPERT OPINION Although better understanding of CC mechanisms has facilitated the development of novel treatments including P2X2/3 receptor inhibitors (e.g. gefapixant), there remain several gaps in the knowledge about the mechanisms and treatment of CC. These include the lack of tests to diagnose cough hypersensitivity syndrome and predictors of response to specific treatments. Further research into cough phenotypes and endotypes will yield important insights and a personalized approach to cough management.
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Affiliation(s)
- Elzbieta M Grabczak
- Department of Internal Medicine, Pulmonary Diseases and Allergy, Medical University of Warsaw , Warsaw, Poland
| | - Marta Dabrowska
- Department of Internal Medicine, Pulmonary Diseases and Allergy, Medical University of Warsaw , Warsaw, Poland
| | - Surinder S Birring
- Centre for Human & Applied Physiological Sciences, School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine, King's College London , London, UK
| | - Rafal Krenke
- Department of Internal Medicine, Pulmonary Diseases and Allergy, Medical University of Warsaw , Warsaw, Poland
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21
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La tos crónica refractaria en la encrucijada. Arch Bronconeumol 2020; 56:545-546. [DOI: 10.1016/j.arbres.2019.11.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 11/13/2019] [Accepted: 11/14/2019] [Indexed: 11/20/2022]
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Singh N, Driessen AK, McGovern AE, Moe AAK, Farrell MJ, Mazzone SB. Peripheral and central mechanisms of cough hypersensitivity. J Thorac Dis 2020; 12:5179-5193. [PMID: 33145095 PMCID: PMC7578480 DOI: 10.21037/jtd-2020-icc-007] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Chronic cough is a difficult to treat symptom of many respiratory and some non-respiratory diseases, indicating that varied pathologies can underpin the development of chronic cough. However, clinically and experimentally it has been useful to collate these different pathological processes into the single unifying concept of cough hypersensitivity. Cough hypersensitivity syndrome is reflected by troublesome cough often precipitated by levels of stimuli that ordinarily don't cause cough in healthy people, and this appears to be a hallmark feature in many patients with chronic cough. Accordingly, a strong argument has emerged that changes in the excitability and/or normal regulation of the peripheral and central neural circuits responsible for cough are instrumental in establishing cough hypersensitivity and for causing excessive cough in disease. In this review, we explore the current peripheral and central neural mechanisms that are believed to be involved in altered cough sensitivity and present possible links to the mechanism of action of novel therapies that are currently undergoing clinical trials for chronic cough.
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Affiliation(s)
- Nabita Singh
- Department of Medical Imaging and Radiation Sciences, Monash University, Clayton, Australia
| | - Alexandria K. Driessen
- Department of Anatomy and Neuroscience, School of Biomedical Science, The University of Melbourne, Parkville, Australia
| | - Alice E. McGovern
- Department of Anatomy and Neuroscience, School of Biomedical Science, The University of Melbourne, Parkville, Australia
| | - Aung Aung Kywe Moe
- Department of Anatomy and Neuroscience, School of Biomedical Science, The University of Melbourne, Parkville, Australia
| | - Michael J. Farrell
- Department of Medical Imaging and Radiation Sciences, Monash University, Clayton, Australia
- Monash Biomedical Imaging, Monash University, Clayton, Australia
| | - Stuart B. Mazzone
- Department of Anatomy and Neuroscience, School of Biomedical Science, The University of Melbourne, Parkville, Australia
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Spanevello A, Beghé B, Visca D, Fabbri LM, Papi A. Chronic cough in adults. Eur J Intern Med 2020; 78:8-16. [PMID: 32434660 DOI: 10.1016/j.ejim.2020.03.018] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 03/17/2020] [Accepted: 03/19/2020] [Indexed: 12/12/2022]
Abstract
Cough, a defense mechanism for clearing the airways of secretions, exudate, or foreign bodies, may become a troublesome symptom. Chronic cough, one of the most frequent symptoms requiring medical attention, is often not due to identifiable causes in adults. Chronic productive cough defines chronic bronchitis, and thus is present in 100% of these patients, and frequently in patients with bronchiectasis, cystic fibrosis, and chronic infectious respiratory diseases. However, chronic cough is most frequently dry. Thus, chronic cough in adults is a difficult syndrome requiring multidisciplinary approaches, particularly to diagnose and treat the most frequent identifiable causes, but also to decide which patients may benefit by treating the central cough hypersensitivity by neuromodulatory therapy and/or non-pharmacologic treatment (speech pathology therapy). Recent guidelines provide algorithms for diagnosis and assessment of cough severity; particularly chronic cough in adults. After excluding life-threatening diseases, chronic cough due to identifiable causes (triggers and/or diseases), particularly smoking and/or the most frequent diseases (asthma, chronic bronchitis, chronic obstructive pulmonary disease, eosinophilic bronchitis, and adverse reactions to drugs [angiotensin-converting enzyme inhibitors and sitagliptin]) should be treated by avoiding triggers and/or according to guidelines for each underlying disease. In patients with troublesome chronic cough due to unknown causes or persisting even after adequate avoidance of triggers, and/or treatment of the underlying disease(s), a symptomatic approach with neuromodulators and/or speech pathology therapy should be considered. Additional novel promising neuromodulatory agents in clinical development (e.g., P2X3 inhibitors) will hopefully become available in the near future.
