Types and applications of cough-related questionnaires

Narrative review of relationship between chronic cough and laryngopharyngeal reflux

Gastroesophageal reflux disease (GERD) as a possible cause of chronic cough is known for decades. However, more than 75% of patients with extraoesophageal symptoms do not suffer from typical symptoms of GERD like pyrosis and regurgitations and have negative upper gastrointestinal endoscopy. For such a condition term laryngopharyngeal reflux (LPR) was introduced and is used for more than two decades. Since the comprehensive information on relationship between chronic cough and LPR is missing the aim of this paper is to summarize current knowledge based on review of published information during last 13 years. Laryngopharyngeal reflux is found in 20% of patients with chronic cough. The main and recognized diagnostic method for LPR is 24-h multichannel intraluminal impedance-pH (MII-pH) monitoring, revealing reflux episodes irritating the upper and lower respiratory tract mucosa. The treatment of LPR should be initiated with dietary and lifestyle measures, followed by proton pump inhibitor (PPI) therapy and other measures. Despite progress, more research is needed for accurate diagnosis and targeted therapies. Key areas for exploration include biomarkers for diagnosis, the impact of non-acid reflux on symptom development, and the efficacy of new drugs. Further studies with a focused population, excluding other causes like asthma, and using new diagnostic criteria for LPR are essential. It's crucial to consider LPR as a potential cause of unexplained chronic cough and to approach diagnosis and treatment with a multidisciplinary perspective.

Modified surgical incision suturing technique in uniportal video-assisted thoracoscopic pulmonary resection

Background

In recent years, single-hole thoracoscopic surgery technology is widely used in major medical centers and chest-specialized hospitals for the treatment of lung diseases. However, the single-hole minimally invasive surgery method focuses on one incision, and all surgical instruments need to pass through the same hole, resulting in repeated extrusion and tissue damage of the surgical incision. Therefore, we have improved the suture method of conventional surgical incision in order to reduce the probability of wound infection and dehiscence, promote early healing, and reduce the severity of postoperative wound scar, thereby enhancing the postoperative rapid recovery of patients. The purpose of this study is to explore the clinical efficacy of a modified surgical incision suture technique applied to uniportal thoracoscopic pulmonary resection.

Methods

This study retrospectively analyzed 151 patients who were admitted to the Department of Thoracic Surgery and underwent pulmonary resection from January 2019 to October 2021 in the North District of Suzhou Municipal Hospital. The patients were divided into two groups according to the different surgical incision suture methods: a modified group and a conventional group. The postoperative general clinical indexes, incision infection rate, secondary suture rate, postoperative incision pain score, and the severity of postoperative incision scar were compared and analyzed between the two groups.

Results

There were no statistically significant differences between the two groups in terms of chest tube duration or postoperative drainage and postoperative incision pain scores; the incision infection rate (1.3% vs. 6.7%, P<0.05), secondary suture rate (2.6% vs. 9.4%, P<0.05), and postoperative scar score (4.853 vs. 5.543, P=0.03) were better in the modified group than in the conventional group, and the differences between the two groups were statistically significant.

Conclusions

Our modified suture method reduces the chance of infection and splitting and the severity of postoperative incision scar formation, promoting early healing. It can be safely and effectively applied to the incision suture of uniportal thoracoscopic pulmonary resection, enhancing the rapid postoperative recovery of patients.

Content validity of the Leicester Cough Questionnaire in adults with refractory or unexplained chronic cough: a qualitative interview study

BACKGROUND

Chronic cough, a cough lasting >8 weeks, includes refractory chronic cough (RCC) and unexplained chronic cough (UCC). Patient-reported outcome (PRO) measures are needed to better understand chronic cough impacts that matter most to patients. The 19-item Leicester Cough Questionnaire (LCQ), an existing PRO measure of chronic cough, assesses impacts of cough across physical, psychological, and social domains. However, the content validity of the LCQ evaluating these concepts in patients with RCC/UCC had not been established.

OBJECTIVES

To evaluate the content validity of the LCQ in patients with RCC/UCC.

DESIGN

A cross-sectional, qualitative interview study.

