ERS guidelines on the diagnosis and treatment of chronic cough in adults and children

[Management of adult bronchiectasis - Consensus-based Guidelines for the German Respiratory Society (DGP) e. V. (AWMF registration number 020-030)]

Bronchiectasis is an etiologically heterogeneous, chronic, and often progressive respiratory disease characterized by irreversible bronchial dilation. It is frequently associated with significant symptom burden, multiple complications, and reduced quality of life. For several years, there has been a marked global increase in the prevalence of bronchiectasis, which is linked to a substantial economic burden on healthcare systems. This consensus-based guideline is the first German-language guideline addressing the management of bronchiectasis in adults. The guideline emphasizes the importance of thoracic imaging using CT for diagnosis and differentiation of bronchiectasis and highlights the significance of etiology in determining treatment approaches. Both non-drug and drug treatments are comprehensively covered. Non-pharmacological measures include smoking cessation, physiotherapy, physical training, rehabilitation, non-invasive ventilation, thoracic surgery, and lung transplantation. Pharmacological treatments focus on the long-term use of mucolytics, bronchodilators, anti-inflammatory medications, and antibiotics. Additionally, the guideline covers the challenges and strategies for managing upper airway involvement, comorbidities, and exacerbations, as well as socio-medical aspects and disability rights. The importance of patient education and self-management is also emphasized. Finally, the guideline addresses special life stages such as transition, family planning, pregnancy and parenthood, and palliative care. The aim is to ensure comprehensive, consensus-based, and patient-centered care, taking into account individual risks and needs.

Productive cough, a forgotten phenotype of refractory chronic cough

BACKGROUND

Refractory chronic cough (RCC) patients typically complain of a dry cough. Sputum production in these patients has rarely been described in the literature. However, sputum production in RCC may be common, troublesome and particularly challenging to manage.

AIMS

We aimed to characterise patients referred to our regional specialist cough clinic who have significant sputum production (≥1 teaspoon of sputum daily) and compare their demographics, symptomatology and investigation results to those presenting with a dry RCC.

METHODS

A retrospective case note analysis of all consecutive referrals to a tertiary cough clinic identified as having a productive cough (≥1 teaspoon of sputum daily) was performed over a 12-month period. They were compared to a paired number of patients with dry RCC.

RESULTS

Patients with productive cough represented nearly a quarter (98/398, 24.6 %) of new patient referrals to the clinic. Demographic information, symptomatology and investigation results were comparable to those with a dry RCC. Over a third, 35.8 % of patients with a productive cough reported expectorating an egg-cupful of sputum or more a day. Nearly half, 40% of those with high volume sputum production (≥egg-cupful daily) had both a normal CT thorax and normal spirometry.

CONCLUSIONS

Patients with RCC can expectorate significant volumes of sputum in the absence of underlying lung disease. This group have similar demographics to those with dry RCC. This is the first piece of work to our knowledge to describe this cohort. Future work needs to acknowledge this forgotten phenotype to ensure that they receive comprehensive evaluation and evidenced based treatment.

Exploring Traits Associated With Central Sensitization Features in Patients With Chronic Cough

The concept of cough hypersensitivity suggests that central sensitization plays a role in the pathophysiology of chronic cough. However, it remains unclear which traits are associated with central sensitization features in patients with chronic cough. A cohort of 317 Korean patients with newly referred chronic cough underwent clinical evaluations. The Central Sensitization Inventory (CSI), a questionnaire originally developed as a screening tool to identify patients with Central Sensitization Syndrome, was also administered. Other patient-reported outcomes (PROs), such as the cough severity visual analogue scale, Leicester Cough Questionnaire (LCQ), Cough Hypersensitivity Questionnaire (CHQ), and the Center for Epidemiological Studies Depression (CES-D) scale, were also administered. Follow-up assessments were conducted one month later. At baseline, the presence of CSI scores of ≥ 40 was associated with being female (89.6% vs. 63.4%; P < 0.001), older age, concomitant symptoms, and cough-related complications. CSI scores correlated with PRO scores, including LCQ (r = -0.424, P < 0.001), CHQ (r = 0.373, P < 0.001), and CES-D (r = -0.660, P < 0.001). Their patterns of correlations were similar in the 1-month longitudinal follow-up data analysis. In conclusion, CSI scores in patients with chronic cough correlated with cough-specific and depression-related PROs, suggesting the potential relevance of central sensitization in certain phenotypes of chronic cough.

Patient-centered care in pulmonary fibrosis: access, anticipate, and act

Comprehensive care integrates individual patient needs and is highly valued for patients with pulmonary fibrosis (PF). The importance of a patient-centered care approach is rooted in the unpredictable progressiveness of the disease course in PF. The respiratory impairment associated with PF has a major impact on the quality of life for both patients and their caregivers. We believe that prioritizing patient preferences could improve the shared decision making process and may ultimately lead to better health outcomes. Despite the growing emphasis for this approach, it remains challenging to adopt it in clinical practice. In this review, we propose the comprehensive Triple A Care Model, consisting of the domains Access, Anticipate, and Act, which emphasizes core elements of patient-centered care for patients with PF. We will provide an overview of the unmet needs in care for patients with PF and elaborate on the current methods for delivering patient-centered care. The latest insights into symptom management and supportive measures and several approaches to improving access to care are discussed, in line with the most recent guidelines.

Multidisciplinary team discussion based on etiological treatment improves refractory chronic cough outcomes

BACKGROUND

Refractory chronic cough (RCC) causes significant impairments in the life quality of patients. Further research into the identification of etiologies and development of the treatment schedules for RCC is needed.

PATIENTS AND METHODS

We established an multidisciplinary team (MDT) clinic, by integrating respiratory medicine, otorhinolaryngology, and gastroenterology departments, to investigate cough etiologies and the effectiveness of treatment. The therapeutic effect was assessed quantitatively using the Cough Visual Analog Scales (VAS), Leicester Cough Questionnaire (LCQ), and Reflux Symptoms Index (RSI) scores.

RESULTS

In total, 213 patients attending the MDT outpatient clinic were examined, and 115 patients with RCC were included for analysis. The RCC diagnosis rate among the outpatient was 88.7%. Common causes of RCC included gastroesophageal reflux cough (63.5%), upper airway cough syndrome (UACS) (43.5%), and cough variant asthma (CVA) (14.8%). After an average treatment period of 2.17 ± 1.06 weeks (wk), 73.9% of the patients had partial cough remission, and 6.1% had complete cough remission. The cough VAS score before and after treatment was 6.11 ± 2.02 vs. 3.66 ± 2.22 (P < 0.05), respectively; LCQ total score before and after treatment was 10.24 ± 3.11 vs. 13.16 ± 3.59 (P < 0.05), respectively; and RSI score before and after treatment was 15.82 ± 7.01 vs. 10.71 ± 6.64 (P < 0.05), respectively.

CONCLUSION

The etiologies of most patients with RCC could be identified in the MDT clinic, and the cough-related symptoms of a significant number of patients with RCC improved in a short period.

Patient-reported assessments of chronic cough in clinical trials: accessory or primary endpoints?

