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Abstract
In recent years, there has been a substantial increase in the development of antitussive therapies and the first new therapy, gefapixant has been licenced in Europe. This review describes current unlicenced treatments for chronic cough and details treatments currently in development for refractory chronic cough and cough in idiopathic pulmonary fibrosis, as well as compounds previously explored.
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Affiliation(s)
- Jaclyn A Smith
- Division of Immunology, Immunity to Infection and Respiratory Medicine, University of Manchester and Manchester Academic Health Science Centre, Wythenshawe Hospital, Southmoor Road, Manchester, M23 9LT, UK.
- Manchester University NHS Foundation Trust, Manchester, UK.
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2
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Guilleminault L, Demoulin-Alexikova S, de Gabory L, Varannes SBD, Brouquières D, Balaguer M, Chapron A, Grassin-Delyle S, Poussel M, Guibert N, Reychler G, Trzepizur W, Woisard V, Crestani S. Guidelines for the management of chronic cough in adults. Endorsed by the French speaking society of respiratory diseases (Société de Pneumologie de Langue Française, SPLF), the Société Française d'Oto-Rhino-Laryngologie et de Chirurgie de la Face et du Cou (SFORL), the Société Française de Phoniatrie et de Laryngologie (SFPL), the Société Nationale Française de Gastro-entérologie (SNFGE). Respir Med Res 2023; 83:101011. [PMID: 37087905 DOI: 10.1016/j.resmer.2023.101011] [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: 03/10/2023] [Accepted: 03/12/2023] [Indexed: 03/29/2023]
Abstract
Patients with chronic cough experience a high alteration of quality of life. Moreover, chronic cough is a complex entity with numerous etiologies and treatments. In order to help clinicians involved in the management of patients with chronic cough, guidelines on chronic cough have been established by a group of French experts. These guidelines address the definitions of chronic cough and the initial management of patients with chronic cough. We present herein second-line tests that might be considered in patients with cough persistence despite initial management. Experts also propose a definition of unexplained or refractory chronic cough (URCC) in order to better identify patients whose cough persists despite optimal management. Finally, these guidelines address the pharmacological and non-pharmacological interventions useful in URCC. Thus, amitryptilline, pregabalin, gabapentin or morphine combined with speech and/or physical therapy are a mainstay of treatment strategies in URCC. Other treatment options, such as P2 × 3 antagonists, are being developed.
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Affiliation(s)
- Laurent Guilleminault
- Pôle des voies respiratoires, service de pneumo-allergologie, Centre Hospitalo-Universitaire de Toulouse, 24 chemin de pouvourville, 31059, Toulouse, France; Toulouse Institute for Infectious and Inflammatory Diseases (Infinity), Inserm U1291, University of Toulouse, CNRS U5282, 31000, Toulouse, France.
| | - Silvia Demoulin-Alexikova
- CHU de Lille, Lille, France Univ. Lille, CNRS, Inserm, CHU Lille - Service des Explorations Fonctionnelles Respiratoires, Institut Pasteur de Lille, U1019-UMR9017-CIIL-Centre d'Infection et d'Immunité de Lille, 59000, Lille, France
| | - Ludovic de Gabory
- Department of Otorhinolaryngology - Head and Neck Surgery, University Hospital of Bordeaux, Bordeaux, Univ. Bordeaux, 33000, France
| | - Stanislas Bruley Des Varannes
- Gastroenterology Department, CHU de Nantes, Institut des Maladies de l'Appareil Digestif, IMAD CIC 1413, Université de Nantes, 44000, Nantes, France
| | - Danielle Brouquières
- Pôle des voies respiratoires, service de pneumo-allergologie, Centre Hospitalo-Universitaire de Toulouse, 24 chemin de pouvourville, 31059, Toulouse, France
| | - Mathieu Balaguer
- Unité de voie et déglutition, hôpital Larrey, CHU de Toulouse, Toulouse, France
| | - Anthony Chapron
- Université de Rennes 1, CHU Rennes, Département de Médecine Générale, 35000, Rennes, France
| | - Stanislas Grassin-Delyle
- Respiratory Diseases Department, Foch Hospital, 92150, Suresnes, France; Infection and Inflammation, Health Biotechnology Department, Paris-Saclay University, UVSQ, INSERM, 78180, Montigny le Bretonneux, France
| | - Mathias Poussel
- CHRU-Nancy, Exploration Fonctionnelle Respiratoire-Centre Universitaire de Médecine du Sport et Activités Physiques Adaptées, F54000, Nancy, France; DevAH, Université de Lorraine, F54000, Nancy, France
| | - Nicolas Guibert
- Pôle des voies respiratoires, service de pneumo-allergologie, Centre Hospitalo-Universitaire de Toulouse, 24 chemin de pouvourville, 31059, Toulouse, France
| | | | - Wojciech Trzepizur
- Department of Respiratory and Sleep Medicine, Angers University Hospital, INSERM 1083, UMR CNRS 6015, MITOVASC, Equipe CarME, SFR ICAT, University of Angers, 49000, Angers, France
| | - Virginie Woisard
- Unité de voie et déglutition, hôpital Larrey, CHU de Toulouse, Toulouse, France
| | - Sabine Crestani
- Unité de voie et déglutition, hôpital Larrey, CHU de Toulouse, Toulouse, France
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3
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Guilleminault L, Demoulin-Alexikova S, de Gabory L, Bruley des Varannes S, Brouquières D, Balaguer M, Chapron A, Grassin Delyle S, Poussel M, Guibert N, Reychler G, Trzepizur W, Woisard V, Crestani S. [Guidelines for the management of chronic cough in adults]. Rev Mal Respir 2023; 40:432-452. [PMID: 37080877 DOI: 10.1016/j.rmr.2023.03.001] [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: 02/01/2023] [Accepted: 03/03/2023] [Indexed: 04/22/2023]
Abstract
Patients with chronic cough experience major alteration in their quality of life. Given its numerous etiologies and treatments, this disease is a complex entity. To help clinicians involved in patient management of patients, guidelines have been issued by a group of French experts. They address definitions of chronic cough and initial management of patients with this pathology. We present herein the second-line tests that might be considered in patients whose coughing has persisted, notwithstanding initial management. The experts have also put forward a definition of unexplained or refractory chronic cough (URCC), the objective being to more precisely identify those patients whose cough persists despite optimal management. Lastly, these guidelines indicate the pharmacological and non-pharmacological interventions of use in URCC. Amitriptyline, pregabalin, gabapentin or morphine combined with speech and/or physical therapy are mainstays in treatment strategies. Other treatment options, such as P2X3 antagonists, are being developed and have generated high hopes among physicians and patients alike.
