Complications of cough: ACCP evidence-based clinical practice guidelines

Effect of esketamine on the EC50 of remifentanil for suppression of choking cough during extubation

Choking cough during awakening from anesthesia is common (15%-94%) and can cause severe discomfort and complications, especially in neck surgery. This study compared the median effective concentration (EC50) of remifentanil combined with esketamine versus remifentanil alone for suppressing cough during extubation in male patients undergoing anterior cervical spine surgery. Group E received 0.25 mg/kg esketamine intravenously 30 min before surgery ended, while group D received a placebo. We observed that the EC50 values were 1.88 ng/mL for group E and 2.55 ng/mL for group D. No significant differences were observed in intraoperative hemodynamics or extubation time. Additionally, group E had lower postoperative pain scores at 2 and 24 h. Findings suggest that combining esketamine with remifentanil reduces the EC50 for cough suppression and effectively lowers early postoperative pain, providing reference for perioperative safety and improvement of prognosis in patients undergoing anterior cervical surgery.

Effects of Dexmedetomidine Combined With Lidocaine Topical Administration on Cough Reflex During Extubation in Thyroidectomy Patients: A Randomized Clinical Trial

BACKGROUND

Cough reflex during extubation can lead to complications such as increased bleeding and hemodynamic instability, especially in thyroidectomy, therefore, effective suppression of cough reflex is clinically important. The aim of the study was to investigate the inhibitory effect of dexmedetomidine combined with lidocaine on the cough reflex during extubation in thyroidectomy.

METHODS

A total of 180 female patients, aged 18 to 65 years, undergoing elective thyroidectomy under general anesthesia, were randomized into 3 groups: dexmedetomidine combined with lidocaine (Dex-Lido group, n = 60), lidocaine alone (Lido group, n = 60), or normal saline (Control group, n = 60). Before tracheal intubation, patients in the Dex-Lido group received dexmedetomidine combined with 2% lidocaine spray, those in the Lido group received 2% lidocaine spray, and those in the Control group received 0.9% normal saline spray, applied to the supraglottic, glottic, and subglottic areas. The primary outcome was the incidence of cough reflex at extubation. Secondary outcomes included cough severity, postoperative sore throat, hoarseness, nausea, and vomiting, as well as the need for analgesics and antiemetics, pain levels, sedation scores, and length of hospital stay.

RESULTS

The incidence of cough reflex during extubation was significantly lower in both the Dex-Lido and Lido groups compared to the Control group (23% vs 70%; odds ratio [OR], 0.13; 95% confidence interval [CI], 0.06-0.29; P < .001 for Dex-Lido; 47% vs 70%; OR, 0.38; 95% CI, 0.18-0.79]; P = .010 for Lido), with a statistically significant difference between the Dex-Lido and Lido groups (23% vs 47%; OR, 0.35; 95% CI, 0.16-0.76; P = .007). Additionally, the severity of the cough reflex was markedly lower in the Dex-Lido group compared to the Control group (8/60 vs 26/60; OR, 0.20; 95% CI, 0.08-0.50; P < .001).

CONCLUSIONS

The combination of dexmedetomidine and lidocaine laryngopharynx spray effectively suppresses the cough reflex during extubation, reduces postoperative sore throat, and stabilizes hemodynamics in female patients undergoing thyroid surgery.

Impact of Propofol Administered before Extubation on Respiratory Adverse Events in Pediatric Patients Undergoing Tonsillectomy and Adenoidectomy: A Randomized Controlled Trial

Aims/Background Perioperative respiratory adverse events (PRAEs) are common in pediatric anesthesia, especially in otolaryngology procedures. In this randomized controlled trial, we investigated the impact of administering propofol before extubation on PRAEs in pediatric patients undergoing tonsillectomy and adenoidectomy. Methods We enrolled children aged 3 to 8 years old, of American Society of Anesthesiologists (ASA) classes I to III, scheduled for tonsillectomy, and randomly divided them into propofol and control groups. The subjects in the propofol group received multiple small doses of propofol (0.5 mg/kg per dose, total 1-2 mg/kg) until the patient resumed regular spontaneous breathing and exhibited no bodily movements. The subjects in the control group received 0.15 mL/kg of saline. The primary outcome was the rate of PRAEs, such as laryngospasm, bronchospasm, breath-holding spell, severe coughing, desaturation, and airway obstruction, post-extubation. The secondary outcomes were the extubation time, pre-extubation Richmond Agitation-Sedation Scale (RASS) score, end-tidal sevoflurane concentration at extubation, incidence of postoperative agitation, time to consciousness, and Face, Legs, Activity, Cry, and Consolability (FLACC) pain score in the recovery room. Results were reported with risk ratios (RR) and their 95% confidence intervals (CI), as well as the p-values indicating statistical significance. Results A total of 239 patients were included, including 119 in the propofol group and 120 in the control group. Our findings indicated no significant difference in the rate of PRAEs between the two groups (5.9% vs 10.8%, RR: 0.54, 95% CI: 0.23 to 1.31, p = 0.17). However, the propofol group showed a notable decrease in moderate to severe coughs (13.4% vs 60.0%, RR: 0.22, 95% CI: 0.14 to 0.36, p < 0.001) and postoperative agitation (4.2% vs 60.8%, RR: 0.07, 95% CI: 0.03 to 0.17, p < 0.001). Conclusion This trial demonstrated that while administering repeated small doses of propofol before extubation does not significantly reduce respiratory adverse events in children undergoing tonsillectomy and adenoidectomy, it does significantly reduce the incidence of severe coughing, improving postoperative recovery and clinical outcomes. Moreover, propofol helps reduce postoperative agitation, enhancing the safety and effectiveness of postoperative care, and maintaining its valuable clinical role in postoperative management. Clinical Trial Registration ClinicalTrials.gov (NCT05769842).

Postoperative exacerbated cough hypersensitivity syndrome induces dramatic respiratory alkalosis, lactatemia, and electrolyte imbalance

BACKGROUND

The perioperative management of patients with chronic cough or cough hypersensitivity syndrome and its sometimes severe effects is currently under-researched and under-reported.

CASE PRESENTATION

A 46-year-old female patient with a history of chronic cough and Cough Hypersensitivity Syndrome. After laparoscopic hiatoplasty and anterior fundoplication under general anesthesia, experienced a pronounced exacerbation of coughing symptoms. Despite prompt and extensive treatment involving antitussives, inhalants, anxiolytics, and sedatives, the symptoms remained uncontrollable. Within a few hours, the patient developed a respiratory alkalosis with severe and life-threatening electrolyte shift (pH 7.705, pCO2 1.72 kPa, K+ 2.1 mmol/l). Lactatemia lasted for more than 12 hours with values up to 6.6 mmol/l. Acute bleeding, pneumothorax, and an acute cardiac event were ruled out. Deep analgosedation and inhalation of high-percentage local anesthetics were necessary to manage the clinical symptoms.

CONCLUSIONS

This case highlights the challenging nature of chronic cough and hypersensitivity syndrome perioperatively. A tailored anesthesiologic approach, exclusion of other provoking medical problems, and knowledge of possible management and treatment options are key.

Comparison between dexmedetomidine and lidocaine for attenuation of cough response during tracheal extubation: A systematic review and meta-analysis

Background and Aims

Tracheal extubation often causes cardiovascular and airway responses, potentially resulting in hazardous consequences. It remains unknown whether dexmedetomidine or lidocaine is more effective for cough suppression. Hence, we conducted a systematic review and meta-analysis of randomised controlled trials to compare the effectiveness and safety of dexmedetomidine and lidocaine in reducing cough response after tracheal extubation in adult patients.

Methods

A thorough search of electronic databases, including PubMed, Embase, Cochrane Library, and Web of Science, was conducted to identify relevant studies (from inception to 31 January 2023). Randomised controlled trials comparing intravenous (IV) dexmedetomidine versus IV lidocaine administration during emergence from anaesthesia to prevent tracheal extubation response in adult patients under general anaesthesia were included. The primary outcome was the incidence of post-extubation cough. Secondary outcomes included emergence time, extubation time, residual sedation, and incidences of bradycardia. Statistical analysis was conducted using RevMan software. The Cochrane risk of bias tool was used to evaluate the potential risk for bias.

