Eosinophilic airway inflammation is common in subacute cough following acute upper respiratory tract infection

Effectiveness and safety of Xingbei Zhike granules in patients with postinfectious cough: A multicenter, randomized, double-blinded, placebo-controlled trial

BACKGROUND

Postinfectious cough (PIC) is a common symptom following a respiratory tract infection. Xingbei Zhike (XBZK) granules, a Chinese patent medicine, has been widely used for PIC in clinics. However, there is a lack of evidence on the effectiveness.

PURPOSE

To investigate whether treatment with XBZK granules is effective for PIC.

STUDY DESIGN

A multicenter, randomized, double-blinded, placebo-controlled trial.

METHODS

Eligible participants from fourteen hospitals were randomly assigned in 3:1 ratio to receive either XBZK granules or placebo for 14 days. The primary outcome was the area under the curve (AUC) of a visual analogue scale (VAS) for cough symptoms. Secondary outcomes included cough symptom score (CSS), time and probability of recovery from cough, traditional Chinese medicine (TCM) syndrome score, relief rates of individual symptoms, Leicester Cough Questionnaire (LCQ) score, and the use of reliever drug.

RESULTS

A total of 235 patients (176 in XBZK and 59 in placebo groups) were included in the analysis. The AUC for cough VAS scores was lower in the XBZK than placebo group (-8.10, 95 % CI -14.12 to -2.07, p = 0.009), indicating superiority. XBZK decreased CSS (-0.68 points, 95 % CI -1.13 to -0.22, p = 0.01), shortened time to cough recovery (-2 days, hazard ratio [HR] 1.48, 95 % CI 1.03 to 2.13, p = 0.02), enhanced the probability of cough recovery (risk ratio [RR] 1.66, 95 % CI 1.07 to 2.58, p = 0.03), lowered TCM syndrome score (-0.99 points, 95 % CI -1.58 to -0.40, p = 0.004), increased the rate of daytime (RR 1.84, 95 % CI 1.07 to 3.15, p = 0.02) and nighttime (RR 2.07, 95 % CI 1.29 to 3.35, p = 0.004) cough recovery, and reduced the viscosity of sputum (RR 2.92, 95 % CI 1.66 to 5.13, p < 0.001) compared to placebo. There were no significant differences in LCQ scores and taking reliever drugs between groups. No severe adverse events were reported in either group.

CONCLUSIONS

XBZK granules are a promising therapy against PIC, effective in lowering the overall severity of cough, shortening the time to cough recovery, and reducing the viscosity of sputum.

Cough and cough hypersensitivity as treatable traits of asthma

Cough is a common and troublesome symptom in people with asthma and is often associated with poorer asthma control and exacerbations. Apart from asthma, other causes or comorbidities might underlie cough in asthma, such as rhinosinusitis and bronchiectasis. Eosinophilic inflammation and bronchoconstriction can lead to an acute episode of cough or worsen chronic cough. Cough hypersensitivity with laryngeal paraesthesia, allotussia, and hypertussia might underlie the cough of asthma through augmented sensory nerve excitability of upper-airway vagal sensory nerves. Cough associated with bronchoconstriction and type 2 inflammation should respond to inhaled corticosteroids and long-acting β-adrenoceptor agonist therapy. For cough hypersensitivity in adults, speech and language therapy and neuromodulators (eg, gabapentin) could be considered. In children, there is no consistent association of asthma with cough sensitivity or between cough and asthma severity. Further research is needed to realise the potential of cough as a measure of asthma control, to understand the mechanisms of cough in asthma, and to develop safe, effective treatments and a precision-medicine approach to the management of cough in asthma in children and adults.

Efficacy and safety of AP-Bio®(KalmCold®) in participants with uncomplicated upper respiratory tract viral infection (common cold) - A phase III, double-blind, parallel group, randomized placebo-controlled trial

INTRODUCTION

Kalmegh (Andrographis paniculata) is commonly used for treating uncomplicated Upper Respiratory Tract Infection (URTI) in complementary and alternative system of medicine. AP-Bio®(KalmCold®) is a standardized extract derived from the leaves of A. paniculata. This study was proposed to evaluate its efficacy using validated scales and objective measures.

