Physiotherapy, and speech and language therapy intervention for patients with refractory chronic cough: a multicentre randomised control trial

Efficacy of Speech-language Pathology Therapy in Chronic Cough: Systematic Review With Meta-analysis

OBJECTIVES

To analyze the efficacy of speech-language pathology therapy in the self-assessment, in the cough frequency, and the vocal quality of adults with chronic cough.

METHODS

This is a systematic review with meta-analysis that answered the clinical question: "In adults with chronic cough, what is the effect of the speech-language pathology therapy in the self-assessment, in the cough frequency, and the vocal quality, compared to another intervention?" (PROSPERO 2021/CRD42021226729). An electronic search (MEDLINE, Web of Science, EMBASE, SCOPUS, Cochrane Library, and Lilacs), and a manual search (Journal of Voice, Brazilian Library of Theses and Dissertations, Open Grey and Clinical Trials) with specific search strategies was performed. The risk of bias was assessed using the Cochrane Collaboration's tool for assessing the risk of bias in randomized trials. Meta-analysis (standardized difference of means, Inverse Variance, and random effects model) and heterogeneity analysis (Chi², Tau², and I²) were performed.

RESULTS

We found 610 studies and selected three. There was an uncertain risk of detection bias. The data were heterogeneous, and there was no difference between interventions in self-perception of cough severity (z = 0.09, P = 0.930; tau² = 0.65, I² = 90%) and in the self-perception of the effects of chronic cough on health status (z = 0.30, P = 0.77; tau² = 0.99, I² = 97%). The estimated mean difference was 0.97 to cough frequency, and it was differ significantly from zero (z = 4.47, P < 0.001) but the results are heterogeneous (Chi² (1) = 22.22, P < 0.001, I² = 95%).

CONCLUSION

The speech-language pathology therapy had a greater effect size than the control interventions on cough frequency. However, in the subjects' perception, there were no differences between the interventions.

Clinical Parameters of the Speech-Language Pathology Assessment of the Chronic Cough: A Scoping Review

OBJECTIVE

to map the clinical parameters used in the speech-language pathology assessment of the chronic cough.

METHODS

a scoping review was performed to answer the clinical question: "What are the clinical parameters included in the speech-language pathology assessment of patients with chronic cough?" Evidence was searched by electronic and manual search. The electronic search included: MEDLINE, Cochrane Library, EMBASE, Web of Science, SCOPUS, and LILACS. Each database had a specific search strategy. The manual search included Journal of Voice, Chest, and Thorax, Brazilian Library of Theses and Dissertations, Open Grey, and Clinical Trials, in addition to scanning the references of the included studies. The extracted data considered information regarding the publication, sample, assessment, and measures used when assessing chronic cough.

RESULTS

the electronic search found 289 studies; the manual search found 1036 studies; 12 were selected for the present study. The most used assessments were: self-assessment (75%), aerodynamic analysis (66.67%), the perceptual auditory judgment of the voice quality (58.33%), acoustic analysis of the voice (41.67%), cough frequency, and cough threshold (41.67%) and electroglottography (25%).

CONCLUSIONS

the subjective instruments were used more frequently, while specific objective instruments, which are recent, were used less frequently. Complementary assessments such as vocal assessment, have been frequently used, also, with no other parameter. A lack of homogeneity was identified in the speech-language pathology assessment and measures of patients with chronic cough, thus, the comparison among studies and clinical analysis is difficult.

Medicare Restriction of Telehealth Speech Services Negatively Impacts Patient Care

OBJECTIVE

Ample literature shows voice and swallowing therapy, in-person or virtual, to be essential for Otolaryngology and Speech-Language Pathology care. In March 2023, Medicare announced discontinuing teletherapy reimbursement in hospital-based outpatient departments, effective May 2023. This decision was subsequently reversed; however, the uncertain interval period provided the opportunity to study the impact of eliminating teletherapy.

STUDY DESIGN

Prospective cohort.

SETTING

Tertiary laryngology center.

METHODS

Affected Medicare patients were contacted via mailed letter, phone, and secure patient portal and offered to change appointments to in-person, teletherapy with cash self-payment ($165-282/session) or cancellation. Demographics and responses were collected. Statistical analyses conducted using Student's t test.

RESULTS

Fifty-three patients (28 female; mean age 66.8 ± 14.2 years) were impacted. 64% (n = 34) changed to in-person appointment, 28% (n = 15) canceled, 8% (n = 4) did not respond. No patients opted to self-pay. 67% of patients that canceled telehealth care cited distance from in-person care location. The mean distance for canceled versus rescheduled patients was 92.3 ± 93.0 versus 32.8 ± 57.4 miles, P = .034. Mean age, gender, and number of sessions were not different between groups. Mean time to third next available therapy appointment was 96 ± 46 versus 46 ± 12 days before and after rule change, P = .007. Upon Medicare's reversal, this trend rebounded to nearly baseline (mean 77 ± 12 days, P = .12).

CONCLUSION

Medicare's discontinuation of reimbursement for teletherapy services caused nearly 30% of patients to cancel voice and swallowing therapy, primarily due to distance. These cancellations led to decreased access to care for Medicare patients with voice/swallowing diagnoses, which affect function, quality of life, and potentially even mortality risk.

Laryngeal Dysfunction Manifesting as Chronic Refractory Cough and Dyspnea: Laryngeal Physiology in Respiratory Health and Disease

TOPIC IMPORTANCE

Laryngeal dysfunction as a cause of chronic refractory cough (CRC) and episodic dyspnea is often missed, which results in unnecessary testing and delays in diagnosis. Understanding laryngeal roles in breathing and airway protection can help to appreciate the propensity to laryngeal dysfunction with aging, chronic lung disease, and sleep apnea.

REVIEW FINDINGS

The human larynx is a complex muscular structure that is responsible for multiple roles of breathing, vocalization, coughing, and swallowing. To undertake these activities, the larynx has a high density of sensory and motor innervation. In addition to common embryological origins with the pharynx and esophagus, with which many laryngeal activities are shared, somatomotor and autonomic pathways regulate emotional, cognitive, and complex motor sequence-planning activities within the larynx. Due to its unique location, the larynx is susceptible to infectious and gastroesophageal reflux-related insults. Couple this with key roles in regulation of airflow and mediation of airway protective reflexes, it is not surprising that neuropathic abnormalities and muscle dysfunction frequently develop. The expression of laryngeal dysfunction as hypersensitivity to mechanical, thermal, chemical, and other stimuli leads to exaggerated airway protective reflexes (laryngeal adductor reflex and cough reflex) manifesting as dyspnea and cough.

SUMMARY

Pulmonologists should incorporate assessment of laryngeal dysfunction during evaluation of CRC and dyspnea. Recognition of laryngeal hypersensitivity in patient with CRC can identify patients who may benefit from cough suppression therapies. Similarly, timely identification of inducible laryngeal obstruction may not only resolve episodic dyspnea but lessen the need for unnecessary testing and treatments.

Clinical Characteristics of Individuals Presenting to Physiotherapy for Voice and Throat Care: A Retrospective Case Notes Review

BACKGROUND

Currently, little is known about the characteristics of individuals presenting for physiotherapy care with voice and throat problems.

PURPOSE

The aim of this study is to describe the demographic and clinical characteristics of individuals presenting to physiotherapy for voice and throat-related problems, and to use this information to clarify the role of physiotherapy in the management of people with voice and throat problems.

METHODS

A retrospective clinical case notes review was conducted of all clients who accessed physiotherapy for voice and throat problems at a private practice based in Christchurch within a 12-month period from 1st October 2020 to 1st October 2021.