Results

In total, seven studies with 450 participants were included. There was no statistically significant difference in the incidence of cough between dexmedetomidine and lidocaine groups [Risk Ratio = 0.76; 95% Confidence Interval: 0.46, 1.24]. Emergence and extubation times were not significantly different between the two groups. Meta-analysis revealed a higher incidence of bradycardia and residual sedation in dexmedetomidine compared to the lidocaine group.

Conclusion

This meta-analysis found no difference in cough, emergence, and extubation time between dexmedetomidine and lidocaine after tracheal extubation. However, residual sedation and bradycardia were more significant in dexmedetomidine than in lidocaine.

Cough and swallow after laparotomy in anesthetized cats

An anesthetized cat animal model was used to evaluate changes in cough and swallow after a small midline upper abdominal incision (laparotomy). Two additional conditions were tested: sealing the laparotomy with gentle suctioning via a small cannula, and subsequent closure of the abdominal wall with suture. These abdominal wall manipulations resulted in no changes in the cough reflex, but produced higher motor drive to pharyngeal musculature (thyropharyngeus and geniohyoid muscles) during swallow. Swallow-breathing coordination phase preference shifted towards swallow occurring more during the inspiratory phase. There were no significant changes in cough motor pattern, or cough and swallow number and temporal features. The respiratory changes were limited to reduced inspiratory motor drive to the diaphragm. The results are consistent with an important role of sensory feedback from the abdominal wall in regulation of swallow motor pattern. The level of reflex modulation may depend on the extent of injury and likely on its position in the abdomen.

Identifying Existing Evidence to Potentially Develop a Machine Learning Diagnostic Algorithm for Cough in Primary Care Settings: Scoping Review

BACKGROUND

Primary care is known to be one of the most complex health care settings because of the high number of theoretically possible diagnoses. Therefore, the process of clinical decision-making in primary care includes complex analytical and nonanalytical factors such as gut feelings and dealing with uncertainties. Artificial intelligence is also mandated to offer support in finding valid diagnoses. Nevertheless, to translate some aspects of what occurs during a consultation into a machine-based diagnostic algorithm, the probabilities for the underlying diagnoses (odds ratios) need to be determined.

OBJECTIVE

Cough is one of the most common reasons for a consultation in general practice, the core discipline in primary care. The aim of this scoping review was to identify the available data on cough as a predictor of various diagnoses encountered in general practice. In the context of an ongoing project, we reflect on this database as a possible basis for a machine-based diagnostic algorithm. Furthermore, we discuss the applicability of such an algorithm against the background of the specifics of general practice.

METHODS

The PubMed, Scopus, Web of Science, and Cochrane Library databases were searched with defined search terms, supplemented by the search for gray literature via the German Journal of Family Medicine until April 20, 2023. The inclusion criterion was the explicit analysis of cough as a predictor of any conceivable disease. Exclusion criteria were articles that did not provide original study results, articles in languages other than English or German, and articles that did not mention cough as a diagnostic predictor.

RESULTS

In total, 1458 records were identified for screening, of which 35 articles met our inclusion criteria. Most of the results (11/35, 31%) were found for chronic obstructive pulmonary disease. The others were distributed among the diagnoses of asthma or unspecified obstructive airway disease, various infectious diseases, bronchogenic carcinoma, dyspepsia or gastroesophageal reflux disease, and adverse effects of angiotensin-converting enzyme inhibitors. Positive odds ratios were found for cough as a predictor of chronic obstructive pulmonary disease, influenza, COVID-19 infections, and bronchial carcinoma, whereas the results for cough as a predictor of asthma and other nonspecified obstructive airway diseases were inconsistent.

CONCLUSIONS

Reliable data on cough as a predictor of various diagnoses encountered in general practice are scarce. The example of cough does not provide a sufficient database to contribute odds to a machine learning-based diagnostic algorithm in a meaningful way.

Abdominal internal oblique muscle hematoma of an obese middle-aged man induced by cough

An obese middle-aged man presented for left abdominal pain. CT scan with contrast medium revealed hematoma in the left abdominal internal oblique muscle.

A randomized, double-blinded, placebo-controlled clinical trial of duloxetine hydrochloride enteric-coated tablets in the treatment of refractory chronic cough

INTRODUCTION

Refractory cough, a chronic cough with an unclear diagnosis or poor treatment response. The symptoms are often stubborn and persistent, causing serious complications and lowering the patient's quality of life. Cough hypersensitivity syndrome (CHS) is proposed as a potential cause, and reducing sensory nerve hyperresponsiveness is suggested as an effective treatment. However, current drugs have low efficacy and benefit rates and numerous side effects. This trail proposes using duloxetine, a selective 5-HT and norepinephrine reuptake inhibitor, as a potential treatment for refractory cough, which has shown promise in treating pain and depression. Duloxetine may inhibit pain conduction and oxidative stress in peripheral nerves by inhibiting the activity of TRPV1 channels, which play an important role in the peripheral afferent pathway of refractory cough. Meanwhile, the antidepressant effects of duloxetine may also play a role in the treatment of refractory cough.

METHODS AND ANALYSIS

This is a single-center, prospective, randomized, double-blind, and controlled trial. A total of 98 individuals will be randomized in a 1:1 ratio to duloxetine group and placebo control group (starting with 20 mg QD, increasing 20 mg daily until 20 mg TID). After a screening period, the second stage runs from baseline to the 42nd (last) day of treatment, with follow-up visits on the 3rd, 7th, 14th, 21st, 28th, 35th, 42nd and 49th days. The main end-stage observation indicators include objective cough frequency, cough visual analog scale (VAS), cough symptom score, Leicester Cough Questionnaire (LCQ), and cough evaluation test (CET); the secondary end-stage observation indicators include capsaicin cough sensitivity, Patient Health Questionnaire-9 (PHQ-9), Major Depression Inventory (MDI), the Generalized Anxiety Disorder-7 scale (GAD-7), Life Events Scale (LES-32), induced sputum supernatant. The safety measures will be AEs/SAEs, vital signs, liver and kidney function, fecal occult blood test.

DISCUSSION

This study is the first randomized, double-blind, and controlled clinical trial investigating the use of duloxetine in the treatment of refractory coughs. The study aims to provide a high-quality basis for evaluating the efficacy and safety of duloxetine for this condition.

TRIAL REGISTRATION

Our study was registered in the Chinese Clinical Trials Register ( www.chictr.org.cn/ ) (ChiCTR2000037429) in 28/08/2020.

Evaluating efficacy and safety of sub-anesthetic dose esketamine as an adjuvant to propofol/remifentanil analgosedation and spontaneous respiration for children flexible fibreoptic bronchoscopy: a prospective, double-blinded, randomized, and placebo-controlled clinical trial

Background: Flexible fiberoptic bronchoscopy (FFB) for children is widely performed under sedation. Currently, the optimal sedation regimen remains unclear. Esketamine is an N-methyl-D-aspartic acid (NMDA) receptor antagonist, which has stronger sedative and analgesic effects and exerts less cardiorespiratory depression than other sedatives. The purpose of this study was to evaluate whether a subanesthetic dose of esketamine as an adjuvant to propofol/remifentanil and spontaneous ventilation compared with control reduces the procedural and anesthesia-related complications of FFB in children. Materials and methods: Seventy-two children ≤ 12 years of age who were scheduled for FFB were randomly assigned, in a 1:1 ratio, to the esketamine-propofol/remifentanil (Group S, n = 36) or to the propofol/remifentanil group (Group C, n = 36). All children were retained spontaneous ventilation. The primary outcome was the incidence of oxygen desaturation (respiratory depression). Perioperative hemodynamic variables, blood oxygen saturation (SPO₂), end-tidal partial pressure of carbon dioxide (PetCO₂), respiratory rate (R), and the Bispectral index (BIS), induction time, procedural time, recovery time, the time to the ward from the recovery room, consumption of propofol and remifentanil during the procedure and the appearance of adverse events, including paradoxical agitation following midazolam administration, injection pain, laryngospasm, bronchospasm, PONV, vertigo, and hallucination were also compared. Results: The incidence of oxygen desaturation was significantly lower in Group S (8.3%) compared to Group C (36.1%, p = 0.005). The perioperative hemodynamic profile including SBP, DBP, and HR were more stable in Group S than that in Group C (p < 0.05). Consumption of propofol and remifentanil was lower in Group S than in Group C (p < 0.05). Furthermore, PAED scores, cough scores and injection pain were lower in the Group S than in Group C (p < 0.05). The recovery time of Group S was slightly longer than that of Group C (p < 0.05). Nobody happened paradoxical agitation following midazolam administration, PONV, vertigo, and hallucinations in both groups (p > 0.05). Conclusion: Our findings indicate that a subanesthetic dose of esketamine as an adjuvant to propofol/remifentanil and spontaneous respiration is an effective regimen for children undergoing FFB. Our findings will provide a reference for clinical sedation practice during these procedures in children. Clinical Trail Registration: Chinese clinicaltrials.gov registry (identifier: ChiCTR2100053302).