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Affiliation(s)
- Antonio Spanevello
- Istituti Clinici Scientifici Maugeri IRCCS, Respiratory Rehabilitation of the Institute of Tradate, Tradate, Varese, Italy; Department of Medicine and Surgery, Respiratory Diseases, University of Insubria, Varese-Como, Italy
| | - Bianca Beghé
- Department of Medicine, Section of Respiratory Diseases, University of Modena and Reggio Emilia, Modena, Italy
| | - Dina Visca
- Istituti Clinici Scientifici Maugeri IRCCS, Respiratory Rehabilitation of the Institute of Tradate, Tradate, Varese, Italy; Department of Medicine and Surgery, Respiratory Diseases, University of Insubria, Varese-Como, Italy
| | - Leonardo M Fabbri
- Azienda Ospedaliera Universitaria, Department of Medical Sciences, Section of Cardiorespiratory and Internal Medicine, University of Ferrara, Via Aldo Moro 8, 44124 Cona Ferrara, Italy.
| | - Alberto Papi
- Azienda Ospedaliera Universitaria, Department of Medical Sciences, Section of Cardiorespiratory and Internal Medicine, University of Ferrara, Via Aldo Moro 8, 44124 Cona Ferrara, Italy
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Driessen AK, Devlin AC, Lundy FT, Martin SL, Sergeant GP, Mazzone SB, McGarvey LP. Perspectives on neuroinflammation contributing to chronic cough. Eur Respir J 2020; 56:13993003.00758-2020. [DOI: 10.1183/13993003.00758-2020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 06/30/2020] [Indexed: 02/07/2023]
Abstract
Chronic cough can be a troublesome clinical problem. Current thinking is that increased activity and/or enhanced sensitivity of the peripheral and central neural pathways mediates chronic cough via processes similar to those associated with the development of chronic pain. While inflammation is widely thought to be involved in the development of chronic cough, the true mechanisms causing altered neural activity and sensitisation remain largely unknown. In this back-to-basics perspective article we explore evidence that inflammation in chronic cough may, at least in part, involve neuroinflammation orchestrated by glial cells of the nervous system. We summarise the extensive evidence for the role of both peripheral and central glial cells in chronic pain, and hypothesise that the commonalities between pain and cough pathogenesis and clinical presentation warrant investigations into the neuroinflammatory mechanisms that contribute to chronic cough. We open the debate that glial cells may represent an underappreciated therapeutic target for controlling troublesome cough in disease.
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Klimek L, Kardos P. [Cough following airway infections]. MMW Fortschr Med 2020; 162:35-42. [PMID: 32221870 DOI: 10.1007/s15006-020-0007-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Ludger Klimek
- Zentrum für Rhinologie und Allergologie, An den Quellen 10, D-65183, Wiesbaden, Deutschland.
| | - Peter Kardos
- Pneumologische Gemeinschaftspraxis Frankfurt, Deutschland
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Tamasauskiene L, Sitkauskiene B. Immune system in the pathogenesis of chronic cough. Immunol Lett 2019; 218:40-43. [PMID: 31901376 DOI: 10.1016/j.imlet.2019.12.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 12/17/2019] [Accepted: 12/30/2019] [Indexed: 02/07/2023]
Abstract
Chronic cough is a common symptom of various chronic diseases. However, the vast majority of individuals with conditions that are commonly associated with cough, such as asthma and GERD, do not have chronic cough. This implies that cough reflex sensitivities differ among individuals. It is known that in the pathogenesis of cough, the nervous system plays a vital role. Recently more information about the role of the immune system and its interaction with the nervous system in the pathogenesis of cough has appeared in the literature. The aim of this article is to review the most recent data about the role of the immune system in the pathogenesis of chronic cough.
