Is opiate action in cough due to sedation?

Efficacy of acupuncture for a cough-related symptom cluster in patients with lung cancer: A randomized controlled trial

PURPOSE

This study was designed to evaluate the effect of acupuncture on cough, expectoration, and shortness of breath in lung cancer patients.

METHODS

Between December 2021 and June 2022, a total of 130 lung cancer patients were recruited, and they were split into control and intervention groups at random. Routine nursing was provided to the control group, whereas routine nursing with acupuncture using LU7 (Lie Que), LU9 (Tai Yuan), BL13 (Fei Shu), and BL20 (Pi Shu) was administered to the intervention group for 7 days. The severity of cough, expectoration, and shortness of breath was assessed 1 day before and after the interventions using the lung cancer-specific module of the MDASI. A two-way ANOVA was performed for group comparisons.

RESULTS

Compared with the control group, the symptoms of cough in the intervention group were significantly improved (F = 5.095, MD = -0.32, 95% CI, -0.59 to 0.04, P = 0.025), while expectoration (F = 0.626, MD = -0.11, 95% CI, -0.38 to 0.16, P = 0.430) and shortness of breath (F = 0.165, MD = -0.05, 95% CI, -0.27 to 0.18, P = 0.685) had no significant change. Cough also identified an obvious interaction effect (P = 0.014), and the post-intervention simple main effect test demonstrated a tangible difference between the two groups (MD = -0.66, 95% CI, -0.99 to 0.33, P < 0.001) post-intervention.

CONCLUSIONS

Acupuncture using LU7, LU9, BL13, and BL20 can relieve the cough of lung cancer patients, but not relieve expectoration and shortness of breath.

Cough hypersensitivity and chronic cough

Chronic cough is globally prevalent across all age groups. This disorder is challenging to treat because many pulmonary and extrapulmonary conditions can present with chronic cough, and cough can also be present without any identifiable underlying cause or be refractory to therapies that improve associated conditions. Most patients with chronic cough have cough hypersensitivity, which is characterized by increased neural responsivity to a range of stimuli that affect the airways and lungs, and other tissues innervated by common nerve supplies. Cough hypersensitivity presents as excessive coughing often in response to relatively innocuous stimuli, causing significant psychophysical morbidity and affecting patients' quality of life. Understanding of the mechanisms that contribute to cough hypersensitivity and excessive coughing in different patient populations and across the lifespan is advancing and has contributed to the development of new therapies for chronic cough in adults. Owing to differences in the pathology, the organs involved and individual patient factors, treatment of chronic cough is progressing towards a personalized approach, and, in the future, novel ways to endotype patients with cough may prove valuable in management.

The Effect of Ramosetron on Remifentanil in Preventing Emergence Cough from Sevoflurane Anesthesia in Female Patients

BACKGROUND

Remifentanil reduces cough during extubation. Ramosetron, a 5-HT3 receptor antagonist, is a potent antiemetic. Regarding the antitussive property of 5-HT receptor agonists, ramosetron can mediate the cough reflex, as increasing the remifentanil requirement. The aim of this study was to evaluate the effect of ramosetron on the optimal effect-site concentration (Ce) of remifentanil for preventing emergence cough from sevoflurane anesthesia in female patients.

METHODS

Forty-seven female patients undergoing laparoscopic cholecystectomy randomly received either ramosetron 0.3 mg (n = 23) or the same volume of normal saline (n = 24) intravenously at the end of surgery. The remifentanil Ce using target controlled infusion in 50% of patients (EC50) and 95% of patients (EC95) were assessed using Dixon's up-and-down or isotonic regression method with a boot¬strapping approach.

RESULTS

Using Dixon's up-and-down method, the EC50 of remifentanil in the control group (1.33 ± 0.38 ng/mL) was comparable to that of ramosetron group (1.50 ± 0.69 ng/mL) (P = 0.615). Using isotonic regression analysis, the EC50 (83% confidence interval) did not differ between the two groups (1.17 [0.86-1.43] ng/mL and 1.13 [0.68-1.56] ng/mL in control and ramosetron groups). However, the EC95 (95% confidence interval) was significantly lower in the control group than in the ramosetron group (1.90 [1.45-1.96] ng/mL and 2.92 [2.35-2.97] ng/mL).

CONCLUSION

Remifentanil Ce for preventing emergence cough was higher in the ramosetron group than the control group. It may indicate the lowering effect of ramosetron on antitussive activity of remifentanil.

Curbing the Cough: Multimodal Treatments for Neurogenic Cough: A Systematic Review and Meta-Analysis

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.

The Association Between Prescribed Opioid Receipt and Community-Acquired Pneumonia in Adults: a Systematic Review and Meta-analysis

BACKGROUND

In the current opioid epidemic, opioid addiction and overdose deaths are a public health crisis. Researchers have uncovered other concerning findings related to opioid use, such as the association between prescribed opioids and respiratory infection, including pneumonias. Potential mechanisms include the immunosuppressive effects of certain opioids, respiratory depression, and cough suppression. We conducted a systematic review assessing whether prescribed opioid receipt is a risk factor for community-acquired pneumonia (CAP).