Chronic cough is a complex disorder that affects up to 5-10% of the general population. It can be challenging to manage as there are few effective treatments, although several novel antitussives are in clinical development. The endpoints used to assess their efficacy in clinical trials should be optimal; most large clinical trials currently use objective measures as the primary outcome, especially cough frequency. There are strengths in this approach, although taking the view that other measures of chronic cough are less important, including patient-rated cough severity, psychosocial impact and other associated symptoms. Patient-reported outcome measures (PROMs) explore patients' personal experiences of health and disease, and the effects of particular conditions on their lives. Numerous validated PROMs exist for chronic cough, from simple visual analogue scales, to those that focus on cough hypersensitivity and cough-specific quality of life. Medicine regulators in the European Union (EU) and United States of America (USA) encourage the use of PROMs in clinical trials but have voiced concerns over their content validity, clinically meaningful thresholds for change, and discordance with objective measures. There are recent and ongoing studies to address these limitations. This review discusses currently available PROMs used to assess chronic cough and discusses their potential role as primary outcome measures in clinical trials.

Neuromodulators in Acute and Chronic Cough in Children: An Update from the Literature

Cough is one of the most common reasons leading to pediatric consultations, negatively impacting the quality of life of patients and caregivers. It is defined as a sudden and forceful expulsion of air from the lungs through the mouth, typically triggered by irritation or the stimulation of sensory nerves in the respiratory tract. This reflex is controlled by a neural pathway that includes sensory receptors, afferent nerves, the brainstem's cough center, efferent nerves, and the muscles involved in coughing. Based on its duration, cough in children may be classified as acute, lasting less than four weeks, and chronic, persisting for more than four weeks. Neuromodulators have shown promise in reducing the frequency and severity of cough by modulating the neural pathways involved in the cough reflex, although they require careful monitoring and patient selection to optimize the outcomes. This review aims to examine the rationale for using neuromodulators in the management of cough in children.

Efficacy of subcutaneous specific immunotherapy for allergic rhinitis combined with asthma: a retrospective analysis

OBJECTIVE

To evaluate the efficacy of subcutaneous specific immunotherapy (SCIT) for allergic rhinitis (AR) combined with asthma.

METHODS

A retrospective analysis of clinical data from 93 patients with AR combined with asthma admitted to our hospital from January 2022 to January 2023 was conducted. Based on the treatment interventions received, the patients were divided into a control group (n=46, receiving sublingual specific immunotherapy [SLIT]) and an observation group (n=47, receiving SCIT). Clinical treatment response, lung function, levels of immune indicators, levels of inflammatory indicators, and occurrence of adverse reactions were compared between the two groups.

RESULTS

The total response rate was 95.74% in the observation group and 84.78% in the control group (P > 0.05). In terms of scores for symptom assessment, Total Nasal Symptom Score (TNSS), Depression Anxiety Stress Scale (DASS), and Nasal Allergy Symptom Score (NASS) scores in both groups decreased after treatment, with greater decreases in the observation group (P < 0.05). In addition, lung function was improved in both groups after treatment as reflected by increased Forced Expiratory Volume in one second to Forced Vital Capacity ratio (FEV1/FVC) and Peak Expiratory Flow (PEF) levels, with greater increases found in the observation group (P < 0.05). Among the immune and inflammatory indicators, Cluster of Differentiation 14 (CD14) and Interleukin-33 (IL-33) levels decreased, while Secretory Protein D-1 (SPD-1), serum Immunoglobulin G4 (sIgG4), Interferon-γ (INF-γ), and Interleukin-27 (IL-27) levels increased in both groups after treatment, with greater changes observed in the observation group (P < 0.05). There was no significant difference in the incidence of adverse reactions between the observation group (14.89%) and the control group (21.74%) (P > 0.05).

CONCLUSION

In the treatment of AR combined with asthma, SCIT can better alleviate clinical symptoms, improve lung function, regulate immune and inflammatory responses in patients, and does not increase the risk of adverse reactions compared to SLIT.

Development of a Comprehensive Cough Therapy Program (CCTP) for chronic cough in India: a qualitative study

PURPOSE

Chronic Cough (CC) is an emerging area of practice in speech language pathology. Behavioral treatment for managing CC has gained attention in the recent past. This study aimed to devise a comprehensive behavioural therapy program for CC by involving allied health professionals (AHPs), who are typically involved in management of CC.

METHODS

A qualitative methodology was used to devise a behavioral treatment module for CC. Practice patterns of medical professionals, AHPs and yoga practitioners for CC were gathered through semi-structured interviews. A constant comparative framework was used to recruit participants until data saturation was achieved. The interview transcripts were analyzed to identify relevant components for the module. A post-interview survey was conducted to finalize the module through a consensus-based approach.

RESULTS

Three themes and respective sub-themes were identified from analysis. The module was developed based on the treatment strategies followed by professionals and was labeled 'Comprehensive Cough Therapy Program (CCTP)'. This comprised four components - similar to what is available in literature - patient education, breathing exercises, laryngeal hydration, and cough control strategies. This was devised using inputs from the interviews and evidence in the literature.

CONCLUSION

In line with global guidelines, this behavioral treatment module can serve as a possible management option for CC.

The discovery and development of gefapixant as a novel antitussive therapy

INTRODUCTION

Gefapixant, a P2X 3 receptor antagonist, shows considerable potential in managing refractory or unexplained chronic cough. Clinical trials have consistently demonstrated its efficacy in significantly reducing cough frequency and alleviating associated symptoms. However, its adverse effect profile, particularly taste disturbances such as dysgeusia and hypogeusia, the incidence of which is dose-dependent, poses a significant challenge to patient compliance and overall treatment satisfaction.

AREAS COVERED

The authors review the mechanism of action of gefapixant, the dose-dependent nature of its adverse effects and the findings from various clinical trials, including Phase 1, Phase 2, and Phase 3 studies. The authors also cover its regulatory status, post-marketing data, and its main competitors.

EXPERT OPINION

Gefapixant represents a significant advancement in treating chronic cough. However, balancing efficacy and tolerability is crucial. Lower effective doses and potential combination therapies may mitigate taste disturbances. Patient education and close monitoring during treatment are also important for optimal outcomes. Further research is needed to refine dosing strategies to minimize side effects while maintaining therapeutic efficacy. This research and personalized treatment approaches are key to optimizing gefapixant therapy, ensuring improved management of chronic cough while reducing adverse effects. However, pharmaceutical trials and proposals must be adapted to align with each regulatory body's specific requirements and concerns.

Longitudinal Cough Frequency Monitoring in Persistent Coughers: Daily Variability and Predictability

PURPOSE

We determined the cough counts and their variability in subjects with persistent cough for 30 days.

METHODS

The Hyfe cough tracker app uses the mobile phone microphone to monitor sounds and recognizes cough with artificial intelligence-enabled algorithms. We analyzed the daily cough counts including the daily predictability rates of 97 individuals who monitored their coughs over 30 days and had a daily cough rate of at least 5 coughs per hour.

RESULTS

The mean (median) daily cough rates varied from 6.5 to 182 (6.2 to 160) coughs per hour, with standard deviations (interquartile ranges) varying from 0.99 to 124 (1.30 to 207) coughs per hour among all subjects. There was a positive association between cough rate and variability, as subjects with higher mean cough rates (OLS) have larger standard deviations. The accuracy of any given day for predicting all 30 days is the One Day Predictability for that day, defined as the percentage of days when cough frequencies fall within that day's 95% confidence interval. Overall Predictability was the mean of the 30-One Day Predictability percentages and ranged from 95% (best predictability) to 30% (least predictability).

CONCLUSION

There is substantial within-day and day-to-day variability for each subject with persistent cough recorded over 30 days. If confirmed in future studies, the clinical significance and the impact on the use of cough counts as a primary end-point of cough interventions of this variability need to be assessed.

Prescription patterns and symptom relief of antitussives and expectorants in patients with cough: a nationwide study in Korea

Background

Limited data are available on the prescription patterns and efficacy of antitussives and expectorants for patients with acute and chronic cough. This study examined the use and efficacy of these medications in a nationally representative sample of Korean patients.