Efficacy of a propofol bolus against placebo to prevent cough at emergence from general anesthesia with desflurane: a randomized controlled trial

PURPOSE

Emergence from anesthesia is a critical period and cough can result in adverse effects. Propofol inhibits airway reflexes and when infused it reduces cough more than inhalation anesthesia does. We evaluated the effect of a propofol bolus given at emergence on the incidence of coughing following a desflurane-based anesthesia.

METHODS

One hundred and fifty-four patients scheduled for elective surgery were prospectively randomized to propofol (0.5 mg·kg-1) or normal saline (NS) administered at the end of the surgery at 1 minimum alveolar concentration (MAC) of desflurane. A "no touch" emergence technique was used until extubation. The primary outcome was the incidence of cough at the discontinuation of desflurane (T0) and reaching a MAC adjusted for age (MACage) of 0.15. Secondary outcomes included incidence and severity of cough until five minutes postextubation (T0-T5), time to extubation, nausea and vomiting, sedation, hemodynamic variations, postoperative hypoventilation, hypoxemia, and sore throat.

RESULTS

We could not draw inferences on the incidence of cough between T0 and MACage of 0.15 because only 27/68 (40%) patients in the NS group and 13/73 (18%) patients in the propofol group regained consciousness before reaching a MACage of 0.15. There were no significant differences between the groups in coughing incidence and severity between T0 and T5 (NS group, 57/68 [84%] vs propofol group, 70/73 [96%] ). The mean time to extubation in the propofol group was prolonged by 3 min 27 sec (95% confidence interval, 1 min 7 sec to 4 min 47 sec; P < 0.001) and more vasopressors were used at emergence (P = 0.02). The incidence of respiratory complications, nausea and vomiting, agitation, and sedation were not different between groups.

CONCLUSION

In the present trial, a propofol bolus administered at emergence did not reduce the incidence of cough occurring between T0 and T5 following a desflurane-based general anesthesia compared with placebo.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT02932397); registered 13 October 2016.

Demographic, clinical, and patient-reported outcome data from 2 global, phase 3 trials of chronic cough

BACKGROUND

The current characterization of patients with refractory or unexplained chronic cough (RCC and UCC, respectively) primarily stems from relatively small clinical studies.

OBJECTIVE

To report the baseline medical history and clinical characteristics of individuals with RCC or UCC who were enrolled in COUGH-1 and COUGH-2, 2 large, global, phase 3 trials of gefapixant, a P2 × 3-receptor antagonist.

METHODS

Adults with a chronic cough lasting for more than 1 year, diagnosis of RCC or UCC, and score greater than 40 mm on a 100-mm cough severity visual analog scale at both screening and baseline were eligible for enrollment. Demographics, medical history, and cough characteristics were collected at baseline. Cough-related measures included objective cough frequency, cough severity visual analog scale, Leicester Cough Questionnaire, and Hull Airway Reflux Questionnaire. The data were summarized using descriptive statistics.

RESULTS

Of 2044 participants, 75% were women; mean age was 58 years, and mean cough duration was approximately 11 years. Among all participants, 73% were previously diagnosed with asthma, gastroesophageal reflux disease, or upper airway cough syndrome. The mean Leicester Cough Questionnaire total score was 10.4, with domain scores reflecting impaired cough-specific quality of life across physical, psychological, and social domains. The mean Hull Airway Reflux Questionnaire score was 39.6, with some of the most burdensome reported items being consistent with features of cough-reflex hypersensitivity. Participant characteristics and cough burden were comparable across geographic regions.

CONCLUSION

Participants with RCC or UCC had characteristics consistent with published demographics associated with chronic cough. These data reflect a global population with burdensome cough of long duration and substantial impairment to quality of life.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov Identifiers: COUGH-1, NCT03449134 (https://www.

CLINICALTRIALS

gov/ct2/show/NCT03449134); COUGH-2, NCT03449147 (https://clinicaltrials.gov/ct2/show/NCT03449147).

Effect of tracheal tube cuff inflation with alkalinized lidocaine versus air on hemodynamic responses during extubation and post-operative airway morbidities in children: prospective observational cohort study, Ethiopia

Background

Endotracheal tube with an inflated cuff was used to manage and maintain the airway during general anesthesia in children. When the lateral pressure exerted by an inflated Endotracheal tube cuff on tracheal mucosa exceeds capillary perfusion pressure, patients may complain of cough, sore throat, and hoarseness in the postoperative period. This study aimed to assess the effect of a tracheal tube cuff filled with alkalinized lidocaine versus air on hemodynamic parameter changes during extubation and post-operative airway morbidity in children.

Methods

Institutional based observational prospective cohort study was conducted among 56 elective children; aged 3–13 years, who underwent operation under general anesthesia with cuffed endotracheal intubation for greater than one hour by grouping into the air (group1) and alkalinized Lidocaine (group2) at Tikur Anbessa specialized Hospital. Hemodynamic parameters (Heart rate and Blood pressure) and other variables were measured starting from 5 min before extubation to 24th hours after extubation of the endotracheal tube. A Comparison of numerical variables between study group was done with an independent t-test. Data were expressed in terms of mean ± standard deviation. Categorical data were assessed by Chi-square tests.

Results

Postoperative Sore throat was lower in alkalinized lidocaine group compared to the air group. The mean heart rate at five minutes after extubation was significantly lower in alkalinized lidocaine group (107.29 ± 6.457 beat per minute (bpm)) compared to the air group (122.04 ± 8.809 bpm), with P ≤ 0.001. Systolic blood pressure was also significantly lower in alkalinized lidocaine group (99.64 ± 8.434 millimeters of mercury (mmHg)) compared to the air group (108.21 ± 11.902 mmHg), p = 0.016 at five minutes after extubation.

Conclusion

Alkalinized lidocaine inflated tracheal tubes have shown improved hemodynamic and laryngotracheal morbidities in children.

Comparison of dexmedetomidine and remifentanil on reducing coughing during emergence from anesthesia with tracheal intubation: A meta-analysis

Background: Dexmedetomidine and remifentanil are well known to suppress airway reflex during emergence from anesthesia, but which one is more effective is unclear. We conducted a meta-analysis to compare the effect of dexmedetomidine and remifentanil on reducing the occurrence of coughing.

Methods: We systematically searched PubMed, Embase, and Cochrane Library for randomized controlled trials (published between 1 January 1950, and 30 December 2021; no language restrictions) comparing dexmedetomidine infusion with remifentanil infusion. The primary endpoint was the incidence of moderate to severe coughing during the recovery period. The secondary endpoints were the time of recovery and extubation, and residual sedation. We assessed pooled data by using a random-effects model.

Results: Eight studies with 502 participants were included. The meta-analysis showed no statistically difference between dexmedetomidine and remifentanil in the occurrence of moderate to severe coughing during emergence from anesthesia (OR 1.45,95%CI 0.62–3.38), the extubation time (MD 0.93 min, 95%CI -0.28–2.14), and the residual sedation (OR 2.52, 95%CI 0.92–6.91). Compared with dexmedetomidine, the average recovery time of remifentanil was shorter (MD 3.88 min, 95%CI 1.01–6.75).

