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Lee JH, Kang SY, Yu I, Park KE, Oh JY, Lee JH, Park SY, Kim MH, Jo EJ, Moon JY, Kim SH, Kim SH, Lee BJ, Song WJ. Cough Response to High-Dose Inhaled Corticosteroids in Patients with Chronic Cough and Fractional Exhaled Nitric Oxide Levels ≥ 25 ppb: A Prospective Study. Lung 2024; 202:275-280. [PMID: 38733542 DOI: 10.1007/s00408-024-00698-y] [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: 03/08/2024] [Accepted: 04/10/2024] [Indexed: 05/13/2024]
Abstract
This study aimed to investigate the effects of high-dose inhaled corticosteroids (ICS) on chronic cough patients with elevated fractional exhaled nitric oxide (FeNO) levels. In a prospective study, adults with chronic cough and FeNO ≥ 25 ppb, without any other apparent etiology, received fluticasone furoate (200 mcg) for three weeks. Outcomes were evaluated using FeNO levels, cough severity, and Leicester Cough Questionnaire (LCQ) before and after treatment. Of the fifty participants (average age: 58.4 years; 58% female), the treatment responder rate (≥ 1.3-point increase in LCQ) was 68%, with a significant improvement in cough and LCQ scores and FeNO levels post-treatment. However, improvements in cough did not significantly correlate with changes in FeNO levels. These findings support the guideline recommendations for a short-term ICS trial in adults with chronic cough and elevated FeNO levels, but the lack of correlations between FeNO levels and cough raises questions about their direct mechanistic link.
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Affiliation(s)
- Ji-Ho Lee
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Sung-Yoon Kang
- Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Iseul Yu
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | | | - Ji-Yoon Oh
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Ji-Hyang Lee
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - So-Young Park
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Min-Hye Kim
- Department of Internal Medicine, College of Medicine, Ewha Womans University, Seoul, Korea
| | - Eun-Jung Jo
- Department of Internal Medicine, School of Medicine, Pusan National University, Busan, Korea
| | - Ji-Yong Moon
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Sae-Hoon Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Sang-Hoon Kim
- Department of Internal Medicine, Eulji University College of Medicine, Seoul, Korea
| | - Byung-Jae Lee
- Division of Allergy, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Woo-Jung Song
- University of Ulsan College of Medicine, Seoul, Korea.
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea.
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2
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Wilhelm M, Hermann C, Rief W, Schedlowski M, Bingel U, Winkler A. Working with patients' treatment expectations - what we can learn from homeopathy. Front Psychol 2024; 15:1398865. [PMID: 38860049 PMCID: PMC11163137 DOI: 10.3389/fpsyg.2024.1398865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 05/13/2024] [Indexed: 06/12/2024] Open
Abstract
The usual homeopathic remedy, "globules," does not contain any pharmacologically active ingredient. However, many patients and practitioners report beneficial effects of homeopathic treatment on various health outcomes. Experimental and clinical research of the last two decades analyzing the underlying mechanisms of the placebo effect could explain this phenomenon, with patients' treatment expectations as the predominant mechanism. Treatment expectations can be optimized through various factors, such as prior information, communication, and treatment context. This narrative review analyses how homeopathy successfully utilizes these factors. Subsequently, it is discussed what evidence-based medicine could learn from homeopathic practice to optimize treatment expectations (e.g., using an empathic, patient-centered communication style, deliberately selecting objects in practice rooms, or using clear treatment rituals and salient contextual stimuli) and thereby treatment effectiveness. Homeopathic remedy does not work beyond the placebo effect but is recommended or prescribed as an active treatment by those who believe in it. Thus, practitioners need to understand the manner in which homeopathy (as an example of inert treatment) works and are advised to reintegrate its underlying effective placebo mechanisms into evidence-based medicine. This promises to increase treatment efficacy, tolerability, satisfaction, and compliance with evidence-based treatments, and addresses the desires patients are trying to satisfy in homeopathy in an ethical, fully informed way that is grounded in evidence-based medicine.