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Affiliation(s)
- Laura Tamasauskiene
- Department of Immunology and Allergology, Lithuanian University of Health Sciences, Lithuania.
| | - Brigita Sitkauskiene
- Department of Immunology and Allergology, Lithuanian University of Health Sciences, Lithuania
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Morjaria JB, Rigby AS, Morice AH. Symptoms and exacerbations in asthma: an apparent paradox? Ther Adv Chronic Dis 2019; 10:2040622319884387. [PMID: 31695864 PMCID: PMC6820175 DOI: 10.1177/2040622319884387] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Accepted: 09/27/2019] [Indexed: 12/23/2022] Open
Abstract
Background: There is a dearth of data on prospectively recorded symptoms in patients with uncontrolled asthma. Asthma symptoms and exacerbation rate are commonly thought to be associated. The aim of this study was to analyse asthma symptoms of cough, wheeze, chest tightness and breathlessness in an uncontrolled asthma cohort. We also examined the effect of maintenance and reliever therapy (MART) on these symptoms and its effect on exacerbation rate. Methods: Adults with uncontrolled asthma electronically recorded their asthma symptom severity scores twice-daily over a period of 48 weeks following randomisation to beclometasone/formoterol twice daily plus pro re nata (prn) salbutamol or MART. Subjects with symptom scores of ⩾2 (ranging from 0 to 3 for each symptom) were considered more symptomatic, whereas those below a score of 2 were considered less severe. The influence treatment on exacerbation frequency and symptom profiles were then correlated. Results: Of the 1701 subjects in the analyses, 1403 were symptomatic with ⩾100 symptom episodes for one symptom. The remaining 298 subjects were classified as pauci-symptomatic. There was poor association between the frequency and symptom severity score for each symptom. Surprisingly, wheeze was the least reported symptom. Females were more likely to be polysymptomatic. MART compared with prn salbutamol markedly attenuated severe asthma exacerbations. This effect was most notable in subjects with fewer symptoms. Conclusions: In uncontrolled asthma, there is a poor correlation between reported symptoms and exacerbation frequency. This post hoc analysis suggests that MART should not be reserved for symptomatic subjects but achieves the greatest benefit in pauci-symptomatic patients with asthma. Trial registration: ClinicalTrials.gov identifier: NCT00861926
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Affiliation(s)
- Jaymin B. Morjaria
- Respiratory Medicine, Hull York Medical School, University of Hull, Castle Hill Hospital, Castle Road, Cottingham, UK
- Department of Respiratory Medicine, Royal Brompton and Harefield NHS Trust, Harefield Hospital, Hill End road, Harefield, UK
- Imperial College, Harefield Hospital, Hill End Road, Harefield, UK
| | - Alan S. Rigby
- Respiratory Medicine, Hull York Medical School, University of Hull, Castle Hill Hospital, Castle Road, Cottingham, UK
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Guilleminault L, Brouquières D, Didier A. [From acute cough to chronic cough in adults: Overview on a common reason for consultation]. Presse Med 2019; 48:353-364. [PMID: 30926203 DOI: 10.1016/j.lpm.2019.02.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 12/26/2018] [Accepted: 02/11/2019] [Indexed: 10/27/2022] Open
Abstract
Cough is divided into two categories: acute cough lasting less than 3 weeks, and chronic cough lasting more than 8 weeks. Acute cough is usually triggered by a viral infection of the upper airways. Evidence of treatment effectiveness is low and management of acute cough is complex in clinical practice. Chronic cough is a common reason for consultation in medicine. The most frequent causes are upper airway diseases, gastroesophageal reflux disease, asthma, eosinophilic bronchitis, and drugs. Before investigation, smoking cessation and drug withdrawal must be achieved for 4 to 6 weeks. Once this step is completed, simple investigations have to be performed in order to find common causes of chronic cough (questioning, physical examination, spirometry, chest X-ray). If no causes have been identified or cough remains despite optimal treatment, exhaustive exploration has to be performed to rule out rare causes. A chronic cough hypersensitivity syndrome is suggested if any causes have been found despite exhaustive assessment or if cough remains with optimal treatments. This syndrome is characterized by an increase in the sensitivity of cough peripheral receptors and is not sensitive to usual therapies. The therapeutic options are limited but innovative treatments such as P2X3 receptor antagonists are in development.
