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Cough Guidelines The European Perspective. Alyn Morice University of Hull. Points of difference. The majority of the guidelines from both ERS, BTS and ACCP are consistent and agreed. However there are some areas of disagreement. Evidenced based vs opinion based.

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Cough Guidelines

The European Perspective

Alyn Morice

University of Hull


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Points of difference

The majority of the guidelines from both ERS, BTS and ACCP are consistent and agreed. However there are some areas of disagreement.

  • Evidenced based vs opinion based


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Trials of over 1000pts in NEJM, Lancet, Annals, JAMA

Compared with preceding meta analysis

12 trials, 19 meta-analyses, 40 endpoints

Only 67% agreement

Meta analysis did not predict the result of the RCT in 35% of cases

Discrepancies between meta-analyses and subsequent large randomized, controlled trials LeLorier J NEJM 1997 337 536-542


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Points of difference

  • Evidenced based vs opinion based

  • Defined diagnosis vs symptom complex


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Definitions

The chief merit of language is clearness, and we know that nothing detracts from this so much as unfamiliar terms

Galen


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The problems of definition in cough diagnosis

  • The asthma syndromes

  • PNDS/UACS

  • GERD/GORD


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No correlation of diagnosis with:-

  • Histology

    • (Irwin RS 2006; 130 362-370)

  • Inflammatory markers in induced sputum

    • (Chaudri R J Allergy Clin Immunol 2004; 113 1063-1070, Birring S Am L Respir Crit Care Med 2004; 169 15-19)

  • Neuropeptides (sputum and serum)

    • (Chaudri R Clin Exp Allergy 2005; 35 949-953)


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The chronic cough survey

  • A cross-sectional survey in Leeds and Bradford

  • Recruitment via 36 general practices

  • Subjects aged 40 - 49 years

  • Randomly selected from the practice computer databases

  • Questionnaires sent to 6,416

  • 4,003 (62%) responded

  • 3,883 (97%) completed the cough questions


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The chronic cough survey

  • Asked how often in the last two months they had experienced bouts or spasms of coughing

  • Responses on a five-point Likert scale:

    • not at all; less than once a month; between once a month and once a week; between once a week and once a day; and once a day or more.

  • cough frequency was dichotomised using a cut-off point of once a week and once a day and above

  • Cough severity treated similarly


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Overall prevalence of chronic cough 12% severity 7%

Ford AC, Forman D, Moayyedi P, Morice AH.

Cough in the community: a cross sectional survey

and the relationship to gastrointestinal symptoms.

Thorax 2006;61:975-9.


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Points of difference

  • Evidenced based vs opinion based

  • Defined diagnosis vs symptom complex

  • History unhelpful vs history diagnostic


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The diagnosis of reflux cough

  • Virtually all reflux is due to transient opening of the lower oesophageal sphincter

    Mittal NEJM 1997


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Hull Cough Clinic

REFLUX COUGH QUESTIONNAIRE


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Symptoms in reflux cough study

  • Hull Cough Clinic between January 2002 and March 2004

  • All new patients probability-based management algorithm

  • Semi-structured history

  • In those with gastroesophageal disease shown on oesophageal

  • manometry and/or 24 hour oesophageal pH monitoring

  • Case notes reviewed.

  • Presenting symptoms were collated to determine

  • the characteristic history of GOR-related cough.

Everett Resp Med 2006


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Points of difference

  • Evidenced based vs opinion based

  • Defined diagnosis vs symptom complex

  • History unhelpful vs history diagnostic

  • Different investigational strategy


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Larynx in reflux cough

Arytenoid erythema

Posterior commisure hypertrophy

Vocal fold oedema

Ventricular obliteration


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Cough counts on two days in the same

individual as recorded by HACC


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Points of difference

  • Evidenced based vs opinion based

  • Defined diagnosis vs symptom complex

  • History unhelpful vs history diagnostic

  • Different investigational strategy

  • Different interpretation of the therapeutic response


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Can some “antihistamines” affect

the VR1 cough receptor


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Disofrol current experience

76 patients with intractable cough

68 female

Reflux 52%

Unknown 23%

Cystic fibrosis 8%

Asthma 4%


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Results of Diary Data in chronic cough

N=27

  • Mean Cough scores

  • Placebo: 4.97 (1.68)

  • MST : 3.44 (1.75)

  • P value : <0.0001

Morice AH et al 2006 AJRCCM


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