Evaluation and treatment of chronic cough

[Chronic bronchitis - new clinical recommendations (main provisions): A review on behalf of the working group for the development and revision of clinical guidelines for chronic bronchitis]

Chronic bronchitis (CB) is one of the most commonly diagnosed non-communicable chronic diseases. At the same time, with such a high incidence of CB registered in the Russian Federation, this pathology requires a balanced approach to the interpretation of clinical and functional indicators and their differentiated approach. The main provisions of the new clinical recommendations on CB, which are reflected in the article, will be useful in the practical work of an internist.

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.

Chronic cough diagnosis, treatment, and referral practices among family physicians in the United States: a survey study

BACKGROUND

Cough is one of the most common presenting problems for patients in primary care and is largely managed in primary care clinical settings. Family physicians' familiarity with chronic cough guidelines and the extent to which these guidelines translate into everyday practice have not been well described. The objective of this study was to characterize current diagnosis, treatment, and referral practices among family physicians and to identify potentially impactful strategies to optimize chronic cough management in primary care.

METHODS

We conducted a cross-sectional survey of 5,000 family physicians to explore diagnosis, treatment, and referral practices related to chronic cough management in adults in primary care. Respondents completed the survey via paper or online. The outcome measures were self-reported numeric ratings and responses related to the survey elements.

RESULTS

588 surveys were completed (11.8% response rate). About half (49.6%) of respondents defined chronic cough in a manner consistent with the American College of Chest Physicians (ACCP) chronic cough guidelines, with the rest differing in opinion primarily regarding duration of symptom presentation. Respondents reported trying to rule out most common causes of chronic cough themselves before referring (mean 3.41 on a 4-point scale where 4 is "describes me completely") and indicated a desire for more resources to help them manage and treat chronic cough. Years in practice and rural/urban setting influenced diagnosis and referral practices.

CONCLUSIONS

Family physicians see chronic cough as a complicated condition that can be and is often diagnosed and treated entirely in a primary care setting. They also value the ability to refer in complex cases. Our results support that family physicians provide evidence-based management of chronic cough.

Efficacy and safety of montelukast adjuvant therapy in adults with cough variant asthma: A systematic review and meta-analysis

BACKGROUND

Montelukast is a highly selective and specific cysteinyl leukotriene receptor antagonist used in the treatment of asthma. Whether montelukast as adjuvant therapy can significantly and safely treat adults with cough variant asthma (CVA) remains inconclusive.

AIMS

This meta-analysis systematically evaluated the efficacy and safety of montelukast as an adjuvant treatment for adults with CVA.

MATERIALS AND METHODS

Randomized controlled trials (RCTs) on montelukast combined with inhaled corticosteroids (ICS) and long-acting β2 agonists (LABAs) to treat CVA in adults, from inception to March 6, 2023, were retrieved from the CNKI, Wanfang, VIP, CBM, PubMed, Embase, Cochrane Library, and Web of Science databases and Clinical Trials website. Review Manager (version 5.4) and Stata (version 15.0) were used to conduct the meta-analysis.

RESULTS

A total of 15 RCTs were ultimately included in the meta-analysis. It was established that montelukast as adjuvant therapy raised the total effective rate (RR = 1.20, 95% confidence interval [CI] [1.13, 1.27], P < 0.01) and improved the FEV1% (SMD = 0.91, 95% CI [0.40, 1.41], P < 0.01), PEF% (SMD = 0.63, 95% CI [0.38, 0.88], P < 0.01), FEV1 (SMD = 1.15, 95% CI [0.53, 1.77], P < 0.01), PEF (SMD = 0.64, 95% CI [0.42, 0.86], P < 0.01), and FEV1/FVC% (SMD = 0.76, 95% CI [0.51, 1.01], P < 0.01) and reduced the recurrence rate (RR = 0.28, 95% CI [0.15, 0.53], P < 0.01). The incidence of adverse reactions was higher in the montelukast auxiliary group compared to the control group but with no statistical difference (RR = 1.32, 95% CI [0.89, 1.96], P = 0.17).