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Affiliation(s)
- Laurent Guilleminault
- CHU de Toulouse, hôpital Larrey, service de pneumologie, pôle des voies respiratoires, 31059 Toulouse, France; Université de Toulouse, CNRS ERL 5311, EFS, INP-ENVT, Inserm, UPS, STROMALab, 31330 Toulouse, France.
| | - Danielle Brouquières
- CHU de Toulouse, hôpital Larrey, service de pneumologie, pôle des voies respiratoires, 31059 Toulouse, France
| | - Alain Didier
- CHU de Toulouse, hôpital Larrey, service de pneumologie, pôle des voies respiratoires, 31059 Toulouse, France
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Kantar A, Seminara M. Why chronic cough in children is different. Pulm Pharmacol Ther 2019; 56:51-55. [PMID: 30851475 DOI: 10.1016/j.pupt.2019.03.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Revised: 02/27/2019] [Accepted: 03/01/2019] [Indexed: 12/11/2022]
Abstract
Recently, there have been robust changes in our knowledge of the neurophysiology of cough and novel clinical etiologies. Specifically, cough hypersensitivity in adults and protracted bacterial bronchitis (PBB) in children have been increasingly investigated, and differences between chronic cough in children and adults have been widely reported. In young children, postinfectious cough, bronchiectasis, airway malacia, PBB, and asthma appear to be the main causes of cough; however, by adolescence, the causes of cough are more likely to become those common in adults, namely, gastroesophageal reflux, asthma, and upper airway syndrome. These differences are attributed to changes in various characteristics of the respiratory tract, immune system, and nervous system between children and adults. New knowledge about the neural aspects of cough has revealed a complex network of pathways that initiate cough. The effect of inflammation on cough neural processing occurs at multiple peripheral and central sites within the nervous system. Evidence exists that direct or indirect neuroimmune interaction induces a complex response, which can be altered by mediators released by the sensory or parasympathetic neurons and vice versa. During childhood, the respiratory tract and the nervous system undergo a series of anatomical and physiological maturation processes that produce the cough neural circuits. Alterations provoked by various pathological processes, noxious agents, infection, and inflammation during the developmental period can lead to persistent or irreversible modifications, which may explain why many adult patients, in addition to expressing high cough sensitivity, remain refractive to disease-specific therapies.
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Affiliation(s)
- Ahmad Kantar
- Paediatric Asthma and Cough Centre, University and Research Hospitals, Gruppo Ospedaliero San Donato, Bergamo, Italy.
| | - Manuela Seminara
- Paediatric Asthma and Cough Centre, University and Research Hospitals, Gruppo Ospedaliero San Donato, Bergamo, Italy
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31
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Dicpinigaitis PV, Enilari O, Cleven KL. Prevalence of Arnold nerve reflex in subjects with and without chronic cough: Relevance to Cough Hypersensitivity Syndrome. Pulm Pharmacol Ther 2019; 54:22-24. [DOI: 10.1016/j.pupt.2018.11.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 11/12/2018] [Indexed: 12/17/2022]
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McGovern AE, Short KR, Kywe Moe AA, Mazzone SB. Translational review: Neuroimmune mechanisms in cough and emerging therapeutic targets. J Allergy Clin Immunol 2018; 142:1392-1402. [DOI: 10.1016/j.jaci.2018.09.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 09/12/2018] [Accepted: 09/18/2018] [Indexed: 12/27/2022]
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Driessen AK, Farrell MJ, Dutschmann M, Stanic D, McGovern AE, Mazzone SB. Reflex regulation of breathing by the paratrigeminal nucleus via multiple bulbar circuits. Brain Struct Funct 2018; 223:4005-4022. [PMID: 30116890 DOI: 10.1007/s00429-018-1732-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 08/04/2018] [Indexed: 01/06/2023]
Abstract