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Affiliation(s)
- L Guilleminault
- Pôle des voies respiratoires, service de pneumo-allergologie, centre hospitalo-universitaire de Toulouse, Toulouse, France; Institut toulousain des maladies infectieuses et inflammatoires (Infinity) INSERM UMR1291, CNRS UMR5051, université de Toulouse III, Toulouse, France.
| | - S Demoulin-Alexikova
- CHU de Lille, Lille, France; Inserm, CNRS, U1019-UMR9017, service des explorations fonctionnelles respiratoires, centre d'infection et d'immunité de Lille (CIIL), Institut Pasteur de Lille, university Lille, CHU Lille, Lille, France
| | - L de Gabory
- Department of otorhinolaryngology - head and neck surgery, university hospital of Bordeaux, Bordeaux, France; University of Bordeaux, 33000 Bordeaux, France
| | - S Bruley des Varannes
- IMAD CIC 1413, gastroenterology department, Institut des maladies de l'appareil digestif, université de Nantes, CHU de Nantes, Nantes, France
| | - D Brouquières
- Pôle des voies respiratoires, service de pneumo-allergologie, centre hospitalo-universitaire de Toulouse, Toulouse, France
| | - M Balaguer
- Unité de voie et déglutition, hôpital Larrey, CHU de Toulouse, Toulouse, France
| | - A Chapron
- Département de médecine générale, université de Rennes 1, CHU Rennes, Rennes, France
| | - S Grassin Delyle
- Respiratory diseases department, Foch hospital, Suresnes, France; Inserm, UVSQ, infection and inflammation, health biotechnology department, Paris-Saclay university, Montigny-le-Bretonneux, France
| | - M Poussel
- Exploration fonctionnelle respiratoire, centre universitaire de médecine du sport et activités physiques adaptées, CHRU de Nancy, 54000 Nancy, France; DevAH, université de Lorraine, 54000 Nancy, France
| | - N Guibert
- Pôle des voies respiratoires, service de pneumo-allergologie, centre hospitalo-universitaire de Toulouse, Toulouse, France
| | - G Reychler
- Université catholique de Louvain, Louvain, Belgique
| | - W Trzepizur
- Department of respiratory and sleep medicine, Angers university hospital, Angers, France; Inserm 1083, UMR CNRS 6015, MITOVASC, équipe CarME, SFR ICAT, university of Angers, 49000 Angers, France
| | - V Woisard
- Unité de voie et déglutition, hôpital Larrey, CHU de Toulouse, Toulouse, France
| | - S Crestani
- Unité de voie et déglutition, hôpital Larrey, CHU de Toulouse, Toulouse, France
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Mini-review: Hypertussivity and allotussivity in chronic cough endotypes. Neurosci Lett 2023; 792:136934. [PMID: 36309151 DOI: 10.1016/j.neulet.2022.136934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 10/12/2022] [Accepted: 10/13/2022] [Indexed: 11/06/2022]
Abstract
In recent years our understanding of the neurophysiological basis of cough has increased substantially. In conjunction, concepts around the drivers of chronic coughing in patients have also significantly evolved. Increasingly it is recognised that dysregulation of the neuronal pathways mediating cough play an important role in certain phenotypes of chronic cough and therefore pathological processes affecting the nervous system are likely to represent key endotypes in patients. Taking inspiration from the study of neuropathic pain, the term hypertussia has been employed to describe the phenomenon of abnormal excessive coughing in response to airway irritation and allotussia to describe coughing in response to stimuli not normally provoking cough. This review aims to summarise current clinical evidence supporting a role for the hyperexcitability of neuronal pathways contributing to chronic coughing and suggest how these might align with the clinical features observed in patients.
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Becker DR, Shelly S, Kavalieratos D, Maira C, Gillespie AI. Immediate Effects of Mindfulness Meditation on the Voice. J Voice 2022:S0892-1997(22)00342-3. [PMID: 36428173 DOI: 10.1016/j.jvoice.2022.10.022] [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] [Received: 09/09/2022] [Revised: 10/23/2022] [Accepted: 10/24/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVES The benefits of mindfulness meditation are well documented. This study evaluated the immediate effects of mindfulness meditation (MM) on the voice and voice user. STUDY DESIGN Prospective experimental study. METHODS Participants: 19 vocally healthy (VH) individuals, and 26 individuals with common voice disorders (CVD; benign lesions and hyperfunctional muscle tension) deemed stimulable for voice therapy. Exclusionary criteria: prior training or regular meditation practice. Participants recorded speech samples before and after a 11.5-minute prerecorded session of MM. PRIMARY OUTCOMES phonatory aerodynamics and participants' self-reported experience of voice. SECONDARY OUTCOMES self-reported anxiety, vocal acoustics, speech breathing patterns, and auditory-perceptual outcomes. Baseline self-reported measures of voice (Voice Handicap Index-10 - VHI-10), breathing (Dyspnea Index - DI), stress (Perceived Stress Scale - PSS), and trait mindfulness (Cognitive and Mindfulness Scale - Revised, CAMS-R, Five Facet Mindfulness Questionnaire - FFMQ) were compared between groups. RESULTS At baseline, CVD had significantly higher VHI-10 (P< 0.001) and DI (P= 0.0014), and lower trait mindfulness (CAMS-R, P= 0.02). No difference between groups for PSS or FFMQ. Changes postMM: decreased CPP for all-voiced sentences for VH (P= 0.003), decreased mean SPL (P= 0.012) on sustained vowel for VH, increased mean phonatory airflow during sustained vowel for CVD (P = 0.012). VH demonstrated a decrease in CPP on the all-voice sentence, and CVD demonstrated an increase, resulting in a significant between group difference (P= 0.013). Participants reported improvements in voice, emotional and physical states. State anxiety decreased for both groups (= < 0.001). No other objective outcomes reached significance. CONCLUSIONS After a brief MM, participants experienced improvement in physical, emotional, and cognitive states, and in their perceptions of their voice. Results indicate that a brief, single session of MM may be beneficial for some, but not sufficient to override habitual voice and speech patterns. Given the benefits of MM, future work should evaluate MM in a standard voice therapy protocol.
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Affiliation(s)
| | - Sandeep Shelly
- Emory Healthcare, Department of Otolaryngology, Atlanta, Geogia
| | - Dio Kavalieratos
- Division of Palliative Medicine, Department of Family and Preventive Medicine, School of Medicine, Emory University, Atlanta, Geogia
| | - Carissa Maira
- Emory Healthcare, Department of Otolaryngology, Atlanta, Geogia
| | - Amanda I Gillespie
- Emory Healthcare, Department of Otolaryngology, Atlanta, Geogia; Department of Otolaryngology, Emory University School of Medicine, Atlanta, Geogia
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Ilicic AM, Oliveira A, Habash R, Kang Y, Kho M, Goldstein R, Brooks D. Non-pharmacological Management of Non-productive Chronic Cough in Adults: A Systematic Review. FRONTIERS IN REHABILITATION SCIENCES 2022; 3:905257. [PMID: 36188925 PMCID: PMC9397766 DOI: 10.3389/fresc.2022.905257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Accepted: 05/03/2022] [Indexed: 11/23/2022]
Abstract
Background Chronic cough is a common reason for medical referral and its prevalence is on the rise. With only one pharmaceutical therapy currently under review for the treatment of refractory chronic cough, exploring non-pharmacological chronic cough management therapies is important. This systematic review summarizes the effectiveness of non-pharmacological chronic cough therapies in adults with non-productive refractory chronic cough or cough due to chronic respiratory diseases. Methods We searched Medline, Embase, Cochrane, CINAHL, and Scopus from inception to September 2021. Randomized controlled trials published in English, Portuguese, or French, and examining the effects of non-pharmacological therapies in adults with chronic non-productive cough (>8 weeks; <2 teaspoons sputum) were included. Mean differences, medians, and odds ratios were calculated as appropriate. Results 16,546 articles were identified and six articles representing five unique studies were included. Studies evaluated 228 individuals with refractory chronic cough or chronic cough due to a chronic respiratory disease [162 women (71%); 52 ± 11 to 61 ± 8 years old]. Obstructive sleep apnea was the only chronic respiratory disease studied. Non-pharmacological therapies included education, cough suppression, breathing techniques, mindfulness, and continuous positive airway pressure. When standing alone, non-pharmacological cough therapies improved cough-specific health related quality of life when not associated with interventions (mean diff MD 1.53 to 4.54), cough frequency (MD 0.59 95%CI 0.36 to 0.95), and voice outcomes (MD 0.3 to 1) when compared to control interventions. Conclusion The evidence of non-pharmacological therapies for non-productive chronic cough is limited. Existing studies reflect the heterogeneity in study design, sample size, and outcome measures. Thus, clinical recommendations for using the most effective interventions remain to be confirmed.