RESULTS

Data were analyzed from 53 patient charts. The typical profile of an individual accessing physiotherapy for voice and throat problems were female (n = 37), NZ European (n = 26), singer (n = 43), with chronic problems (n = 20), of a nontraumatic origin (n = 45). Voice problems were present in 39 cases and muscle-related problems were present in 42 cases. Treatment primarily included manual therapy and various modes of exercise therapy.

CONCLUSIONS

The clinical characteristics described offer insight into the demographic and clinical characteristics of individuals accessing physiotherapy services for voice and throat problems. A high prevalence of muscle-related problems and wider issues were identified, consistent with the physiotherapy skill set. Physiotherapy appears to complement existing ENT or SLT services by identifying and managing muscle-related voice problems and addressing wider factors contributing to voice and throat problems.

The Therapeutic Landscape in Chronic Cough

In recent years, there has been a substantial increase in the development of antitussive therapies and the first new therapy, gefapixant has been licenced in Europe. This review describes current unlicenced treatments for chronic cough and details treatments currently in development for refractory chronic cough and cough in idiopathic pulmonary fibrosis, as well as compounds previously explored.

Cough in Children and Adults: Diagnosis, Assessment and Management (CICADA). Summary of an updated position statement on chronic cough in Australia

INTRODUCTION

Cough is the most common symptom leading to medical consultation. Chronic cough results in significant health care costs, impairs quality of life, and may indicate the presence of a serious underlying condition. Here, we present a summary of an updated position statement on cough management in the clinical consultation.

MAIN RECOMMENDATIONS

Assessment of children and adults requires a focused history of chronic cough to identify any red flag cough pointers that may indicate an underlying disease. Further assessment with examination should include a chest x-ray and spirometry (when age > 6 years). Separate paediatric and adult diagnostic management algorithms should be followed. Management of the underlying condition(s) should follow specific disease guidelines, as well as address adverse environmental exposures and patient/carer concerns. First Nations adults and children should be considered a high risk group. The full statement from the Thoracic Society of Australia and New Zealand and Lung Foundation Australia for managing chronic cough is available at https://lungfoundation.com.au/resources/cicada-full-position-statement.

CHANGES IN MANAGEMENT AS A RESULT OF THIS STATEMENT

Algorithms for assessment and diagnosis of adult and paediatric chronic cough are recommended. High quality evidence supports the use of child-specific chronic cough management algorithms to improve clinical outcomes, but none exist in adults. Red flags that indicate serious underlying conditions requiring investigation or referral should be identified. Early and effective treatment of chronic wet/productive cough in children is critical. Culturally specific strategies for facilitating the management of chronic cough in First Nations populations should be adopted. If the chronic cough does not resolve or is unexplained, the patient should be referred to a respiratory specialist or cough clinic.

Respiratory distress symptom intervention for non-pharmacological management of the lung cancer breathlessness-cough-fatigue symptom cluster: randomised controlled trial

OBJECTIVES

In lung cancer, three prominent symptoms, such as breathlessness, cough and fatigue, are closely related with each other forming a 'respiratory distress symptom cluster'. The aim of this study was to determine the clinical and cost-effectiveness of the respiratory distress symptom intervention (RDSI) for the management of this symptom cluster in people with lung cancer.

METHODS

A single blind, pragmatic, randomised controlled trial conducted in eight centres in England, UK. A total of 263 patients with lung cancer were randomised, including 132 who received RDSI and 131 who received standard care. To be eligible, participants self-reported adverse impact in daily life from at least two of the three symptoms, in any combination. Outcomes were change at 12 weeks for each symptom within the cluster, including Dyspnoea-12 (D-12), Manchester Cough in Lung Cancer (MCLC) and Functional Assessment of Chronic Illness-Fatigue.

RESULTS

At baseline, nearly 60% of participants reported all three symptoms. At trial completion the total trial attrition was 109 (41.4%). Compared with the control group, the RDSI group demonstrated a statistically significant improvement in D-12 (p=0.007) and MCLC (p<0.001). The minimal clinically important difference MCID) was achieved for each outcome: D-12 -4.13 (MCID >3), MCLC -5.49 (MCID >3) and FACIT-F 4.91 (MCID >4).

CONCLUSION

RDSI is a clinically effective, low-risk intervention to support the management of the respiratory distress symptom cluster in lung cancer. However, the study did experience high attrition, which needs to be taken onto consideration when interpreting these results.

TRIAL REGISTRATION NUMBER

NCT03223805.

Prevalence of Anxiety as a Variable in Treatment Outcomes for Individuals With Chronic Refractory Cough

PURPOSE

Anxiety is a mental state characterized by an intense sense of tension, worry, or apprehension relative to something adverse that might happen in the future. Anxiety is a known comorbidity in cough patients, yet its prevalence among those with chronic refractory cough (CRC) is unknown. Anxiety is not typically assessed during evaluation for CRC, but treatments for CRC such as neuromodulators and behavioral cough suppression therapy (BCST) may potentially attenuate anxiety. This preliminary study investigates the potential prevalence of anxiety in CRC and its possible role in treatment outcomes.

METHOD

CRC patients seen in a specialty clinic at the University of Utah or the University of Montana completed the Leicester Cough Questionnaire (LCQ) pre- and post-BCST treatment. Participants were dichotomized into positive anxiety screen (PAS) and negative anxiety screen (NAS) groups based on presence or absence of documented anxiety within electronic medical records at the University of Utah and based on a Generalized Anxiety Disorder-7 score > 5 at the University of Montana.

RESULTS

Of the 86 total participants, 37 (43%) were in the PAS group (29 females, Mage = 56 ± 13) and 49 (57%) were in the NAS group (36 females, Mage = 64 ± 14). Eighty-nine percent of CRC participants with a PAS reported a clinically meaningful improvement in LCQ total score following treatment compared to 65% of NAS participants. Furthermore, mean pre- to posttreatment change scores on the LCQ were significantly greater within the PAS group (p = .002, Cohen's d = 0.7, indicating a moderate to large effect size).

CONCLUSION

This preliminary study suggests that (a) anxiety may be prevalent among those with CRC and (b) those patients who screen positive for anxiety report greater benefit from BCST.

Factors influencing behavioral cough suppression therapy in children with nonspecific chronic cough

BACKGROUND

Behavioral cough suppression therapy (BCST) with a speech-language pathologist is a common treatment for chronic nonspecific cough (a.k.a., tic cough) in children. Yet, the outcomes and duration of pediatric BCST have eluded formal investigation. This study examined whether BCST improves cough in children with nonspecific cough and factors that predict the course of treatment. Additionally, the cough characteristics and comorbidities associated with the condition were examined.

METHODS

A retrospective, observational cohort design was utilized. Cough characteristics, medical history, and BCST treatment details and outcomes for 151 children were extracted from the electronic medical record of a large outpatient pediatric otolaryngology clinic.

RESULTS

Cough was dry and onset unaccompanied by illness in most cases. Roughly half of patients reported gradual onset and cough proceeded by tickle. On average, patients experienced symptoms for 19 months (SD = 20.09) before diagnosis. Rates of comorbid General Anxiety Disorder were elevated compared to pediatric norms. Additionally, high rates of asthma (22.1%), reflux (62.3%), and disordered sleep breathing (19.2%) were observed. Common findings on laryngoscopy included interarytenoid edema and erythema. Vocal fold changes were observed in 22.9% of children. BCST reduced cough in 92.5% of patients following an average of 1.7 sessions. Comorbid behavioral health diagnoses (p = 0.013) or induced laryngeal obstruction symptoms (p = 0.025) were significant predictors of increased therapy sessions. Cough proceeded by tickle significantly predicted fewer sessions in therapy (p = 0.011).