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Affiliation(s)
- Marcel Wilhelm
- Department of Clinical Psychology, Philipps-University Marburg, Marburg, Germany
| | - Christiane Hermann
- Department of Clinical Psychology, Justus-Liebig-University Giessen, Giessen, Germany
| | - Winfried Rief
- Department of Clinical Psychology, Philipps-University Marburg, Marburg, Germany
| | - Manfred Schedlowski
- Institute of Medical Psychology and Behavioral Immunobiology, University Clinic Essen, Essen, Germany
- Department of Clinical Neuroscience, Osher Center for Integrative Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Ulrike Bingel
- Department of Neurology, Center for Translational Neuro-and Behavioral Sciences, University Medicine Essen, Essen, Germany
- Translational Pain Research Unit, University Medicine Essen, Essen, Germany
| | - Alexander Winkler
- Department of Clinical Psychology, Justus-Liebig-University Giessen, Giessen, Germany
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3
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Lee JH, Lee JH, Park SY, Koskela HO, Song WJ. Is fractional exhaled nitric oxide a treatable trait in chronic cough: a narrative review. J Thorac Dis 2023; 15:5844-5855. [PMID: 37969307 PMCID: PMC10636432 DOI: 10.21037/jtd-23-135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Accepted: 09/24/2023] [Indexed: 11/17/2023]
Abstract
Background and Objective Current management of chronic cough is largely based on sequential therapeutic trials. The concept of treatable traits was first introduced for individualized treatment of chronic airway diseases; however, it has emerged as a potentially useful strategy in revising the management of chronic cough. This narrative review aimed to analyze the literature to determine if fractional exhaled nitric oxide (FeNO) is a treatable trait in chronic cough, compared to other type 2 biomarkers, and to summarize current knowledge and gaps in the clinical application. Methods An online electronic search was performed on PubMed, Web of Science, and Scopus of English-language literature with following keywords: cough, nitric oxide (NO), eosinophils, biomarker, and treatable trait. Relevance and eligibility of each article were assessed by one or more of the authors and a narrative review was composed. Key Content and Findings Eosinophilic or type 2 airway inflammation is a major treatable trait in patients with chronic cough. Induced sputum tests are regarded as the gold standard for defining inflammatory phenotype, however, technically demanding and cannot be widely applied in clinical practice. FeNO, a practical biomarker, has emerged as an alternative to induced sputum analyses. Mechanistic and clinical evidence indicated that FeNO had a potential for diagnostic utility and treatment response predictability. Conclusions FeNO measurement may help to identify patients with chronic cough that will benefit from corticosteroid treatment. Further studies are warranted to determine the diagnostic roles of FeNO in the management of patients with chronic cough.
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Affiliation(s)
- Ji-Ho Lee
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Ji-Hyang Lee
- Department of Allergy and Clinical Immunology, Airway Sensation and Cough Research Laboratory, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - So-Young Park
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Republic of Korea
| | - Heikki Olavi Koskela
- Unit for Medicine and Clinical Research, Pulmonary Division, Kuopio University Hospital, Kuopio, Finland
- School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Woo-Jung Song
- Department of Allergy and Clinical Immunology, Airway Sensation and Cough Research Laboratory, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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4
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Jo EJ, Lee JH, Won HK, Kang N, Kang SY, Lee SE, Lee JH, Kim MY, Shim JS, An J, Yoo Y, Park SY, Kim BK, Moon JY, Park HK, Kim MH, Kwon HS, Kim SH, Kim SH, Chang YS, Kim SH, Birring SS, Lee BJ, Song WJ. Baseline Cohort Profile of the Korean Chronic Cough Registry: A Multicenter, Prospective, Observational Study. Lung 2023; 201:477-488. [PMID: 37658853 DOI: 10.1007/s00408-023-00644-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 08/19/2023] [Indexed: 09/05/2023]
Abstract
PURPOSE The Korean Chronic Cough Registry study was initiated to characterize patients with chronic cough (CC) and investigate their outcomes in real-world clinical practice. This report aims to describe the baseline cohort profile and study protocols. METHODS This multicenter, prospective observational cohort study included newly referred CC patients and those already being treated for refractory or unexplained chronic cough (RUCC). Cough status was assessed using a visual analog scale, the Leicester Cough Questionnaire (LCQ), and the Cough Hypersensitivity Questionnaire (CHQ). RESULTS A total of 610 patients (66.9% women; median age 59.0 years) were recruited from 18 centers, with 176 being RUCC patients (28.9%). The median age at CC onset was 50.1 years, and 94.4% had adult-onset CC (≥ 19 years). The median cough duration was 4 years. Compared to newly referred CC patients, RUCC patients had a longer cough duration (6.0 years vs. 3.0 years) but had fewer symptoms and signs suggesting asthma, rhinosinusitis, or gastroesophageal acid reflux disease. Subjects with RUCC had lower LCQ scores (10.3 ± 3.3 vs. 11.6 ± 3.6; P < 0.001) and higher CHQ scores (9.1 ± 3.9 vs. 8.4 ± 4.1; P = 0.024). There were no marked differences in the characteristics of cough between refractory chronic cough and unexplained chronic cough. CONCLUSIONS Chronic cough typically develops in adulthood, lasting for years. Cough severity and quality of life impairment indicate the presence of unmet clinical needs and insufficient cough control in real-world clinical practice. Longitudinal follow-up is warranted to investigate the natural history and treatment outcomes.