METHODS

First, previously completed qualitative interview results in adults with RCC/UCC (N = 30) were evaluated and mapped to LCQ concepts. Next, a clinical cough expert reviewed each LCQ item and assessed the salience of its concepts for patients with RCC/UCC. Finally, semistructured interviews-including both concept elicitation and cognitive debriefing-were conducted in adults with RCC/UCC (N = 20) to elicit a comprehensive set of participant experiences and to assess the appropriateness of using the LCQ in this population.

RESULTS

Concepts reported in the past and present qualitative interviews were included across all LCQ items, and most impacts reported to be the "most bothersome" were assessed in the LCQ. In the current study, all participants indicated that reduced cough frequency would be an important treatment target. During cognitive debriefing, each LCQ item was endorsed by ⩾70% of participants. Additionally, participants were generally able to understand, recall, and select a response for each LCQ item. All participants and the clinical expert indicated that the LCQ was appropriate and assessed the impacts most relevant to patients with RCC/UCC.

CONCLUSION

Our findings support the content validity of the LCQ and demonstrate that this measure is fit-for-purpose and includes important cough impacts in adults with RCC/UCC.

Methods of Cough Assessment and Objectivization

Cough is one of the most important airway defensive reflexes aimed at removing foreign particles or endogenously produced materials from the airways and provides protection against aspiration. Generally considered, cough is a vital physiological defensive mechanism for lung health. However, in case of cough dysregulation this reflex can become pathological and leads to an adverse influence on daily life. Therefore, it is necessary to effectively evaluate the severity of cough for its diagnosis and treatment. There are subjective and objective methods for assessing cough. These methods should help describe the heterogeneity of cough phenotypes and may establish better treatment by monitoring response to nonpharmacological or pharmacological therapies. It is important to keep in mind that the clinical assessment of cough should include both tools that measure the amount and severity of the cough. The importance of a combined subjective and objective evaluation for a comprehensive assessment of cough has been advocated in the guidelines of the European Respiratory Society on cough evaluation. This review article provides an overview of subjective and objective methods for assessing and monitoring cough in children and adults comparing to animal models. Key words Cough frequency; Cough intensity; Cough reflex sensitivity; Cough monitors; Cough assessment.

Cough Assessment and Management in Pulmonary Rehabilitation- A Canadian Survey

Pulmonary rehabilitation is a cornerstone intervention for controlling respiratory symptoms in people with chronic respiratory diseases. Chronic cough affects up to 90% of people with chronic respiratory diseases, however, it is currently unknown whether chronic cough is assessed and/or managed in pulmonary rehabilitation. This study aimed to determine if and how chronic cough is assessed and managed in pulmonary rehabilitation. This was a cross-sectional study. Pulmonary rehabilitation programs in Canada were identified via online websites. A representative from each program was invited to complete an online survey including the following topics: program demographics, assessment and management practices, and barriers and facilitators. Of 133 programs contacted, 31 returned a completed survey (23% response rate). Approximately half (52%) of respondents reported enrolling patients with chronic cough. Of those, 45% reported assessing and 62% reported intervening in chronic cough. Inadequate knowledge of assessment and management techniques was commonly identified to be a barrier and increased education was suggested as a possible facilitator. Based on pulmonary rehabilitation programs that responded to our survey, chronic cough is a prevalent symptom; however, it is scarcely assessed and managed. A need for structured education and the use of standardised strategies were reported as facilitators to the assessment and management of chronic cough in pulmonary rehabilitation.

Herbal medicine for the treatment of chronic cough: a systematic review and meta-analysis