Conclusion: Dexmedetomidine and remifentanil infusion had no difference in the occurrence of moderate to severe coughing during emergence from anesthesia.

Clinical Trial Registration:https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42021239710

Effects of lidocaine administration via the perforated outer cuff of a dual-cuff endotracheal tube and remifentanil administration on recovery from general anaesthesia for female patients undergoing thyroidectomy: a single centre, double-blind, randomised study

Background

Cough caused by endotracheal tube (ETT) placement is ubiquitous and correlates with adverse outcomes. Remifentanil administration via target-controlled infusion (TCI) is one of the cough prevention measures used during recovery. In a pilot study, lidocaine administered via the perforated outer cuff of a dual-cuff endotracheal tube was also found to prevent cough due to ETT placement. We therefore compared these two cough prevention approaches during recovery after thyroidectomy in a single-centre, double-blind, randomised study conducted in China during the period from 09/10/2020 to 30/04/2021.

Methods

Ninety-eight female patients aged 18–65 years with American Society of Anaesthesiologists Physical Status scores of I and II were scheduled to undergo thyroidectomy. The ETT contained an internal cuff covered by a perforated outer cuff to allow for lidocaine delivery. Patients were randomised to receive either 4 ml of saline solution (Group R, n = 49) or 4 ml of 2% lidocaine in the outer cuff (Group L, n = 49) at the beginning of skin suturing. Remifentanil (2 ng/ml) was maintained in Group R until extubation, while remifentanil was maintained in Group L until the end of skin suturing. The primary outcome was cough during patient transfer, at 1 min before extubation, and at extubation. The secondary outcomes were haemodynamics and other recovery parameters.

Results

Primary outcomes were compared between remifentanil vs. lidocaine application, namely, the incidence of cough during patient transfer (0% in Group R vs. 0% in Group L), at 1 min before extubation (22.45% in Group R vs. 4.08% in Group L; P = 0.015), and at extubation (61.22% in Group R vs. 20.41% in Group L; P < 0.001). Compared with remifentanil, lidocaine more effectively decreased heart rate elevation and hypoxemia at 5 min after extubation, the spontaneous respiration recovery time, the extubation time, the duration of post-anaesthesia care unit (PACU) stay, Richmond Agitation-Sedation Scale scores in the agitated range and Critical-Care Pain Observation Tool scores.

Conclusion

Lidocaine administered via the perforated outer cuff of the ETT significantly improved recovery from general anaesthesia compared to remifentanil in female patients after thyroidectomy.

Trial registration

Chinese Clinical Trial Registry (No. ChiCTR2000038653), registered on 27/09/2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-022-01734-1.

Comparison of the effects of intravenous propofol and propofol with low-dose ketamine on preventing postextubation cough and laryngospasm among patients awakening from general anaesthesia: A prospective randomised clinical trial

BACKGROUND

Coughing and laryngospasm are undesirable consequences occurring when patients awaken from general anaesthesia. The objective of the study aimed to compare the effects of intravenous propofol and propofol with low-dose ketamine on preventing postextubation cough and laryngospasm.

METHODS

In all, 120 patients scheduled surgery under general anaesthesia were randomly assigned into three groups. Patients in the control group (C-group) received intravenous 0.9% NaCl, while patients in the propofol group (P-group) received intravenous 0.25mg/kg propofol and patients in the propofol combined with ketamine group (PK-group) received intravenous 0.25mg/kg of propofol plus 0.15mg/kg of ketamine. Drugs were administered before extubation. Incidence and severity of coughing and laryngospasm were recorded by a blinded anaesthesiologist.

RESULTS

Subjects of the PK-group (25%) experienced significantly reduced incidence of postoperative cough than that in the P-group (55%) and C-group (72.5%) (all P < 0.05). The severity of cough in the PK-group was significantly less than that in the P-group and C-group (P = 0.039 and P < 0.001, respectively). No significant difference was found in the incidence and severity of laryngospasm between comparison groups.

CONCLUSION

Intravenous combination of propofol and low-dose ketamine significantly reduced the incidence and severity among patients awakening from general anaesthesia.

Management of musculoskeletal pain in patients with idiopathic pulmonary fibrosis: a review

Idiopathic pulmonary fibrosis (IPF) is a chronic, progressive, fibrotic, and fatal interstitial lung disease (ILD) of unknown etiology that primarily affects the elderly. Patients with IPF suffer from a heavy symptom burden and usually have a poor quality of life. Dyspnea and dry cough are predominant symptoms of IPF. Although pain is not considered one of the main symptoms of IPF, it can occur for a variety of reasons, such as hypoxia, coughing, muscle and nerve damage, deconditioning, and steroid use. The prevalence of pain in IPF patients varies greatly, ranging from around 30 to 80%, with the prevalence being estimated mostly among patients in the end-of-life period. It manifests itself in the form of muscle pain, joint discomfort, or back and chest pain. Approaches to the treatment of chronic musculoskeletal pain in patients with IPF include pharmacological and non-pharmacological measures that are also important to optimize the treatment of other symptoms (dyspnea and cough) and the optimal treatment of comorbidities. Given the scarcity of data on this symptom in the literature, this article summarizes what is currently known about the etiology and treatment of musculoskeletal pain in IPF.

Cough syncope as a cause of motor vehicle crash: fatal distraction?

Coughing is a rare cause of syncope that can contribute to motor vehicle crashes. The precise pathophysiological mechanisms responsible for the syncope are unclear. We report six occasions in which motor vehicle drivers have been involved in serious crashes and cough syncope was cited as the cause. In each occasion, an alternative cause leading to the crash could be identified. Cough as a cause of syncope should be a diagnosis of exclusion and used with great caution as a medico-legal defence. A suggested criterion for confirmation of cough syncope is recommended.

Gender Difference in Chronic Cough: Are Women More Likely to Cough?

Chronic cough is a common complaint for patients to seek medical cares all over the world. Worldwide, about two thirds of chronic cough patients are females. However, in some regions of China the prevalence of chronic cough between sexes is roughly the same. Estrogen and progesterone can not only have an effect on transient receptor potential vanilloid 1 channel, eosinophils and mast cells, but also influence laryngeal dysfunction, gastroesophageal reflux disease and obstructive sleep apnea hypopnea syndrome, which may lead to increased cough sensitivity in women. On the other hand, the quality of life was adversely affected more in female patients with chronic cough. Both hormones possibly cause gender difference in chronic cough.

Comparison of remifentanil concentrations with and without dexmedetomidine for the prevention of emergence cough after nasal surgery: a randomized double-blinded trial

Background

Preventing emergence cough after nasal surgery is critical. Emergence cough can provoke immediate postoperative bleeding, which leads to upper airway obstruction. In the present study, we compared the effect-site concentration (Ce) of remifentanil to prevent emergence cough after propofol anesthesia for nasal surgery when remifentanil was or was not combined with dexmedetomidine.

Methods

Forty-seven patients with propofol-remifentanil anesthesia for nasal surgery were randomly assigned to a dexmedetomidine group (Group D, n = 23) or a saline group (Group S, n = 24). Group D and Group S were infused with dexmedetomidine (0.5 μg/kg) and saline, respectively, for 10 min before the completion of surgery. A predetermined Ce of remifentanil was infused until extubation. Remifentanil Ce to prevent cough in 50 and 95% of patients (EC₅₀ and EC₉₅) was estimated using modified Dixon’s up-and-down method and isotonic regression. Hemodynamic and recovery parameters were recorded.

Results

The EC₅₀ of remifentanil Ce was significantly lower in Group D than in Group S (2.15 ± 0.40 ng/mL vs. 2.66 ± 0.36 ng/mL, p = 0.023). The EC₉₅ (95% CI) of remifentanil Ce was also significantly lower in Group D [2.75 (2.67–2.78) ng/mL] than in Group S [3.16 (3.06–3.18) ng/mL]. Emergence and recovery variables did not differ between the two groups.