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Affiliation(s)
- Eun-Jung Jo
- Department of Internal Medicine, School of Medicine, Pusan National University, Busan, Korea
| | - Ji-Hyang Lee
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Ha-Kyeong Won
- Department of Internal Medicine, Veterans Health Service Medical Center, Seoul, Korea
| | - Noeul Kang
- Division of Allergy, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, 06351, Korea
| | - Sung-Yoon Kang
- Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Seung Eun Lee
- Department of Internal Medicine, School of Medicine, Pusan National University, Busan, Korea
- Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Ji-Ho Lee
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Mi-Yeong Kim
- Department of Internal Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Ji-Su Shim
- Department of Internal Medicine, College of Medicine, Ewha Womans University, Seoul, Korea
| | - Jin An
- Department of Pulmonary, Allergy and Critical Care Medicine, Kyung Hee University Hospital at Gangdong, College of Medicine, Kyung Hee University, Seoul, Korea
| | - Youngsang Yoo
- Department of Internal Medicine, Gangneung Asan Hospital, Gangneung, Korea
| | - So-Young Park
- Department of Internal Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Byung-Keun Kim
- Division of Pulmonology, Allergy and Critical Care Medicine, Department of Internal Medicine, University College of Medicine, Seoul, Korea
| | - Ji-Yong Moon
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Han-Ki Park
- Department of Allergy and Clinical Immunology, School of Medicine, Kyungpook National University Chilgok Hospital, Kyungpook National University, Daegu, Korea
| | - Min-Hye Kim
- Department of Internal Medicine, College of Medicine, Ewha Womans University, Seoul, Korea
| | - Hyouk-Soo Kwon
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Sae-Hoon Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Sang-Heon Kim
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Yoon-Seok Chang
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Sang-Hoon Kim
- Department of Internal Medicine, Eulji University College of Medicine, Seoul, Korea
| | - Surinder S Birring
- Centre for Human & Applied Physiological Sciences, School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Byung-Jae Lee
- Division of Allergy, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, 06351, Korea.
| | - Woo-Jung Song
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea.
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5
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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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6
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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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7
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Rouadi PW, Idriss SA, Bousquet J, Laidlaw TM, Azar CR, Al-Ahmad MS, Yañez A, Al-Nesf MAY, Nsouli TM, Bahna SL, Abou-Jaoude E, Zaitoun FH, Hadi UM, Hellings PW, Scadding GK, Smith PK, Morais-Almeida M, Maximiliano Gómez R, Gonzalez Diaz SN, Klimek L, Juvelekian GS, Riachy MA, Canonica GW, Peden D, Wong GW, Sublett J, Bernstein JA, Wang L, Tanno LK, Chikhladze M, Levin M, Chang YS, Martin BL, Caraballo L, Custovic A, Ortego-Martell JA, Lesslar OJ, Jensen-Jarolim E, Ebisawa M, Fiocchi A, Ansotegui IJ. WAO-ARIA consensus on chronic cough - Part III: Management strategies in primary and cough-specialty care. Updates in COVID-19. World Allergy Organ J 2022; 15:100649. [PMID: 35600836 PMCID: PMC9117692 DOI: 10.1016/j.waojou.2022.100649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 03/30/2022] [Accepted: 04/01/2022] [Indexed: 11/18/2022] Open
Abstract
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.
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Affiliation(s)
- Philip W. Rouadi
- Department of Otolaryngology – Head and Neck Surgery, Eye and Ear University Hospital, Beirut, Lebanon
- Ear, Nose and Throat Department, Dar Al Shifa Hospital, Hawally, Kuwait
| | - Samar A. Idriss
- Department of Otolaryngology – Head and Neck Surgery, Eye and Ear University Hospital, Beirut, Lebanon
- Department of Audiology and Otoneurological Evaluation, Edouard Herriot Hospital, Lyon, France
| | - Jean Bousquet
- Hospital Charité, Universitätsmedizin Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
- Department of Dermatology and Allergy, Comprehensive Allergy Center, Berlin Institute of Health, Berlin, Germany
- Macvia France, Montpellier France
- Université Montpellier, Montpellier, France
| | - Tanya M. Laidlaw
- Department of Medicine, Harvard Medical School, Division of Allergy and Clinical Immunology, Brigham and Women's Hospital Boston, Massachusetts, USA
| | - Cecilio R. Azar
- Department of Gastroenterology, American University of Beirut Medical Center (AUBMC), Beirut, Lebanon
- Department of Gastroenterology, Middle East Institute of Health (MEIH), Beirut, Lebanon
- Department of Gastroenterology, Clemenceau Medical Center (CMC), Beirut, Lebanon
| | - Mona S. Al-Ahmad
- Department of Microbiology, Faculty of Medicine, Kuwait University, Kuwait
| | - Anahi Yañez
- INAER - Investigaciones en Alergia y Enfermedades Respiratorias, Buenos Aires, Argentina
| | - Maryam Ali Y. Al-Nesf
- Allergy and Immunology Section, Department of Medicine, Hamad Medical Corporation, P.O. Box 3050, Doha, Qatar
| | | | - Sami L. Bahna
- Allergy & Immunology Section, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | | | - Fares H. Zaitoun
- Department of Allergy Otolaryngology, LAU-RIZK Medical Center, Beirut, Lebanon
| | - Usamah M. Hadi
- Clinical Professor Department of Otolaryngology Head and Neck Surgery, American University of Beirut, Lebanon
| | - Peter W. Hellings
- KU Leuven Department of Microbiology, Immunology and Transplantation, Laboratory of Allergy and Clinical Immunology, Leuven, Belgium