Objectives: Chronic cough is a frequent condition worldwide that significantly impairs quality of life. Herbal medicine (HM) has been used to treat chronic cough due to the limited effectiveness of conventional medications. This study aimed to summarize and determine the effects of HM on patients with chronic cough. Methods: A comprehensive search of 11 databases was conducted to find randomized controlled clinical trials (RCTs) that reported the effects of HM for patients with chronic cough on 16 March 2023. The primary outcome was cough severity, and the secondary outcomes included cough-related quality of life, cough frequency, total effective rate (TER), and cough recurrence rate. The methodological quality of the included studies was assessed using the Cochrane risk of bias tool, and the certainty of the evidence for effect estimates was assessed using the Grading of Recommendations, Assessment, Development, and Evaluations tool. Results: A total of 80 RCTs comprising 7,573 patients were included. When HM was used as an alternative therapy to conventional medication, there were inconsistent results in improving cough severity. However, HM significantly improved cough-related quality of life and TER and significantly lowered the cough recurrence rate compared with conventional medication. When used as an add-on therapy to conventional medication, HM significantly improved cough severity, cough-related quality of life, and TER and significantly lowered the recurrence rate. In addition, HM had a significantly lower incidence of adverse events when used as an add-on or alternative therapy to conventional medication. The subgroup analysis according to age and cause of cough also showed a statistically consistent correlation with the overall results. The certainty of the evidence for the effect of HM was generally moderate to low due to the risk of bias in the included studies. Conclusion: HM may improve cough severity and cough-related quality of life, and lower the cough recurrence rate and incidence of adverse events in patients with chronic cough. However, due to the high risk of bias and clinical heterogeneity of the included studies, further high-quality placebo-controlled clinical trials should be conducted using a validated and objective assessment tool. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023418736, CRD42023418736.

Regulatory functional role of NLRP3 inflammasome during Mycoplasma hyopneumoniae infection in swine

Mycoplasma hyopneumoniae causes enzootic pneumonia, a highly contagious respiratory disease in swine that causes significant economic losses worldwide. It is unknown whether the nucleotide oligomerization domain-like receptor (NLR) family pyrin domain containing 3 (NLRP3) inflammasome regulates the immune response in swine during M. hyopneumoniae infection. The current study utilized an in vivo swine model of M. hyopneumoniae infection to investigate the regulatory functional role of the NLRP3 inflammasome during M. hyopneumoniae infection. Notable histopathological alterations were observed in M. hyopneumoniae-infected swine tissues, which were associated with an inflammatory response and disease progression. Swine M. hyopneumoniae infection was associated with an increase in the expression of the NLRP3 inflammasome, which stimulated pro-inflammatory cytokines such as tumor necrosis factor-alpha, interleukin 18, and interleukin 1 beta (IL-1β). The impact of the NLRP3 inhibitor, MCC950 on NLRP3 and pro-inflammatory cytokines in M. hyopneumoniae-infected swine was examined to investigate the relationship between the NLRP3 inflammasome and M. hyopneumoniae infection. Taken together, our findings provide strong evidence that the NLRP3 inflammasome plays a critical regulatory functional role in M. hyopneumoniae infection in swine.

Evaluation of noscapine-licorice combination effects on cough relieving in COVID-19 outpatients: A randomized controlled trial

Background: As February 2023, SARS-CoV-2 is still infecting people and children worldwide. Cough and dyspnea are annoying symptoms almost present in a large proportion of COVID-19 outpatients, and the duration of these symptoms might be long enough to affect the patients' quality of life. Studies have shown positive effects for noscapine plus licorice in the previous COVID-19 trials. This study aimed to assess the effects of the combination of noscapine and licorice-for relieving cough in outpatients with COVID-19. Methods: This randomized controlled trial was conducted on 124 patients at the Dr. Masih Daneshvari Hospital. Participants over 18 years of age with confirmed COVID-19 and cough were allowed to enter the study if the onset of symptoms was less than 5 days. The primary outcome was to assess the response to treatment over 5 days using the visual analogue scale. Secondary outcomes included the assessment of cough severity after 5 days using Cough Symptom Score, as well as the cough-related quality of life and dyspnea relieving. Patients in the noscapine plus licorice group received Noscough^® syrup 20 mL every 6 h for 5 days. The control group received diphenhydramine elixir 7 mL every 8 h. Results: By day five, 53 (85.48%) patients in the Noscough^® group and 49 (79.03%) patients in the diphenhydramine group had response to treatment. This difference was not statistically significant (p-value = 0.34). The presence of dyspnea was significantly lower in the Noscough^® group versus diphenhydramine at day five (1.61% in the Noscough^® group vs. 12.9% in the diphenhydramine group; p-value = 0.03). The cough-related quality of life and severity also significantly favored Noscough^® syrup (p-values <0.001). Conclusion: Noscapine plus licorice syrup was slightly superior to diphenhydramine in relieving cough symptoms and dyspnea in the COVID-19 outpatients. The severity of cough and cough-related quality of life were also significantly better in the noscapine plus licorice syrup. Noscapine plus licorice may be a valuable treatment in relieving cough in COVID-19 outpatients.