Conclusion

The remifentanil EC₅₀ to prevent cough after propofol-remifentanil anesthesia was significantly lower (approximately 19%) when a combination of remifentanil and 0.5 μg/kg dexmedetomidine was used than when remifentanil infusion alone was used in patients undergoing nasal surgery. Therefore, the Ce of remifentanil may be adjusted to prevent emergence cough when used in combination with dexmedetomidine.

Trial registration

ClinicalTrials.gov (NCT03622502, August 9, 2018).

Effects of smoking on the optimal effect-site concentration of remifentanil required for preventing cough during anesthetic emergence in male patients undergoing laparoscopic or robotic cholecystectomy

Target-controlled infusion of remifentanil is known to reduce cough effectively during emergence from general anesthesia. The effect of smoking on emergence cough remains controversial. Therefore, we aimed to investigate the effect-site concentration (Ce) of remifentanil in the male patients undergoing laparoscopic or robotic cholecystectomy for suppressing emergence cough in smokers and non-smokers.Twenty smokers and 24 non-smokers (sex, male; age range, 20-65 years) were enrolled in this study. Anesthesia was maintained using sevoflurane and remifentanil. The Ce of remifentanil in 50% (EC50) and 95% (EC95) of the patients required for suppressing emergence cough were determined for each group (smokers and non-smokers) using Dixon up-and-down method and isotonic regression method with a bootstrapping approach.Dixon up-and-down method revealed that the EC50 value was significantly higher in smokers (3.51 ± 0.60 ng/mL) than in non-smokers (2.71 ± 0.30 ng/mL) (P < 0.001). In smokers and non-smokers, isotonic regression revealed EC50 to be 4.40 (83% CI, 4.17-4.58) ng/mL and 2.58 (83% CI, 2.31-2.87) ng/mL, respectively, and EC95 to be 4.76 (95% CI, 4.73-4.78) ng/mL and 3.15 (95% CI, 3.04-3.18) ng/mL, respectively.The Ces of remifentanil required to prevent cough during emergence were significantly higher in smokers than in non-smokers. Therefore, clinicians should pay attention to the smoking history of a patient to prevent cough during emergence.

Prevention of Sternal Wound Infections in Women Using an External Sternum Fixation Corset

Purpose: Deep sternal wound infection (DSWI) and mediastinitis are devastating complications after median sternotomy. Previous studies demonstrated an effective prevention of sternal wound infection (SWI) using an external sternal corset in high-risk cardiac surgery patients. The aim of this study is to assess the preventive effect of the Stern-E-Fix corset in high-risk poststernotomy female patients.

Methods: A total of 145 high-risk female patients undergoing cardiac surgery through median sternotomy were retrospectively analyzed. Patients were divided into group A (n = 71), who received the Stern-E-Fix corset (Fendel & Keuchen GmbH, Aachen, Germany), and group B (n = 74), who received the elastic thorax bandage (SanThorax) postoperatively for 6 weeks. The mean follow-up period was 12 weeks.

Results: Incidence of SWI was 7% in group A vs. 17.6% in group B (p = 0.025). One patient presented with DSWI in group A vs. seven patients in group B (p = 0.063). No patient developed mediastinitis in group A vs. four patients in group B (p = 0.121). In all, 4.2% of group A patients required operative wound therapy vs. 16.2% of group B patients (p = 0.026). The length of hospital stay was significantly longer in group B (p = 0.006).

Conclusion: Using an external supportive sternal corset (Stern-E-Fix) yields a significantly better and effective prevention against development of sternal dehiscence, DSWI, and mediastinitis in high-risk poststernotomy female patients.

Factors and potential treatments of cough after pulmonary resection: A systematic review

Cough is a common complication following pulmonary resection. Persistent and severe cough after pulmonary resection can cause significant impairments in quality of life among postoperative patients. Complications of cough can be life-threatening. To improve patients' probability and quality of life, factors that induce cough after pulmonary resection (CAP) and potential treatments should be explored and summarized. Previous studies have identified various factors related to CAP. However, those factors have not been categorized and analyzed in a sensible manner. Here, we summarized the different factors and classified them into four groups. Potential therapies might be developed to selectively target different factors that affect CAP. However, the exact mechanism underlying CAP remains unknown, making it difficult to treat and manage CAP. In this review, we summarized the latest studies in our understanding of the factors related to CAP and potential treatments targeting those factors. This review can help understand the mechanism of CAP and develop efficient therapies and management.

Life-Threatening and Non-Life-Threatening Complications Associated With Coughing: A Scoping Review

BACKGROUND

This is an update of the section on complications that are associated with coughing in the 2006 CHEST cough guidelines that addresses two aims: (1) to systematically identify and thematically categorize the diverse complications of cough by providing a guide for future studies and (2) to identify gaps in the literature for future research.

RESEARCH QUESTION

What are the potential complications that are associated with the act of coughing that have been reported in infants, children, adolescents, and adults?

STUDY DESIGN AND METHODS

A scoping review was performed with the use of PubMed and SCOPUS databases that were searched from their beginning until September 6, 2019.

RESULTS

Two hundred forty-seven publications met our inclusion criteria. To these, we added 38 articles from the 2006 complications paper that were not identified in the literature search plus the paper itself for a final total of 286 publications that formed the basis of this review. Since 2006, three new categories of complications have been reported: ear, nose and throat; disease transmission; and laboratory testing. Multiple additional complications that fall outside of these three categories have also been identified and included in the following categories: cardiovascular, constitutional symptoms, dermatologic, GI, genitourinary, musculoskeletal, neurologic, ophthalmologic, psychosocial/quality of life, and respiratory. Not previously highlighted is that some of the complications led to serious morbidity that included death, especially in patients with comorbid conditions, and potentially resulted in harm to others when cough resulted in a motor vehicle accident.

INTERPRETATION

Our work identified a large number of cough complications that we thematically categorized primarily by organ system so that future studies of each system or each complication can be conducted. The gap in the literature that future studies should address is to identify the frequency of the complications and the strength of their association with cough. Only then will one be able to describe the findings in a manner that allows specific recommendations for avoiding these complications. In the meantime, patients with cough should be evaluated and treated according to evidence-based guidelines to mitigate or prevent the myriad of potential complications that are associated with coughing.

Incidence of airway complications associated with deep extubation in adults

Background

Endotracheal extubation is the most crucial step during emergence from general anesthesia and is usually carried out when patients are awake with return of airway reflexes. Alternatively, extubations can also be accomplished while patients are deeply anesthetized, a technique known as “deep extubation”, in order to provide a “smooth” emergence from anesthesia. Deep extubation is seldomly performed in adults, even in appropriate circumstances, likely due to concerns for potential respiratory complications and limited research supporting its safety. It is in this context that we designed our prospective study to understand the factors that contribute to the success or failure of deep extubation in adults.

Methods

In this prospective observational study, 300 patients, age ≥ 18, American Society of Anesthesiologists Physical Status (ASA PS) Classification I - III, who underwent head-and-neck and ocular surgeries. Patients’ demographic, comorbidity, airway assessment, O₂ saturation, end tidal CO₂ levels, time to exit OR, time to eye opening, and respiratory complications after deep extubation in the OR were analyzed.

Results

Forty (13%) out of 300 patients had at least one complication in the OR, as defined by persistent coughing, desaturation SpO₂ < 90% for longer than 10s, laryngospasm, stridor, bronchospasm and reintubation. When comparing the complication group to the no complication group, the patients in the complication group had significantly higher BMI (30 vs 26), lower O₂ saturation pre and post extubation, and longer time from end of surgery to out of OR (p < 0.05).

Conclusions

The complication rate during deep extubation in adults was relatively low compared to published reports in the literature and all easily reversible. BMI is possibly an important determinant in the success of deep extubation.