METHODS

Participants were randomized in a ratio of 1:1:1 to receive either AP-Bio® 200 mg/day, AP-Bio® 400 mg/day or placebo for 7 days. The primary outcome measure was Wisconsin Upper Respiratory Symptom Survey (WURSS-21) score. The secondary outcome measures were nasal mucous weight, nasal muco-ciliary clearance function and Interleukin-8 in nasal wash, as well as safety and tolerability.

RESULTS

A total of n = 331 participants were screened and N = 300 participants were enrolled. The absolute WURSS-21 global score [mean (Standard Deviation - SD)] in the AP-Bio® 400 mg group [5.70 (5.31)] was less than the AP-Bio® 200 mg group [5.81 (4.83)] on Day-3. However, it was much higher in the placebo group [9.55 (14.27)]. AP-Bio® 400 mg group (Mean Difference - MD [Standard Error - SE] = -3.85 [1.52]; 95% CI = -6.85, - 0.85; adjusted p = 0.034) and 200 mg group (MD [SE] = -3.74 [1.51]; 95% CI = -6.73, - 0.76; adjusted p = 0.038) had significantly lower score than placebo. Similarly, on Day-3, the change in global score from baseline was significantly better in the AP-Bio® 400 mg group (MD [SE] = -3.91; [1.82] 95% CI = -7.50, - 0.32; adjusted p = 0.038) and AP-Bio® 200 mg group (MD [SE] = -3.84 [1.97]; 95% CI = -7.72, - 0.04; adjusted p = 0.044) in comparison to the placebo group. Nasal mucous weight, tissue paper counts used, and interleukin-8 showed a trend towards AP-Bio® groups having a favourable outcome when compared with placebo but did not reach statistical significance due to a small sample size. None of the study participants complained of any adverse physical symptoms. However, incident eosinophilia was noted in n = 20 participants on day 3. (n = 6 in AP-Bio® 200 mg group, n = 7 in Ap-Bio® 400 mg group and n = 13 in placebo group; p = 0.181).

CONCLUSIONS

Participants in both the AP-Bio® dose groups showed positive tendency towards resolution of URTI symptoms when compared with placebo on Day-3 but not on Day-5 and Day-7.

Infectious and Inflammatory Pathways to Cough

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.

A History of Recurrent Episodes of Prolonged Cough as a Predictive Value for Determining Cough Variant Asthma in a Primary Care Setting

Background

Many patients visit primary care clinics with a complaint of cough. General practitioners (GPs) developed a list of the causative diseases of cough that can produce a patient's symptoms and signs. Then, the patients' medical histories were evaluated to determine whether the diagnosis of cough variant asthma (CVA) or post-infectious cough (PIC) could have been predicted.

Methods

We retrospectively investigated 195 outpatients with a complaint of cough. Medical histories of "recurrent episodes of prolonged cough" and "upper respiratory infection" were obtained during the initial visit. The accuracy of medical histories in predicting CVA and PIC was calculated on the area under the curve (AUC).

Results

Among eligible patients with cough, PIC was diagnosed in 99 patients (50.8%), CVA in 40 patients (20.5%), upper airway cough syndrome in 28 patients (14.4%), and chronic obstructive pulmonary disease in 11 patients (5.6%). Among the patients with CVA and those with PIC, 93% and 12%, respectively, had a history of recurrent episodes of prolonged cough. For the diagnosis of CVA, having a history of recurrent episodes of prolonged cough showed a moderately accurate AUC (0.76, 95% CI: 0.71-0.82). On the other hand, for the diagnosis of PIC, having no history of recurrent episodes of prolonged cough also showed a moderately accurate AUC (0.87, 95% CI: 0.82-0.92).

Conclusion

The medical history of recurrent episodes of prolonged cough is useful for the prediction of CVA as well as PIC.

Gender difference in the association between cough severity and quality of life among patients with postinfectious cough

Background

Despite close link exists between cough severity and quality of life (QoL), whether gender difference is implied in the effect of cough on QoL has not been studied yet. This study primarily aims to investigate whether the association between cough severity and QoL is modified by gender in patients with postinfectious cough.