Chronic cough-the limitation and advances in assessment techniques

Accurate and consistent assessments of cough are essential to advance the understanding of the mechanisms of cough and individualised the management of patients. Considerable progress has been made in this work. Here we reviewed the currently available tools for subjectively and objectively measuring both cough sensitivity and severity. We also provided some opinions on the new techniques and future directions. The simple and practical Visual Analogue Scale (VAS), the Leicester Cough Questionnaire (LCQ), and the Cough Specific Quality of Life Questionnaire (CQLQ) are the most widely used self-reported questionnaires for evaluating and quantifying cough severity. The Hull Airway Reflux Questionnaire (HARQ) is a tool to elucidate the constellation of symptoms underlying the diagnosis of chronic cough. Chemical excitation tests are widely used to explore the pathophysiological mechanisms of the cough reflex, such as capsaicin, citric acid and adenosine triphosphate (ATP) challenge test. Cough frequency is an ideal primary endpoint for clinical research, but the application of cough counters has been limited in clinical practice by the high cost and reliance on aural validation. The ongoing development of cough detection technology for smartphone apps and wearable devices will hopefully simplify cough counting, thus transitioning it from niche research to a widely available clinical application.

Making cough count in tuberculosis care

Cough assessment is central to the clinical management of respiratory diseases, including tuberculosis (TB), but strategies to objectively and unobtrusively measure cough are lacking. Acoustic epidemiology is an emerging field that uses technology to detect cough sounds and analyze cough patterns to improve health outcomes among people with respiratory conditions linked to cough. This field is increasingly exploring the potential of artificial intelligence (AI) for more advanced applications, such as analyzing cough sounds as a biomarker for disease screening. While much of the data are preliminary, objective cough assessment could potentially transform disease control programs, including TB, and support individual patient management. Here, we present an overview of recent advances in this field and describe how cough assessment, if validated, could support public health programs at various stages of the TB care cascade.

Identifying patients who suffered from post-discharge cough after lung cancer surgery

PURPOSE

To establish a discharge cutoff point (CP) on a simple patient-reported cough score to identify patients requiring post-discharge cough intervention.

METHODS

Data were extracted from a prospective cohort study of patients undergoing lung cancer surgery. Symptoms were assessed using the MD Anderson Symptom Inventory-Lung Cancer Module. Group-based trajectory modeling was used to identify patient subgroups defined by post-discharge cough trajectories. Generalized linear model and bootstrap resampling with 2000 samples were used to determine the optimal cutoff points of discharge cough scores and their robustness. Analysis of variance, chi-square test, and mixed-effects model were used to validate the optimal cutoff points.

RESULTS

The cough trajectories of post-discharge followed three patterns (high, middle, low); higher cough was associated with poor recovery of the enjoyment of life within 4 weeks after discharge (P < 0.001). The CP (3, 6) of discharge cough demonstrated as the optimal CP (F = 21.72). When discharged, 45.66% (179/392) of patients suffered a none/mild cough (0-2 points), 41.82% (164/392) suffered a moderate cough (3-5 points), and 12.5% (49/392) suffered a severe cough (6-10 points). Among these patients, there was a significant difference in the proportion of returning to work at 1 month after discharge (non-mild: 77.70%; moderate: 60.74%; severe: 48.57%; p < 0.001).

CONCLUSIONS

Moderate-to-severe cough is relatively common in patients undergoing lung cancer surgery, and the higher the cough trajectory, the worse the recovery to normal life. Therefore, these patients with a cough score ≥ 3 or ≥ 6 at discharge may require additional medical intervention and extensive care.

WAO-ARIA consensus on chronic cough - Part III: Management strategies in primary and cough-specialty care. Updates in COVID-19

Background

Chronic cough management necessitates a clear integrated care pathway approach. Primary care physicians initially encounter the majority of chronic cough patients, yet their role in proper management can prove challenging due to limited access to advanced diagnostic testing. A multidisciplinary approach involving otolaryngologists and chest physicians, allergists, and gastroenterologists, among others, is central to the optimal diagnosis and treatment of conditions which underly or worsen cough. These include infectious and inflammatory, upper and lower airway pathologies, or gastro-esophageal reflux. Despite the wide armamentarium of ancillary testing conducted in cough multidisciplinary care, such management can improve cough but seldom resolves it completely. This can be due partly to the limited data on the role of tests (eg, spirometry, exhaled nitric oxide), as well as classical pharmacotherapy conducted in multidisciplinary specialties for chronic cough. Other important factors include presence of multiple concomitant cough trigger mechanisms and the central neuronal complexity of chronic cough. Subsequent management conducted by cough specialists aims at control of cough refractory to prior interventions and includes cough-specific behavioral counseling and pharmacotherapy with neuromodulators, among others. Preliminary data on the role of neuromodulators in a proof-of-concept manner are encouraging but lack strong evidence on efficacy and safety.