- University Hospitals Leuven, Department of Otorhinolaryngology, Leuven, Belgium
- University Hospital Ghent, Department of Otorhinolaryngology, Laboratory of Upper Airways Research, Ghent, Belgium
- Academic Medical Center, University of Amsterdam, Department of Otorhinolaryngology, Amsterdam, the Netherlands
| | | | - Peter K. Smith
- Clinical Medicine Griffith University, Southport Qld, 4215, Australia
| | | | | | - Sandra N. Gonzalez Diaz
- Universidad Autónoma de Nuevo León, Hospital Universitario and Facultad de Medicina, Monterrey, Nuevo León, Mexico
| | - Ludger Klimek
- Center for Rhinology and Allergology, Wiesbaden, Germany
| | - Georges S. Juvelekian
- Department of Pulmonary, Critical Care and Sleep Medicine at Saint George Hospital University Medical Center, Beirut, Lebanon
| | - Moussa A. Riachy
- Department of Pulmonary and Critical Care, Hôtel-Dieu de France university Hospital, Beirut, Lebanon
| | - Giorgio Walter Canonica
- Humanitas University & Personalized Medicine Asthma & Allergy Clinic-Humanitas Research Hospital-IRCCS-Milano Italy
| | - David Peden
- UNC Center for Environmental Medicine, Asthma, and Lung Biology, Division of Allergy, Immunology and Rheumatology, Department of Pediatrics UNC School of Medicine, USA
| | - Gary W.K. Wong
- Department of Pediatrics, Chinese University of Hong Kong, Hong Kong, China
| | - James Sublett
- Department of Pediatrics, Section of Allergy and Immunology, University of Louisville School of Medicine, 9800 Shelbyville Rd, Louisville, KY, USA
| | - Jonathan A. Bernstein
- University of Cincinnati College of Medicine, Department of Internal Medicine, Division of Immunology/Allergy Section, Cincinnati, OH, USA
| | - Lianglu Wang
- Department of Allergy, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing Key Laboratory of Precision Medicine for Diagnosis and Treatment of Allergic Disease, State Key Laboratory of Complex Severe and Rare Diseases, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Beijing, 100730, China
| | - Luciana K. Tanno
- Université Montpellier, Montpellier, France
- Desbrest Institute of Epidemiology and Public Health, UMR UA-11, INSERM University of Montpellier, Montpellier, France
- WHO Collaborating Centre on Scientific Classification Support, Montpellier, France
| | - Manana Chikhladze
- Medical Faculty at Akaki Tsereteli State University, National Institute of Allergy, Asthma & Clinical Immunology, KuTaisi, Tskaltubo, Georgia
| | - Michael Levin
- Division of Paediatric Allergology, Department of Paediatrics, University of Cape Town, South Africa
| | - Yoon-Seok Chang
- Division of Allergy and Clinical Immunology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea
| | - Bryan L. Martin
- Department of Otolaryngology, Division of Allergy & Immunology, The Ohio State University, Columbus, OH, USA
| | - Luis Caraballo
- Institute for Immunological Research, University of Cartagena. Cartagena de Indias, Colombia
| | - Adnan Custovic
- National Heart and Lund Institute, Imperial College London, UK
| | | | | | - Erika Jensen-Jarolim
- Institute of Pathophysiology and Allergy Research, Center of Pathophysiology, Infectiology and Immunology, Medical University Vienna, Austria
- The interuniversity Messerli Research Institute, Medical University Vienna and University of Veterinary Medicine, Vienna, Austria
| | - Motohiro Ebisawa
- Clinical Research Center for Allergy and Rheumatology, National Hospital Organization Sagamihara National Hospital, Sagamihara, Japan
| | - Alessandro Fiocchi
- Translational Pediatric Research Area, Allergic Diseases Research Unit, Bambino Gesù Children's Hospital IRCCS, Rome, Holy See
| | - Ignacio J. Ansotegui
- Department of Allergy and Immunology, Hospital Quironsalud Bizkaia, Bilbao, Spain
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8
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Morice A, Dicpinigaitis P, McGarvey L, Birring SS. Chronic cough: new insights and future prospects. Eur Respir Rev 2021; 30:30/162/210127. [PMID: 34853095 PMCID: PMC9488126 DOI: 10.1183/16000617.0127-2021] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 08/20/2021] [Indexed: 11/25/2022] Open
Abstract
Chronic cough is defined in adults as a cough that lasts for ≥8 weeks. When it proves intractable to standard-of-care treatment, it can be referred to as refractory chronic cough (RCC). Chronic cough is now understood to be a condition of neural dysregulation. Chronic cough and RCC result in a serious, often unrecognized, disease burden, which forms the focus of the current review. The estimated global prevalence of chronic cough is 2–18%. Patients with chronic cough and RCC report many physical and psychological effects, which impair their quality of life. Chronic cough also has a significant economic burden for the patient and healthcare systems. RCC diagnosis and treatment are often delayed for many years as potential treatable triggers must be excluded first and a stepwise empirical therapeutic regimen is recommended. Evidence supporting most currently recommended treatments is limited. Many treatments do not address the underlying pathology, are used off-label, have limited efficacy and produce significant side-effects. There is therefore a significant unmet need for alternative therapies for RCC that target the underlying disease mechanisms. Early clinical data suggest that antagonists of the purinergic P2X3 receptor, an important mediator of RCC, are promising, though more evidence is needed. Chronic cough exerts a considerable burden on patients and healthcare systems. In addition to effective targeted therapies, further data are needed to understand the pathophysiology, epidemiology and disease burden.https://bit.ly/3Be9JZI
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Affiliation(s)
- Alyn Morice
- Centre for Clinical Sciences, Hull York Medical School, University of Hull, Hull, UK
| | - Peter Dicpinigaitis
- Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA