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Affiliation(s)
- Ana Maria Ilicic
- School of Rehabilitation Science, McMaster University, Hamilton, ON, Canada
| | - Ana Oliveira
- School of Rehabilitation Science, McMaster University, Hamilton, ON, Canada
- West Park Healthcare Centre, Toronto, ON, Canada
- Lab 3R Respiratory Research and Rehabilitation Laboratory, University of Aveiro (ESSUA), Aveiro, Portugal
- Department of Medical Sciences, iBiMED – Institute of Biomedicine, University of Aveiro, Aveiro, Portugal
| | | | - Yejin Kang
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Michelle Kho
- School of Rehabilitation Science, McMaster University, Hamilton, ON, Canada
- St. Joseph's Healthcare, Hamilton, ON, Canada
- The Research Institute of St. Joe's, St. Joseph's Healthcare, Hamilton, ON, Canada
| | - Roger Goldstein
- West Park Healthcare Centre, Toronto, ON, Canada
- Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
| | - Dina Brooks
- School of Rehabilitation Science, McMaster University, Hamilton, ON, Canada
- West Park Healthcare Centre, Toronto, ON, Canada
- Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
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Rao SJ, Ruckart KW, Nosow LM, Morris AK, Carter Wright S, Madden LL. Chronic Cough: Evaluation of Patients' Motivation to Undergo Cough Suppression Therapy. J Voice 2022:S0892-1997(22)00033-9. [PMID: 35279346 DOI: 10.1016/j.jvoice.2022.02.007] [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: 12/14/2021] [Revised: 01/31/2022] [Accepted: 02/04/2022] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Chronic cough is a persistent cough lasting greater than eight weeks. The prevalence rate is estimated to be 9% to 33% in the United States. There are several treatment modalities described in current literature including medical, surgical, and behavioral interventions. Behavioral intervention with a speech-language pathologist (SLP) includes education on laryngeal hygiene and the voluntary control of cough as well as respiratory retraining to suppress or reduce the duration of cough. Cough suppression therapy, like other behavioral therapies, requires patient motivation and commitment to participation and completion in therapy. METHODS This study was a prospective cross-sectional survey at a single academic institution. Adult patients evaluated by a laryngologist for chronic cough regardless of their primary etiology were included. Patients who were tracheostomy dependent, on oxygen therapy, had vocal fold paralysis/immobility, or had undergone previous laryngeal surgery were excluded. Patients were surveyed at the end of the initial clinic visit or at the beginning of the first cough suppression therapy session. Subjects reported their motivational factors for undergoing cough suppression therapy. RESULTS The majority of patients, 21 (58.33%), identified as female, 15 patients (41.20%) identified as male, and no patients identified as transgender, nonbinary, and/or other gender. The patients in this study had a mean age of 57.75 (12.12) years. 35 patients (97.22%) were interested in cough suppression therapy. The mean presenting cough severity index (CSI) was 19.39 (10.28) with the mean cough duration of 8.69 (12.10) years. CONCLUSIONS Patients primarily sought cough suppression therapy due to intrinsic factors rather than extrinsic influence. By understanding the relationship between symptomatology and patient motivation, clinicians can better counsel their patients and improve methods to assess candidacy for behavioral treatment.
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Affiliation(s)
- Shambavi J Rao
- Department of Otolaryngology-Head and Neck Surgery, Wake Forest School of Medicine, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - Kathryn W Ruckart
- Department of Otolaryngology-Head and Neck Surgery, Wake Forest School of Medicine, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - Lillian M Nosow
- Department of Otolaryngology-Head and Neck Surgery, Wake Forest School of Medicine, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - Amy K Morris
- Department of Otolaryngology-Head and Neck Surgery, Wake Forest School of Medicine, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - S Carter Wright
- Department of Otolaryngology-Head and Neck Surgery, Wake Forest School of Medicine, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - Lyndsay L Madden
- Department of Otolaryngology-Head and Neck Surgery, Wake Forest School of Medicine, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina.
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Wamkpah NS, Peterson AM, Lee JJ, Jia L, Hardi A, Stoll C, Huston M. Curbing the Cough: Multimodal Treatments for Neurogenic Cough: A Systematic Review and Meta-Analysis. Laryngoscope 2022; 132:107-123. [PMID: 33085095 PMCID: PMC8058694 DOI: 10.1002/lary.29146] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 09/15/2020] [Accepted: 09/16/2020] [Indexed: 02/01/2023]
Abstract
OBJECTIVES/HYPOTHESIS Neurogenic cough affects 11% of Americans and causes significant detriment to quality of life. With the advent of novel therapies, the objective of this review is to determine how procedural therapies (e.g., superior laryngeal nerve block) compare to other established pharmacologic and non-pharmacologic treatments for neurogenic cough. METHODS With the assistance of a medical librarian, a systematic review was performed using PICOS (patients, interventions, comparator, outcome, study design) format: adults with neurogenic cough receiving any pharmacologic or non-pharmacologic treatment for neurogenic cough compared to adults with neurogenic cough receiving any other relevant interventions, or treated as single cohorts, assessed with cough-specific quality of life outcomes, in all study designs and case series with ≥ 10 cases. Case reports, review articles, non-human studies, non-English language articles, and unavailable full-text articles were excluded. RESULTS There were 2408 patients with neurogenic cough in this review, treated with medical therapy (77%), speech therapy (19%), both medical and speech therapy (1%), and procedural therapy (3%). The included studies ranged from low to intermediate quality. Overall, most interventions demonstrated successful improvement in cough. However, the heterogeneity of included study designs precluded direct comparisons between intervention types. CONCLUSION This meta-analysis compared various treatments for neurogenic cough. Procedural therapy should be considered in the armamentarium of neurogenic cough treatments, particularly in patients refractory to, or intolerant of, the side effects of medical therapy. Lastly, this review illuminates key areas for improving neurogenic cough diagnosis, such as strict adherence to diagnostic and treatment guidelines, sophisticated reflux testing, and standardized, consistent outcome reporting. Laryngoscope, 132:107-123, 2022.