Methods

Secondary analyses were performed in 180 participants with postinfectious cough in a multisite randomized controlled trial. Baseline demographics, clinical characteristics and score of cough specific quality of life questionnaire (CQLQ) were collected. Linear regression analyses were conducted to examine gender difference in CQLQ score and the association between cough severity and CQLQ score.

Results

Difference between women and men was not significant in CQLQ total score in the unadjusted analysis (P = 0.077). Women had a 2.20-point higher CQLQ total score than men (95% confidence interval (CI) 0.11–4.30; P = 0.039), after adjusting for age, cough duration, cough severity, and clinical center. Gender significantly modified the association between cough severity and CQLQ total score (coefficient 1.80, 95% CI 0.29–3.30; P = 0.020), after adjusting for age, cough duration, and study center. An increase of 1-point in cough severity was associated with a 2.55-point (95% CI 1.16–3.95) increase in CQLQ total score in women versus a 1.26-point (95% CI 0.20–2.31) increase in men (P = 0.020).

Conclusions

Female sex may be associated with worse QoL than men, and women’s QoL may be more significantly impaired as cough symptom deteriorates. Gender difference should be taken into account in the clinical settings and research of cough and cough related QoL.

Trial registration: Chinese Clinical Trial Registry, ChiCTRTRC12002297. Registered 19 June 2012, http://www.chictr.org.cn/abouten.aspx.

The diagnostic utility of the frequency scale for the symptoms of gastroesophageal reflux disease questionnaire (FSSG) for patients with subacute/chronic cough

BACKGROUND

The frequency scale for the symptoms of GERD (FSSG) questionnaire, which originally consists of acid-reflux and dysmotility symptom domains, is a succinct questionnaire to evaluate gastroesophageal reflux disease (GERD) symptoms.

OBJECTIVES

To evaluate the utility of subjective questionnaire of GERD for the diagnosis of GERD-related cough by using FSSG questionnaire.

METHODS

We recruited 256 patients with subacute/chronic cough between April 2012 and March 2018, who were analyzed using FSSG questionnaire and blood eosinophil counts. GERD-related cough was inferred through the presence of classic reflux symptoms including heartburn and/or typical coughing trigger (e.g. phonation, rising, lying, eating, and intake of certain food). The diagnosis was confirmed by response to specific treatments for GERD. Receiver operating characteristic curve analysis was performed to determine the cutoff score for the diagnosis.

RESULTS

One-hundred ten patients (43%) were diagnosed as having GERD-related cough. FSSG questionnaire was relevant for diagnosing GERD-related cough, with the area under the curve (AUC) of 0.70 (p < 0.0001, cutoff score 7 points, sensitivity 75%, specificity 62%). When limited to patients with blood eosinophils of ≤150/μL or those with sputum eosinophils of ≤3%, sensitivity and specificity of the diagnosis was increased, respectively (sensitivity and specificity; 79% and 65% for blood eosinophils and 82% and 68% for sputum eosinophils. p < 0.0001, AUC 0.74 for both).

CONCLUSIONS

The subjective questionnaire of GERD (FSSG) would be helpful in diagnosing GERD-related cough, particularly in patients with low blood or sputum eosinophil counts.

Efficacy and safety of Zihua Wenfei granules in treatment of postinfectious cough (wind-cold invading lungs syndrome): study protocol for a randomized controlled trial

Background

Postinfectious cough usually develops and persists following respiratory tract infection. The protracted cough is embarrassing and troublesome and significantly impairs daily life. However, the optimal treatment available for this condition is still not known. This study aims to investigate the efficacy and safety of a new Chinese herbal prescription, Zihua Wenfei granule (ZHWFG), in treatment of postinfectious cough (wind-cold invading lungs syndrome).