CONCLUSION

Existing evidence indicated that the use of montelukast as an adjuvant therapy had therapeutic efficacy superior to ICS + LABA alone for the treatment of adult patients with CVA. However, further research is needed, especially a combination of high-quality long-term prospective studies and carefully designed RCTs.

Interdisciplinary collaboration in the diagnosis and management of chronic cough: the role and importance of primary care providers

Chronic cough (CC) is associated with many conditions, so identifying contributing causes poses a diagnostic challenge. However, guidelines written for US physicians do not explicitly outline suggested roles for primary care providers (PCPs) in the approach to patients with CC, including refractory or unexplained CC. The objective of this review is to describe the role of PCPs in the diagnosis and treatment of CC in adults. This narrative review draws upon literature (identified via a PubMed search performed January 9, 2023, using primary care/disease state-related terms) and expertise from specialist physicians to provide recommendations for CC management in primary care. Cough is one of the top reasons patients seek care from PCPs; accordingly, PCPs are often the first physicians to conduct workup and initiate treatment. Patients with CC often experience a burdensome cough that lasts for years, have high healthcare resource utilization (HCRU), undergo multiple or failed treatment trials, and have limited success finding an etiology. Although specialist referral may be needed for many diagnostic tests, initial aspects of CC workup and management should be completed in primary care. Often more accessible than specialists, real-world evidence on HCRU suggests PCPs are important stakeholders in diagnosing and managing CC, including during initial workup and treatment for the most common causes of CC (i.e. upper-airway cough syndrome, asthma, noneosinophilic asthmatic bronchitis, and gastroesophageal reflux disease). Thorough workup at the primary care level may facilitate earlier identification of CC cause(s), improving patient journey to diagnosis and management.

The angiotensin receptor and neprilysin inhibitor, LCZ696, in heart failure: A meta-analysis of randomized controlled trials

BACKGROUND

LCZ696 is a novel neuroendocrine inhibitor that has been widely used in heart failure (HF). However, its advantage over other neuroendocrine inhibitors, such as angiotensin-converting enzyme inhibitors (ACEis) and angiotensin-receptor blockers (ARBs) has not been fully elucidated. This study aimed to provide the latest evidence regarding the efficacy and safety of LCZ696 as compared to other ACEis and ARBs with regards to the treatment of HF.

METHODS

We systematically searched databases, including PubMed, Embase, and the Cochrane Library, for relevant randomized controlled trials (RCTs). The outcome measures included all-cause mortality, rate of hospitalizations for HF, rate of death from cardiovascular causes, change in N-terminal pro-brain natriuretic peptide (NT-proBNP) levels, and decline of renal function.

RESULTS

Five RCTs involving 19,078 patients were identified. The meta-analysis indicated that LCZ696 was associated with a significant reduction in all-cause mortality (hazard ratio [HR] = 0.84; 95% confidence interval [CI], 0.76-0.93; P = .0005), rate of hospitalizations for HF (HR = 0.80; 95% CI, 0.73-0.87; P < .00001), reduction in NT-proBNP levels (rate ratio = 0.78; 95% CI, 0.70-0.88; P < .0001), and decline in renal function (odds ratio = 0.77; 95% CI, 0.68-0.88; P < .0001) compared with ACEis and ARBs. However, there was no statistical difference in the rate of death from cardiovascular causes (HR = 0.86; 95% CI, 0.72-1.03; P = .09) between LCZ696 and ACEis and ARBs.

CONCLUSION

LCZ696 is superior to ACEis and ARBs in the treatment of HF. Hence, it should be more widely used clinically.

Superior Laryngeal Nerve Block for Treatment of Neurogenic Cough

OBJECTIVES

This study aimed to add to the body of evidence for efficacy of Superior Laryngeal Nerve (SLN) blocks for treatment of neurogenic cough. Efficacy at short- and long-term intervals are presented as well as relationships with laryngoscopic findings.