| | - Lorcan McGarvey
- Centre for Experimental Medicine, Dentistry, and Biomedical Sciences, Queen's University, Belfast, UK
| | - Surinder S Birring
- Centre for Human & Applied Physiological Sciences, School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine, King's College Hospital, London, UK
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9
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Ambrosino P, Accardo M, Mosella M, Papa A, Fuschillo S, Spedicato GA, Motta A, Maniscalco M. Performance of fractional exhaled nitric oxide in predicting response to inhaled corticosteroids in chronic cough: a meta-analysis. Ann Med 2021; 53:1659-1672. [PMID: 34528479 PMCID: PMC8451665 DOI: 10.1080/07853890.2021.1979242] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Accepted: 09/05/2021] [Indexed: 02/08/2023] Open
Abstract
Background. Chronic cough is a disabling condition with a high proportion of diagnostic and therapeutic failures. Fractional exhaled nitric oxide (FeNO) has been considered a useful biomarker for predicting inhaled corticosteroids (ICS) response. We evaluated the relationship between FeNO and ICS response in chronic cough by performing a systematic review with meta-analysis.Methods. PubMed, Web of Science, Scopus and EMBASE databases were systematically searched. Differences were expressed as Odds Ratio (OR) with 95% confidence intervals (95%CI). Pooled sensitivity, specificity, positive (PLR) and negative likelihood ratio (NLR), and area under the hierarchical summary receiver operating characteristic curve (HSROCAUC) were estimated.Results. Nine articles on 740 chronic-cough patients showed that the response rate to ICS was 87.4% (95%CI: 83.8-91.0) in 317 patients with a high FeNO and 46.3% (95%CI: 41.6-51.0) in 423 controls, with an attributable proportion of 47.0% and a diagnostic OR of 9.1 (95%CI: 3.7-22.4, p < .001). The pooled estimate of diagnostic indexes resulted in a sensitivity of 68.5% (95%CI: 46.7-84.4) and specificity of 81.9% (95%CI: 63.0-92.3), with a HSROCAUC of 0.82 (95%CI: 0.64-0.90). In a realistic scenario with a pre-test probability set at 30%, based on a pooled PLR of 3.79 (95%CI: 1.24-7.47) and NLR of 0.38 (95%CI: 0.22-0.66), the post-test probability was 62% with a high FeNO and 14% if the test was negative. Subgroup analyses confirmed a better performance for the recommended FeNO cut-off greater than 25 ppb. Meta-regression and sensitivity analyses showed no impact of major demographic and clinic variables on results.Conclusions. A high FeNO before starting ICS therapy may help identify chronic-cough patients responding to treatment, with a better performance ofhigher cut-off values. Further studies are needed to evaluate the real usefulness of this biomarker to guide cough therapy and optimise strategies in different healthcare settings (community, hospital, rehabilitation).Key messagesChronic cough is a disabling condition with a high proportion of diagnostic and therapeutic failures.Fractional exhaled nitric oxide (FeNO) may be a useful biomarker for identifying chronic cough patients who respond to steroid treatment.A FeNO cut-off lower than 25 ppb should be considered irrelevant for this clinical application.
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Affiliation(s)
| | | | - Marco Mosella
- Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
| | - Antimo Papa
- Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
| | | | | | - Andrea Motta
- Institute of Biomolecular Chemistry, National Research Council, ICB-CNR, Naples, Italy
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10
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Hao H, Bao W, Xue Y, Zhou Y, Huang Z, Yin D, Zhang Y, Zhang P, Lv C, Han L, Zhou X, Yin J, Zhang M. Spirometric Changes in Bronchodilation Tests as Predictors of Asthma Diagnosis and Treatment Response in Patients with FEV 1 ≥ 80% Predicted. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:3098-3108.e4. [PMID: 33766580 DOI: 10.1016/j.jaip.2021.03.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 03/01/2021] [Accepted: 03/02/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND Many patients with mild asthma are undiagnosed and untreated due to the low diagnostic sensitivity of bronchodilation test (BDT). OBJECTIVE To investigate whether airway reversibility in BDT and fractional exhaled nitric oxide (Feno) can predict the response to antiasthma therapy (RAT) in patients with suspected asthma. METHODS This open-label, prospective cohort study included patients with chronic recurrent asthma symptoms, normal FEV1, and negative BDT results. Inhaled corticosteroids and long-acting β agonists were given for 4 weeks. A positive RAT was defined as improved symptoms and an increase of more than 200 mL in FEV1 after inhaled corticosteroid/long-acting β agonist treatment. Lung tissues from another 19 patients who underwent pneumectomy for lung nodules were also analyzed. RESULTS Of 110 patients recruited, 102 completed the study. Patients in the positive RAT group had a higher Feno and greater absolute (Δ) and percent (Δ%) improvements in forced vital capacity, FEV1, and forced expiratory flows (FEFs) in BDT than in the negative RAT group. The area under the curves of Feno, ΔFEV1%, ΔFEF25-75% (percent improvement in FEF at 25%-75% of forced vital capacity), and ΔFEF75% (percent improvement in FEF at 75% of forced vital capacity) for positive RAT were 0.703, 0.824, 0.736, and 0.710, with cutoff values of 33 parts per billion and 3.50%, 15.26%, and 26.04%, respectively. A joint model of Feno and ΔFEV1% increased the area under the curve to 0.880. Inflammatory cytokines were higher in the lung tissues of patients with predicted positive RAT than in those with predicted negative RAT. CONCLUSIONS ΔFEV1% in BDT together with Feno predicted a positive RAT and an asthma diagnosis in patients with a normal FEV1 and negative BDT. Evidence of pathological changes increases the credibility of the predictive model.