Methods

This study is a prospective, multi-center, randomized, double-blinded, parallel group, placebo-controlled trial. A total of 216 adult participants with postinfectious cough will be enrolled from six study centers across China. All participants are randomly allocated to one of three parallel treatment groups: (1) 15 g of active ZHWFG three times daily, (2) 10 g of active ZHWFG plus 5 g of ZHWFG-matched placebo three times daily, and (3) 15 g of ZHWFG-matched placebo three times daily. The treatment duration is 14 consecutive days. The primary outcomes are cough resolution rate and cough relief rate. Secondary outcomes include time to cough resolution, time to cough relief, change from baseline in cough symptom score, cough visual analog scale value, traditional Chinese medicine syndrome score at days 7 and 14, and change of CQLQ from baseline to post-treatment as well as adverse events.

Discussion

This trial may not only investigate the efficacy and safety of ZHWFG in the management of postinfectious cough (wind-cold invading lungs syndrome), but also add the evidence of Chinese herbal medicine in treatment of postinfectious cough and provide an alternative option for the management of postinfectious cough.

Trial registration

ChiCTR1900022078. Registered on 23 March 2019. http://www.chictr.org.cn/showproj.aspx?proj=36547.

Cough: A Practical and Multifaceted Approach to Diagnosis and Management

Cough is a common symptom often confronted in the clinical setting. Time and resources attributed to cough place an undue burden on patients and the health care system. One characteristic of cough that likely contributes to this is the multifactorial nature of cough. Physicians are trained to find a single diagnosis to explain symptoms. With cough, if all factors contributing are not identified and treated together, the cough often remains unresolved. This article provides a practical approach to treatment and management of cough, emphasizing causes and potentiators.

Common Cold - an Umbrella Term for Acute Infections of Nose, Throat, Larynx and Bronchi

Acute respiratory tract infections, i. e. rhinitis, sinusitis, pharyngitis, laryngitis, bronchitis, belong to the most common medical conditions with a high economic burden. Nonetheless, there is little agreement concerning their differential diagnosis.This paper will discuss to what extent different anatomical sites of acute respiratory tract infections can be uniquely identified or whether the overlap and consecutive development in signs and symptoms renders these distinctions meaningless.Acute respiratory tract infections are variable but definition of diagnostic categories based on the anatomical sites of the dominant complaints shows that signs and symptoms both overlap to a great extent and/or emerge successively. Thus, in common cold distinguishing between acute symptom-based diagnoses arising from different anatomical sites of the aerodigestive system remains elusive. Therefore, preferred symptomatic treatments should foster a resolution of all possible symptoms as opposed to an isolated treatment of a single symptom (e. g. mucus hypersecretion) according to the presumed anatomical site (i. e. acute bronchitis).

Association between fractional exhaled nitric oxide and clinical characteristics and outcomes in patients with subacute cough

OBJECTIVES

To investigate the relationships between fractional exhaled nitric oxide (FENO) and clinical characteristics and outcomes in patients with subacute cough.

METHODS

Patients with subacute cough (n = 189) after upper respiratory tract infection were enrolled in this single-center prospective study, and were divided into low-FENO (<25 ppb) and high-FENO groups (≥25 ppb). Empirical therapies (without inhaled or systemic corticosteroids) were prescribed based on clinical experience and follow-up until the disease course reached 8 weeks. FENO values, cough symptom scores (CSS), and Leicester Cough Questionnaire (LCQ) scores were obtained, analyzed, and compared between two groups of patients.

RESULTS

The low-FENO and high-FENO groups comprised 136 and 53 patients, respectively. The multiple regression analysis showed that blood eosinophil count and gender were independent factors for elevated FENO (β = 1.38, 0.25, respectively). LCQ scores, total CSS, and daytime CSS were comparable between the low-FENO and high-FENO groups. The nighttime CSS of the high-FENO group were significantly higher than that of the low-FENO group (P = .03). The CSS and LCQ score were improved in both groups but were comparable between groups after 10 days treatment.

CONCLUSIONS

Patients with subacute cough and high-FENO levels have more severe nocturnal cough than those of patients with low-FENO levels. However, FENO levels do not appear to correlate with the clinical outcomes or treatment response. The significance of FENO in the management of subacute cough needs to be further evaluated, at least in the current empirical treatment without corticosteroids.