Sensory neurons of the jugular vagal ganglia innervate the respiratory tract and project to the poorly studied medullary paratrigeminal nucleus. In the present study, we used neuroanatomical tracing, pharmacology and physiology in guinea pig to investigate the paratrigeminal neural circuits mediating jugular ganglia-evoked respiratory reflexes. Retrogradely traced laryngeal jugular ganglia neurons were largely (> 60%) unmyelinated and expressed the neuropeptide substance P and calcitonin gene-related peptide, although a population (~ 30%) of larger diameter myelinated jugular neurons was defined by the expression of vGlut1. Within the brainstem, vagal afferent terminals were confined to the caudal two-thirds of the paratrigeminal nucleus. Electrical stimulation of the laryngeal mucosa evoked a vagally mediated respiratory slowing that was mimicked by laryngeal capsaicin application. These laryngeal reflexes were modestly reduced by neuropeptide receptor antagonist microinjections into the paratrigeminal nucleus, but abolished by ionotropic glutamate receptor antagonists. D,L-Homocysteic acid microinjections into the paratrigeminal nucleus mimicked the laryngeal-evoked respiratory slowing, whereas capsaicin microinjections evoked a persistent tachypnoea that was insensitive to glutamatergic inhibition but abolished by neuropeptide receptor antagonists. Extensive projections from paratrigeminal neurons were anterogradely traced throughout the pontomedullary respiratory column. Dual retrograde tracing from pontine and ventrolateral medullary termination sites, as well as immunohistochemical staining for calbindin and neurokinin 1 receptors, supported the existence of different subpopulations of paratrigeminal neurons. Collectively, these data provide anatomical and functional evidence for at least two types of post-synaptic paratrigeminal neurons involved in respiratory reflexes, highlighting an unrecognised complexity in sensory processing in this region of the brainstem.
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Affiliation(s)
- Alexandria K Driessen
- Department of Anatomy and Neuroscience, The University of Melbourne, Parkville, VIC, 3010, Australia.
| | - Michael J Farrell
- Department of Medical Imaging and Radiation Sciences, Monash Biomedicine Discovery Institute, Monash University, Clayton, VIC, 3800, Australia
| | - Mathias Dutschmann
- The Florey Institute for Neuroscience and Mental Health, The University of Melbourne, Parkville, VIC, 3010, Australia
| | - Davor Stanic
- The Florey Institute for Neuroscience and Mental Health, The University of Melbourne, Parkville, VIC, 3010, Australia
| | - Alice E McGovern
- Department of Anatomy and Neuroscience, The University of Melbourne, Parkville, VIC, 3010, Australia
| | - Stuart B Mazzone
- Department of Anatomy and Neuroscience, The University of Melbourne, Parkville, VIC, 3010, Australia.
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Zalvan C, Berzofsky C, Tiwari R, Geliebter J. Trigger Reduction Prior to Systemic Drugs for Neurogenic Chronic Cough. Laryngoscope 2018; 129:198-202. [PMID: 30098039 DOI: 10.1002/lary.27459] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 06/04/2018] [Accepted: 07/02/2018] [Indexed: 12/14/2022]
Abstract
OBJECTIVE/HYPOTHESIS Neurogenic chronic cough typically presents as a postviral chronic cough, often with paroxysms of coughing preceded by a tickle sensation with multiple triggers and often recalcitrant to multiple treatments for reflux disease, sinus disease, and asthma. Current treatment uses neuromodulating agents with moderate success. Post nasal drainage and laryngopharyngeal reflux can be triggers in the setting of laryngopharyngeal hypersensitivity. Treatment will focus on trigger reduction using nasal toilet and a dietary regimen for laryngopharyngeal reflux. STUDY DESIGN Systematic review of retrospective cohort studies METHODS: One-year retrospective review of new patients with cough (R05.0) excluding asthma, proton pump inhibitor response, and sinus or pulmonary disease. Cough severity index (CSI) and reflux symptom index (RSI) were evaluated initially and 6 weeks after trigger-reduction treatment using nasal saline irrigation, nasal steroids, nasal antihistamines, and a plant-based diet with alkaline water. RESULTS Of 119 patients, 29 met the criteria. Using the six-point reduction (improvement) in RSI as an accepted response, 20 of 29 patients (68.9%, P = .0014) experienced a clinical response. Using reduction in RSI and CSI as a continuous variable to assess response, patients experienced a 10 (95% confidence interval [CI]: 6.75-13.2) and 10.9 (95% CI: 7.4-14.3) mean point reduction, respectively. The mean percent reduction in RSI following 6 weeks of treatment was 54.7% (95% CI: 41.5-68.0; P = .0001). These patients experienced a 59.8% (95% CI: 43.4-76.2; P = .0001) reduction in CSI. CONCLUSIONS A trigger-reduction approach using nasal toilet and a plant-based diet in patients with neurogenic chronic cough prior to the initiation of systemic neuromodulating medications should be considered. LEVEL OF EVIDENCE 4 Laryngoscope, 129:198-202, 2019.