Methods

We examined 4,206,016 individuals from the National Health Insurance Service (NHIS)-National Health Information Database (NHID) between 2015 and 2017. Among them, a sample of 10% (n=420,602) was retrieved for the diagnosis of respiratory diseases using the International Classification of Diseases, 10th edition (ICD-10; J00-J99), or the prescription of antitussives and expectorants for cough (ICD-10; R05). The acute cough group included those who were prescribed medications within 4 weeks of initial diagnosis (prescription within 14 days), whereas the chronic cough group included patients who were prescribed medications within 16 weeks of initial diagnosis (prescription within 56 days). If the prescription was discontinued or not changed to an alternative drug after the initial prescription, these cases were considered to have achieved symptom relief.

Results

This study included 288,460 patients (971,065 cases) with acute cough and 5,888 patients (15,399 cases) with chronic cough. 'Expectorants, excluding combinations with cough suppressants' had the highest prescription rates in both groups (acute cough, 63.8%; chronic cough, 61.7%), and showed the highest symptom relief regardless of the number of medications prescribed (acute cough, 84.3%; chronic cough, 70.4%).

Conclusions

'Expectorants, excluding combinations with cough suppressants' were the most prescribed and effective medications for relieving cough symptoms in Korea patients. Further studies are needed to determine the optimal duration for using antitussives and expectorants in cough management.

Role of Spirometry, Radiology, and Flexible Bronchoscopy in Assessing Chronic Cough in Children

Chronic cough in children is a common and multifaceted symptom, often requiring a comprehensive approach for accurate diagnosis and effective management. This review explores the use of spirometry, radiology (chest X-rays and computed tomography (CT) scans), and flexible bronchoscopy in the assessment of chronic cough in children through current guidelines and studies. The strengths, clinical indications, and limitations of each modality are examined. Spirometry, radiology, and in some cases flexible bronchoscopy are integral to the assessment of chronic cough in children; however, a tailored approach, leveraging the strengths of each modality and guided by clinical indications, enhances diagnostic accuracy and therapeutic outcomes of pediatric chronic cough.

Exploring the concept of disease control in chronic cough

Background

Disease control in chronic diseases is an overarching concept that reflects the degree to which the goals of therapy are met. However, to date, there is no consensus on the definition of disease control in chronic cough. This study aimed to provide a conceptual exploration of patient-reported cough control in chronic cough.

Methods

This research is comprised of two subanalyses. First, patients with chronic cough receiving care at referral clinics were evaluated. Correlation analyses were performed between patient-reported cough control (a 5-point Likert scale), cough-specific patient-reported outcomes (PROs) and generic health PRO scores. Second, a survey was conducted among patients with refractory chronic cough and physicians to identify factors pertinent to cough control.

Results

The analysis of 341 patients (mean age: 55.5±15.1 years; female: 66.6%) revealed that cough control rating was moderately correlated with cough severity visual analogue scale and Leicester Cough Questionnaire scores, while demonstrating weaker correlations with cough-associated throat symptoms, cough-related complications or general health-related quality of life (QoL). In the survey of patients and physicians, both groups considered certain factors, such as cough frequency, severity and impact on QoL, to be relevant to the concept of cough control. However, patients rated "need for cough rescue drug" notably higher than physicians.

Conclusion

Patient-reported cough control was associated with cough severity or impact on QoL; however, cough control may not be fully captured by conventional cough PRO measurement tools. Further studies are warranted to define the consensus and tools to measure disease control in chronic cough.

Prevalence of refractory and unexplained chronic cough in adults treated in cough centre

Background

Refractory chronic cough and unexplained chronic cough pose significant clinical challenges, impairing patients' quality of life. However, a precise definition of refractory chronic cough remains elusive. This study aimed to assess the prevalence of refractory and unexplained chronic cough among patients referred to our cough centre and to analyse the prevalence of refractory chronic cough relative to its definition.

Methods

This prospective cohort study included all patients who were diagnosed at a cough clinic between 2018 and 2022. The response to therapy was measured based on reduction in cough severity (via a visual analogue scale) and improvement in cough-related quality of life (via the Leicester Cough Questionnaire). Refractory chronic cough was defined as persistent cough severity, with no or minimal improvement (change in visual analogue scale <30 mm) after two or more treatment attempts and cough severity ≥40 out of 100 mm on the visual analogue scale.

Results

Of 201 patients treated for chronic cough, only three (1.5%) were diagnosed with unexplained chronic cough. Among 166 patients monitored for therapy response, 71 (42.8%) experienced a cough severity reduction of ≥30 mm on the visual analogue scale, while 100 (60.2%) showed an improvement of ≥1.5 points on the Leicester Cough Questionnaire. Based on the basic refractory chronic cough definition, 51 of 166 patients (30.7%) were diagnosed with refractory chronic cough. If applying stricter criteria (persistent severe cough (≥40 mm on the visual analogue scale), insufficient therapy response (<30 mm reduction on the visual analogue scale) and <1.5-point improvement on the Leicester Cough Questionnaire), 45 of 166 patients (27.1%) would be diagnosed with refractory chronic cough.

Conclusions

Refractory chronic cough is common in patients referred to cough clinics. The prevalence of refractory chronic cough differs slightly depending on the diagnostic criteria. Therefore, the definition of refractory chronic cough used in routine practice needs to be clarified.

A systematic review of the psychometric properties of the Leicester Cough Questionnaires based on the COSMIN guidelines

BACKGROUND

Chronic cough affects around 10 % of the general adult population, impairing all aspects of quality of life.

RESEARCH QUESTION

What are the Leicester Cough Questionnaire's psychometric properties?

STUDY DESIGN AND METHODS

Electronic searches of PubMed, CINAHL, and ScienceDirect databases were conducted from inception until October 1rst 2022. All full-text articles, published in French or English, aimed at evaluating the LCQ's content validity or psychometric properties were included. The COSMIN Risk of Bias checklist was applied to assess their methodological quality and results. Results were qualitatively summarised and rated by a modified GRADE approach.

RESULTS

40 studies were included accounting for 8731 adults, subject to cough or a respiratory condition. Chronic cough (>8 weeks) was the most represented. The LCQ's total score is relevant and comprehensible for the assessment of the impact of cough on QoL. The original 3-factor model showed a satisfactory model fit. Good convergent validity was found for the total and physical domain scores. These scores demonstrate good internal consistency and test retest reliability, with some variability noted and they are responsive to change. Recent estimates of MID thresholds were 1.7 and 0.4 for total and domain scores respectively. The quality of the studies is globally poor.

INTERPRETATION

The LCQ is a valid outcome to assess the intra-individual impact of cough on QoL and to detect large changes in quality of life mainly in a short-term clinical trial setting.

CLINICAL TRIAL REGISTRATION

The protocol was registered with PROSPERO (CRD42022355191).

Associations between abnormal sleep behavior and indoor environmental risk factors among children with a chronic cough in Wuxi, China: a cross-sectional study

BACKGROUND

Indoor environmental factors, such as pet ownership, presence of cockroaches, mattress quality, fuel usage (gas or electricity), use of biomass for cooking and heating, exposure to tobacco smoke or household molds can significantly affect the sleep quality of children with chronic cough. However, data regarding the effects of indoor environmental conditions on sleep in this population are limited. This study aimed to assess the prevalence of abnormal sleep behaviors and to establish associations between indoor environmental factors and sleep behaviors among children with chronic cough in Wuxi, China.