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Affiliation(s)
- Nneoma S Wamkpah
- Department of Otolaryngology-Head and Neck Surgery, Washington University in St. Louis, St. Louis, Missouri, U.S.A
| | - Andrew M Peterson
- University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, U.S.A
| | - Jake J Lee
- Department of Otolaryngology-Head and Neck Surgery, Washington University in St. Louis, St. Louis, Missouri, U.S.A
| | - Lena Jia
- Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - Angela Hardi
- Bernard Becker Medical Library, Washington University in St. Louis, St. Louis, Missouri, U.S.A
| | - Carolyn Stoll
- Washington University Division of Public Health Sciences, St. Louis, Missouri, U.S.A
| | - Molly Huston
- Division of Laryngology, Department of Otolaryngology-Head and Neck Surgery, Washington University in St Louis, St. Louis, Missouri, U.S.A
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Abu-Zaid A, Aljaili AK, Althaqib A, Adem F, Alhalal DA, Almubarak AF, Aldughaither SM, Alghabban SA, Alfaraj G, Masoud AT, Alsuhaibani NA. Safety and efficacy of gefapixant, a novel drug for the treatment of chronic cough: A systematic review and meta-analysis of randomized controlled trials. Ann Thorac Med 2021; 16:127-140. [PMID: 34012479 PMCID: PMC8109686 DOI: 10.4103/atm.atm_417_20] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 09/06/2020] [Indexed: 11/23/2022] Open
Abstract
AIM We conducted this systematic review and meta-analysis to investigate the efficacy and safety of gefapixant, a novel P2X3 receptor antagonist, in patients with chronic cough. METHODS We searched four databases for randomized controlled trials (RCTs). We assessed the cough frequency, severity, total Leicester cough questionnaire (LCQ) score, and adverse events. We analyzed the data using Open Meta-Analyst and Review Manager Software. RESULTS We included four unique studies (comprising five stand-alone RCTs) with 439 patients. Compared to placebo, gefapixant had positive anti-tussive effects by improving awake cough frequency (mean difference [MD] = -5.27, 95% confidence interval [CI] [-6.12, -4.42], P < 0.00001), night cough frequency (MD = -3.71, 95% CI [-6.57, -0.85], P = 0. 01), 24 h cough frequency (MD = -4.18, 95% CI [-5.01, -3.36], P < 0.00001), cough severity using the Visual Analog Scale (MD = -13.36, 95% CI [-17.80, -8.92], P < 0.00001), cough severity diary (MD = -0.88, 95% CI [-1.25, -0.51], P < 0.00001), and total LCQ score (MD = 2.00, 95% CI [1.15, 2.86], P = 0. 00001). Meta-regression analyses showed a positive correlation between the gefapixant dose and the incidence of any adverse event (relative risk [RR] = 0.239, 95% CI [0.093, 1.839], P = 0.001) and incidence of adverse event related to treatment (RR = 0.520, 95% CI [0.117, 0.922], P = 0.011). CONCLUSIONS In patient with chronic cough, gefapixant exhibits favorable anti-tussive outcomes by improving the cough frequency, severity, and quality of life. While gefapixant is largely tolerable, its side effects (notably taste alteration) are dose dependent.
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Affiliation(s)
- Ahmed Abu-Zaid
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
- College of Graduate Health Sciences, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | | | - Amnah Althaqib
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Fatima Adem
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | | | | | | | | | - Ghaidaa Alfaraj
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
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Hilton E, Satia I, Holt K, Woodcock AA, Belcher J, Smith JA. The Effect of Pain Conditioning on Experimentally Evoked Cough: Evidence of Impaired Endogenous Inhibitory Control Mechanisms in Refractory Chronic Cough. Eur Respir J 2020; 56:2001387. [PMID: 32703776 DOI: 10.1183/13993003.01387-2020] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 06/28/2020] [Indexed: 01/31/2023]
Abstract
The pathophysiology of refractory chronic cough (RCC) is unclear. We hypothesised that endogenous inhibitory control mechanisms, such as those activated by noxiousstimuli inducing pain (conditioned pain modulation (CPM)), may be capable of inhibiting coughing and urge to cough evoked by inhaled capsaicin. Furthermore, these mechanisms may be impaired in patients with RCC.The objective was to investigate the effects of pain on cough and urge to cough (UTC) in healthy volunteers (HV) and RCC. HV and RCC patients underwent a randomised, controlled, 4-way cross-over study comparing the effect of 4 interventions on capsaicin evoked coughing and UTC. The interventions comprised immersing a hand in i) noxious cold-water, ii) warm water, iii) warm water but instructed to voluntarily supress coughing and iv) no intervention. The co-primary outcomes were numbers of evoked coughs and UTC scores.Twenty HV (mean age 50.1(±SD14.2), M:F 10:10) and 20 RCC (age 60.1(±7.9), M:F 9:11) participated. Overall, noxious cold water reduced capsaicin evoked UTC scores and cough numbers compared with warm water (1.6 (95% C.I. 1.3-2.0) versus 2.2 (1.8-2.6) p<0.001; 4.8 coughs (3.7-6.2) versus 7.9 coughs (6.7-9.5) p<0.001, respectively). HV and RCC demonstrated similar reductions in the UTC during noxious cold-water immersion, but noxious cold water and voluntary suppression interventions were less effective in RCC than HV in reducing capsaicin evoked cough (p=0.041).Endogenous inhibitory control mechanisms, specifically those activated by pain, can reduce both coughing and the UTC. Impairment of endogenous inhibitory control mechanisms may contribute to excessive coughing in RCC.
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Affiliation(s)
- Emma Hilton
- Division of Infection, Immunity and Respiratory Medicine, and Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- Equal contributors
| | - Imran Satia
- Division of Infection, Immunity and Respiratory Medicine, and Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- Department of Medicine, Division of Respirology, McMaster University, Hamilton, Canada
- Equal contributors
| | - Kimberley Holt
- Division of Infection, Immunity and Respiratory Medicine, and Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- Manchester University NHS Foundation Trust, Manchester, UK
| | - Ashley A Woodcock
- Division of Infection, Immunity and Respiratory Medicine, and Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- Manchester University NHS Foundation Trust, Manchester, UK
| | - John Belcher
- Manchester University NHS Foundation Trust, Manchester, UK
| | - Jaclyn A Smith
- Division of Infection, Immunity and Respiratory Medicine, and Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- Manchester University NHS Foundation Trust, Manchester, UK
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Satia I, Nagashima A, Usmani OS. Exploring the role of nerves in asthma; insights from the study of cough. Biochem Pharmacol 2020; 179:113901. [PMID: 32156662 DOI: 10.1016/j.bcp.2020.113901] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 03/03/2020] [Indexed: 12/30/2022]
Abstract
Cough in asthma predicts disease severity, prognosis, and is a common and troublesome symptom. Cough is the archetypal airway neuronal reflex, yet little is understood about the underlying neuronal mechanisms. It is generally assumed that symptoms arise because of airway hyper-responsiveness and/or airway inflammation, but despite using inhaled corticosteroids and bronchodilators targeting these pathologies, a large proportion of patients have persistent coughing. This review focuses on the prevalence and impact of cough in asthma and explores data from pre-clinical and clinical studies which have explored neuronal mechanisms of cough and asthma. We present evidence to suggest patients with asthma have evidence of neuronal dysfunction, which is further heightened and exaggerated by both bronchoconstriction and airway eosinophilia. Identifying patients with excessive coughing with asthma may represent a neuro-phenotype and hence developing treatment for this symptom is important for reducing the burden of disease on patients' lives and currently represents a major unmet clinical need.