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Affiliation(s)
- Huijuan Hao
- Department of Respiratory and Critical Care Medicine, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Wuping Bao
- Department of Respiratory and Critical Care Medicine, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yishu Xue
- Department of Respiratory and Critical Care Medicine, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yan Zhou
- Department of Respiratory and Critical Care Medicine, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Zhixuan Huang
- School of Mathematical Sciences, Tongji University, Shanghai, China
| | - Dongning Yin
- Department of Respiratory and Critical Care Medicine, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yingying Zhang
- Department of Respiratory and Critical Care Medicine, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Pengyu Zhang
- Department of Respiratory and Critical Care Medicine, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Chengjian Lv
- Department of Respiratory and Critical Care Medicine, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Lei Han
- Department of Respiratory and Critical Care Medicine, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Xin Zhou
- Department of Respiratory and Critical Care Medicine, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Junfeng Yin
- School of Mathematical Sciences, Tongji University, Shanghai, China
| | - Min Zhang
- Department of Respiratory and Critical Care Medicine, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, China.
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11
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Fraser SD, Thackray-Nocera S, Shepherd M, Flockton R, Wright C, Sheedy W, Brindle K, Morice AH, Kaye PM, Crooks MG, Hart SP. Azithromycin for sarcoidosis cough: an open-label exploratory clinical trial. ERJ Open Res 2020; 6:00534-2020. [PMID: 33263056 PMCID: PMC7682709 DOI: 10.1183/23120541.00534-2020] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 09/09/2020] [Indexed: 11/23/2022] Open
Abstract
Background Chronic cough is a distressing symptom for many people with pulmonary sarcoidosis. Continuous treatment with a macrolide antibiotic may improve cough. We aimed to assess the potential efficacy of azithromycin in patients with sarcoidosis and self-reported cough. Methods We conducted a noncontrolled, open-label clinical trial of azithromycin 250 mg once daily for 3 months in patients with pulmonary sarcoidosis who reported a chronic cough. The primary outcome was number of coughs in 24 h. Secondary outcomes were cough visual analogue scales and quality of life measured using the Leicester Cough Questionnaire and King's Sarcoidosis Questionnaire. Safety outcomes included QTc interval on ECG. Measurements were made at baseline and after 1 and 3 months of treatment. Results All 21 patients were white, median age 57 years, 9 males, 12 females, median 3 years since diagnosis. Five were taking oral corticosteroids and none were taking other immunosuppressants. Twenty patients completed the trial. The median (range) number of coughs in 24 h was 228 (43–1950) at baseline, 122 (20–704) at 1 month, and 81 (16–414) at 3 months (p=0.002, Friedman's test). The median reduction in cough count at 3 months was 49.6%. There were improvements in all patient-reported outcomes. Azithromycin was well tolerated. Conclusion In a noncontrolled open-label trial in people with sarcoidosis who reported a chronic cough, 3 months of treatment with azithromycin led to improvements in a range of cough metrics. Azithromycin should be tested as a treatment for sarcoidosis cough in a randomised placebo-controlled trial. In a noncontrolled open-label trial in people with sarcoidosis who reported a chronic cough, 3 months of treatment with azithromycin led to improvements in a range of cough metricshttps://bit.ly/2FB5tfq
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Affiliation(s)
- Simon D Fraser
- Respiratory Research Group, Hull York Medical School, Castle Hill Hospital, Cottingham, UK
| | - Susannah Thackray-Nocera
- Respiratory Clinical Trials Unit, Hull University Teaching Hospitals NHS Trust, Castle Hill Hospital, Cottingham, UK
| | - Marica Shepherd
- Respiratory Clinical Trials Unit, Hull University Teaching Hospitals NHS Trust, Castle Hill Hospital, Cottingham, UK
| | - Rachel Flockton
- Respiratory Clinical Trials Unit, Hull University Teaching Hospitals NHS Trust, Castle Hill Hospital, Cottingham, UK
| | - Caroline Wright
- Respiratory Research Group, Hull York Medical School, Castle Hill Hospital, Cottingham, UK.,Respiratory Clinical Trials Unit, Hull University Teaching Hospitals NHS Trust, Castle Hill Hospital, Cottingham, UK
| | - Wayne Sheedy
- Respiratory Research Group, Hull York Medical School, Castle Hill Hospital, Cottingham, UK
| | - Kayleigh Brindle
- Respiratory Clinical Trials Unit, Hull University Teaching Hospitals NHS Trust, Castle Hill Hospital, Cottingham, UK
| | - Alyn H Morice
- Respiratory Research Group, Hull York Medical School, Castle Hill Hospital, Cottingham, UK
| | - Paul M Kaye
- York Biomedical Research Institute, University of York, York, UK
| | - Michael G Crooks
- Respiratory Research Group, Hull York Medical School, Castle Hill Hospital, Cottingham, UK
| | - Simon P Hart
- Respiratory Research Group, Hull York Medical School, Castle Hill Hospital, Cottingham, UK
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12
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Abstract