Is the Use of BIMA in CABG Sub-Optimal? A Review of the Current Clinical and Economic Evidence Including Innovative Approaches to the Management of Mediastinitis

Bilateral internal mammary artery (BIMA) in coronary artery bypass grafting (CABG) has traditionally been limited. This review looks at the recent outcome data on BIMA in CABG focusing on the management of risk factors for mediastinitis, one of the potential barriers for more extensive BIMA utilization. A combination of pre-, intra- and postoperative strategies are essential to reduce mediastinitis. Limited data indicate that the incidence of mediastinitis can be reduced using closed incision negative-pressure wound therapy as a part of these strategies with the possibility of offering patients best treatment options by extending BIMA to those with a higher risk of mediastinitis. Recent economic data imply that the technology may challenge the current low uptake of BIMA by reducing the short-term cost differentials between single internal mammary artery and BIMA. Given that most published randomized controlled trials and meta-analyses of observational long-term outcome data favor BIMA, if short-term complications of BIMA including mediastinitis can be controlled adequately, there may be opportunities for more extensive use of BIMA leading to improved long-term outcomes. An ongoing study looking at BIMA in high-risk patients may provide evidence to support the hypothesis that mediastinitis should not be a factor in limiting the use of BIMA in CABG.

A novel risk score to predict cardiovascular complications in patients with coronavirus disease 2019 (COVID-19): A retrospective, multicenter, observational study

Background

We conducted this study to explore a novel risk score to predict cardiovascular complications in patients with coronavirus disease 2019 (COVID‐19).

Methods

The current study was a retrospective, multicenter, observational study. The clinical data of COVID‐19 patients at admission were collected. Patients were randomly divided into training set and testing set (70% vs. 30% of patients). Independent risk factors were identified via logistic regression analysis.

Results

Finally, 1207 patients were included. Ten independent risk factors associated with cardiovascular complications were identified in training set: male (odds ratio [OR]: 1.84; 95% confidence interval [CI]: 1.18, 2.85), age ≥ 60 years old (OR: 2.01; 95% CI: 1.3, 3.2), cough (OR: 1.86; 95% CI: 1.16, 3), chronic heart disease (OR: 2.3; 95% CI: 1.19, 4.46), lymphocyte count ≤1.1 × 10⁹/L at admission (OR: 1.60; 95% CI: 1.03, 2.47), blood urea nitrogen ≥7 mmol/L at admission (OR: 2.14; 95% CI: 1.27, 3.62), estimated glomerular filtration rate ≤90 ml/min/1.73 m² at admission (OR: 2.08; 95% CI: 1.13, 3.83), activated partial thromboplastin time ≥37 s (OR: 3.07; 95% CI: 1.37, 6.86), D‐dimer ≥ 0.5 mg/L (OR: 2.12; 95% CI: 1.33, 3.36) and procalcitonin ≥0.5 μg/L (OR: 3.58; 95% CI: 1.40, 9.14). The area under curve of ROC curve was 0.773 (95% CI: 0.723, 0.822; p < .01). The risk score had robustness and generalizability after validation. Cardiovascular complications were significantly associated with poorer survivals (log‐rank test: p < .001).

Conclusions

We developed and validated a novel risk score, which has a promising predictive capacity for cardiovascular complications in COVID‐19 patients.

Cough Radiculopathy: Postinfectious Cough-Related Acute Lumbar Radiculopathy

Cough is a protective reflex of airways and lungs. Cough may result in several complications. Postinfectious cough is a cough that begins during an acute respiratory tract infection, usually is self-limited, and is due to airway hyperresponsiveness as a result of airway inflammation. Cough radiculopathy has been once reported by Torrington and Adornato in the form of acute cervical radiculopathy. This is a case of acute lumbar radiculopathy as a result of postinfectious cough. Literature review did not show a similar case.

Management of Respiratory Symptoms in Those with Serious Illness

Respiratory symptoms are common in patients living with serious illness, both in cancer and nonmalignant conditions. Common symptoms include dyspnea (breathlessness), cough, malignant pleural effusions, airway secretions, and hemoptysis. Basic management of respiratory symptoms is within the scope of primary palliative care. There are pharmacologic and nonpharmacologic approaches to treating respiratory symptoms. This article provides clinicians with treatment approaches to these burdensome symptoms.

The Wide-Ranging Spectrum of Cough-Induced Complications and Patient Harm

Cough is one of the most common complaints encountered in every setting; however, complications associated with coughing have received relatively little attention. An exhaustive systematic review of the English literature revealed an exceedingly large and varied spectrum of cough-induced complications affecting many systems, including upper airways, chest wall and thorax, abdominal wall, heart and aorta, central nervous system, eye, gastrointestinal tract, urogenital system, and emotional and psychological harm. Prospective studies and prevalence data are conspicuously missing. Reported cough-induced pathology ranges from rare (the majority) to common and from trivial (eg, lightheadedness, subconjunctival hemorrhage) to severe and life-threatening (eg, cervical artery dissection, rupture of a normal spleen). Other seemingly benign entities may mask a serious underlying pathology (eg, cough headache, cough syncope). A substantial proportion of patients experience anxiety and insomnia, and their quality of life is affected. Thus, the wide spectrum of cough-induced pathology need to be recognized and considered in patients complaining of cough. Suppression of cough must not be neglected in patients at risk, and areas of uncertainty need to be clarified by future prospective studies.

Cough, Aortobronchial Fistula, and Air Migration in the Remnant Aneurysm Sac: An Unforeseen Path?

The pressure gap between the aortic lumen and bronchial air spaces makes hemoptysis the most frequent feature of aortobronchial fistula (ABF). However, air migration can be a rare cause of ABF. The literature has demonstrated some “indirect routes” that would serve as a bridge between ABF and consecutive air migrations. However, evidence suggesting the presence of a “direct route” between them is lacking. We present an extremely rare case of newly onset cough-induced “perigraft space ABF” and ABF-related air migration in the remnant aneurysm sac occurring 3 years after an aortic surgery and a near-misdiagnosis of a delayed graft infection.

A cross sectional study to determine the prevalence of cough and its impact in patients with lung cancer: a patient unmet need

BACKGROUND

There is absence of literature related to cough prevalence and its characteristics in lung cancer patients, with information deriving only from broader symptoms occurrence studies. The aims of this study were to provide a snapshot of the prevalence of all-cause-cough in lung cancer patients and to characterise cough in terms of its impact and severity.

METHODS

A cross-sectional study recruiting consecutive lung cancer patients over a pre-defined period of time and using cough-specific validated tools in a tertiary referral centre in the UK, including a cough severity VAS and the Manchester Cough in Lung Cancer scale (MCLCS).

RESULTS

Data was collected from 202 patients. All-cause cough prevalence was 57% (through VAS) both in the screened (N = 223) and research (N = 202) population or 67% (through the MCLCS), and cough severity was moderate at a mean of 32 mm (in a 100 mm VAS). Age, sex, smoking status, lung cancer histology, stage and comorbidities were not associated with cough prevalence. The only variable associated with lower cough reports was being 'on anticancer treatment'; fewer patients on treatment reported a cough (40%) compared to those off treatment (54%) (p = 0.04). The impact of cough (as measured by MCLCS) was also significant (mean score = 22). About 18% of patients felt moderate/severe distress from their cough and about 15% often or always reported disturbed sleep due to coughing. Half the patients felt their cough warranted treatment.

CONCLUSIONS

Cough is a common symptom in lung cancer with considerable impact on patients' lives. Cough presence and severity should regularly be assessed in clinical practice. There is an urgent need to focus on developing more potent antitussive treatments and improve the management of this complex and distressing symptom.

Optimal effect-site concentration of propofol for tracheal suctioning during emergence from ophthalmic surgery

In ophthalmic surgery, coughing during emergence from general anesthesia may have a detrimental effect on intraocular pressure. Tracheal suction during emergence may elicit this reflex. The optimal effect-site concentration (EC) of propofol to prevent triggering of the cough reflex during tracheal suctioning is unknown. The aim of this study is to assess the optimal EC of propofol for tracheal suctioning during emergence in patients undergoing ophthalmic surgery.Twenty-one patients were enrolled, all of them American Society of Anesthesiologists (ASA) physical status I or II non-smokers undergoing ophthalmic surgery. Anesthesia was induced and maintained under total intravenous anesthesia using target-controlled infusion. During emergence from general anesthesia, tracheal suction was performed at different propofol concentrations as required for Dixon's up-and-down method with a step size of 0.2 μg/ml. A propofol concentration at which the cough reflex was not triggered during tracheal suctioning was considered successful.The EC50 of propofol for tracheal suction without cough was 1.4 μg/ml and the EC95 was 1.6 μg/ml.Tracheal suction may be accomplished without triggering the cough reflex when the propofol effect-site concentration is higher than 1.6 μg/ml.