INTERPRETATION

Although randomized clinical trials are needed, these data suggest that BCST is a low-risk, effective treatment for children with nonspecific cough.

Mechanisms and management of cough in interstitial lung disease

INTRODUCTION

Many patients with interstitial lung diseases (ILDs), especially fibrotic ILDs, experience chronic cough. It negatively impacts both physical and psychological well-being. Effective treatment options are limited.

AREAS COVERED

The pathophysiology of chronic cough in IPF is complex and involves multiple mechanisms, including mechanical distortion of airways, parenchyma, and nerve fibers. The pathophysiology of cough in other fibrosing ILDs is poorly understood and involves various pathways. The purpose of this review is to highlight mechanisms of chronic cough and to present therapeutic evidence for its management in the most commonly occurring diffuse fibrosing lung diseases including idiopathic pulmonary fibrosis (IPF), connective tissue disease-related interstitial lung disease (CTD-ILD), sarcoidosis-related ILD (Sc-ILD), chronic hypersensitivity pneumonitis-related ILD (CHP-ILD), and post-COVID-19-related interstitial lung disease (PC-ILD).

EXPERT OPINION

This review guides the management of chronic cough in fibrosing ILDs. In this era of precision medicine, chronic cough management should be individualized in each interstitial lung disease.

A Non-Pharmacological Cough Therapy for People with Interstitial Lung Diseases: A Case Report

Purpose

To explore the feasibility of a non-pharmacological cough control therapy (CCT) customized for a client with interstitial lung disease (ILD).

Client Description

An 83-year-old female with hypersensitivity pneumonitis, and chronic cough for 18 years treated previously with pharmacological treatment for the underlying lung disease and gastroesophageal reflux disease, as well as lozenges and breathing and relaxation strategies.

Intervention

Four cough education and self-management sessions (45-60 minutes each) facilitated by a physiotherapist and speech-language pathologist via videoconference were conducted. Session topics included mechanisms of cough in ILD, breathing and larynx role in cough control, trigger identification, cough suppression and control strategies, and psychosocial support towards behaviour change using motivational interviewing.

Measures and Outcome

The following assessments were conducted prior to and one week after the intervention: semi-structured interviews, Leicester Cough Questionnaire, King's Brief Interstitial Lung Disease questionnaire, Functional Assessment of Chronic Illness Therapy Fatigue Scale, modified Borg Scale for severity and intensity of cough, and the Global Rating of Change Questionnaire.

Implications

Implementing the CCT was feasible. The client reported increased perceived cough control, a reduction in exhaustion from coughing bouts, and a better understanding of the mechanisms behind cough management and suppression. Improvements were also observed in cough-related quality of life, severity, and intensity.

Superior Laryngeal Nerve Block Response Rates in 54 Neurogenic Cough Patients

OBJECTIVE

Neurogenic cough related to hypersensitivity of the internal branch of the superior laryngeal nerve (SLN) is often treated with neuromodulating medications, which can cause considerable side effects. An alternative therapy is steroid and local anesthetic injection of the SLN ("SLN block"), initially proposed to benefit those with lateralizing symptoms (tenderness over the thyrohyoid membrane or unilateral cough source). Our objectives are to determine if SLN block produces subjective symptomatic improvements and if repeat injections further improve symptoms, and evaluate clinical factors potentially predictive of response.

METHODS

Retrospective chart review of 54 patients receiving SLN blocks at a tertiary medical academic center from January 2010 to June 2020. Medical history and anticipated predictors of positive response, including stigmata of laryngeal hypersensitivity, were recorded. Outcomes included symptomatic response, number of injections required, and side effects. Response was defined subjectively by asking patients whether the injection was beneficial and objectively by using CSI scores.

RESULTS

Fifty-four patients met the inclusion criteria. Thirty-eight patients (70.4%) endorsed improvement. No variables were identified as positive predictors of response. Thirty-two of the 38 (84.2%) endorsed improvement after one injection. Six of 15 (40%) patients who failed the first injection had positive response to the second. No significant side effects were reported.

CONCLUSION

No localizing symptoms, specific cough features, or aspects of the medical history helped predict response, suggesting that a broader range of patients may be offered the intervention. The majority of patients reported symptomatic improvement and repeat injections may benefit patients with initial nonresponse.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:2647-2653, 2023.

Management of non-pharmacologic therapy for chronic refractory cough: Mechanism, composition, applicable population, and assessment

Chronic cough is common in the clinic and can seriously affect the quality of life of patients. Following the existing guidelines for treatment, refractory chronic cough is defined as a clinical condition in which the cause of the cough remains unclear after comprehensive examination and treatment, or the cause is clear but symptomatic treatment is ineffective. It has been found that non-pharmacologic therapy can effectively improve the quality of life and reduce the frequency of coughing for some patients with refractory chronic cough. Compared with pharmacological therapy, non-pharmacologic therapy has no obvious adverse effects; therefore, non-pharmacologic therapy has good application prospects in the diagnosis and treatment of refractory chronic cough. This paper summarizes the composition, indication, action and mechanism of non-pharmacologic therapy in the diagnosis and treatment of refractory chronic cough and prospects for research on non-pharmacologic therapy.

State of the Art for Refractory Cough: Multidisciplinary Approach

Chronic cough is a common problem that can be refractory to medical treatment. Nonpharmaceutical management of chronic cough has an important role in well selected patients. This review article outlines the history of chronic cough management, current approaches to speech pathology management of the condition and new modalities of nonpharmaceutical treatment. There is a need for further research into nonpharmaceutical options with well described randomised control trials.

Epidemiology, clinical presentation, pathophysiology, and management of long COVID: an update

The increasing number of coronavirus disease 2019 (COVID-19) infections have highlighted the long-term consequences of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection called long COVID. Although the concept and definition of long COVID are described differently across countries and institutions, there is general agreement that it affects multiple systems, including the immune, respiratory, cardiovascular, gastrointestinal, neuropsychological, musculoskeletal, and other systems. This review aims to provide a synthesis of published epidemiology, symptoms, and risk factors of long COVID. We also summarize potential pathophysiological mechanisms and biomarkers for precise prevention, early diagnosis, and accurate treatment of long COVID. Furthermore, we suggest evidence-based guidelines for the comprehensive evaluation and management of long COVID, involving treatment, health systems, health finance, public attitudes, and international cooperation, which is proposed to improve the treatment strategies, preventive measures, and public health policy making of long COVID.

Applying behaviour change theory to speech and language therapy intervention for inducible laryngeal obstruction

BACKGROUND

Speech and language therapists (SLTs) provide interventions for inducible laryngeal obstruction (ILO) despite a current lack of evidence to inform intervention delivery. This study is the first step to develop an evidence-based intervention for ILO, using behaviour change theory and the Behaviour Change Technique Taxonomy version 1 (BCTTv1). Outcomes will inform the early development stage of a complex speech and language therapy intervention for ILO, enabling more precise reporting of ILO intervention studies, as per CONSORT guidelines.

AIMS

(1) To identify whether the BCTTv1 is a useful tool for characterising speech and language therapy interventions for ILO, based on existing literature, current practice and patient interviews. (2) To identify key behaviour change techniques (BCT) used within existing complex speech and language therapy interventions for ILO METHODS AND PROCEDURES: A five-phase study was conducted: (1) a systematic literature search of six electronic databases (Medline, EMBASE, CINAHL (EBSCO), Scopus, Trip, Web of Science) and grey literature between 2008 and 2020; (2) observations of six speech and language therapy intervention sessions; (3) a semi-structured interview with an SLT to validate the observed BCTTs; (4) consensus from four national expert SLTs regarding application of synthesised BCTT data to their own experiences of ILO interventions; and (5) patient engagement to review and comment on findings.