METHODS

A cross-sectional design was employed in this study, involving children aged 3-18 years. Data on sociodemographic factors, allergies, home environmental exposures, and sleep characteristics of the participants were collected using paper-based questionnaires. The association between indoor environmental factors and sleep behaviors in children with chronic cough was analyzed using logistic regression models.

RESULTS

The findings demonstrated that the prevalence of chronic cough among children in Wuxi was 15.50%. The chronic cough group exhibited a significantly higher incidence of eczema, wheezing, rhinitis, food allergy, and nasosinusitis than the non-chronic cough group. In addition, children with chronic cough also tended to have a family history of sleep disorders and adenoid hypertrophy (P < 0.01). After adjusting for confounding factors, a significant association was observed between bruxism (teeth grinding) and chronic cough (sometimes: odds ratio [OR] = 1.04; confidence interval [CI] = 1.01-1.08; always: OR = 1.11; CI = 1.04-1.19; P < 0.01). Among children with chronic cough, recent home decoration was associated with sleepwalking (OR = 1.04; CI = 1.00-1.07; P < 0.05), mold exposure was associated with bruxism (OR = 1.15; CI = 1.0-1.31; P < 0.05), and carpet use at home was associated with apnea (OR = 1.09; CI = 1.02-1.17; P < 0.05), twitching during sleep (OR = 1.13; CI = 1.00-1.27; P < 0.01) and morning headache (OR = 1.14; CI = 1.05-1.23; P < 0.01).

CONCLUSION

Children with chronic cough are more prone to some abnormal sleep behaviors than children without chronic cough. Household decoration within a year, household mold exposure, and carpet use were all significantly positively associated with abnormal sleep behaviors in children with chronic cough. Our study provides novel insights into the impact of the indoor environment on children's sleep and the occurrence of chronic cough, offering guidance for tailored health promotion programs for families.

Development and validation of a novel questionnaire to describe and assess sensations and triggers associated with refractory and unexplained chronic cough

INTRODUCTION

Refractory or unexplained chronic cough (RUCC) is a common clinical problem with no effective diagnostic tools. The Sensations and Triggers Provoking Cough questionnaire (TOPIC) was developed to characterise cough in RUCC versus cough in other conditions.

METHODS

Content analysis of participant interviews discussing the sensations and triggers of chronic cough informed TOPIC development. Participants with chronic cough completed the draft-TOPIC (a subset repeating 5-7 days later), St George's Respiratory Questionnaire (SGRQ), Cough Severity Diary (CSD) and Global Rating of Change Scale. The draft-TOPIC item list was reduced in hierarchical and Rasch analysis to refine the questionnaire to the TOPIC.

RESULTS

49 items describing the triggers and sensations of cough were generated from participant interviews (RUCC n=14, chronic obstructive pulmonary disease (COPD) n=11, interstitial lung disease (ILD) n=10, asthma n=11, bronchiectasis n=3, cystic fibrosis n=7). 140 participants (median age 60.0 (19.0-88.0), female 56.4%; RUCC n=39, ILD n=38, asthma n=45, COPD n=6, bronchiectasis n=12) completed draft-TOPIC, where items with poor 'fit' for RUCC were removed to create TOPIC (8 trigger items, 7 sensation items). Median TOPIC score was significantly higher in RUCC (37.0) vs ILD (24.5, p=0.009) and asthma (7.0, p<0.001), but not bronchiectasis (20.0, p=0.318) or COPD (18.5, p=0.238), likely due to small sample sizes. The Rasch model demonstrated excellent fit in RUCC (χ2=22.04, p=0.85; PSI=0.88); as expected. When all participant groups were included, fit was no longer demonstrated (χ2=66.43, p=0.0001, PSI=0.89) due to the increased heterogeneity (CI=0.077). TOPIC correlated positively with SGRQ (r=0.47, p<0.001) and CSD (r=0.63, p<0.001). The test-retest reliability of TOPIC (intraclass correlation coefficient) was excellent (r=0.90, p<0.001).

CONCLUSIONS

High TOPIC scores in the RUCC patients suggest their cough is characterised by specific sensations and triggers. Validation of TOPIC in cough clinics may demonstrate value as an aid to identify features of RUCC versus cough in other conditions.

Characteristics of US Medicare Beneficiaries with Chronic Cough vs. Non-Chronic Cough: 2011-2018

Background: Chronic cough (CC), characterized as a cough lasting >8 weeks, is a common multi-factorial syndrome in the community, especially in older adults. Methods: Using a pre-existing algorithm to identify patients with CC within the 2011-2018 Medicare beneficiaries, we examined trends in gabapentinoid use through repeated cross-sectional analyses and identified distinct utilization trajectories using group-based trajectory modeling (GBTM) in a retrospective cohort study. Individuals without CC but with any respiratory conditions related to cough served as a comparator group. Results: Among patients with CC, gabapentinoid use increased from 18.6% in 2011 to 24.1% in 2018 (p = 0.002), with a similar upward trend observed in the non-CC cohort but with overall lower usage (14.7% to 18.4%; p < 0.001). Patients with CC had significantly higher burdens of respiratory and non-respiratory comorbidities, as well as greater healthcare service and medication use compared to the non-CC cohort. The GBTM analyses identified three distinct gabapentinoid utilization trajectories for CC and non-CC patients: no use (77.3% vs. 84.5%), low use (13.9% vs. 10.3%), and high use (8.8% vs. 5.2%). Conclusions: Future studies are needed to evaluate the safety and effectiveness of gabapentinoid use in patients with refractory or unexplained CC in real-world settings.

Awareness and practices of Speech Language Pathologists (SLPs) working with chronic cough in India: a call for action

OBJECTIVE

A cough persisting beyond eight weeks is referred as chronic cough (CC) and is a common symptom of many respiratory conditions and non-respiratory conditions. The role of a speech language pathologist (SLP) in CC is emerging and this study aimed to profile the awareness and practice patterns of SLPs practicing in India.

STUDY DESIGN

Cross-sectional study.

METHOD

An online survey was used to profile the assessment, treatment and counselling practices in CC among SLPs working in India. It sought to identify the awareness levels among SLPs regarding their role and availability of behavioural interventions for CC. Only SLPs who dealt with CC could complete the entire survey while other SLPs, filled regarding awareness and availability of behavioural interventions.

RESULTS

127 eligible responses obtained from SLPs working across clinical settings in India were analysed. 75.59% (n=96) of them had not seen patients with CC in their career. 47.24% (n=60) of them were aware that behavioural interventions were available for CC. Thirty-one SLPs completed the entire survey and their practice patterns indicated that few clinicians used cough-specific protocols while largely relying on voice and swallowing related assessment and treatment for CC.

CONCLUSION

This survey the lack of awareness of SLPs' role in CC and that their practices are dominated by existing procedures for voice and swallowing disorders. Increasing the awareness of SLP's role in CC may increase the caseload of patients referred and expand the SLP's scope of practice. Development of guidelines in CC practice and inclusion in coursework/curriculum are future considerations.

Association of Cough Severity with Asthma Control and Quality of Life in Patients with Severe Asthma

PURPOSE

Symptoms are important components in determining asthma control and in the adjustment of treatment levels. However, clinical relevance of cough in severe asthma is not well-understood. This study aimed to evaluate the severity and association of cough with patient-reported outcomes (PROs) in patients with severe asthma.

METHODS

This study analyzed cross-sectional data from the Korean Severe Asthma Registry. The severity of coughing and wheezing symptoms was assessed using a Visual Analog Scale (VAS) ranging from 0 to 100 for each symptom. Additionally, PROs included the Asthma Control Test (ACT), the Severe Asthma Questionnaire (SAQ), and the EuroQoL 5-Dimension (EQ-5D) index. Multivariate linear regression analysis was employed to explore the relationship between cough severity and other PRO scores.