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Affiliation(s)
- I Satia
- McMaster University, Department of Medicine, Division of Respirology, Canada; Firestone Institute for Respiratory Health, St Joseph's Hospital, Canada; University of Manchester, Division of Infection, Immunity and Respiratory Medicine, and Manchester Academic Health Science Centre, Manchester, United Kingdom.
| | - A Nagashima
- McMaster University, Department of Medicine, Division of Respirology, Canada
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Wallace E, Guiu Hernandez E, Ang A, Hiew S, Macrae P. A systematic review of methods of citric acid cough reflex testing. Pulm Pharmacol Ther 2019; 58:101827. [PMID: 31326628 DOI: 10.1016/j.pupt.2019.101827] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 07/16/2019] [Accepted: 07/17/2019] [Indexed: 12/12/2022]
Abstract
INTRODUCTION This systematic review summarises and appraises methods of citric acid cough reflex testing (CRT) documented in published literature. METHODS Electronic databases, MEDLINE, EMBASE, CINAHL, PsychINFO, Scopus were searched up to and including 11th February 2018. Studies reporting a method of citric acid CRT, published in peer-reviewed journals in English or Spanish, were assessed for the inclusion criteria. Of the selected studies, information on the instrumentation and CRT protocol was extracted. RESULTS A total of 129 studies were included. Instrumentation and protocols differed widely across studies. Reporting of methods of citric acid CRT was sub-standard, with many crucial methodological components omitted from published manuscripts, preventing their full replication. CONCLUSIONS Considerable methodological variability exists for citric acid CRT in published literature. The findings suggest that caution is warranted in comparing citric acid cough thresholds across studies. Full replication of previously published methods of citric acid CRT is limited due to crucial elements of the citric acid CRT protocol being omitted from published manuscripts. These findings have implications on the use of citric acid CRT in clinical and pharmaceutical studies to evaluate the effects of antitussive medications and cough therapies.
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Affiliation(s)
- Emma Wallace
- University of Canterbury, Rose Centre for Stroke Recovery and Research, Dept of Communication Disorders, Christchurch, New Zealand.
| | - Esther Guiu Hernandez
- University of Canterbury, Rose Centre for Stroke Recovery and Research, Dept of Communication Disorders, Christchurch, New Zealand
| | - Alicia Ang
- University of Canterbury, Rose Centre for Stroke Recovery and Research, Dept of Communication Disorders, Christchurch, New Zealand
| | - Sarah Hiew
- University of Canterbury, Rose Centre for Stroke Recovery and Research, Dept of Communication Disorders, Christchurch, New Zealand
| | - Phoebe Macrae
- University of Canterbury, Rose Centre for Stroke Recovery and Research, Dept of Communication Disorders, Christchurch, New Zealand
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13
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Cho PS, Fletcher HV, Turner RD, Jolley C, Birring SS. Impaired cough suppression in chronic refractory cough. Eur Respir J 2019; 53:13993003.02203-2018. [DOI: 10.1183/13993003.02203-2018] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 02/18/2019] [Indexed: 11/05/2022]
Abstract
Functional brain imaging in individuals with chronic cough demonstrates reduced activation in cortical regions associated with voluntary cough suppression. Little is known about the ability of patients with chronic cough to suppress cough. This study aimed to compare the ability to voluntarily suppress cough during inhaled capsaicin challenge in participants with chronic refractory cough with that in healthy controls. In addition, this study aimed to assess the repeatability of capsaicin challenge test with voluntary cough suppression.Participants with chronic refractory cough and healthy controls underwent inhaled capsaicin challenge tests while attempting to suppress their cough responses. After 5 days, either a conventional capsaicin challenge test with no cough suppression attempt, or a repeat test with an attempt at cough suppression was performed. Threshold capsaicin concentrations required to elicit one, two and five coughs were calculated by interpolation. Objective 24-h cough frequency was measured in individuals with chronic refractory cough.Healthy controls were able to suppress capsaicin-evoked cough while participants with chronic refractory cough were not. Geometric mean±sd capsaicin dose thresholds for five coughs with (CS5) and without (C5) suppression attempts were 254.40±3.78 versus 45.89±3.95 µmol·L−1, respectively, in healthy controls (p=0.033) and 3.34±5.04 versus 3.86±5.13 µmol·L−1, respectively, in participants with chronic refractory cough (p=0.922). Capsaicin dose thresholds for triggering five coughs with self-attempted cough suppression were significantly lower in participants with chronic refractory cough than in healthy controls; geometric mean±sd 4.94±4.43 versus 261.10±4.34 µmol·L−1, respectively; mean difference (95% CI) 5.72 (4.54–6.91) doubling doses (p<0.001). Repeatability of cough suppression test in both patients and healthy controls was high; intraclass correlation coefficients of log(CS5) values 0.81 and 0.87, respectively. CS5 was associated with objective cough frequency (ρ=−0.514, p=0.029).Participants with chronic refractory cough were less able to voluntarily suppress capsaicin-evoked cough compared to healthy controls. This may have important implications for the pathophysiology and treatment of chronic cough.
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Blanck P, Perleth S, Heidenreich T, Kröger P, Ditzen B, Bents H, Mander J. Effects of mindfulness exercises as stand-alone intervention on symptoms of anxiety and depression: Systematic review and meta-analysis. Behav Res Ther 2017; 102:25-35. [PMID: 29291584 DOI: 10.1016/j.brat.2017.12.002] [Citation(s) in RCA: 96] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 11/17/2017] [Accepted: 12/15/2017] [Indexed: 12/18/2022]
Abstract
Mindfulness-based interventions (MBIs) are currently well established in psychotherapy with meta-analyses demonstrating their efficacy. In these multifaceted interventions, the concrete performance of mindfulness exercises is typically integrated in a larger therapeutic framework. Thus, it is unclear whether stand-alone mindfulness exercises (SAMs) without such a framework are beneficial, as well. Therefore, we conducted a systematic review and meta-analysis regarding the effects of SAMs on symptoms of anxiety and depression. Systematic searching of electronic databases resulted in 18 eligible studies (n = 1150) for meta-analyses. After exclusion of one outlier SAMs had small to medium effects on anxiety (SMD = 0.39; CI: 0.22, 0.56; PI: 0.07, 0.70; p < .001, I2 = 18.90%) and on depression (SMD = 0.41; CI: 0.19, 0.64; PI: -0.05, 0.88; p < .001; I2 = 33.43%), when compared with controls. Summary effect estimates decreased, but remained significant when corrected for potential publication bias. This is the first meta-analysis to show that the mere, regular performance of mindfulness exercises is beneficial, even without being integrated in larger therapeutic frameworks.
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Affiliation(s)
- Paul Blanck
- Center for Psychological Psychotherapy, University of Heidelberg, Germany.
| | - Sarah Perleth
- Center for Psychological Psychotherapy, University of Heidelberg, Germany
| | - Thomas Heidenreich
- Department for Social Work, Health and Care, University of Applied Sciences Esslingen, Germany
| | - Paula Kröger
- Center for Psychological Psychotherapy, University of Heidelberg, Germany
| | - Beate Ditzen
- Institute of Medical Psychology, Center for Psychosocial Medicine, University of Heidelberg, Germany
| | - Hinrich Bents
- Center for Psychological Psychotherapy, University of Heidelberg, Germany
| | - Johannes Mander
- Center for Psychological Psychotherapy, University of Heidelberg, Germany.
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Abstract
Chronic obstructive pulmonary disease (COPD) and asthma are both common respiratory diseases that are associated with airflow reduction/obstruction and pulmonary inflammation. Whilst drug therapies offer adequate symptom control for many mild to moderate asthmatic patients, severe asthmatics and COPD patients symptoms are often not controlled, and in these cases, irreversible structural damage occurs with disease progression over time. Transient receptor potential (TRP) channels, in particular TRPV1, TRPA1, TRPV4 and TRPM8, have been implicated with roles in the regulation of inflammation and autonomic nervous control of the lungs. Evidence suggests that inflammation elevates levels of activators and sensitisers of TRP channels and additionally that TRP channel expression may be increased, resulting in excessive channel activation. The enhanced activity of these channels is thought to then play a key role in the propagation and maintenance of the inflammatory disease state and neuronal symptoms such as bronchoconstriction and cough. For TRPM8 the evidence is less clear, but as with TRPV1, TRPA1 and TRPV4, antagonists are being developed by multiple companies for indications including asthma and COPD, which will help in elucidating their role in respiratory disease.