METHODS

A retrospective chart review of patients treated with SLN block between 2018 and 2020 was conducted. Patient demographics, videostroboscopic findings, and patient-subjective perception of outcomes were recorded and analyzed. Cough Severity Index (CSI) scores from pre-injection, short-term follow-up, and long-term follow-up were compared.

RESULTS

Twenty patients underwent SLN block in the clinic setting. Four patients were excluded for incomplete records. The indication was neurogenic cough refractory to medical management and/or cough suppression therapy. Patients with short-term follow-up (n = 13) had statistically significant decrease in CSI scores, with a mean baseline CSI of 24.3 decreasing to 16.15 (P = .006). Patients with evidence of Vocal Fold Motion/Vibratory Abnormalities (VFA) (n = 8) showed improvement in short-term CSI scores, with a mean baseline CSI of 24.13 decreasing to 14.5 (P = .004). Those without evidence of VFA did not have statistically significant improvement in short-term CSI scores. At long-term follow-up, patients with VFA had improvements that approached statistical significance with a mean baseline CSI of 22.56 decreasing to 14.56 (P = .057), while patients without VFA showed no improvement.

CONCLUSIONS

Our results are consistent with previous literature indicating efficacy of SLN block. The presence of VFA may be an indicator of patients who experience increased therapeutic effect.

LEVEL OF EVIDENCE

4 Laryngoscope, 2021.

Suhuang Zhike Capsules for the Treatment of Cough Variant Asthma: A Meta-analysis

Cough variant asthma (CVA) is a unique type of asthma characterized by cough as the only or primary clinical presentation. Inhaled glucocorticoid is the main treatment in clinical practice currently, but its efficacy remains relatively unsatisfactory. Traditional Chinese medicine has certain advantages in the treatment of CVA, and at present, the most commonly used traditional Chinese medicine is Suhuang Zhike Capsule (SZC). The aim of this study was to systematically evaluate the efficacy and safety of SZC in the treatment of CVA using a meta-analysis. A comprehensive search of papers published in the PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure (CNKI), Chinese Biomedical Literature database (CBM), Wanfang Database, and VIP Information (VIP) from January 2018 to June 2019 was conducted. Review Manager 5.3 was used to carry out a meta-analysis of 10 studies that fulfilled the inclusion criteria. In a total of 10 randomized controlled trials, 896 CVA patients were included. The results showed the following: (1) compared with conventional Western medicine, SZC can effectively increase the efficacy rate of CVA (RR 1.25, 95% CI, 1.16-1.35, P < 0.00001) and (2) compared with other traditional Chinese medicines, SZC can effectively increase the efficacy rate of CVA (RR 1.44, 95% CI, 1.01-2.05, P=0.05), In conclusion, our study builds on existing clinical evidence showing that SZC is safe and effective in treating CVA. However, larger randomized controlled trials are required for further validation.

[The cough variant asthma]

Cough variant asthma (CVA) was first described by W. Corrao. CVA was described as the isolated chronic cough as the only presenting symptom responsive to bronchodilator therapy.This phenotype of asthma is present with airway hyperresponsiveness, eosinophilic inflammation airways and bronchodilator responsive coughing without typical manifestation of asthma such as wheezing or dyspnea. CVA shares common features with classic asthma such as eosinophilic inflammation and airway remodeling. Because of that, CVA is clinically considered as a variant type of asthma.

[Clinical effect of fluticasone propionate, montelukast sodium and ketotifen in treatment of cough variant asthma in children]

OBJECTIVE

To study the clinical effect of different combinations of fluticasone propionate (Flu), montelukast sodium (Mon) and ketotifen (Ket) in the treatment of children with cough variant asthma (CVA).