Deep sternal wound infections: Evidence for prevention, treatment, and reconstructive surgery

Median sternotomy is the most popular approach in cardiac surgery. Post-sternotomy wound complications are rare, but the occurrence of a deep sternal wound infection (DSWI) is a catastrophic event associated with higher morbidity and mortality, longer hospital stays, and increased costs. A literature review was performed by searching PubMed from January 1996 to August 2017 according to the guidelines in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. The following keywords were used in various combinations: DSWI, post-sternotomy complication, and sternal reconstruction. Thirty-nine papers were included in our qualitative analysis, in which each aspect of the DSWI-related care process was analyzed and compared to the actual standard of care. Plastic surgeons are often involved too late in such clinical scenarios, when previous empirical treatments have failed and a definitive reconstruction is needed. The aim of this comprehensive review was to create an up-to-date operative flowchart to prevent and properly treat sternal wound infection complications after median sternotomy.

Effects of intravenous infusion of lidocaine and dexmedetomidine on inhibiting cough during the tracheal extubation period after thyroid surgery

Background

Intravenous lidocaine and dexmedetomidine treatments have been proposed as methods for inhibiting cough. We compared the efficacy of intravenous lidocaine and dexmedetomidine treatments on inhibiting cough during the tracheal extubation period after thyroid surgery.

Methods

One hundred eighty patients undergoing thyroid surgeries were randomly allocated to the LIDO group (received lidocaine 1.5 mg/kg loading, 1.5 mg/kg/h infusion), the DEX group (received dexmedetomidine 0.5 μg/kg loading, 0.4 μg/kg/h infusion) and the CON group (received saline), with 60 cases in each group. The primary outcomes of cough were recorded. Secondary outcomes included hemodynamic variables, awareness time, volume of drainage, the postoperative visual analogue scale and adverse effects were recorded.

Results

The incidence of cough were significantly lower in the LIDO group (28.3%) and the DEX group (31.7%) than that in the CON group (66.7%) (P = 0.000). Additionally, both moderate and severe cough were significantly lower in the LIDO group (13.3%) and the DEX group (13.4%) than these in the CON group (43.4%) (P < 0.05). Compared with the two treatment groups, both mean arterial blood pressure and heart rate were significantly increased in the CON group during tracheal extubation (P < 0.05). Compared with the CON group, the volume of drainage was significantly reduced in the two treatment groups within 48 h after surgery (P < 0.05). compared with the CON group, the postoperative visual analogue scale was significantly lower in groups LIDO and DEX after surgery(P < 0.05). Compared with the LIDO group and the CON group, the time to awareness was longer in the DEX group (P < 0.05). In the DEX group, bradycardia was noted in 35 patients, while no bradycardia was noted in LIDO group and CON group.

Conclusion

Compared with intravenous infusions of normal saline, both lidocaine and dexmedetomidine had equal effectiveness in attenuating cough and hemodynamic changes during the tracheal extubation period after thyroid surgery, and both of these treatments were able to reduce the volume of postoperative bleeding and provide better analgesic effect after surgery. But intravenous infusions of dexmedetomidine resulted in bradycardia and delayed the time to awareness when compared with lidocaine and normal saline.

Trial registration

ChiCTR1800017482. (Prospective registered). Initial registration date was 01/08/2018.

COUGHING-INDUCED SUPRACHOROIDAL HEMORRHAGE SIMULATING MELANOMA IN TWO CASES

PURPOSE

To describe two cases of coughing-induced suprachoroidal hemorrhage referred as choroidal melanoma.

METHODS

Observational case reports.

RESULTS

Two female patients (ages 54 and 60 years) were referred with possible choroidal melanoma. Both gave a history of 1 day of heavy coughing with Valsalva maneuver within 2 weeks before discovery of the tumor. In one case, the patient used anticoagulants for aortic valve replacement and the other patient used antiasthma medications. One patient noted sharp ocular pain one week before presentation to this service. In both cases, the choroidal lesion was at the globe equator, near a vortex ampulla, and appeared homogeneously dark brown and with acoustic hollowness on ultrasonography, concerning for choroidal melanoma. However, neither lesion demonstrated intrinsic vascularity on fluorescein angiography or indocyanine angiography. Both lesions showed isoautofluorescence and optical coherence tomography evidence of shallow choroidal folds with inner choroidal elevation over a dome-shaped, optically-lucent deep choroidal mass, consistent with suprachoroidal hemorrhage. Fine needle aspiration biopsy in 1 case confirmed blood without melanoma. Both cases were observed with complete spontaneous resolution of the hemorrhage and normal-appearing choroid within 2 months.

CONCLUSION

Coughing-induced suprachoroidal hemorrhage can simulate melanoma. Clinical and imaging features can assist in diagnosis. The hemorrhage generally resolves within few months.

Comparison of sevoflurane and desflurane on effect-site concentration of remifentanil for preventing anesthetic emergence cough in elderly female patients undergoing laparoscopic cholecystectomy

Purpose

Among inhalational anesthetics, desflurane is widely believed to provoke upper airway irritation including coughing and laryngospasm. Remifentanil has been generally used to prevent cough due to its unique pharmacodynamics. However, there was no study that compared optimal remifentanil effect-site concentration (Ce) to prevent emergence cough according to the type of inhalational agent in elderly female patients. Thus, we investigated the Ce of remifentanil for preventing cough during emergence from sevoflurane and desflurane anesthesia in elderly female patients.

Methods

Forty-three female patients between 60 and 75 years of age undergoing laparoscopic cholecystectomy were randomly allocated to sevoflurane group (n=22) or desflurane group (n=21). The optimal remifentanil Ce using target-controlled infusion for 50% of patients (EC₅₀) and 95% of patients (EC₉₅) was assessed by Dixon’s up-and-down method or isotonic regression method with a bootstrapping approach.

Results

By Dixon’s up-and-down method, the EC₅₀ of remifentanil in sevoflurane group (2.08±0.47 ng/mL) was comparable with that in desflurane group (2.25±0.40 ng/mL) (P=0.385). The EC₅₀ (83% CIs) and EC₉₅ (95% CIs) by isotonic regression also did not show significant difference between two groups [2.06 (1.45–2.23) and 2.46 (2.35–2.48) ng/mL in sevoflurane group and 2.14 (1.45–2.56) and 2.88 (2.47–2.98) ng/mL in desflurane group, respectively].

Conclusion

There was no difference in the remifentanil Ce to prevent emergence cough between sevoflurane and desflurane anesthesia. Therefore, the clinicians may not need to adjust the remifentanil Ce to prevent emergence cough according to inhalational agents in elderly female patients.

Treatments for subacute cough in primary care: systematic review and meta-analyses of randomised clinical trials

BACKGROUND

Subacute cough following a non-specific viral infection lasting 3-8 weeks is common. However, despite many treatment options there are no systematic reviews evaluating these.

AIM

To provide a systematic overview of treatment options and outcomes evaluated in randomised clinical trials (RCTs).

DESIGN AND SETTING

Systematic review and meta-analyses assessing the overall effects of any treatment for subacute cough.

METHOD

The authors systematically searched PubMed/MEDLINE and the Cochrane Central Register of Controlled Trials (last search March 2017) for RCTs in adult patients with subacute cough. The authors considered trials evaluating any outcome of any drug or non-drug treatments, apart from traditional Chinese and Asian medicines. They combined treatment effects on cough-related outcomes in random effects meta-analyses.

RESULTS

Six eligible RCTs including 724 patients were identified. These assessed montelukast, salbutamol plus ipratropium bromide, gelatine, fluticasone propionate, budesonide, and nociception opioid 1 receptor agonist and codeine. Five studies reported effects on various cough severity scores at various timepoints. No treatment option was associated with a clear benefit on cough recovery or other patient-relevant outcomes in any of the studies or in meta-analyses for cough outcomes at 14 days and 28 days. Reported adverse events were rather mild and reported for 14% of patients across all treatments.