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Abstract
Chronic cough is a common and troublesome condition affecting approximately 12% of the general population. It is associated with poor quality of life with psychological, social and physical consequences. Patients typically complain of a dry irritating cough, driven by a strong urge to cough associated with a sensation or irritation located in the throat. Treatment of potential 'causes', ie asthma, gastro-oesophageal reflux disease and rhino-sinusitis, may produce a complete or partial response, but the response of some patients to opiates and alpha-2-delta ligand antagonists (gabapentin and pregabalin) supports the concept that this is primarily a neurological disorder, characterised by hyper-responsiveness of the nerves. Novel and highly effective neuronal treatments are in development and offer hope of better symptom control with fewer side effects within a few years. This review focuses on understanding the mechanism of chronic cough, current management approaches and research that may lead to novel therapies.
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Affiliation(s)
- Imran Satia
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, and Manchester Academic Health Sciences Centre. University Hospital of South Manchester NHS Foundation Trust, Manchester, UK
| | - Huda Badri
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, and Manchester Academic Health Sciences Centre. University Hospital of South Manchester NHS Foundation Trust, Manchester, UK
| | - Bashar Al-Sheklly
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, and Manchester Academic Health Sciences Centre. University Hospital of South Manchester NHS Foundation Trust, Manchester, UK
| | - Jaclyn Ann Smith
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, and Manchester Academic Health Sciences Centre. University Hospital of South Manchester NHS Foundation Trust, Manchester, UK
| | - Ashley A Woodcock
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, and Manchester Academic Health Sciences Centre. University Hospital of South Manchester NHS Foundation Trust, Manchester, UK
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Affiliation(s)
- Jaclyn A Smith
- Division of Infection Immunity and Respiratory Medicine, School of Biological Sciences, University of Manchester, Manchester, UK.,University Hospital of South Manchester, Manchester, UK
| | - Jemma Haines
- University Hospital of South Manchester, Manchester, UK
| | - Janelle Yorke
- Division of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK.,The Christie NHS Foundation Trust, Manchester, UK
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Cinelli E, Iovino L, Bongianni F, Pantaleo T, Mutolo D. GABAA- and glycine-mediated inhibitory modulation of the cough reflex in the caudal nucleus tractus solitarii of the rabbit. Am J Physiol Lung Cell Mol Physiol 2016; 311:L570-80. [PMID: 27402692 DOI: 10.1152/ajplung.00205.2016] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Accepted: 07/05/2016] [Indexed: 01/05/2023] Open
Abstract
Cough-related sensory inputs from rapidly adapting receptors (RARs) and C fibers are processed by second-order neurons mainly located in the caudal nucleus tractus solitarii (NTS). Both GABAA and glycine receptors have been proven to be involved in the inhibitory control of second-order cells receiving RAR projections. We investigated the role of these receptors within the caudal NTS in the modulation of the cough reflex induced by either mechanical or chemical stimulation of the tracheobronchial tree in pentobarbital sodium-anesthetized, spontaneously breathing rabbits. Bilateral microinjections (30-50 nl) of the receptor antagonists bicuculline and strychnine as well as of the receptor agonists muscimol and glycine were performed. Bicuculline (0.1 mM) and strychnine (1 mM) caused decreases in peak abdominal activity and marked increases in respiratory frequency due to decreases in both inspiratory time (Ti) and expiratory time (Te), without concomitant changes in arterial blood pressure. Noticeably, these microinjections induced potentiation of the cough reflex consisting of increases in the cough number associated with decreases either in cough-related Ti after bicuculline or in both cough-related Ti and Te after strychnine. The effects caused by muscimol (0.1 mM) and glycine (10 mM) were in the opposite direction to those produced by the corresponding antagonists. The results show that both GABAA and glycine receptors within the caudal NTS mediate a potent inhibitory modulation of the pattern of breathing and cough reflex responses. They strongly suggest that disinhibition is one important mechanism underlying cough regulation and possibly provide new hints for novel effective antitussive strategies.
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Affiliation(s)
- Elenia Cinelli
- Dipartimento di Medicina Sperimentale e Clinica, Sezione Scienze Fisiologiche, Università degli Studi di Firenze, Florence, Italy
| | - Ludovica Iovino
- Dipartimento di Medicina Sperimentale e Clinica, Sezione Scienze Fisiologiche, Università degli Studi di Firenze, Florence, Italy
| | - Fulvia Bongianni
- Dipartimento di Medicina Sperimentale e Clinica, Sezione Scienze Fisiologiche, Università degli Studi di Firenze, Florence, Italy
| | - Tito Pantaleo
- Dipartimento di Medicina Sperimentale e Clinica, Sezione Scienze Fisiologiche, Università degli Studi di Firenze, Florence, Italy
| | - Donatella Mutolo
- Dipartimento di Medicina Sperimentale e Clinica, Sezione Scienze Fisiologiche, Università degli Studi di Firenze, Florence, Italy
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Harrison SL, Lee A, Janaudis-Ferreira T, Goldstein RS, Brooks D. Mindfulness in people with a respiratory diagnosis: A systematic review. PATIENT EDUCATION AND COUNSELING 2016; 99:348-355. [PMID: 26561308 DOI: 10.1016/j.pec.2015.10.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Revised: 09/29/2015] [Accepted: 10/17/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVES To describe how mindfulness is delivered and to examine the effect of mindfulness on health-related quality of life (HRQOL), mindful awareness and stress in adults with a respiratory diagnosis. METHOD Five electronic databases were searched. Data were extracted and assessed for quality by two reviewers. RESULTS Data were extracted from four studies. Interventions were based on Mindfulness-Based Stress Reduction and delivered by trained instructors. Recordings of mindfulness were provided for home-based practice. One study targeted the intervention exclusively to anxious individuals with a respiratory diagnosis. Adherence to mindfulness was poor. No effects were seen on disease-specific HRQOL (standardized mean difference (SMD)=-0.21 95% CI: -0.36 to 0.48, p=0.78), mindful awareness (SMD=0.09 95% CI: -0.34 to 0.52, p=0.68) or stress levels (SMD =-0.11 95% CI: -0.46 to 0.23, p=0.51). CONCLUSION Mindfulness interventions, delivered to individuals with a respiratory diagnosis, varied widely in terms of delivery and the outcomes assessed making it difficult to draw any conclusions regarding its effectiveness.