Objectives

The World Allergy Organization (WAO)/Allergic Rhinitis and its Impact on Asthma (ARIA) Joint Committee on Chronic Cough reviewed the recent literature on management of chronic cough in primary, multidisciplinary, and cough-specialty care. Knowledge gaps in diagnostic testing, classical and neuromodulator pharmacotherapy, in addition to behavioral therapy of chronic cough were also analyzed.

Outcomes

This third part of the WAO/ARIA consensus on chronic cough suggests a management algorithm of chronic cough in an integrated care pathway approach. Insights into the inherent limitations of multidisciplinary cough diagnostic testing, efficacy and safety of currently available antitussive pharmacotherapy, or the recently recognized behavioral therapy, can significantly improve the standards of care in patients with chronic cough.

Lymph Node Dissection Is a Risk Factor for Short-Term Cough after Pulmonary Resection

Cough is a common complication after pulmonary resection. However, the factors associated with cough that develop after pulmonary resection are still controversial. In this study, we used the Simplified Cough Score (SCS) and the Leicester Cough Questionnaire (LCQ) score to investigate potential risk factors for postoperative cough. Between January 2017 and June 2021, we collected the clinical data of 517 patients, the SCS at three days after surgery and the LCQ at two weeks and six weeks after surgery. Then, univariate and multivariate analyses were used to identify the independent risk factors for postoperative cough. The clinical baseline data of the cough group and the non-cough group were similar. However, the cough group had longer operation time and more blood loss. The patients who underwent lobectomy were more likely to develop postoperative cough than the patients who underwent segmentectomy and wedge resection, while the patients who underwent systematic lymph node dissection were more likely to develop postoperative cough than the patients who underwent lymph node sampling and those who did not undergo lymph node resection. When the same lymph node management method was applied, there was no difference in the LCQ scores between the patients who underwent wedge resection, lobectomy and segmentectomy. The lymph node resection method was an independent risk factor for postoperative cough (p < 0.001). Conclusions: Lymph node resection is an independent risk factor for short-term cough after pulmonary resection with video-assisted thoracoscopic surgery, and damage to the vagus nerve and its branches (particularly the pulmonary branches) is a possible cause of short-term cough. The mechanism of postoperative cough remains to be further studied.

Effects of preserving the bronchial artery on cough after thoracoscopic lobectomy

BACKGROUND

The purpose of this prospective study was to explore the influence of both preoperative three-dimensional (3D) reconstruction and intraoperative preservation of the bronchial artery (BA) on postoperative cough after thoracoscopic lobectomy.

METHODS

A total of 60 patients who had received a combination of thoracoscopic lobectomy and systematic lymph node dissection were included in this study. They were divided into two groups, namely the BA preservation group (Group A), and conventional surgical treatment group (Group B). In group A, we used Exoview software for 3D reconstruction of the BA before the operation and the BA was preserved during the operation. 3D reconstruction of the BA was not performed before surgery in group B. The incidence of postoperative cough, the Mandarin Chinese version of the Leicester cough questionnaire (LCQ-MC), physiological, psychological and social dimensions and total score of the two groups were compared and analyzed.

RESULTS

The scores and total scores of LCQ-MC in group B were lower than those in group A one and two months after surgery. There were significant differences between the two groups in physiological and psychological dimensions and total scores (p < 0.05), but there was no significant difference in social dimension between the two groups (p > 0.05). The incidence of postoperative cough in group A (16.7%) was lower than that in group B (30%), while the difference was not statistically significant (p = 0.222).

CONCLUSIONS

Preoperative 3D reconstruction and intraoperative preservation of the BA can reduce the severity of postoperative cough.