OUTCOMES AND RESULTS

Forty-seven BCTs in total were coded across all three sources. Thirty-two BCTs were identified in clinical observations; 31 in interviews with SLTs and 18 in the literature. Only six BCT were identified in all three sources. Expert SLTs confirmed clinical application and relevance. Patients reported finding the concept of BCT challenging but highlighted the value of psychoeducation to support their understanding of symptoms and in turn to understand the rationale behind speech and language therapy intervention recommendations.

CONCLUSION

This study indicates that the BCTTv1 is a suitable framework to identify and describe intervention components used within speech and language therapy interventions for ILO. A practice-research gap exists, reinforcing that existing literature does not capture the complexity of speech and language therapy intervention for ILO. Further research is needed to develop our understanding of the BCTs that support optimal behaviour change for this patient group.

WHAT THIS PAPER ADDS

What is already known on the subject There is growing recognition for the value of speech and language therapists (SLTs) in delivering complex interventions for patients with inducible laryngeal obstruction (ILO), including evidence to suggest that their intervention can improve quality of life for patients and reduce excessive healthcare use. There are, however, no randomised controlled trials in this field; thus it is unclear what constitutes the most effective intervention. What this study adds This study demonstrates the complexity of speech and language therapy interventions for ILO and highlights the practice-research gap. It identifies a range of behaviour change techniques that are used in existing practice and captures patient views relating to the components identified within this study. What are the clinical implications of this work? Findings highlight the value of providing education about factors that might be driving ILO symptoms and in turn the importance of sharing with patients the rationale for treatment recommendations that necessitate a change in their behaviours. Identified behaviour change techniques can be used when developing and implementing SLT interventions for ILO.

From bench to bedside: The role of cough hypersensitivity in chronic cough

BACKGROUND

Chronic cough is a burdensome condition characterized by persistent cough lasting longer than 8 weeks. Chronic cough can significantly affect quality of life, physical function and productivity, with many people troubled with a cough that lasts for months or even years. People with chronic cough commonly report a persistent urge to cough with frequent bouts of coughing triggered by innocuous stimuli, which has led to the concept of cough hypersensitivity.

MAIN BODY

Both central and peripheral neural pathways regulate cough, and although mechanisms driving development of cough hypersensitivity are not fully known, sensitization of these neural pathways contributes to excessive cough triggering in cough hypersensitivity. Effective therapies that control chronic cough are currently lacking. Recent therapeutic development has focused on several ion channels and receptors involved in peripheral activation of cough (e.g., transient receptor potential channels, P2 × 3 receptors and voltage-gated sodium channels) or central cough processing (e.g., neurokinin-1 [NK-1] receptors and nicotinic acetylcholine receptors).

CONCLUSION

These targeted therapies provide novel insights into mechanisms underlying cough hypersensitivity and may offer new treatment options for people with chronic cough. In this review, we explore preclinical and clinical studies that have improved our understanding of the mechanisms responsible for chronic cough and discuss the most promising targeted approaches to date, including trials of P2 × 3-receptor antagonists and NK-1-receptor antagonists.

Cough and cough hypersensitivity as treatable traits of asthma

Cough is a common and troublesome symptom in people with asthma and is often associated with poorer asthma control and exacerbations. Apart from asthma, other causes or comorbidities might underlie cough in asthma, such as rhinosinusitis and bronchiectasis. Eosinophilic inflammation and bronchoconstriction can lead to an acute episode of cough or worsen chronic cough. Cough hypersensitivity with laryngeal paraesthesia, allotussia, and hypertussia might underlie the cough of asthma through augmented sensory nerve excitability of upper-airway vagal sensory nerves. Cough associated with bronchoconstriction and type 2 inflammation should respond to inhaled corticosteroids and long-acting β-adrenoceptor agonist therapy. For cough hypersensitivity in adults, speech and language therapy and neuromodulators (eg, gabapentin) could be considered. In children, there is no consistent association of asthma with cough sensitivity or between cough and asthma severity. Further research is needed to realise the potential of cough as a measure of asthma control, to understand the mechanisms of cough in asthma, and to develop safe, effective treatments and a precision-medicine approach to the management of cough in asthma in children and adults.

Guidelines for the management of chronic cough in adults. Endorsed by the French speaking society of respiratory diseases (Société de Pneumologie de Langue Française, SPLF), the Société Française d'Oto-Rhino-Laryngologie et de Chirurgie de la Face et du Cou (SFORL), the Société Française de Phoniatrie et de Laryngologie (SFPL), the Société Nationale Française de Gastro-entérologie (SNFGE)

Patients with chronic cough experience a high alteration of quality of life. Moreover, chronic cough is a complex entity with numerous etiologies and treatments. In order to help clinicians involved in the management of patients with chronic cough, guidelines on chronic cough have been established by a group of French experts. These guidelines address the definitions of chronic cough and the initial management of patients with chronic cough. We present herein second-line tests that might be considered in patients with cough persistence despite initial management. Experts also propose a definition of unexplained or refractory chronic cough (URCC) in order to better identify patients whose cough persists despite optimal management. Finally, these guidelines address the pharmacological and non-pharmacological interventions useful in URCC. Thus, amitryptilline, pregabalin, gabapentin or morphine combined with speech and/or physical therapy are a mainstay of treatment strategies in URCC. Other treatment options, such as P2 × 3 antagonists, are being developed.

[Guidelines for the management of chronic cough in adults]

Patients with chronic cough experience major alteration in their quality of life. Given its numerous etiologies and treatments, this disease is a complex entity. To help clinicians involved in patient management of patients, guidelines have been issued by a group of French experts. They address definitions of chronic cough and initial management of patients with this pathology. We present herein the second-line tests that might be considered in patients whose coughing has persisted, notwithstanding initial management. The experts have also put forward a definition of unexplained or refractory chronic cough (URCC), the objective being to more precisely identify those patients whose cough persists despite optimal management. Lastly, these guidelines indicate the pharmacological and non-pharmacological interventions of use in URCC. Amitriptyline, pregabalin, gabapentin or morphine combined with speech and/or physical therapy are mainstays in treatment strategies. Other treatment options, such as P2X3 antagonists, are being developed and have generated high hopes among physicians and patients alike.

Cough desensitization treatment for patients with refractory chronic cough: results of a second pilot randomized control trial

OBJECTIVE

The purpose of this study was to collect pilot efficacy data on a novel treatment for refractory chronic cough (RCC), which we call cough desensitization treatment (CDT).

DESIGN AND METHODS

In this parallel cohort, sham-controlled, randomized controlled trial, 21 adults with RCC were randomly assigned to 12 sessions of either CDT (progressive doses of aerosolized capsaicin while behaviorally suppressing cough; n = 11) or a sham treatment (repeated exposure to aerosolized saline; n = 9). The Leicester Cough Questionnaire (LCQ) was the primary outcome measure. Perceived cough severity with a visual analogue scale and cough challenge testing (for measuring cough-reflex sensitivity) were secondary outcome measures. Data were analyzed with mixed effects linear regression and follow-up contrasts.

RESULTS

Results on all measures favored CDT. Excluding one sham participant, whose baseline LCQ scores were deemed unreliable, mean change in LCQ at 3-weeks post treatment was 6.35 and 2.17 in the CDT and sham groups, respectively. There was moderate to strong evidence of a greater improvement in the CDT group in total LCQ score (p = .058) and LCQ Psychological domain (p = .026) and Physical domain (p = .045) scores. Strong evidence was found for a greater reduction in urge-to-cough during CCT in the CDT group (p = .037) and marginal for a reduction in the capsaicin cough-reflex sensitivity (p = .094). There was weak evidence of a greater reduction in cough severity in the CDT group (p = .103).