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Affiliation(s)
- Samantha L Harrison
- The Department of Respiratory Medicine, West Park Healthcare Centre, Toronto, ON, Canada; Department of Physical Therapy, University of Toronto, Toronto, ON, Canada; Health and Social Care Institute, Teesside University, Middlesbrough, UK.
| | - Annemarie Lee
- The Department of Respiratory Medicine, West Park Healthcare Centre, Toronto, ON, Canada; Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
| | - Tania Janaudis-Ferreira
- The Department of Respiratory Medicine, West Park Healthcare Centre, Toronto, ON, Canada; Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
| | - Roger S Goldstein
- The Department of Respiratory Medicine, West Park Healthcare Centre, Toronto, ON, Canada; Department of Physical Therapy, University of Toronto, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Dina Brooks
- The Department of Respiratory Medicine, West Park Healthcare Centre, Toronto, ON, Canada; Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
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20
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Clinical features of the urge-to-cough in patients with chronic cough. Respir Med 2015; 109:701-7. [DOI: 10.1016/j.rmed.2015.03.011] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Revised: 03/22/2015] [Accepted: 03/27/2015] [Indexed: 11/20/2022]
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Abdulqawi R, Dockry R, Holt K, Layton G, McCarthy BG, Ford AP, Smith JA. P2X3 receptor antagonist (AF-219) in refractory chronic cough: a randomised, double-blind, placebo-controlled phase 2 study. Lancet 2015; 385:1198-205. [PMID: 25467586 DOI: 10.1016/s0140-6736(14)61255-1] [Citation(s) in RCA: 339] [Impact Index Per Article: 37.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Preclinical studies suggest that P2X3 receptors are expressed by airway vagal afferent nerves and contribute to the hypersensitisation of sensory neurons. P2X3 receptors could mediate sensitisation of the cough reflex, leading to chronic cough. We aimed to investigate the efficacy of a first-in-class oral P2X3 antagonist, AF-219, to reduce cough frequency in patients with refractory chronic cough. METHODS We did a double-blind, placebo-controlled, two-period, crossover study at one UK centre. With a computer-generated sequence, we randomly assigned patients with refractory chronic cough to AF-219, 600 mg twice a day, or to placebo (1:1), and then, after a 2 week washout, assigned patients to receive the other treatment. Patients, health-care providers, and investigators were masked to sequence assignment. We assessed daytime cough frequency (primary endpoint) at baseline and after 2 weeks of treatment using 24 h ambulatory cough recordings. The primary analysis used a mixed effects model with the intention-to-treat population. This study was registered at ClinicalTrials.gov, number NCT01432730. FINDINGS Of 34 individuals assessed between Sept 22, 2011, and Nov 29, 2012, we randomly assigned 24 patients (mean age 54·5 years; SD 11·1). In the observed case analysis, cough frequency was reduced by 75% when patients were allocated to AF-219 compared when allocated to placebo (p=0·0003). Daytime cough frequency fell from a mean 37 coughs per h (SD 32) to 11 (8) coughs per h after AF-219 treatment versus 65 (163) coughs per h to 44 (51) coughs per h after placebo. Six patients withdrew before the end of the study because of taste disturbances, which were reported by all patients taking AF-219. INTERPRETATION P2X3 receptors seem to have a key role in mediation of cough neuronal hypersensitivity. Antagonists of P2X3 receptors such as AF-219 are a promising new group of antitussives. FUNDING Afferent Pharmaceuticals.
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Affiliation(s)
- Rayid Abdulqawi
- Centre for Respiratory Medicine and Allergy, Institute of Inflammation and Repair, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK; University Hospital of South Manchester, Education and Research Centre, University Hospital of South Manchester, Manchester, UK
| | - Rachel Dockry
- Centre for Respiratory Medicine and Allergy, Institute of Inflammation and Repair, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK; University Hospital of South Manchester, Education and Research Centre, University Hospital of South Manchester, Manchester, UK
| | - Kimberley Holt
- Centre for Respiratory Medicine and Allergy, Institute of Inflammation and Repair, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK; University Hospital of South Manchester, Education and Research Centre, University Hospital of South Manchester, Manchester, UK
| | | | | | | | - Jaclyn A Smith
- Centre for Respiratory Medicine and Allergy, Institute of Inflammation and Repair, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK; University Hospital of South Manchester, Education and Research Centre, University Hospital of South Manchester, Manchester, UK.
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Ando A, Farrell MJ, Mazzone SB. Cough-related neural processing in the brain: A roadmap for cough dysfunction? Neurosci Biobehav Rev 2014; 47:457-68. [DOI: 10.1016/j.neubiorev.2014.09.018] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2013] [Revised: 06/29/2014] [Accepted: 09/25/2014] [Indexed: 01/05/2023]
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Yeh GY, Wayne PM, Litrownik D, Roberts DH, Davis RB, Moy ML. Tai chi mind-body exercise in patients with COPD: study protocol for a randomized controlled trial. Trials 2014; 15:337. [PMID: 25168853 PMCID: PMC4158042 DOI: 10.1186/1745-6215-15-337] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Accepted: 07/22/2014] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) is a chronic, progressively debilitating condition that is prevalent in the US and worldwide. Patients suffer from progressive dyspnea and exercise intolerance. Physical exercise is beneficial, but conventional pulmonary rehabilitation programs are underutilized. There remains a need for novel interventions that improve symptoms, quality-of-life, and functional capacity. Tai chi is an increasingly popular mind-body exercise that includes physical exercise, breathing training, mindful awareness, and stress management--components that are essential to the self-management of COPD. There are, however, limited data on the effectiveness of tai chi as a therapeutic intervention in this population. METHODS/DESIGN The Primary Aims are to evaluate the efficacy, safety, and feasibility of a 12-week tai chi program for patients with COPD. We utilize a randomized controlled trial design, with participants assigned in a 2:1 ratio to either a group tai chi program (N = 63) or a time/attention-matched education control (N = 31). Our primary outcomes are COPD-specific quality-of-life and exercise capacity. Secondary outcomes include dyspnea, mood, functional status, self-efficacy, and lung function. Cardiopulmonary exercise testing is done in a subset of patients (N = 50). To explore optimal training duration, a subgroup of patients in tai chi are randomly assigned to complete an additional 12 weeks training (total 24 weeks) (Exploratory Aim 1). To explore the impact of a simplified seated intervention including only a subset of tai chi's training components, a third randomly assigned group (N = 31) receives a 12- week mind-body breathing program (N = 31) (Exploratory Aim 2). DISCUSSION Results of the BEAM study (Breathing, Education, Awareness, Movement) will provide preliminary evidence regarding the value of tai chi for improving quality of life and exercise capacity in patients with COPD, including information regarding optimal duration. They will also inform the feasibility and potential benefit of an alternative mind-body breathing intervention, and provide insight regarding how isolated mind-body exercise components contribute to the overall effects of tai chi. Should the results be positive, tai chi and related mind-body practices may offer a novel exercise option that is potentially accessible to a large proportion of patients with COPD. TRIAL REGISTRATION This trial is registered in Clinical Trials.gov, ID number NCT01551953. Date of Registration March 1 2012.
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Affiliation(s)
- Gloria Y Yeh
- />Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, 1309 Beacon Street, Brookline, MA 02446 USA
| | - Peter M Wayne
- />Osher Center for Integrative Medicine, Harvard Medical School, 900 Commonwealth Ave, Boston, MA 02446 USA
- />Division of Preventive Medicine, Brigham and Women’s Hospital, Boston, MA USA
| | - Daniel Litrownik
- />Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, 1309 Beacon Street, Brookline, MA 02446 USA
| | - David H Roberts
- />Division of Pulmonary, Sleep and Critical Care Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215 USA
| | - Roger B Davis
- />Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, 1309 Beacon Street, Brookline, MA 02446 USA
| | - Marilyn L Moy
- />Pulmonary and Critical Care Section, Department of Medicine, Veterans Administration Boston Healthcare System, 1400 VFW Parkway, Boston, MA 02132 USA
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Pacheco A. Chronic cough: from a complex dysfunction of the neurological circuit to the production of persistent cough. Thorax 2014; 69:881-3. [PMID: 24969642 DOI: 10.1136/thoraxjnl-2014-205661] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Chronic cough or cough that lasts more than 8 weeks, once a chest x-ray and spirometry are confirmed normal, is caused by an alteration in a section of the route between peripheral receptors, mainly in the upper and lower airway and oesophagus, spinal cord and the cough centre in the brain stem involving the cortex. These mechanisms of cough have their homology in the circuit of chronic pain, and on that basis, should expand future research of chronic cough. Clinically chronic cough is easy to diagnose by an excessive response or hypertussia to low-intensity stimuli or banal stimuli, which we now call hypersensitivity cough syndrome, quantified by a positive reflex cough with capsaicin or citric acid. However, hypersensitivity cough syndrome can be impossible to quantify in the laboratory when the hyper-responsiveness originates in the central nervous system. This is normally caused by excessive peripheral input or convergence of stimuli from different sources. Once central hypersensitivity is acquired, peripheral input is not as important for activation of the cough.