Chronic cough is a common condition, and generally affects about 3% of Korean adults with a significant influence on quality of life (QoL). Despite continued clinical and academic efforts, there are unmet needs for chronic cough prevention and management in Korea. Epidemiologically, there are two major challenges: an aging population and air pollution. Korea is one of the most rapidly aging countries, and the relative proportion of elderly to younger people is expected to double within the next two decades. Air pollution is a major concern, but there is very limited evidence on the effects of air pollutant on cough in Korean patients. Clinically, upper and lower airway diseases, such as rhinitis/rhinosinusitis and cough variant asthma/eosinophilic bronchitis, are reported to account for about 75% of chronic cough in Korean adults, which formed the basis in formulating clinical practice guidelines. However, further studies are warranted to resolve clinical uncertainty, particularly for the evaluation and treatment of upper airway conditions in chronic cough. The prevalence of gastroesophageal reflux disease (GERD) is increasing, thus its relevance to cough among Koreans may warrant re-evaluation. Infection-associated chronic cough, such as tuberculosis, is another continuing concern. The proportion of chronic refractory or unexplained cough is assumed to be 10–20% among patients visiting referral clinics for chronic cough. This review presents our perspectives on current epidemiological and clinical issues of chronic cough in Korea, and addresses major knowledge gaps and future research priorities.
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Affiliation(s)
- Ji-Hyang Lee
- Department of Allergy and Clinical Immunology, Airway Sensation and Cough Research Laboratory, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Woo-Jung Song
- Department of Allergy and Clinical Immunology, Airway Sensation and Cough Research Laboratory, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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13
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Song WJ, An J, McGarvey L. Recent progress in the management of chronic cough. Korean J Intern Med 2020; 35:811-822. [PMID: 32422697 PMCID: PMC7373968 DOI: 10.3904/kjim.2020.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 03/09/2020] [Indexed: 02/07/2023] Open
Abstract
Chronic cough is a common clinical condition with significant impact on quality of life and for which effective therapy remains an unmet clinical need. Over the past decade, there has been a major shift in how we approach this problem, driven by better appreciation of the clinical manifestation of chronic cough and an improved understanding of the associated neurobiology. "Cough hypersensitivity syndrome" has been proposed as a new diagnostic term for chronic cough, encompassing different phenotypes of the condition. Accumulating evidence suggests that this new concept is clinically relevant. However, while it is gaining widespread endorsement within the allergy and respiratory community, raising its profile in routine clinical practice is a priority. Thus, the present paper reviews recent progress in our understanding and management of chronic cough, with focus on mechanistic and clinical studies. It also provides detail on knowledge gaps and future research directions.
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Affiliation(s)
- Woo-Jung Song
- Department of Allergy and Clinical Immunology, Airway Sensation and Cough Research Laboratory, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin An
- Department of Allergy and Clinical Immunology, Airway Sensation and Cough Research Laboratory, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Lorcan McGarvey
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast, UK
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14
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Eccles R. The Powerful Placebo Effect in Cough: Relevance to Treatment and Clinical Trials. Lung 2020; 198:13-21. [PMID: 31834478 PMCID: PMC7012959 DOI: 10.1007/s00408-019-00305-5] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 12/04/2019] [Indexed: 12/12/2022]
Abstract
Interest in the placebo effect of medicines has developed from the use of placebo treatments as controls in clinical trials into a whole new area of research around how placebos fit into a psychosocial model of therapeutics. The large placebo effect associated with cough medicines is both a problem and an opportunity for researchers: a problem for clinical trials on new actives as the active must beat the large placebo effect, and an opportunity for harnessing the placebo effect to produce effective cough medicines without any pharmacologically active ingredient. This review discusses the mechanisms associated with the placebo effect of cough medicines and distinguishes between a 'perceived placebo effect' and a true 'placebo effect'. The efficacy of sweeteners in cough syrups is discussed as well as viscosity, mucoadhesion, and flavoring. The complexity of modern cough medicines is demonstrated by an example of a medicine which contains one active ingredient, and eighteen excipients which provide a complex and intense sensory experience to enhance the placebo effect and complement the pharmacological activity of the medicine.
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Affiliation(s)
- Ron Eccles
- Cardiff School of Biosciences, Cardiff University, Museum Avenue, Cardiff, CF10 3AX, Wales, UK.