METHODS

A total of 280 children with CVA who were admitted to the department of respiratory medicine from June 2015 to January 2018 were randomly divided into Flu+Mon+Ket, Flu+Mon, Flu+Ket, Mon+Ket, Flu, Mon and Ket groups, with 40 children in each group. The children in each group were given corresponding drug(s), and the course of treatment was 3 months for all groups. The condition of cough, cough symptom score, pulmonary function and adverse drug reactions were evaluated after 2 and 3 months of treatment. The children were followed up to observe recurrence.

RESULTS

After treatment, cough symptom score tended to decrease in all 7 groups, with increases in percentage of forced expiratory volume in 1 second (FEV1%) and percentage of predicted peak expiratory flow (PEF%). After 2 months of treatment, the Flu+Mon+Ket group had a significantly lower cough symptom score and significantly higher FEV1% and PEF% than the other groups (P<0.05). After 2 and 3 months of treatment, the Ket group had a significantly higher cough symptom score and significantly lower FEV1% and PEF% than the other groups (P<0.05). After 3 months of treatment, there were no significant differences in cough symptom score, FEV1% and PEF% among the other groups (P>0.05). There was a low incidence rate of adverse events in all 7 groups, and there was no significant difference among the 7 groups (P>0.05). The Ket group had a significantly higher recurrence rate of cough than the other groups (P<0.001), while there was no significant difference in this rate among the other groups (P>0.0024).

CONCLUSIONS

For children with CVA, a combination of Flu, Mon and Ket has a better clinical effect than a combination of two drugs and a single drug at 2 months of treatment and is safe. After 3 months of treatment, Flu or Mon alone has a similar effect to drug combination. Ket alone has a poor clinical effect and a high recurrence rate after drug withdrawal.

Treatment of Chronic Cough: Single-Institution Experience Utilizing Behavioral Therapy

Objective

Chronic cough remains a challenging condition, especially in cases where it persists despite comprehensive medical management. For these particular patients, there appears to be an emerging role for behavior modification therapy. We report a series of patients with refractory chronic cough to assess if there is any benefit of adding behavioral therapy to their treatment regimen.

Study Design

A case series with planned chart review of patients treated for chronic cough.

Setting

The review was performed with an outpatient electronic health record system at a tertiary care center.

Subjects and Methods

The charts of all patients treated for chronic cough by a single laryngologist over a 30-month period were analyzed. Patients’ response to treatment and rate of cough improvement were assessed for those with refractory chronic cough who underwent behavior modification therapy.

Results

Thirty-eight patients with chronic cough were initially treated empirically for the most common causes of cough, of which 32% experienced improvement. Nineteen patients who did not significantly improve with medical management underwent behavior modification therapy with a speech-language pathologist. Of these patients, 84% experienced resolution or marked improvement of their symptoms.

Conclusion

Behavioral therapy may be underutilized in practice and could lead to improvement of otherwise recalcitrant cough.

Immunization against pertussis in adolescents and adults

Pertussis is a highly contagious infectious disease caused by Bordetella pertussis that can be extremely serious, particularly in young infants. For many years the efforts of health authorities throughout the world to prevent pertussis had the main goals of reducing the morbidity of infants and children under 5 years of age, maintaining protection for several years during the school-age period and developing a significant herd immunity to directly and indirectly reduce the risk of the spread of the disease among young infants and the risk of transmission of the infection from preschool children to infants. However, the increased risk of B. pertussis infection among adolescents and adults due to the waning immunity to this bacterium induced by vaccines and natural infection seems to be the main reason for the resurgence of pertussis. We discuss the reasons for the administration of pertussis vaccines to individuals for whom they were previously not recommended, the expected results of the administration of additional pertussis vaccine doses and the differences in the administration of pertussis vaccines in different countries. An analysis of the literature revealed several reports indicating the need for the modification of immunization schedules against pertussis, with booster doses among adolescents and the need for the vaccination of pregnant women. However, to monitor the true epidemiology of pertussis, effective programmes to collect pertussis cases, adequate reporting systems and vaccination coverage monitoring should be urgently implemented.