RESULTS

A total of 498 patients with severe asthma (age: 57.9 ± 13.1 years, females: 60.2%) were analyzed. The cough VAS score was higher than the wheeze score (median 30, [interquartile range 10-50] vs. 20 [0-50]; P < 0.001). Additionally, 22.5% of patients ranked in a higher tertile for cough severity compared to wheezing, while 18.5% ranked higher for wheezing severity than cough. Significant correlations were observed between cough and wheeze VAS scores (r = 0.61, P < 0.05) and between each symptom's VAS score and the SAQ (cough: r = -0.41, P < 0.001; wheeze: r = -0.52, P < 0.001), ACT scores (cough: r = -0.50, P < 0.001; wheeze: r = -0.63, P < 0.001) and EQ-5D index (cough: r = -0.40, P < 0.001; wheeze: r = -0.45, P < 0.001). In univariate regression analysis, the cough VAS score had weaker descriptive power (R2) values than the wheeze VAS score in relation to the PRO measures. Nevertheless, cough severity remained significantly associated with ACT, SAQ scores and EQ-5D index in multivariate analyses adjusted for wheeze severity and other confounders.

CONCLUSION

Cough frequently presents as a severe symptom in patients with severe asthma and could have distinct impact on asthma control and quality of life.

Patient Perception of Cough in Interstitial Lung Disease; Impact of Cough Hypersensitivity

INTRODUCTION

Cough is common in interstitial lung disease (ILD) and is associated with disease progression, yet its mechanisms are understudied. We investigated cough hypersensitivity features and impact in ILD.

METHODS

Participants with ILD and cough (n = 195) completed a multiple choice and free text questionnaire on cough sensations/triggers and impacts.

RESULTS

The majority of participants were male (54%), aged > 65 (64%), with idiopathic pulmonary fibrosis (IPF, 75%). Common cough triggers were body position (74%), physical activity (72%), and talking (62%). Common laryngeal sensations were globus (43%), and itch/tickle (42%). Cough impacted everyday life in 55%, and all activities in 31%, causing exhaustion (59%), social embarrassment (70%), urinary incontinence (46% females), and syncope/pre-syncope (12%). The total number of cough-provoking sensations/triggers correlated with impacts; ρ = 0.73, p < 0.001.

CONCLUSION

Cough hypersensitivity symptoms are prevalent in ILD and detrimentally affect quality of life. Further studies investigating mechanisms of cough hypersensitivity and targeted pharmacotherapy are warranted.

Patient satisfaction with the management of refractory and unexplained chronic cough in Canada: Results from a national survey

BACKGROUND

Chronic cough (persisting for ≥8 weeks) is a common disorder affecting approximately 5 to 10% of adults worldwide that is sometimes refractory to treatment (refractory chronic cough [RCC]) or has no identifiable cause (unexplained chronic cough [UCC]). There is minimal information on the patient's experience of RCC/UCC in Canada. The aim of this study was to evaluate the patient journey and perceptions related to RCC/UCC management in Canada.

METHODS

Our exploratory study included Canadians in the Leger Opinion Panel and focused on individuals with RCC or UCC. Key entry criteria were: age ≥18 years, cough on most days for ≥8 weeks, no smoking within 1 year, no serious respiratory disease or lung cancer, and not taking angiotensin-converting enzyme inhibitors. Individuals who met entry criteria were invited to complete an approximately 30-minute online survey with questions on demographic characteristics, healthcare professional (HCP) interactions, diagnosis of underlying conditions, current treatments, and satisfaction with HCPs and chronic cough therapies.

RESULTS

A total of 49,076 individuals completed the chronic cough screening questionnaire (July 30, 2021 to September 1, 2021): 1,620 (3.3%) met entry criteria for RCC or UCC, and 1,046 (2.1%) completed the online survey (mean age of 45 years, 61% female). Most respondents (58%) reported their chronic cough was managed by a general practitioner (GP). Forty-four percent of respondents did not have a diagnosis of an underlying condition for their cough. Breathing tests (39%) and chest imaging (34%) were the most common diagnostic tests. Cough suppressants (18%) were the most frequent current treatment. Respondents were moderately satisfied with their HCPs, but more than half considered their treatment ineffective and 34% had considered no longer seeking medical attention because of a lack of treatment success.

CONCLUSIONS

Individuals with RCC/UCC in Canada are largely unsatisfied with the effectiveness of treatment. Additional HCP education and new treatment options are needed to improve patient satisfaction.

Chronic Cough and Cerebellar Ataxia With Neuropathy and Bilateral Vestibular Areflexia Syndrome (CANVAS): Screening for Mutations in Replication Factor C Subunit 1 (RFC1)

INTRODUCTION

A common complaint in patients is chronic cough (CC), which may be refractory (RCC) or unexplained (UCC). Recent studies point, as a possible cause of CC, to the hereditary cerebellar ataxia with neuropathy and bilateral vestibular areflexia syndrome (CANVAS), with an estimated carrier prevalence of 1 in 20000.

AIM

In patients with CC, determine the prevalence of the biallelic (AAGGG)exp mutation in replication factor C subunit 1 (RFC1) responsible for CANVAS, test the usefulness of the Rydel-Seiffer fork test, and evaluate patient quality of life (QoL).

METHODS

Clinical and functional data were collected for the 33 included patients undergoing CC studies in our specialized unit. Performed were an etiological study of CC following European Respiratory Society recommendations, a genetic study of RFC1 mutations, and Rydel-Seiffer fork testing to detect possible peripheral vibratory sensitivity impairment. Administered to evaluate QoL were 4 questionnaires.

RESULTS

Prevalence of biallelic (AAGGG)exp in RFC1 was 6.1% (n=2) overall, increasing to 7.1% in the RCC subgroup, and to 33.3% in the Rydel-Seiffer fork altered results subgroup. Prevalence of monoallelic (AAGGG)exp in RFC1 was 18.2% (n=6) overall, rising to 50.0% (n=2) in the UCC subgroup.

CONCLUSION

Genetic screening for (AAGGG)exp in RFC1, and also use of the Rydel-Seiffer fork test, should be considered in specialized CC consultations for patients with RCC and UCC. Detecting possible CANVAS symptoms in CC studies would identify candidates for early genetic screening, of interest in reducing the disease burden for patients and health systems alike.

Burden of Disease Associated with Refractory and Unexplained Chronic Cough in Canada: Results from a National Survey

INTRODUCTION

Chronic cough (persisting for ≥ 8 weeks) is a common disorder that includes refractory chronic cough (RCC; cough that persists despite treatment of underlying disease) and unexplained chronic cough (UCC; cough with no identifiable cause). We evaluated self-reported health-related quality of life (HR-QoL) and work/activity impairment associated with RCC/UCC in Canada.

METHODS

Our exploratory study included Canadians in the Leger Opinion Panel with RCC or UCC. Key entry criteria were ≥ 18 years of age, cough for ≥ 8 weeks, not currently smoking/quit ≥ 1 year ago, no serious respiratory disease or lung cancer, and not taking angiotensin-converting enzyme inhibitors. Respondents completed a 30-min online survey with general and cough-specific HR-QoL questionnaires, including the EuroQol (EQ) visual analogue scale (VAS), EQ-5-dimension 5-level (EQ-5D-5L), cough severity VAS, Leicester Cough Questionnaire (LCQ), and Work Productivity and Activity Impairment-Specific Health Problem (WPAI-SPH).