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Affiliation(s)
- Craig Zalvan
- Department of Otolaryngology, New York Medical College, Valhalla, New York, U.S.A
| | - Craig Berzofsky
- Department of Otolaryngology, New York Medical College, Valhalla, New York, U.S.A
| | - Raj Tiwari
- Department of Microbiology and Immunology, New York Medical College, Valhalla, New York, U.S.A
| | - Jan Geliebter
- Department of Otolaryngology, New York Medical College, Valhalla, New York, U.S.A.,Department of Microbiology and Immunology, New York Medical College, Valhalla, New York, U.S.A
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Bowen AJ, Huang TL, Nowacki AS, Trask D, Kaltenbach J, Taliercio R, Benninger MS, Milstein CF, Bryson PC. Tachyphylaxis and Dependence in Pharmacotherapy for Unexplained Chronic Cough. Otolaryngol Head Neck Surg 2018; 159:705-711. [PMID: 30016197 DOI: 10.1177/0194599818788062] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Objective Unexplained chronic cough (UCC) is a perplexing condition treated with neuromodulators. Although previous literature describes the effectiveness of neuromodulators, there is little on the development of tachyphylaxis or dependence to neuromodulators over time. Our objective is to capture the experience of a large cohort of patients with UCC over an extended period, looking for these 2 phenomena. Study Design Case series with chart review. Setting Tertiary care hospital. Subjects and Methods We performed a retrospective review of patients diagnosed with UCC from 2010 to 2014. Patient outcomes were measured through percentage improvement scores. Treatment failures were attributed to no benefit, intolerable side effects, or tachyphylaxis. Tachyphylaxis was defined as the need for higher doses of medication following diminishing therapeutic benefit, while dependence was defined as a failure to stop therapy following attempted de-escalation or resurgence following drug cessation. Results Sixty-eight patients were included in the study. Tachyphylaxis was observed among 35% of patients while dependence was observed among 27% of successfully treated patients, together effecting >50% of the cohort. Sixty-eight percent of patients ultimately experienced successful treatment with neuromodulators, demonstrating strikingly distinct responses to different neuromodulator drug classes. Conclusion Tachyphylaxis and dependence occur frequently during UCC treatment and have a major impact on treatment outcomes. Patients sometimes demonstrate distinct responses to different neuromodulator classes. The majority of patients will experience successful treatment for their cough, although several trials may be required.
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Affiliation(s)
- Andrew J Bowen
- 1 Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Tiffany L Huang
- 2 School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Amy S Nowacki
- 3 Cleveland Clinic Lerner Research Institute, Cleveland, Ohio, USA
| | - Douglas Trask
- 4 Verity Health System, Los Angeles, California, USA
| | - James Kaltenbach
- 3 Cleveland Clinic Lerner Research Institute, Cleveland, Ohio, USA
| | | | | | | | - Paul C Bryson
- 6 Cleveland Clinic Head and Neck Institute, Cleveland, Ohio, USA
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36
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Affiliation(s)
- Michael S Benninger
- Chairman, Head and Neck Institute, The Cleveland Clinic, Cleveland, United States.
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Bowen AJ, Nowacki AS, Contrera K, Trask D, Kaltenbach J, Milstein CF, Adessa M, Benninger MS, Taliercio R, Bryson PC. Short- and Long-term Effects of Neuromodulators for Unexplained Chronic Cough. Otolaryngol Head Neck Surg 2018; 159:508-515. [DOI: 10.1177/0194599818768517] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Objective To evaluate the short- and long-term effects of tricyclic antidepressants (TCAs) and gabapentin in the treatment of unexplained chronic cough (UCC). Study Design Prospective cohort. Setting Tertiary care hospital. Subjects and Methods Patients seen between July 2016 and March 2017 were included following a formal workup and clinical evaluation indicative of UCC. Patients were placed on either a TCA (amitriptyline or nortriptyline) or gabapentin. Leicester Cough Questionnaire (LCQ) and percentage improvement scores were obtained prior to treatment initiation and at 2 and 6 months of neuromodulator treatment. A linear mixed model assessed the change in LCQ score between the 2 treatment time points and baseline scores. Results Twenty-eight patients completed a total of 37 neuromodulator trials. Gabapentin demonstrated statistically significant improvement in LCQ scores at 2 months (2.48 points, P≤ .01) and 6 months (5.40 points, P = .01) of treatment as compared with baseline. Patients taking TCAs demonstrated statistically significant improvement of LCQ scores at 2 months of treatment (3.46 points, P≤ .01). However, the majority of patients discontinued treatment, most commonly secondary to the development of tachyphylaxis after 2 months, precluding analysis at 6 months. Conclusion While both neuromodulator classes demonstrated short-term benefit, the majority of patients discontinue treatment prior to 6 months, with patients taking TCAs discontinuing more frequently than patients on gabapentin. Future investigations are warranted evaluating tachyphylaxis and the utility of dual treatment therapies designed to address peripheral and central sensory pathways involved in UCC.