DISCUSSION

Although the study is limited due to the small sample size, the data provide additional evidence supporting further research on CDT. CDT resulted in a greater change in the primary efficacy measure (LCQ) than both pharmaceutical and behavioral treatments currently found in the literature.

TRIAL REGISTRATION

This trial (NCT05226299) was registered on Clinicaltrials.gov on 07/02/2022.

Emerging drugs in the treatment of chronic cough

INTRODUCTION

Chronic cough is a debilitating condition that is among the most common reasons for seeking medical attention yet remains challenging to manage. Identifying an underlying respiratory, nasal or upper gastrointestinal disease triggering cough is the first step in assessment, but once this has been ruled out or adequately treated, many patients remain troubled with chronic cough.

AREAS COVERED

This narrative review discusses the role of existing treatments and describes the current research landscape for the development of new therapies for chronic cough greater than 8 weeks that is refractory (RCC) or unexplained (UCC). The literature search includes published studies found on pubmed and conference abstracts until 2023.

EXPERT OPINION

RCC/UCC can occur due to neuronal dysregulation of the vagus nerve or central nervous system. Hence, novel anti-tussives have targeted ion channels involved in the neuronal signaling which triggers cough. Although some therapies targeting receptors such as TRPV1 have failed to show efficacy, P2X3 antagonists have emerged as the most promising therapy for patients impacted by chronic cough. Disease specific therapies such as for idiopathic pulmonary fibrosis are in early development.

Approach to post COVID-19 persistent cough: A narrative review

A large proportion of patients who completely recovered from acute coronavirus disease 2019 (COVID-19) infection later continued to experience symptoms even after recovery, irrespective of the severity of the disease. Various terms with varying duration were used for those who had persistent symptoms, of which cough was the most common. We systematically searched the published literature concerning post-COVID-19 cough, its prevalence, and the potential ways to reduce it in clinical practice. The aim of this review was to provide an overview of existing literature concerning post-COVID-19 cough. Literature shows that augmented cough reflex sensitivity is responsible for persistent cough after acute viral upper respiratory infection (URI). Overall, the heightened cough reflex associated with SARSCoV2 induces neurotropism, neuroinflammation, and neuroimmunomodulation via the vagal sensory nerves. Therapies for post-COVID-19 cough aim at the suppression of cough reflex. For a patient who does not respond to early symptomatic treatment, Inhaled corticosteroids can be given a trial to suppress airway inflammation. More trials of novel cough therapies in patients with post-COVID-19 cough using various outcome measures need to be studied in future research. Several agents are currently available for symptomatic relief. However, non-response or refractory cough continues to preclude adequate symptom relief.

Yardstick for managing cough, part 1: In adults and adolescent patients older than 14 years of age

Nationwide statistics in the United States and Australia reveal that cough of undifferentiated duration is the most common complaint for which patients of all ages seek medical care in the ambulatory setting. Management of chronic cough is one of the most common reasons for new patient visits to pulmonologists. Because symptomatic cough is such a common problem and so much has been learned about how to diagnose and treat cough of all durations but especially chronic cough, this 2-part yardstick has been written to review in a practical way the latest evidence-based guidelines most of which have been developed from recent high quality systematic reviews on how best to manage cough of all durations in adults, adolescents, and children. In this manuscript, part 1 of the 2-part series, we provide evidence-based, and expert opinion recommendations on the management of chronic cough in adult and adolescent patients (>14 years of age).

Effect of Behavioral Cough Suppression Therapy Delivered via Telehealth

OBJECTIVES/HYPOTHESIS

Behavioral cough suppression therapy (BCST) has demonstrated up to 88% effectiveness at treating refractory chronic cough (RCC). With onset of the COVID-19 pandemic, along with many other medical services, BCST shifted to telehealth delivery. Our group hypothesized that BCST delivered via telemedicine by a specialized Speech-Language Pathologist would be comparable to previously reported response to treatment for in-person settings.

STUDY DESIGN

Retrospective review.

METHODS

An Emory IRB approved, retrospective review of electronic medical records was completed for RCC patients who received BCST via telehealth from March 2020 through January 2022 at Emory Voice Center. Patients were included in the study if they had a diagnosis of RCC, were referred for BCST, were seen for at least one therapy session in the telehealth setting, and provided Cough Severity Index (CSI) data pre and post-treatment. Patients were excluded if they had incomplete datasets, a known pulmonary condition, structural laryngeal disorders, smoking history, dysphagia, and ACE-inhibitor use. Change in CSI score pre- and post-treatment was calculated to determine treatment effect. Paired-samples t-tests were conducted to compare pre-and post-treatment CSI score change.

RESULTS

Fifty-one RCC patients were included in this study; 88% were female with an average age of 60 years (SD = 12.68). Post-treatment CSI scores were significantly lower than pretreatment CSI scores (P < 0.0001). These findings are comparable to historical documented CSI change achieved with in-person BCST.

CONCLUSIONS

This study provides preliminary evidence of the efficacy of BCST via telehealth for treating RCC. The findings of this study support the continued flexibility in speech-language pathology service delivery to include in-person and telehealth platforms for RCC beyond the COVID-19 pandemic.

An Investigation of Symptom Clusters and Sentinel Symptoms During the First 2 Cycles of Postoperative Chemotherapy in Patients With Lung Cancer

BACKGROUND

Lung cancer has the highest incidence and mortality of all cancers in China. Patients after a lobectomy experience serious physical and psychological symptoms during chemotherapy. Studies are lacking about symptom clusters (SCs) and sentinel symptoms during the postoperative chemotherapy period in lung cancer patients.

OBJECTIVE

The aim of this study was to explore SCs and sentinel symptoms during cycles 1 and 2 of postoperative chemotherapy in patients with lung cancer.

METHODS

Using a longitudinal study design, patients in treatment for lung cancer were measured at 2 separate points following a lobectomy: chemotherapy cycle 1 and chemotherapy cycle 2. The MD Anderson Symptom Inventory lung cancer-specific module and First Appearance of Symptoms Time Sheet were completed.

RESULTS

A total of 180 postoperative patients with lung cancer participated in the study. Four SCs were identified at chemotherapy cycle 1: gastrointestinal SC, respiratory tract SC, psychological SC, and somatic SC. The sentinel symptoms were nausea, cough, sadness, and fatigue. At chemotherapy cycle 2, similar SCs were identified, with the exception of merging the psychological SC and somatic SC, resulting in 3 clusters: gastrointestinal SC, respiratory tract SC, and psychological-somatic SC. The sentinel symptoms were nausea, cough, and fatigue.

CONCLUSIONS

Symptom clusters and sentinel symptoms were stable during the first 2 cycles of postoperative chemotherapy in patients with lung cancer.

IMPLICATIONS FOR PRACTICE

The understanding of SCs and sentinel symptoms could be beneficial to assess and manage both in postoperative patients with lung cancer during chemotherapy. Nurses should pay close attention to sentinel symptoms and develop effective interventions.

Normative Values for the Leicester Cough Questionnaire in Healthy Individuals

INTRODUCTION

The primary self-assessment questionnaire used for patients with chronic cough is the Leicester Cough Questionnaire (LCQ). The LCQ is a validated questionnaire that ranges in total score from 3 to 21. While it is known that a higher score on the LCQ reflects a better quality of life, normative data have not been reported for this questionnaire.

OBJECTIVE

The purpose of this study was to determine normative LCQ scores on a healthy population without cough.