[Perceptions of family doctors, pulmonologists and allergists on the approach to patients with chronic cough. Results of an anonymous survey]

OBJECTIVE

To understand the perception of family doctors, pulmonologists and allergists about the current approach to chronic cough and its impact on patients' quality of life.

MATERIAL AND METHODS

Cross-sectional and anonymous survey disseminated through the scientific societies SEAIC, SEMERGEN, semFYC, SEMG and SEPAR. The participants were 620 family doctors, 92 pulmonologists and 62 allergists. A descriptive analysis of the answers was conducted. Response percentages, medians and interquartile intervals were presented. The differences in the percentages between specialties were evaluated with the chi-square.

RESULTS

Only half of the respondents chose a duration greater than 8 weeks as a criterion for diagnosing chronic cough, and less than half considered refractory/unexplained chronic cough a disease in itself. Family doctors perceived that chronic cough had less impact on patients than did pulmonologists or allergists. After a diagnosis of refractory/unexplained chronic cough, all 3specialties considered the most common approach to be to initiate treatment and to do the follow-up of the patient themselves. Most stated that they had no protocols for managing chronic cough, and more than 90% considered these to be necessary.

CONCLUSIONS

The management of patients with chronic cough by family doctors, pulmonologists or allergists seems to be heterogeneous. There is a need for protocols that standardise diagnosis, referral and treatment criteria to optimise patients' management and reduce the impact of chronic cough.

Efficacy of broccoli and glucoraphanin in COVID-19: From hypothesis to proof-of-concept with three experimental clinical cases

COVID-19 is described in a clinical case involving a patient who proposed the hypothesis that Nuclear factor (erythroid-derived 2)-like 2 (Nrf2)-interacting nutrients may help to prevent severe COVID-19 symptoms. Capsules of broccoli seeds containing glucoraphanin were being taken before the onset of SARS-CoV-2 infection and were continued daily for over a month after the first COVID-19 symptoms. They were found to reduce many of the symptoms rapidly and for a duration of 6-12 h by repeated dosing. When the patient was stable but still suffering from cough and nasal obstruction when not taking the broccoli capsules, a double-blind induced cough challenge confirmed the speed of onset of the capsules (less than 10 min). A second clinical case with lower broccoli doses carried out during the cytokine storm confirmed the clinical benefits already observed. A third clinical case showed similar effects at the onset of symptoms. In the first clinical trial, we used a dose of under 600 μmol per day of glucoraphanin. However, such a high dose may induce pharmacologic effects that require careful examination before the performance of any study. It is likely that the fast onset of action is mediated through the TRPA1 channel. These experimental clinical cases represent a proof-of-concept confirming the hypothesis that Nrf2-interacting nutrients are effective in COVID-19. However, this cannot be used in practice before the availability of further safety data, and confirmation is necessary through proper trials on efficacy and safety.

Causes of chronic cough in adolescent and adult patients

Background: Adolescents differ from adults in certain aspects, but the differences in the etiology of chronic cough between adolescents and adults have not been specifically investigated. The purpose of this study is to evaluate the causes of chronic cough in adolescent patients in comparison with those in adult patients.

Methods: The electronic medical records were retrospectively screened for patients with the initial diagnosis of chronic cough from 2016 to 2018. Clinical variables and the causes of chronic cough were collected in patients who met inclusion criteria. Patients were assigned to adolescent (13 to 18 years) and adult (> 18 years) group based on age. The distribution of causes of chronic cough was compared by t-test and χ2 tests between adolescent and adult groups using SPSS. Significant level was set at 0.05.

Results: The enrolled patients consisted of 16 adolescents and 73 adults with chronic cough. The most common causes of chronic cough were cough-variant asthma and upper airway cough syndrome in both adolescents and adults. The frequency of post infectious cough in adolescents was significantly higher than that in adults (12.5% vs. 1.36%; p= 0.024). Although no significant difference between the two groups was found, there was a trend that suggested that habitual cough was more common in the adolescent group (6.25%:1.36%); while gastroesophageal reflux disease (GERD) did not show similar results (6.25%:20.54%).

Conclusion: There are moderate differences in the causes of chronic cough between adolescent and adult patients. Realizing those differences would be helpful for clinicians to establish an appropriate differential diagnosis and make referral decisions.