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15
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Song WJ, Chung KF. Exploring the clinical relevance of cough hypersensitivity syndrome. Expert Rev Respir Med 2020; 14:275-284. [PMID: 31914340 DOI: 10.1080/17476348.2020.1713102] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Introduction: Knowledge of the pathophysiology of cough has continued to advance over recent decades. Establishing anatomic-diagnostic protocols, based on the anatomy and distribution of vagus nerve pathways regulating the cough reflex, was the first breakthrough in modern clinical medicine for chronic cough. The unmet clinical need has prompted revised thinking regarding the pathophysiology of and the clinical approach to chronic cough.Areas covered: The paradigm of cough hypersensitivity syndrome (CHS) has been recently proposed, wherein aberrant neuro-pathophysiology is a common etiology. This review covers major findings on chronic cough and cough hypersensitivity, particularly focused on recently-published studies and explores the clinical relevance and applicability of CHS based on current knowledge and discuss knowledge gaps and future research directions.Expert opinion: This paradigm has provided new opportunities in managing chronic cough and evidence is accumulating to support the validity of CHS. It also warrants the re-appraisal of existing clinical evidence and investigation of how to refine our clinical strategy. While CHS highlights the importance of clinical thinking from the viewpoint of cough, the value of anatomic-diagnostic protocols should remain. Moreover, given the considerable heterogeneity in clinical presentation, cough-associated disease conditions, and treatment responses across different patients, precise molecular endotyping remains key to making further to advancing clinical practice .
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Affiliation(s)
- Woo-Jung Song
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kian Fan Chung
- National Heart & Lung Institute, Imperial College London & Royal Brompton and Harefield NHS Trust, London, UK
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16
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Won HK, Lee JH, An J, Sohn KH, Kang MG, Kang SY, Morice AH, Cho SH, Song WJ. Impact of Chronic Cough on Health-Related Quality of Life in the Korean Adult General Population: The Korean National Health and Nutrition Examination Survey 2010-2016. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2020; 12:964-979. [PMID: 32935489 PMCID: PMC7492512 DOI: 10.4168/aair.2020.12.6.964] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Revised: 03/27/2020] [Accepted: 05/21/2020] [Indexed: 12/28/2022]
Abstract
Purpose Chronic cough is a prevalent condition in the community and may pose considerable impairment to quality of life (QoL). However, its disease burden remains largely undefined in the general population. The present study investigated the relationship between chronic cough and health-related QoL in a Korean nationwide population database, with an emphasis on clinical conditions which may confound the impact of cough. Methods This study analyzed cross-sectional datasets of adults (aged ≥ 40 years) in the Korean National Health and Nutrition Examination Survey 2010–2016. Health-related QoL was assessed using the 3-level EuroQoL 5-dimension component (EQ-5D-3L) index score. The presence of chronic cough and other conditions were defined using structured questionnaires. Results The prevalence of chronic cough was 3.48% ± 0.17% among adults aged ≥ 40 years. The overall EQ-5D-3L index score was significantly lower in subjects with than without chronic cough (0.79 ± 0.01 vs. 0.86 ± 0.00, P < 0.001). In subgroup analyses by age and sex, chronic cough had a notably large impact on QoL in women aged ≥ 65 years (vs. those without chronic cough: 0.55 ± 0.04 vs. 0.70 ± 0.01, P < 0.001), although the mean difference in the scores exceeded the minimally important difference score of 0.05 in all subgroups. In multivariate analyses, chronic cough was significantly associated with QoL, independent of confounders including depression, arthritis, asthma, and chronic obstructive pulmonary disease. In dimension analyses, chronic cough was more associated with anxiety/depression, pain/discomfort, and usual activities than with self-care or mobility in the EQ-5D. Conclusions The present study demonstrated significant associations between chronic cough and health-related QoL in a nationwide large general adult population aged ≥ 40 years, which were independent of clinical confounders. The impact of chronic cough was greater in women aged ≥ 65 years. These findings indicate a considerable burden of chronic cough in the general population and warrant further investigations to assess the disease burden of chronic cough in a global scale.
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Affiliation(s)
- Ha Kyeong Won
- Department of Internal Medicine, Veterans Health Service Medical Center, Seoul, Korea
| | - Ji Hyang Lee
- Department of Allergy and Clinical Immunology, Airway Sensation and Cough Research Laboratory, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin An
- Department of Allergy and Clinical Immunology, Airway Sensation and Cough Research Laboratory, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyoung Hee Sohn
- Department of Internal Medicine, Kyung Hee University Medical Center, Seoul, Korea
| | - Min Gyu Kang
- Division of Allergy and Clinical Immunology, Department of Internal Medicine, Chungbuk National University Hospital, Cheongju, Korea
| | - Sung Yoon Kang
- Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Alyn H Morice
- Respiratory Research Group, Hull York Medical School, Castle Hill Hospital, University of Hull, Cottingham, United Kingdom
| | - Sang Heon Cho
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Woo Jung Song
- Department of Allergy and Clinical Immunology, Airway Sensation and Cough Research Laboratory, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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17
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Song WJ, Millqvist E, Morice AH. New ERS cough guidelines: A clinical framework for refining the patient management strategy. Asia Pac Allergy 2019; 9:e36. [PMID: 31720247 PMCID: PMC6826112 DOI: 10.5415/apallergy.2019.9.e36] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Accepted: 10/15/2019] [Indexed: 11/05/2022] Open
Affiliation(s)
- Woo-Jung Song
- Department of Allergy and Clinical Immunology, Airway Sensation and Cough Research Laboratory, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Eva Millqvist
- Department of Allergology, Institution of Internal Medicine, The Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Alyn H Morice
- Respiratory Research Group, University of Hull, Hull York Medical School, Castle Hill Hospital, Cottingham, East Yorkshire, United Kingdom
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