CONCLUSION

Evidence on treatment options for subacute cough is weak. There is no treatment showing clear patient-relevant benefits in clinical trials.

Risk factors of cough in non-small cell lung cancer patients after video-assisted thoracoscopic surgery

Background

Cough is a common respiratory complication in non-small cell lung cancer (NSCLC) patients after surgery. Previous studies have proposed a number of risk factors for postoperative cough; however, these studies are mainly based on traditional thoracotomies and tend to lack adequate objective assessment methods. The purpose of this study was to identify the risk factors of cough in NSCLC patients after video-assisted thoracoscopic surgery (VATS) using the Leicester Cough Questionnaire in Mandarin Chinese (LCQ-MC) to evaluate postoperative cough.

Methods

A total of 198 NSCLC patients were enrolled. Overall, 91 patients (46.0%) developed cough after VATS, and 73 patients remained cough after 1 month. Univariate and multivariate logistic regression analyses were performed to identify the independent risk factors of postoperative cough.

Results

The independent factors of postoperative cough included female sex [odds ratio (OR) 2.399, 95% confidence interval (CI): 1.260-4.565, P=0.008], duration of anesthesia (over 164 minutes; OR 2.810, 95% CI: 1.368-5.771, P=0.005), resection of the lower paratracheal nodes (OR 3.697, 95% CI: 1.439-9.499, P=0.007), and resection of the subcarinal nodes (OR 4.175, 95% CI: 1.203-14.495, P=0.024). The follow-up LCQ-MC total score after 1 month (18.00±1.80) was significantly higher than the postoperative total score (16.35±2.26; P=0.004).

Conclusions

Female sex, duration of anesthesia over 164 minutes, lower paratracheal node resection and subcarinal node resection were independent risk factors related to cough in NSCLC patients after VATS. In addition, the LCQ-MC performed satisfactorily in describing the longitudinal changes in cough symptoms.

Identification and management of cough-induced laryngotracheitis

Chronic cough is associated with repetitive injury to the upper airway and trachea, which can lead to an underdiagnosed pathology known as “cough-induced” laryngotracheitis (CILT). In this report, we describe a case of CILT that responded well to dual therapy.

Staggering the dose of sugammadex lowers risks for severe emergence cough: a randomized control trial

Background

Cough on emergence has been reported as a common adverse reaction with sugammadex reversal. We investigated if staggering the dose of sugammadex will reduce emergence cough in a single-center, randomized, double-blinded study.

Methods

A hundred and twenty ASA 1–3 adults were randomly reversed with 1 mg/kg sugammadex prior to extubation followed by another 1 mg/kg immediately after extubation (staggered group), single dose of 2 mg/kg sugammadex (single bolus group) or neostigmine 0.02 mg/kg with glycopyrrolate (neostigmine group).

Results

We found 70% of patients (n = 28) reversed with single boluses of sugammadex had Grade 3 emergence cough compared to 12.5% (n = 5) in the staggered sugammadex group and 17.5% (n = 7) in the neostigmine group (p < 0.001). Besides cough, emergence agitation also appeared highest in the single bolus sugammadex group (n = 14, 35%, p = 0.005). On the other hand, staggering sugammadex lowered risks of developing severe cough (RR 0.2, p < 0.001) and agitation (RR 0.43, p = 0.010) on emergence in addition to cough (RR 0.25, p = 0.039) and early sore throat (RR 0.70, p = 0.036) in the post-anesthetic care unit. The risks for severe emergence cough (RR 0.86, p = 0.762), severe cough in the post-anesthetic care unit (RR 1.0, p = 1.000) and sore throat (RR 1.17, p = 0.502) were also not different between the staggered sugammadex group and control given neostigmine. In terms of timing, there was no delay in time taken from discontinuing anesthetic agents to reversal and extubation if sugammadex was staggered (emergence time 6.0 ± 3.2 s, p = 0.625 and reversal time 6.5 ± 3.5, p = 0.809).

Conclusions

Staggering the dose of sugammadex for reversal will effectively decrease common emergence and early postoperative complications.

Trial registration

ANZCTR Number ACTRN12616000116426. Retrospectively registered on 2nd February 2016.

Bronchoprotective effect of deep inspirations in cough variant asthma: A distinguishing feature in the spectrum of airway disease?

PURPOSE

To assess the effect of deep inspirations (DIs) on airway behaviour in individuals with classic asthma (CA), cough variant asthma (CVA), and methacholine (MCh)-induced cough but normal airway sensitivity (COUGH) during bronchoprovocation.

METHODS

Twenty-five adults (18 female; 44.8 ± 12.3 years (Mean ± SD); n = 9 CA, n = 9 CVA, and n = 7 COUGH) completed two single-dose MCh challenges, with and without DIs. Bronchoprotection was assessed by comparing changes in bronchoconstriction (FEV₁, FVC, FEV₁/FVC, FEF₅₀, FEF_25-75), gas trapping (RV, RV/TLC) and impulse oscillometry (IOS) measurements.

RESULTS

The% changes in FEV₁ with and without DIs were not significantly different within any group. Decreases in FEF₅₀ and FEF_25-75 were greater in CA (p = 0.041 and p = 0.029), decreases in FVC (% predicted) and FEV₁/FVC(%) were less in CVA (p = 0.048 and p = 0.010), and increases in RV (L) and RV/TLC (% predicted) were less in COUGH (p = 0.007 and p = 0.028), respectively. No differences in IOS measurements were noted.

CONCLUSIONS

DIs triggered bronchoconstriction in CA, bronchoprotection in CVA, and prevented gas trapping in COUGH.

Aortopulmonary Fistula Presenting without an Endoleak after Thoracic Endovascular Aortic Repair

Herein, we report the case of a 60-year-old man, a smoker with a history of arterial hypertension and diabetes mellitus. After computed tomography (CT) for an episode of hemoptysis, the patient underwent elective thoracic endovascular aortic repair (TEVAR) because of a degenerative aneurysm of the descending thoracic aorta. The area of perianeurysmal pulmonary atelectasis reported on the CT scan was not considered. Three months later, he developed an aortopulmonary fistula without endoleaks. Although TEVAR is a relatively safe procedure, no detail should be overlooked in the preoperative evaluation in order to avoid life-threatening complications. Further, the effectiveness and modality of prolonged antibiotic prophylaxis and/or preoperative respiratory physiotherapy should be assessed in such cases.

Grey Turner's and Cullen's signs induced by spontaneous hemorrhage of the abdominal wall after coughing

Grey Turner's and Cullen's signs are rare clinical signs, which most appear in patients with severe acute pancreatitis. The present patient complained of abdominal pain after coughing. However, contrast-enhanced CT revealed a hemorrhage of the abdominal wall. Therefore, spontaneous hemorrhage of the abdominal wall was diagnosed. The patient recovered through immobilization and hemostasis therapy. This case report and literature review aims to remind clinicians of manifestations and treatment of spontaneous hemorrhage.

Symptomatic Treatment of Cough Among Adult Patients With Lung Cancer: CHEST Guideline and Expert Panel Report

BACKGROUND

Cough among patients with lung cancer is a common but often undertreated symptom. We used a 2015 Cochrane systematic review, among other sources of evidence, to update the recommendations and suggestions of the American College of Chest Physicians (CHEST) 2006 guideline on this topic.

METHODS

The CHEST methodologic guidelines and the Grading of Recommendations, Assessment, Development, and Evaluation framework were used. The Expert Cough Panel based their recommendations on data from the Cochrane systematic review on the topic, uncontrolled studies, case studies, and the clinical context. Final grading was reached by consensus according to the Delphi method.

RESULTS

The Cochrane systematic review identified 17 trials of primarily low-quality evidence. Such evidence was related to both nonpharmacologic (cough suppression) and pharmacologic (demulcents, opioids, peripherally acting antitussives, or local anesthetics) treatments, as well as endobronchial brachytherapy.

CONCLUSIONS

Compared with the 2006 CHEST Cough Guideline, the current recommendations and suggestions are more specific and follow a step-up approach to the management of cough among patients with lung cancer, acknowledging the low-quality evidence in the field and the urgent need to develop more effective, evidence-based interventions through high-quality research.