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Chamberlain S, Garrod R, Birring SS. Cough suppression therapy: does it work? Pulm Pharmacol Ther 2013; 26:524-7. [PMID: 23524013 DOI: 10.1016/j.pupt.2013.03.012] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2012] [Revised: 03/07/2013] [Accepted: 03/12/2013] [Indexed: 10/27/2022]
Abstract
Cough suppression therapy (CST), also known as cough suppression physiotherapy and speech pathology management is a promising non-pharmacological therapeutic option for patients with refractory chronic cough. CST may consist of education, improving laryngeal hygiene and hydration, cough suppression techniques, breathing exercises and counselling. It is an out-patient therapy delivered in 2-4 sessions. There is evidence to support the efficacy of CST: a randomised controlled trial reported a significant reduction in cough symptoms and other studies have reported improved cough related quality of life, reduced cough reflex hypersensitivity and cough frequency. The mechanism of action of CST is not clear, but it has been shown to reduce cough reflex sensitivity, paradoxical vocal fold movement (PVFM) and extrathoracic hyperresponsiveness. Further research is needed to determine the optimal components of CST, the characteristics of patients in whom it is most effective and to increase the understanding of its mechanisms of action. The effectiveness of CST in other respiratory conditions such as asthma, pulmonary fibrosis, chronic obstructive pulmonary disease and sarcoidosis should also be investigated.
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Affiliation(s)
- Sarah Chamberlain
- King's College London, Division of Asthma, Allergy and Lung Biology, Denmark Hill, London SE5 9RS, UK
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Mazzone SB, McGovern AE, Yang SK, Woo A, Phipps S, Ando A, Leech J, Farrell MJ. Sensorimotor circuitry involved in the higher brain control of coughing. COUGH 2013; 9:7. [PMID: 23497672 PMCID: PMC3602068 DOI: 10.1186/1745-9974-9-7] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Accepted: 01/16/2013] [Indexed: 02/07/2023]
Abstract
There is an overwhelming body of evidence to support the existence of higher brain circuitries involved in the sensory detection of airways irritation and the motor control of coughing. The concept that cough is purely a reflex response to airways irritation is now superseded by the recognition that perception of an urge-to-cough and altered behavioral modification of coughing are key elements of cough disorders associated with airways disease. Understanding the pathways by which airway sensory nerves ascend into the brain and the patterns of neural activation associated with airways irritation will undoubtedly provide new insights into disordered coughing. This brief review aims to explore our current understanding of higher order cough networks by summarizing data from recent neuroanatomical and functional studies in animals and humans. We provide evidence for the existence of distinct higher order network components involved in the discrimination of signals arising from the airways and the motor control of coughing. The identification of these network components provides a blueprint for future research and the development of targeted managements for cough and the urge-to-cough.
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Affiliation(s)
- Stuart B Mazzone
- School of Biomedical Sciences, University of Queensland, St Lucia, Brisbane, QLD, 4072, Australia.
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Kelsall A, Houghton LA, Jones H, Decalmer S, McGuinness K, Smith JA. A novel approach to studying the relationship between subjective and objective measures of cough. Chest 2010; 139:569-575. [PMID: 20864619 DOI: 10.1378/chest.10-0438] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Currently, no data are available on the relationship between changes in objective and subjective measures of cough, the magnitude of change in cough frequency perceived by patients as clinically meaningful, or the sample sizes required to show significant changes in cough therapeutic trials. Because patients anecdotally report reductions in cough severity while undergoing esophageal testing, we aimed to address these issues by assessing objective and subjective measures of cough with and without an esophageal catheter. METHODS Twenty-four-hour cough monitoring was performed on two occasions, with and without esophageal impedance/pH monitoring in 62 patients with chronic cough (mean age 56.8 years [SD±10.8]; 43 women; median cough duration 3.3 years [interquartile range (IQR), 2.0-10.0]). Cough was assessed objectively measuring coughs per hour and subjectively using a numerical cough score and a visual analog scale (VAS), scored separately for day and night, and then averaged to represent each 24-h period. RESULTS Objective cough frequency was reduced by a median of 33.3% (IQR, -68.8% to -13.0%; P<.001) with the catheter. The averaged day and night cough scores and VAS scores also significantly decreased, but changes in these did not correlate with decreases in cough frequency. Sample-size calculations suggested that crossover designs using objective cough frequency may be preferable in therapeutic trials. CONCLUSIONS These observations provide useful information on the reduction in objective cough frequency scored as an improvement by patients with chronic cough and offer guidance for the design and powering of future therapeutic trials. TRIAL REGISTRY ISRCTN; No.: ISRCTN62337037; URL: http://www.controlled-trials.com.
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Affiliation(s)
- Angela Kelsall
- Respiratory Research Group, University of Manchester, NHS Foundation Trust, Manchester, England; North West Lung Centre, University Hospital of South Manchester, NHS Foundation Trust, Manchester, England
| | - Lesley A Houghton
- Neurogastroenterology Unit, University of Manchester, NHS Foundation Trust, Manchester, England
| | - Helen Jones
- Respiratory Research Group, University of Manchester, NHS Foundation Trust, Manchester, England; Neurogastroenterology Unit, University of Manchester, NHS Foundation Trust, Manchester, England
| | - Samantha Decalmer
- Respiratory Research Group, University of Manchester, NHS Foundation Trust, Manchester, England
| | - Kevin McGuinness
- Respiratory Research Group, University of Manchester, NHS Foundation Trust, Manchester, England; North West Lung Centre, University Hospital of South Manchester, NHS Foundation Trust, Manchester, England
| | - Jaclyn A Smith
- Respiratory Research Group, University of Manchester, NHS Foundation Trust, Manchester, England.
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Abstract
Chronic cough is common, blights patients' lives and is hard to treat. Chronic cough patients demonstrate high objective cough rates and as a group have increased cough reflex sensitivity. However, conventional cough challenge techniques show substantial overlap with normal subjects. This suggests that other important mechanisms have yet to be determined. For the last two decades, chronic cough has been considered to be caused by gastro-oesophageal reflux, post-nasal drip or asthma. However, many patients with these conditions do not have cough, and in those with cough, the response to specific treatments is unpredictable at best. In addition, many chronic cough patients do not have an identifiable cause. This raises questions about the concept of a triad of treatable causes for chronic cough. Our current understanding of the neurophysiology of the cough reflex is largely derived from animal work with limited data in humans. By analogy with chronic pain syndromes, both peripheral and central sensitization may be important mechanisms in chronic cough, and are under active investigation. We need to understand the mechanisms underlying sensitization, how they interact with cough triggers and their relationship with the sensations that drive the urge to cough, and the subsequent motor cough response in chronic cough. Only then will we develop effective interventions.
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Affiliation(s)
- Ashley Woodcock
- University Hospital of South Manchester, Southmoor Road, Manchester, UK.
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