METHODS

The LCQ was distributed via electronic survey to the authors' universities, professional affiliation email lists, and personal contacts. Participants were included if they were at least 18, nonsmokers, and without abnormal cough, without pulmonary disease, and without neurological disease. Participants answered questions regarding age, gender, and race/ethnicity, and completed the 19 LCQ questions.

RESULTS

One hundred forty-three (118 women) LCQ responses were analyzed. Average participant age was 47 years (SD = 13) and 133 (93%) were Caucasian. The mean LCQ Total score was 20.23 (SD = 0.85) with scores ranging from 17.05 to 21.

CONCLUSIONS

This study determined the following LCQ scores should be considered normal threshold scores: Total score - 17.68, Physical domain - 5.36, Psychological domain - 5.81, and Social domain - 6.06. The findings of this study will assist clinicians in determining severity of cough impact on quality of life using the LCQ. Further research is needed to ensure more complete participant demographic representation.

Effectiveness of the Therapy Program for Management of Chronic Cough: Preliminary Data From a Randomized Clinical Trial

PURPOSE

The purpose of this study is to analyze the effectiveness of the Therapy Program for Management of Chronic Cough (TMCC) in laryngeal sensations and symptoms related to the cough in individuals with chronic refractory cough (CRC).

METHOD

This research is a randomized double-blind clinical trial (Register Number: RBR-4m6x29). Eleven participants were allocated to two groups by parallel randomization: The Experimental Group-consisting of six individuals who underwent the TMCC; and the Control Group-consisting of five individuals who underwent the Comprehensive Vocal Rehabilitation Program (CVRP). Two primary outcomes were analyzed: self-perception of laryngeal sensations (Newcastle Laryngeal Hypersensitivity Questionnaire [LHQ-Br]) and self-perception of symptoms of upper airway-related cough (Cough Severity Index [CSI-Br]). The two-way repeated-measures analysis of variance was used to compare the evaluation moments and intervention groups. For multiple comparisons, the Tukey test with Bonferroni correction was used. To evaluate the effect size, eta partial square was used.

RESULTS

There was no difference between groups for any outcomes analyzed. There was a statistically significant difference with a large effect size for the moment factor in all outcomes. A statistically significant difference was observed with a large effect size for the interaction effect between group and moment for LHQ-Br total and CSI-Br psychological and functional.

CONCLUSIONS

The TMCC and CVRP were effective for the rehabilitation of CRC, considering the viewpoint of the subject. The TMCC improved laryngeal sensations and psychological and functional symptoms, while CVRP was relevant to improve psychological and functional symptoms in individuals with CRC.

Patient-Reported Qualitative Analysis of Chronic Refractory Cough

PURPOSE

Chronic cough has been shown to be associated with adverse effects on quality of life. There is a paucity of research characterizing quality-of-life factors associated with chronic refractory cough (CRC), a cough persisting > 8 weeks despite evaluation and treatment of possible etiologies. The purpose of this study was to elucidate the features of CRC from the patient's perspective, including presenting symptoms, past treatment methods, and quality-of-life factors.

METHOD

Prospective semistructured interviews were conducted, recorded, and transcribed for 20 patients diagnosed with CRC. Exclusion criteria included lung disease, smoking history, laryngeal cancer, and neurological disease. Grounded theory analysis was completed on transcribed interviews.

RESULTS

Eighteen participants were women. Mean participant age was 53.5 years (SD = 1.41), and average cough duration was 52 months (SD = 71.6 months). Responses to 30 open-ended questions revealed four dominant themes with 24 subthemes.

CONCLUSIONS

CRC affects patient quality of life. Understanding patient perspective on CRC diagnosis and treatment helps providers better understand the physical and emotional toll CRC takes on patients. Findings suggest that providers should spend more time counseling patients regarding their treatment and diagnosis, as patients with CRC do not always fully understand their diagnosis and resort to self-blame.

Healthcare utilization and costs in chronic cough

BACKGROUND

Chronic cough is a common reason for medical consultations and is associated with considerable physical and psychological morbidity. This study investigated healthcare use and cost in chronic cough and assessed its relationship with cough severity, health status, objective cough frequency (CF), and anxiety and depression.

METHODS

This was a prospective study of consecutive patients with chronic cough from a specialist clinic who completed a cough severity visual analogue scale (VAS), cough-specific health status (Leicester Cough Questionnaire; LCQ) and general health status EuroQol EQ-5D-5L, Generalized Anxiety Disorder (GAD7), Patient Health Questionnaire (PHQ9), and 24-hour objective CF monitoring with Leicester Cough Monitor (LCM). Case notes were reviewed for cough-specific healthcare use 12 months before and after the first cough clinic consultation. Resource use included general practitioner and hospital clinic visits, investigations, and treatments. Unit costs for healthcare use were derived predominantly from National Health Service Reference Costs.

RESULTS

One hundred participants with chronic cough were recruited (69% female, median duration 3 years, mean age 58 years). The diagnoses of cough were unexplained (57%), refractory (27%), and other (16%). Cough severity, health status, and CF were: median (IQR) VAS = 59.5 (30-79) mm, mean (SD) LCQ = 11.9 (4.0), mean (SD) EQ-5D-5L = 0.846 (0.178), and geometric mean (SD) CF = 15.3 (2.5) coughs/hr, respectively. The mean (SD) total cost per individual for cough-related healthcare utilization was £1,663 (747). Diagnostic investigations were the largest contributor to cost (63%), followed by cough clinic consultations (25%). In multivariate analysis, anxiety (GAD7) and cough-related health status (LCQ) were associated with increased cost (p ≤.001 and .037).

CONCLUSION

Healthcare cost associated with chronic cough are largely due to diagnostic investigations and clinic consultations. The predictors of costs were health status (LCQ) and anxiety. Further studies should investigate the optimal management protocols for patients with chronic cough.

Cough hypersensitivity and chronic cough

Chronic cough is globally prevalent across all age groups. This disorder is challenging to treat because many pulmonary and extrapulmonary conditions can present with chronic cough, and cough can also be present without any identifiable underlying cause or be refractory to therapies that improve associated conditions. Most patients with chronic cough have cough hypersensitivity, which is characterized by increased neural responsivity to a range of stimuli that affect the airways and lungs, and other tissues innervated by common nerve supplies. Cough hypersensitivity presents as excessive coughing often in response to relatively innocuous stimuli, causing significant psychophysical morbidity and affecting patients' quality of life. Understanding of the mechanisms that contribute to cough hypersensitivity and excessive coughing in different patient populations and across the lifespan is advancing and has contributed to the development of new therapies for chronic cough in adults. Owing to differences in the pathology, the organs involved and individual patient factors, treatment of chronic cough is progressing towards a personalized approach, and, in the future, novel ways to endotype patients with cough may prove valuable in management.

The Evolving Clinical Practice of Chronic Cough

Chronic cough, defined as a cough lasting for greater than 8 weeks, accounts for a substantial number of primary care and specialist consultations in the United States. Although cough can arise from a myriad number of serious respiratory diseases, attention has traditionally focused on diagnosing and treating gastroesophageal reflux, upper airway cough syndrome, and eosinophilic airway inflammation (asthma and nonasthmatic eosinophilic bronchitis) in patients with normal chest imaging. The newly described paradigm and entity of cough hypersensitivity syndrome (CHS) becomes useful when the etiology of cough remains elusive or when the cough remains refractory despite appropriate therapy for underlying causes. We present an update on the evolving understanding of refractory chronic cough and/or unexplained chronic cough as manifestations of laryngeal hypersensitivity and CHS. This includes a focus on understanding the pathophysiology underlying current and novel therapeutics for CHS, while also ensuring that common causes of chronic cough continue to be evaluated and treated in a systematic multidisciplinary manner.