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Affiliation(s)
- Andrew Jay Bowen
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
| | - Amy S. Nowacki
- Cleveland Clinic Lerner Research Institute, Cleveland, Ohio, USA
| | - Kevin Contrera
- Cleveland Clinic Head and Neck Institute, Cleveland, Ohio, USA
| | - Douglas Trask
- Cleveland Clinic Head and Neck Institute, Cleveland, Ohio, USA
| | - James Kaltenbach
- Cleveland Clinic Lerner Research Institute, Cleveland, Ohio, USA
| | | | - Michelle Adessa
- Cleveland Clinic Head and Neck Institute, Cleveland, Ohio, USA
| | | | | | - Paul C. Bryson
- Cleveland Clinic Head and Neck Institute, Cleveland, Ohio, USA
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Bonvini SJ, Belvisi MG. Cough and airway disease: The role of ion channels. Pulm Pharmacol Ther 2017; 47:21-28. [PMID: 28669932 DOI: 10.1016/j.pupt.2017.06.009] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 06/27/2017] [Accepted: 06/29/2017] [Indexed: 01/07/2023]
Abstract
Cough is the most common reason for patients to visit a primary care physician, yet it remains an unmet medical need. It can be idiopathic in nature but can also be a troublesome symptom across chronic lung diseases such as asthma, COPD and idiopathic pulmonary fibrosis (IPF). Chronic cough affects up to 12% of the population and yet there are no safe and effective therapies. The cough reflex is regulated by vagal, sensory afferent nerves which innervate the airway. The Transient Receptor Potential (TRP) family of ion channels are expressed on sensory nerve terminals, and when activated can evoke cough. This review focuses on the role of 4 TRP channels; TRP Vannilloid 1 (TRPV1), TRP Ankyrin 1 (TRPA1), TRP Vannilloid 4 (TRPV4) and TRP Melastatin 8 (TRPM8) and the purinergic P2X3 receptor and their possible role in chronic cough. We conclude that these ion channels, given their expression profile and their role in the activation of sensory afferents and the cough reflex, may represent excellent therapeutic targets for the treatment of respiratory symptoms in chronic lung disease.
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Affiliation(s)
- Sara J Bonvini
- Respiratory Pharmacology Group, Airway Disease Section, National Heart & Lung Institute, Imperial College, Exhibition Road, London SW7 2AZ, UK
| | - Maria G Belvisi
- Respiratory Pharmacology Group, Airway Disease Section, National Heart & Lung Institute, Imperial College, Exhibition Road, London SW7 2AZ, UK.
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Prevalence of Arnold Nerve Reflex in Adults and Children With Chronic Cough. Chest 2017; 153:675-679. [PMID: 29197546 DOI: 10.1016/j.chest.2017.11.019] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2017] [Revised: 11/18/2017] [Accepted: 11/20/2017] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Cough originates from stimulation of structures innervated by the vagus nerve, including the airways and distal esophagus. Arnold nerve reflex describes the induction of cough by stimulation of the external auditory canal, which is innervated by the auricular branch of the vagus. Historically, the prevalence of this reflex has been reported in the range of 2% to 3% on the basis of studies of outpatients in otolaryngology practices, but has not been investigated in healthy volunteers or in patients with chronic cough. METHODS Two hundred adults and 100 children with chronic cough, as well as 100 adult and 100 pediatric volunteers, underwent evaluation consisting of stimulation of the external auditory canal of each ear with a cotton-tipped applicator. Cough occurring within 10 seconds of stimulation was considered induced by the intervention. RESULTS Arnold nerve reflex was present in 25.5% of adults and 3% of children with chronic cough. The prevalence of the reflex was 2% among healthy adults and children. In adults with chronic cough, Arnold nerve reflex was observed more commonly in women (31.6%) than men (12.5%) and was unilateral in the majority of patients (90.2%). CONCLUSIONS The greater than 12 fold prevalence of Arnold nerve reflex in adults with chronic cough compared with healthy volunteers supports the concept of cough hypersensitivity syndrome (CHS), in which vagal hypersensitivity is proposed to underlie chronic refractory cough. The absence of increased prevalence among children with chronic cough suggests that cough hypersensitivity syndrome is an acquired condition, perhaps triggered by viral respiratory infection or other environmental factor.