RESULTS

Of 49,076 individuals who completed the chronic cough screening questionnaire (July 30-September 1, 2021), 1,620 (3.3%) met entry criteria for RCC/UCC and 1,046 (2.1%) completed the survey. The mean age of respondents was 45 years and 61% were female. Respondents reported impairments in global HR-QoL (EQ-VAS 73.8, 61% with anxiety/depression on the EQ-5D-5L) and cough-specific HR-QoL (mean cough severity VAS score 29.7, LCQ index 15.2). Work and non-work activities were reduced by 34% and 30%, respectively, on the WPAI-SPH.

CONCLUSION

RCC/UCC is prevalent in Canada and associated with impaired HR-QoL, particularly in mental health domains. Additional support and management options may be required to fully address this burden.

Characteristics, demographics, and epidemiology of possible chronic cough in Sweden: A nationwide register-based cohort study

AIM

To show clinical characteristics, treatments, and comorbidities in chronic cough in a nationwide cohort.

METHODS

Two cohorts were created. A national cohort with individuals from two population-based databases; the National Patient Register and Swedish Prescribed Drug Register. Secondly, a regional cohort including primary care data. Adults with at least one cough diagnosis (ICD-10 R05) and/or individuals with ≥2 dispensed prescriptions for relevant cough-medication within the inclusion period, 2016-2018, were identified. Individuals on medications which may instigate cough or suggest acute infection or diagnosed with conditions where cough is a cardinal symptom, were excluded. Those remaining were defined as having possible refractory or unexplained chronic cough (RCC/UCC).

RESULTS

Altogether 62,963 individuals were identified with possible RCC/UCC, giving a national prevalence of about 1%. Mean age was 56 years and 60% were females. Many (44%) of the individuals with possible RCC/UCC visited cough relevant specialist clinics during the study period, but less than 20% received a cough diagnosis. A majority (63%) had evidence of RCC/UCC in the 10 years prior to inclusion in the study. In the regional cohort, including primary care data, the prevalence of RCC/UCC was doubled (2%). Cough medicines were mainly prescribed by primary care physicians (82%).

CONCLUSION

Most individuals with possible RCC/UCC sought medical care in primary care, and had a long history of cough, with various treatments tried, indicating a substantial burden of the condition. Referrals to specialist care were very rare. The results underline the need for a structured multidisciplinary approach and future therapeutic options.

Higher ambient temperatures may worsen obstructive sleep apnea: A nationwide smartwatch-based analysis of 6.2 million person-days

Obstructive sleep apnea (OSA) is a serious type of sleep disorder that can lead to cardiometabolic and neurocognitive diseases. We utilized smart device-based photoplethysmography technology to collect sleep data from the Chinese population from 2019 to 2022. Distributed lag nonlinear models combined with a generalized nonlinear model or a linear mixed effects model were used to investigate the short-term associations between daily temperature and indicators of OSA severity. We included a total of 6,232,056 d of sleep monitoring data from 51,842 participants with moderate to severe risk of OSA from 313 Chinese cities. The relationships between ambient temperature and OSA exacerbation, apnea-hypopnea index (AHI), and minimum oxygen saturation (MinSpO2) were almost linear and present only on the same day. Higher temperatures were associated with a greater risk of OSA exacerbation, with an 8.4% (95% confidence interval (CI): 7.6%-9.3%) increase per 10 °C increase in temperature. A 10 °C increase in daily temperature corresponded to an AHI increase of 0.70 events/h (95% CI: 0.65-0.76) and a MinSpO2 decrease of 0.18% (95% CI: 0.16%-0.19%). Exposure to elevated temperatures during the night can also lead to adverse effects. The effects of higher temperatures on OSA severity were stronger among men, participants with a body mass index ≥ 24 kg/m2, those aged 45 years and older, individuals with a history of hypertension and diabetes, and during the cold season. This large-scale, nationwide, longitudinal study provides robust evidence suggesting that higher ambient temperatures may immediately worsen OSA.

Drugs Targeting Cough Receptors: New Therapeutic Options in Refractory or Unexplained Chronic Cough

Refractory chronic cough is a disabling disease with very limited therapeutic options. A better understanding of cough pathophysiology has led to the development of emerging drugs targeting cough receptors. Recent strides have illuminated novel therapeutic avenues, notably centred on modulating transient receptor potential (TRP) channels, purinergic receptors, and neurokinin receptors. By modulating these receptors, the goal is to intervene in the sensory pathways that trigger cough reflexes, thereby providing relief without compromising vital protective mechanisms. These innovative pharmacotherapies hold promise for improvement of refractory chronic cough by offering improved efficacy and potentially mitigating adverse effects associated with current recommended treatments. A deeper comprehension of their precise mechanisms of action and clinical viability is imperative for optimising therapeutic interventions and elevating patient care standards in respiratory health. This review delineates the evolving landscape of drug development in this domain, emphasising the significance of these advancements in reshaping the paradigm of cough management.

Diagnostic utility of spirometry for children with induced laryngeal obstruction or chronic non-specific cough

PURPOSE

To determine the diagnostic utility of spirometry in distinguishing children with Induced Laryngeal Obstruction (ILO) or chronic non-specific cough (a.k.a. tic cough) from those with mild or moderate to severe asthma.

METHODS

Retrospective cross sectional design. Children diagnosed with ILO (N = 70), chronic non-specific cough (N = 70), mild asthma (N = 60), or moderate to severe asthma (N = 60) were identified from the electronic medical record of a large children's hospital. Spirometry was completed before ILO, non-specific cough, or asthma diagnoses were made by pediatric laryngologists or pulmonologists. Spirometry was performed following American Thoracic Society guidelines and was interpreted by a pediatric pulmonologist. Forced Vital Capacity (FVC), Forced Expiratory Volume in 1 Second (FEV1), FEV1/FVC Ratio (FEV1/FVC), Forced Mid-Expiratory Flow 25--75 % (FEF25-75%), pulmonologist interpretation of flow volume loops, and overall exam findings were extracted from the medical record.

RESULTS

Ninety seven percent of children with ILO or chronic non-specific cough presented with spirometry values within normative range. Patients with ILO, non-specific cough, and mild asthma presented with FVC, FEV1, FEV1/FVC, and FEF25-75% values in statistically similar range. Children with moderate to severe asthma presented with significantly reduced FVC (p < .001), FEV1 (p < .001), FEV1/FVC (p < .001), and FEF25-75% (p < .001) values when compared with patients in the other groups. Flow volume loops were predominantly normal for children with ILO and non-specific cough.

CONCLUSIONS

Findings indicate that ILO and chronic non-specific cough can neither be diagnosed nor differentiated from mild asthma using spirometry alone. Spirometry should therefore be used judiciously with this population, bearing in mind the limitations of the procedure. Future research should determine the most effective and efficient ways of delineating ILO and non-specific cough from other respiratory conditions in children.

Chronic cough: symptom, sign or disease?

Heritability can be added to the characteristics of chronic cough, making it a disease in its own right https://bit.ly/3ykD6gB.

Heritability of cough across two generations: the RHINESSA study

Aim

Heritability of cough has not yet been studied. We aimed to evaluate if individuals with cough are more likely to have offspring who develop cough, and if these associations differ by type of cough (productive/nonproductive).