Non-pharmacological Management of Non-productive Chronic Cough in Adults: A Systematic Review

Background

Chronic cough is a common reason for medical referral and its prevalence is on the rise. With only one pharmaceutical therapy currently under review for the treatment of refractory chronic cough, exploring non-pharmacological chronic cough management therapies is important. This systematic review summarizes the effectiveness of non-pharmacological chronic cough therapies in adults with non-productive refractory chronic cough or cough due to chronic respiratory diseases.

Methods

We searched Medline, Embase, Cochrane, CINAHL, and Scopus from inception to September 2021. Randomized controlled trials published in English, Portuguese, or French, and examining the effects of non-pharmacological therapies in adults with chronic non-productive cough (>8 weeks; <2 teaspoons sputum) were included. Mean differences, medians, and odds ratios were calculated as appropriate.

Results

16,546 articles were identified and six articles representing five unique studies were included. Studies evaluated 228 individuals with refractory chronic cough or chronic cough due to a chronic respiratory disease [162 women (71%); 52 ± 11 to 61 ± 8 years old]. Obstructive sleep apnea was the only chronic respiratory disease studied. Non-pharmacological therapies included education, cough suppression, breathing techniques, mindfulness, and continuous positive airway pressure. When standing alone, non-pharmacological cough therapies improved cough-specific health related quality of life when not associated with interventions (mean diff MD 1.53 to 4.54), cough frequency (MD 0.59 95%CI 0.36 to 0.95), and voice outcomes (MD 0.3 to 1) when compared to control interventions.

Conclusion

The evidence of non-pharmacological therapies for non-productive chronic cough is limited. Existing studies reflect the heterogeneity in study design, sample size, and outcome measures. Thus, clinical recommendations for using the most effective interventions remain to be confirmed.

Expiratory Muscle Strength Treatment for Refractory Chronic Cough: A Short-term Single Exercise Program

OBJECTIVES

Patients with chronic cough are some of the most challenging to treat. This preliminary study is the first to examine the effects of a single exercise muscle strength training program to reduce cough severity in patients who failed other treatments.

METHODS

A total of 19 females were included in this study, ranging from age 24 to 80. The maximum phonation time (MPT), laryngeal airway resistance (LAR), maximum inspiratory pressure (MIP) and maximum expiratory pressure (MEP), Voice Handicap Index-10, (VHI-10) and the Cough Severity Index (CSI) values were obtained pre- and post-treatment. ANOVA two-factor without replication was used to compare values pre- and post-treatment.

RESULTS

MIP (Mean of 62.00 to a mean of 78.53) and MEP (Mean of 90.00 to a mean of 112.16) showed significant increase post-treatment. In addition, LAR (Mean of 73.30 to a mean of 60.67) and CSI (Mean of 19.37 to a mean of 15.00) significantly decreased post-treatment. General changes in pre- and post-treatment values were identified with MPT (Mean of 14.89 to a mean of 16.17) and VHI-10 (Mean of 8.00 to a mean of 6.76). A follow-up questionnaire indicated that the majority of patients felt their cough was better after 4 weeks.

CONCLUSIONS

Muscle strength training provides a tool to aid in the control of cough for patients who are refractory to medical and other behavioral treatments. Improvement in cough may be associated with a reduction in subglottic pressure and increased air flow resulting in lower laryngeal airway resistance.

Cough desensitization treatment: A randomized, sham-controlled pilot trial for patients with refractory chronic cough

BACKGROUND

The purpose of this study was to determine feasibility of treating refractory chronic cough (RCC) with progressive doses of capsaicin paired with cough suppression.

METHODS

In this sham-controlled, parallel RCT, 14 adults with RCC were randomly assigned to either behavioral cough suppression therapy (BCST) plus 6 treatment sessions involving exposure to nebulized capsaicin in progressively larger concentrations while actively suppressing cough (n = 8), or BCST plus 6 sessions of exposure to a single subthreshold dose of capsaicin (sham; n = 6). The Leicester Cough Questionnaire (LCQ) was the primary outcome measure. Urge-to-cough (UTC) testing, measuring both UTC and cough frequency, served as secondary outcome measures. Data was analyzed with mixed effects linear regression and follow-up contrasts.

RESULTS

Results on all measures favored the treatment group; however, there was only strong evidence of a difference in treatment effect on cough frequency during UTC testing. Mean change in LCQ at 3-weeks post treatment was 2.95 and 1.75 (p = .23), in the treatment and sham groups, respectively. Cough frequency during UTC testing reduced by 97% and 56% (p < .0001) at three weeks post, respectively. Within-group comparisons revealed strong evidence of change in the treatment group (p < .001) and moderate evidence of a change in the sham group (p = .08) in LCQ.

CONCLUSIONS

Conclusions from this study are limited due to the very small sample size; however, the study provides feasibility and proof-of-concept evidence to support further investigation of treating RCC with repeated exposure to nebulized capsaicin paired with BCST.

Physiotherapy for large airway collapse: an ABC approach

Large airway collapse (LAC) describes the phenomenon of excessive, abnormal, inward movement of the large airways (i.e. trachea and/or main bronchi and/or bronchus intermedius) occurring during the expiratory phase of the respiratory cycle. It is an increasingly well-recognised problem and a prevalent comorbidity in other chronic respiratory conditions (e.g. COPD and asthma). LAC is associated with pervasive respiratory features such as a barking cough, exertional dyspnoea and an increased propensity to lower respiratory tract infection. These symptoms are unpleasant, and patients are often limited in their daily life and their function. The pathophysiology of this condition impairs airway clearance and can cause breathlessness and exercise intolerance, due to a loss of airway patency during expiratory flow. Dysfunctional adaptations to breathing and coughing may further amplify symptoms. This article provides, for the first time, clinically focused physiotherapeutic intervention advice based on our understanding of the pathophysiology of LAC, to support conservative management. It uses the available evidence from LAC, transferable evidence from other conditions and knowledge based on clinical experience. It proposes a practical "ABC model" to ensure physiotherapy assessment and treatments are centred around optimising three key clinical areas: Airways, including airway clearance and cough; Breathing, including breathlessness and breathing pattern; and Capacity for exercise, including an assessment of functional exercise ability.

Curbing the Cough: Multimodal Treatments for Neurogenic Cough: A Systematic Review and Meta-Analysis

OBJECTIVES/HYPOTHESIS

Neurogenic cough affects 11% of Americans and causes significant detriment to quality of life. With the advent of novel therapies, the objective of this review is to determine how procedural therapies (e.g., superior laryngeal nerve block) compare to other established pharmacologic and non-pharmacologic treatments for neurogenic cough.

METHODS

With the assistance of a medical librarian, a systematic review was performed using PICOS (patients, interventions, comparator, outcome, study design) format: adults with neurogenic cough receiving any pharmacologic or non-pharmacologic treatment for neurogenic cough compared to adults with neurogenic cough receiving any other relevant interventions, or treated as single cohorts, assessed with cough-specific quality of life outcomes, in all study designs and case series with ≥ 10 cases. Case reports, review articles, non-human studies, non-English language articles, and unavailable full-text articles were excluded.

RESULTS

There were 2408 patients with neurogenic cough in this review, treated with medical therapy (77%), speech therapy (19%), both medical and speech therapy (1%), and procedural therapy (3%). The included studies ranged from low to intermediate quality. Overall, most interventions demonstrated successful improvement in cough. However, the heterogeneity of included study designs precluded direct comparisons between intervention types.