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McGovern AE, Ajayi IE, Farrell MJ, Mazzone SB. A neuroanatomical framework for the central modulation of respiratory sensory processing and cough by the periaqueductal grey. J Thorac Dis 2017; 9:4098-4107. [PMID: 29268420 DOI: 10.21037/jtd.2017.08.119] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Sensory information arising from the airways is processed in a distributed brain network that encodes for the discriminative and affective components of the resultant sensations. These higher brain networks in turn regulate descending motor control circuits that can both promote or suppress behavioural responses. Here we explore the existence of possible descending neural control pathways that regulate airway afferent processing in the brainstem, analogous to the endogenous descending analgesia system described for noxious somatosensation processing and placebo analgesia. A key component of this circuitry is the midbrain periaqueductal grey, a region of the brainstem recently highlighted for its altered activity in patients with chronic cough. Understanding the nature and plasticity of descending neural control may help identify novel central therapeutic targets to alleviate the neuronal hypersensitivity underpinning many symptoms of respiratory disease.
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Affiliation(s)
- Alice E McGovern
- Department of Anatomy and Neuroscience, The University of Melbourne, Parkville VIC 3010, Australia
| | - Itopa E Ajayi
- Department of Anatomy and Neuroscience, The University of Melbourne, Parkville VIC 3010, Australia
| | - Michael J Farrell
- Monash Biomedicine Discovery Institute and Department of Medical Imaging and Radiation Sciences, Monash University, Clayton VIC 3800, Australia
| | - Stuart B Mazzone
- Department of Anatomy and Neuroscience, The University of Melbourne, Parkville VIC 3010, Australia
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Keller JA, McGovern AE, Mazzone SB. Translating Cough Mechanisms Into Better Cough Suppressants. Chest 2017; 152:833-841. [DOI: 10.1016/j.chest.2017.05.016] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 05/14/2017] [Accepted: 05/17/2017] [Indexed: 12/19/2022] Open
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Song WJ, Morice AH. Cough Hypersensitivity Syndrome: A Few More Steps Forward. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2017; 9:394-402. [PMID: 28677352 PMCID: PMC5500693 DOI: 10.4168/aair.2017.9.5.394] [Citation(s) in RCA: 81] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Revised: 03/07/2017] [Accepted: 03/09/2017] [Indexed: 01/17/2023]
Abstract
Cough reflex is a vital protective mechanism against aspiration, but when dysregulated, it can become hypersensitive. In fact, chronic cough is a significant medical problem with a high degree of morbidity. Recently, a unifying paradigm of cough hypersensitivity syndrome has been proposed. It represents a clinical entity in which chronic cough is a major presenting problem, regardless of the underlying condition. Although it remains a theoretical construct, emerging evidence suggests that aberrant neurophysiology is the common etiology of this syndrome. Recent success in randomized clinical trials using a P2X3 receptor antagonist is the first major advance in the therapeutics of cough in the past 30 years; it at last provides a strategy for treating intractable cough as well as an invaluable tool for dissecting the mechanism underpinning cough hypersensitivity. Additionally, several cough measurement tools have been validated for use and will help assess the clinical relevance of cough in various underlying conditions. Along with this paradigm shift, our understanding of cough mechanisms has improved during the past decades, allowing us to continue to take more steps forward in the future.
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Affiliation(s)
- Woo Jung Song
- Division of Allergy and Clinical Immunology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Alyn H Morice
- Centre for Cardiovascular and Metabolic Research, University of Hull, Hull York Medical School, Castle Hill Hospital, Cottingham, East Yorkshire, United Kingdom.
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