METHODS

A systematic literature search of published studies was conducted using Ovid MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), Embase, Web of Science, AMED, and CINAHL from database inception through March 11, 2020. We included any clinical trial, cohort, or case-control study that reported an association between prescribed opioid receipt and CAP in adults. Two reviewers independently performed data extraction and quality assessment using the Newcastle-Ottawa Quality Assessment Scale. The risk of CAP from prescribed opioid receipt was studied by pooling studies using random effects meta-analysis.

RESULTS

We identified 3229 studies after removing duplicates. After detailed selection, 33 articles were reviewed in full and eight studies (representing 567,472 patients) met inclusion criteria. The pooled effect for the four case-control studies and three cohort studies showed a significant increase in the risk of CAP requiring hospitalization among those with prescribed opioid receipt compared with those without opioid prescribed receipt (OR 1.57 [95% CI (1.34, 1.84)]; HR 1.18 [95% CI (1.00, 1.40)]).

CONCLUSION

The findings suggest prescribed opioid receipt is a risk factor for CAP. The included studies examined post-operative patients and patients with chronic medical conditions. Further research is needed to examine the impact of opioids on the incidence of CAP in an otherwise healthy population.

A systematic review of methods of citric acid cough reflex testing

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.

Cough Hypersensitivity Syndrome: A Few More Steps Forward

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.

Codeine versus placebo for chronic cough in children

BACKGROUND

Cough in children is a commonly experienced symptom that is associated with increased health service utilisation and burden to parents. The presence of chronic (equal to or more than four weeks) cough in children may indicate a serious underlying condition such as inhaled foreign body or bronchiectasis. Codeine (and derivative)-based medications are sometimes used to treat cough due to their antitussive properties. However, there are inherent risks associated with the use of these medications such as respiratory drive suppression, anaesthetic-induced anaphylaxis, and addiction. Metabolic response and dosage variability place children at increased risk of experiencing such side effects. A systematic review evaluating the quality of the available literature would be useful to inform management practices.

OBJECTIVES

To evaluate the safety and efficacy of codeine (and derivatives) in the treatment of chronic cough in children.

SEARCH METHODS

We searched the Cochrane Airways Group Register of Trials, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (1946 to 8 June 2016), EMBASE (1974 to 8 June 2016), the online trials registries of the World Health Organization and ClinicalTrials.gov, and the bibliographic references of publications. We imposed no language restrictions.

SELECTION CRITERIA

We considered studies eligible for analysis when: the participant population included children aged less than 18 years with chronic cough (duration equal to or more than four weeks at the time of intervention); and the study design evaluated codeine or codeine-based derivatives against placebo through a randomised controlled trial.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the search results to determine eligibility against a standardised criteria, and we had a pre-planned method for analysis.

MAIN RESULTS

We identified a total of 556 records, of which 486 records were excluded on the basis of title and abstract. We retrieved the remaining 70 references in full to determine eligibility. No studies fulfilled the inclusion criteria of this review, and thus we found no evidence to support or oppose the use of codeine or derivatives as antitussive agents for chronic cough in children.While chronic cough is not the same as acute cough, systematic reviews on the use of codeine efficacy for acute cough in children conclude an overall lack of evidence to support or oppose the use of over-the-counter cough and cold medications containing codeine (or derivatives) for treatment of acute cough in children. The lack of sufficient evidence to support the use of these medications has been consistently reaffirmed by medical experts in international chronic cough guidelines and by governing medical and pharmaceutical authorities in the USA, Europe, Canada, New Zealand, and Australia. Due to the lack of sufficient evidence to support efficacy, and the known risks associated with use - in particular the increased risks for children - these medications are now not recommended for children less than 12 years of age and children between 12 to 18 years with respiratory conditions.

AUTHORS' CONCLUSIONS

This review has highlighted the absence of any randomised controlled trials evaluating codeine-based medications in the treatment of childhood chronic cough. Given the potential adverse events of respiratory suppression and opioid toxicity, national therapeutic regulatory authorities recommend the contraindication of access to codeine in children less than 12 years of age. We suggest that clinical practice adhere to clinical practice guidelines and thus refrain from using codeine or its derivatives to treat cough in children. Aetiological-based management practices continue to be advocated for children with chronic cough.

Cough hypersensitivity as a neuro-immune interaction

Cough is an intrinsic protective reflex. However, chronic cough affects a considerable proportion of general population and has a major impact on quality of life. A recent paradigm shift to ‘cough hypersensitivity syndrome’ suggests that chronic cough arises from hypersensitivity of the airway sensory nerves. As cough reflex is determined by interaction of the nervous system with immune system, persistent dysregulation of one or both of these systems may lead to chronic cough hypersensitivity. Here we review the current evidence for the neuro-immune interactions that underlie cough hypersensitivity and discuss future therapeutic strategies.