CONCLUSION

This meta-analysis compared various treatments for neurogenic cough. Procedural therapy should be considered in the armamentarium of neurogenic cough treatments, particularly in patients refractory to, or intolerant of, the side effects of medical therapy. Lastly, this review illuminates key areas for improving neurogenic cough diagnosis, such as strict adherence to diagnostic and treatment guidelines, sophisticated reflux testing, and standardized, consistent outcome reporting. Laryngoscope, 132:107-123, 2022.

Syncope: a complication of chronic cough

Cough syncope is a rare but serious and potentially life-threatening complication of chronic cough. Early identification, comprehensive diagnostic evaluation and appropriate driving advice are fundamental to protect patients and the public. https://bit.ly/3CDAqYa.

Long-Term Treatment Outcomes after Behavioral Speech Therapy for Chronic Refractory Cough

INTRODUCTION

Current literature reveals that up to 88% of individuals undergoing behavioral speech therapy (BST) for chronic refractory cough (CRC) demonstrate benefit at 4-8 weeks post-treatment. However, investigations of BST are confounded by overlapping use of neuromodulators, missing follow-up data, and an absence of long-term outcomes. This study investigated treatment outcomes beyond 6 months in individuals diagnosed with CRC, and whose treatment outcomes were clinically undocumented.

METHODS

Participants with CRC 6 months or greater beyond treatment completion were recruited. Participants completed a post-treatment Leicester Cough Questionnaire (LCQ) and a telephone interview. Demographic data, cough characteristics, treatment adherence, BST outcomes, and pre- and post-treatment LCQ scores were evaluated.

RESULTS

80 individuals met inclusion criteria and 29 consented to participate. Of these, 27 were recommended BST. The majority were female (19/27) with average age of 58 years (SD = 12). Mean cough duration was 60 months (SD = 98) and mean post-BST duration was 20 months (SD = 9). A significant increase in pre- to post-treatment LCQ scores occurred [4.4 (SD = 4.2)] (p < 0.0001).

CONCLUSION

This study addressed long-term BST benefit for CRC and demonstrated a significant improvement in long-term post-treatment LCQ total scores more than a year after BST for CRC. More than half of participants indicated improvement or elimination of their cough. These findings further support the benefit of BST for CRC. Future research should consider patient perspectives about treatment outcomes given that 44% of participants reported no benefit from BST.

Confronting COVID-19-associated cough and the post-COVID syndrome: role of viral neurotropism, neuroinflammation, and neuroimmune responses

Cough is one of the most common presenting symptoms of COVID-19, along with fever and loss of taste and smell. Cough can persist for weeks or months after SARS-CoV-2 infection, often accompanied by chronic fatigue, cognitive impairment, dyspnoea, or pain-a collection of long-term effects referred to as the post-COVID syndrome or long COVID. We hypothesise that the pathways of neurotropism, neuroinflammation, and neuroimmunomodulation through the vagal sensory nerves, which are implicated in SARS-CoV-2 infection, lead to a cough hypersensitivity state. The post-COVID syndrome might also result from neuroinflammatory events in the brain. We highlight gaps in understanding of the mechanisms of acute and chronic COVID-19-associated cough and post-COVID syndrome, consider potential ways to reduce the effect of COVID-19 by controlling cough, and suggest future directions for research and clinical practice. Although neuromodulators such as gabapentin or opioids might be considered for acute and chronic COVID-19 cough, we discuss the possible mechanisms of COVID-19-associated cough and the promise of new anti-inflammatories or neuromodulators that might successfully target both the cough of COVID-19 and the post-COVID syndrome.

Impact and disease burden of chronic cough

Cough is an important physiological mechanism to protect the lower airways, but it is also one of the most common symptoms that lead patients to seek medical consultations. Chronic cough, usually defined by cough duration longer than 8 weeks in adults, is prevalent in the community and impairs quality of life in individual patients. There are several characteristics that may differentiate pathologic coughs from protective cough responses, including cough duration, frequency, hypersensitivity, impaired cough suppressibility, or treatment refractoriness. However, the impact of cough, or its perceived severity, is a sum of the patient's experience of coughing and is a factor that may finally define cough as a disease. Social isolation is a major impact of chronic cough, which is now worse due to the coronavirus disease 2019 pandemic and a widespread fear of cough as a source of contagion. Emotional impact and economic impact (medical cost, reduced work productivity, and job loss) are also important complications of chronic cough, and they interact in a vicious cycle, aggravated by social isolation and treatment failures. This paper is a narrative review that aims to address the impact and disease burden of chronic cough in adult patients. We review the literature, but also introduce the findings from recent qualitative interviews and the patients' experiences of the impact and burden of chronic cough and discuss unmet needs in these patients.

Evaluation and Management Outcomes and Burdens in Patients with Refractory Chronic Cough Referred for Behavioral Cough Suppression Therapy

PURPOSE

The purpose of this study was to investigate the typical symptoms and medical management characteristics of adult patients with refractory chronic cough (RCC) who are referred to speech-language pathology (SLP) for behavioral cough suppression therapy (BCST) in order to estimate cost-effectiveness and efficiency of current practice patterns for this population.

METHODS

One hundred sixty-four (164) patients with RCC referred for BCST were surveyed. Patients completed an initial survey at BCST onset related to symptom pattern and prior treatment, including the Leicester Cough Questionnaire (LCQ). Every four to six weeks patients completed follow-up surveys to assess their response to BCST.

RESULTS

Mean age was 58 years (83.5% women). The majority of patients reported their cough began two or more years prior to BCST. Approximately half (49%) reported seeing four or more physicians (including primary care physicians) and being prescribed four or more medications (57%) prior to BCST. Medications targeting post-nasal drip (72%), reflux (70%), asthma (56%), and allergies (56%) were most commonly prescribed. BCST resulted in a clinically significant improvement in 70.1% of participants. The mean change in LCQ for those who improved with BCST was 6.61. Over half (58%) reported they were quite satisfied to completely satisfied with their treatment response. The average time from enrollment to study completion was 64 days.

CONCLUSION

The results of this study suggest early intervention with BCST may be a cost-effective and efficient option for patients with RCC.

Is laryngeal hypersensitivity the basis of unexplained or refractory chronic cough?

Refractory chronic cough (RCC) and unexplained chronic cough (UCC) are common problems seen in primary care and subspecialty clinics. The role of cough hypersensitivity and laryngeal dysfunction in contributing to the persistence of cough in RCC/UCC is not well recognised. Data of patients with RCC and UCC evaluated in 2019 by an interdisciplinary cough clinic led by a pulmonologist and speech-language pathology team was reviewed. Patients completed validated questionnaires including the Leicester cough questionnaire (LCQ), voice handicap index (VHI) and dyspnoea index (DI) questionnaire at initial encounter. Presence of cough hypersensitivity was based upon a history of allotussia and hypertussia. Laryngeal dysfunction was diagnosed in those with a history of laryngeal paresthesias, throat clearing, voice abnormalities, upper airway dyspnoea and documentation of functional or anatomic laryngeal abnormalities on nasoendoscopy. Of the 60 UCC/RCC patients analysed, 75% of patients were female and 85% were over 40 years of age. Cough hypersensitivity was documented in all patients and multiple cough triggers occurred in 75% of patients. 95%, 50% and 25% of patients reported laryngeal paresthesias, voice abnormalities and upper airway dyspnoea, respectively. Significant associations between LCQ and VHI and DI scores occurred when adjusting for age, sex, ethnicity and body mass index. Laryngeal functional abnormalities were documented on 44 out of 60 patients on nasoendoscopy. Hypertussia, allotussia and laryngeal dysfunction are common in patients with RCC and UCC. Evaluation of UCC and RCC can delineate laryngeal hypersensitivity and allows appropriate treatment to be directed at this phenotype.