Methods

The RHINESSA Generation Study (Respiratory Health In Northern Europe, Spain and Australia) includes 7155 parents (initially aged 30-54) answering detailed questionnaires in 2000 and 2010, and 8176 offspring ≥20 years answering similar questionnaires in 2012-2019. Chronic cough was categorised as productive or nonproductive (dry) cough. Associations between parental and offspring cough were analysed using mixed-effects logistic regression, adjusting for offspring age, sex, body mass index, smoking history, education level, current asthma, rhinitis, nocturnal gastroesophageal reflux; parent sex and smoking history; centre and family.

Results

Among parents with nonproductive cough, 11% of their offspring reported nonproductive cough, compared with 7% of offspring to parents without nonproductive cough, adjusted odds ratio (aOR) 1.59 (95% confidence interval 1.20-2.10). Among parents with productive cough, 14% of their offspring reported productive cough, compared with 11% of offspring to parents without productive cough, aOR 1.34 (1.07-1.67). No associations were found between parent productive cough-offspring nonproductive cough, nor between parent nonproductive cough-offspring productive cough.

Conclusions

Parents with chronic cough are more likely to have offspring with chronic cough independent of parental asthma, suggesting cough to be a separate heritable trait. The type of cough is important, as the nonproductive cough in parent associates only with nonproductive cough in offspring, and the same applied for productive cough.

Cerebellar ataxia, neuropathy and vestibular areflexia syndrome: a neurogenic cough prototype

Chronic cough is a frequent disorder that is defined by cough of more than 8 weeks duration. Despite extensive investigation, some patients exhibit no aetiology and others do not respond to specific treatments directed against apparent causes of cough. Such patients are identified as having unexplained or refractory chronic cough. Recently, a high proportion of patients with chronic cough in the context of cerebellar ataxia, neuropathy and vestibular areflexia syndrome (CANVAS) was highlighted. CANVAS is a rare neurological disorder with a biallelic variation in the replication factor C subunit 1 (RFC1) gene corresponding mostly to an intronic AAGGG repeat expansion. Chronic cough in patients with CANVAS shares similar characteristics with cough hypersensitivity syndrome. The high prevalence of chronic cough in CANVAS gives the opportunity to better understand the neurogenic mechanism of chronic cough. In this review, we will describe the characteristics and mechanisms of CANVAS. We will also address the potential mechanisms responsible for chronic cough in CANVAS. Finally, we will address chronic cough management in the context of CANVAS.

A survey of UK respiratory specialists' opinion on the management of chronic cough

Chronic cough is a common presentation to respiratory specialists. Here, we survey their opinion on diagnosis, investigation and management. Whilst investigations were appropriate, treatments were not guideline-based. Further education is needed. https://bit.ly/4a7W7Ay.

Coughing our guts up: how do we diagnose reflux cough?

Should Peptest be routinely used in a cough clinic? The answer is yes, but only as part of more intricate workup in which discovering the nature of the reflux is as important as identifying its presence. https://bit.ly/3QkbChb.

Severity grading of the Leicester Cough Questionnaire in chronic cough

Leicester Cough Questionnaire total scores were graded to severe (3.00-12.28), moderate (12.29-17.53) and mild (17.54-21.00), based on the prevalence of multiple self-reported doctor's visits due to cough among 1248 subjects with current cough https://bit.ly/3UkCe4i.

Prevalence, clinical characteristics, and disease burden of chronic cough in Italy: a cross-sectional study

BACKGROUND

Chronic cough has been associated with reduced health-related quality of life, negative impacts on sleep, work, and other daily activities, and increased use of health care resources. Little is known about the prevalence of chronic cough in Italy. In the present study we sought to estimate the prevalence of chronic cough in Italy, describe sociodemographic and clinical characteristics associated with chronic cough, and characterize the impact of chronic cough on overall health and wellness, work and other daily activities, and health care resource use.

METHODS

We conducted a cross-sectional study to collect sociodemographic and health-related data from Italian residents who participated in the 2020 National Health and Wellness Survey (N = 10,026). To assess the characteristics and burden of chronic cough, adults who indicated that they had experienced chronic cough during the prior 12 months were compared with propensity score-matched controls without chronic cough.

RESULTS

The estimated weighted lifetime and 12-month prevalence of chronic cough were estimated as 9.2% and 6.3%, respectively. Compared with matched controls, respondents with chronic cough had significantly lower measures of overall physical and mental health (P < .001 for both comparisons), and significantly higher rates of anxiety, depression, and sleep disorders (P < .001 for all comparisons). Chronic cough was significantly associated with higher rates of impairment of work and other activities (P < .001 for all comparisons) in the past 7 days, any-cause emergency department visits and hospitalizations in the prior 6 months (P < .001 for both comparisons), and more visits to general and specialist health care providers (P < .001 for both comparisons) in the prior 6 months.

CONCLUSIONS

In Italy, chronic cough affects an estimated 3.3 million adults annually and represents a significant burden to individuals and the health care system.

TAKE HOME MESSAGE

Little is known about the prevalence of chronic cough in Italy. We found that, in Italy chronic cough represents a significant burden to individuals and the health care system, affecting an estimated 3.3 million adults annually.

How to diagnose GERC more effectively: reflections on post-reflux swallow-induced peristaltic wave index and mean nocturnal baseline impedance

INTRODUCTION

Post-reflux swallow-induced peristaltic wave index (PSPWI) and mean nocturnal baseline impedance (MNBI) are novel parameters reflect esophageal clearance capacity and mucosal integrity. They hold potential in aiding the recognition of gastroesophageal reflux-induced chronic cough (GERC). Our study aims to investigate their diagnostic value in GERC.

METHODS

This study included patients suspected GERC. General information and relevant laboratory examinations were collected, and final diagnosis were determined following guidelines for chronic cough. The parameters of multichannel intraluminal impedance-pH monitoring (MII-pH) in patients were analyzed and compared to explore their diagnostic value in GERC.

RESULTS

A total of 186 patients were enrolled in this study. The diagnostic value of PSPWI for GERC was significant, with the area under the working curve (AUC) of 0.757 and a cutoff value of 39.4%, which was not statistically different from that of acid exposure time (AET) (p > 0.05). The combined diagnostic value of AET > 4.4% and PSPWI < 39.4% was superior to using AET > 4.4% alone (p < 0.05). Additionally, MNBI and distal MNBI also contributed to the diagnosis of GERC, with AUC values of 0.639 and 0.624, respectively. AET > 4.4% or PSPWI < 39.4% is associated with a 44% reduction in missed diagnoses of non-acid GERC compared to AET > 6.0% or symptom association probability (SAP) ≥ 95%, and may be more favorable for identifying GERC.

CONCLUSION

The diagnostic value of PSPWI for GERC is comparable to that of AET. Combining PSPWI < 39.4% or AET > 4.4% can improve the diagnostic efficiency by reducing the risk of missed diagnoses in cases where non-acid reflux is predominant. Distal MNBI and MNBI can serve as secondary reference indices in the diagnosis of GERC.

Bibliometric Analysis of Cough Variant Asthma from 1993 to 2022

Purpose

Cough variant asthma (CVA) is a chronic inflammatory disease characterized by recurrent coughing, a prevalent cause of chronic cough in children and adults. As a unique form of asthma, researchers have recently become increasingly interested in developing effective diagnostic and treatment methods. Currently, there has been no bibliometric analysis in CVA. Therefore, this study aims to enrich this knowledge network by examining the current development status, research focal points, and emerging trends in this field.

Methods

Articles and reviews on CVA published between 1993 and 2022 were collected from the Web of Science Core Collection (WoSCC) database. Relevant data from the reports were extracted, and collaborative network analysis was performed using CiteSpace and VOSviewer software.

Results

772 articles were included in this study, indicating a significant increase since 2019. The countries with the highest output are China, Japan. The Journal of Asthma and Pulmonary Pharmacology Therapeutics emerged as the most prolific journals in this field. Keyword analysis revealed 22 clusters, highlighting airway inflammation, airway hyperresponsiveness, and eosinophil as the main focus and frontier of research on CVA.

Conclusion

From the visual analysis results, the research of CVA is still in the development stage, and there is no unified definition of pathogenesis, diagnostic criteria and treatment strategies. Therefore, researchers and teams should actively carry out cross-institutional and cross-regional cooperation, expand cooperation areas, and carry out high-quality clinical research in the future.

Development of an Italian version of the Leicester cough questionnaire and its relationship with other symptom-specific measures for patients with chronic cough

OBJECTIVE

To implement subjective methods for measuring the impact of chronic cough on patients' daily life, including an Italian version of the symptom-specific, health status measure for patients with chronic cough, i.e. the Leicester Cough Questionnaire (LCQ).

METHODS

Sixty-five chronic cough patients attended a tertiary cough clinic on two separate occasions 8 weeks apart. The visual analogue scale for cough severity (VAS), the LCQ and the cough disturbance score (CDS) were administered on both occasions. The LCQ was adapted for Italian conditions following a forward-backward translation procedure. Concurrent validation, internal consistency, repeatability and responsiveness were determined.

RESULTS

The CDS, VAS and LCQ were correlated (r coefficients ranging from 0.69 to 0.94, p < 0.01). The internal consistency for each LCQ domain was high (alpha coefficient range 0.87-0.93), as was the 8-week repeatability of the LCQ in the patients (n = 36, 60 %) who displayed no change in CDS and VAS (intra-class correlation coefficient = 0.86, p < 001) over the same period. Patients who reported an improvement in CDS and VAS after 8 weeks (n = 29) also demonstrated significant improvements in each LCQ domain. The mean difference in LCQ total score before and after improvements was 2.26 (95 % CI: 1.58-4.47).

CONCLUSIONS

The Italian version of the LCQ appears to be just as valid as the other language versions of the questionnaire. In addition, the CDS appears to be a clinically useful, symptom-specific measure of the overall disturbance provoked by cough.

Clinical efficacy of montelukast sodium combination therapy for cough variant asthma in children: A meta-analysis

This meta-analysis aims to assess the clinical effectiveness of combination therapy with montelukast sodium for the treatment of cough variant asthma (CVA) in children, intending to provide clinical evidence and data to guide the selection of clinical therapy. A literature review was conducted using numerous databases, including China National Knowledge Infrastructure (CNKI), Wanfang database, Embase, PubMed, and Web of Science, from inception to December 2023. Trials meeting the criteria for the combined treatment of montelukast sodium for CVA in children were included. Stata 16.0 software was utilized for meta-analysis. The combined treatment group received montelukast sodium in addition to the control group, while the control group received budesonide, fluticasone propionate, salmeterol-fluticasone, or ketotifen alone. This investigation included 18 papers. All subjects were from the Chinese population. Compared to the control group, the combined treatment group demonstrated a higher effective rate (relative ratio [RR] = 1.23, 95% confidence interval [CI]: 1.18-1.29, p < .001), but no difference in the incidence of adverse reactions (RR = 0.65, 95% CI: 0.42-1.02, p = .060) after treatment. Moreover, the peak expiratory flow (PEF) (SMD = 1.69, 95% CI: 1.09-2.30, p < .001), forced vital capacity (FVC) (SMD = 1.67, 95% CI: 0.94-2.39, p < .001), forced expiratory volume in 1 s (FEV1) (SMD = 1.74, 95% CI: 1.09-2.40, p < .001), and FEV1/FVC (SMD = 1.84, 95% CI: 0.41-3.28, p = .012) were significantly higher in the combined treatment group than in the control group after treatment. Compared with the control group, the levels of tumor necrosis factor-α (SMD = -2.38, 95% CI: -3.22 to -1.55, p < .001), IL-4 (SMD = -2.65, 95% CI: -3.26 to -2.04, p < .001), and IgE (SMD = -2.98, 95% CI: -3.24 to -2.72, p < .001) were significantly lower in the combined treatment group after treatment. The combined use of montelukast sodium in the treatment of pediatric CVA in China is associated with a significant clinical effect, making it a reasonable therapeutic approach.

European Respiratory Society clinical practice guideline on symptom management for adults with serious respiratory illness

Respiratory symptoms are ubiquitous and impair health-related quality of life in people with respiratory disease. This European Respiratory Society (ERS) task force aimed to provide recommendations for symptomatic treatment in people with serious respiratory illness. The ERS task force comprised 16 members, including representatives of people with serious respiratory illness and informal caregivers. Seven questions were formulated, six in the PICO (Population, Intervention, Comparison, Outcome) format, which were addressed with full systematic reviews and evidence assessed using GRADE (Grading of Recommendations Assessment, Development and Evaluation). One question was addressed narratively. An "evidence-to-decision" framework was used to formulate recommendations. To treat symptoms in people with serious respiratory illness, the task force suggests the use of graded exercise therapy (conditional recommendation, low certainty of evidence); and suggests the use of a multicomponent services, handheld fan and breathing techniques (conditional recommendations, very low certainty of evidence). The task force suggests not to use opioids (conditional recommendation, very low certainty of evidence); and suggests either administering or not administering supplemental oxygen therapy (conditional recommendation, low certainty of evidence). The task force suggests that needs assessment tools may be used as part of a comprehensive needs assessment, but do not replace patient-centred care and shared decision making (conditional recommendation, low certainty of evidence). The low certainty of evidence, modest impact of interventions on patient-centred outcomes, and absence of effective strategies to ameliorate cough highlight the need for new approaches to reduce symptoms and enhance wellbeing for individuals who live with serious respiratory illness.

Cough Response to High-Dose Inhaled Corticosteroids in Patients with Chronic Cough and Fractional Exhaled Nitric Oxide Levels ≥ 25 ppb: A Prospective Study

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.

Epidemiology and Healthcare Service Utilization among Adults with Chronic Cough

Background and objective: Chronic cough (CC) is a prevalent yet underexplored medical condition, with limited real-world data regarding its healthcare burden. This study investigates the epidemiology, associated comorbidities, and healthcare service utilization among patients with CC. Methods: In this retrospective cohort study, adult patients with at least 3 physician diagnoses of cough over a period spanning a minimum of 8 weeks and a maximum of 12 months anytime between 2009 and 2018, were defined as patients with CC (PwCC). The reference group were adults without cough matched in a 1:1 ratio for age, sex, and place of residence. Results: The study included 91,757 PwCC, reflecting a prevalence of 5.5%. Of those, 59,296 patients (mean [SD] age, 53.9 [16.8] years; 59.6% females) were first diagnosed with CC during the study period, representing a 10-year incidence rate of 3.26% (95%CI: 3.24-3.29%). Diseases associated with the highest OR for CC included lung cancer (OR = 3.32; 95%CI: 2.90-4.25), whooping cough (OR = 3.04; 95%CI: 2.70-3.60), and respiratory infections (OR = 2.81; 95%CI: 2.74-2.88). Furthermore, PwCC demonstrated increased healthcare service utilization, leading to a higher adjusted annual estimated mean cost (USD 4038 vs. USD 1833, p < 0.001). Conclusions: Chronic cough emerges as a relatively prevalent complaint within community care, exerting a considerable economic burden. This study underscores the need for heightened awareness, comprehensive management strategies, and resource allocation to address the multifaceted challenges associated with chronic cough.