Unexplained chronic cough
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Unexplained Chronic Cough. Dr Surinder Birring Consultant Respiratory Physician Honorary Senior Lecturer King’s College Hospital & King’s College London London. Outline. Case study Impact on QOL Unexplained cough Non-pharmacological therapy. Why is cough important?.

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Unexplained Chronic Cough

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Unexplained chronic cough

Unexplained Chronic Cough

Dr Surinder Birring

Consultant Respiratory Physician

Honorary Senior Lecturer

King’s College Hospital & King’s College London

London


Outline

Outline

  • Case study

  • Impact on QOL

  • Unexplained cough

  • Non-pharmacological therapy


Why is cough important

Why is cough important?

  • Most common reason to consult GP

  • Antitussive drug sales USA >$4billion/yr

  • Chronic cough (>8wk): 12% population

  • 10-38% of out-patients referrals


Unexplained chronic cough

Causes of chronic cough

  • Lung cancer

  • COPD

  • TB

  • Fibrosis

  • Heart failure

  • Sarcoidosis

  • Foreign body

  • Abnormal:

  • Examination

  • CXR

  • Spirometry


Case study

Case study

  • 64 year old lady

  • Seen by 3 respiratory consultants

  • Referred to cough clinic by GP

  • Tickly dry cough 2003

  • Post nasal drip

  • Reflux

  • Never smoked


Investigations

Investigations

  • CXR/CT normal

  • FEV1 normal

    Post Nasal Drip

  • ENT review/nasal steroid/antihistamine

    Asthma

  • Oral / inhaled corticosteroids

    GOR

  • 3month+ omeprazole

  • 24-hr oes pH study -ve


Unexplained chronic cough1

Unexplained chronic cough

  • Idiopathic cough

  • Refractory cough

  • Persistent cough

  • Psychogenic cough

  • Tic cough

  • Sensory neuropathic cough


Unexplained chronic cough

Is she coughing?

24 Hour cough monitor: LCM

Hidden Markov Models

Ambulatory

Single coughs

Automated

24 Hours

Birring et al, ERJ 2008; 31:1013-1018


Unexplained chronic cough

Adverse impact of chronic cough

Worried about serious illness77%

Concerned something is wrong72%

Frequent nausea56%

Exhaustion54%

Others think something is wrong with me53%

Embarrassment49%

Self-consciousness46%

Difficulty speaking on the telephone39%

Urine incontinence30%

Absence from work11%

French C et al, Arch Intern Med 1998; 158:1657


Unexplained chronic cough

Depressive symptoms in

chronic cough

60

50

40

CES-D Score > 16 (%)

30

20

10

0

IHD

Asthma

Heart Failure

Diabetes

Chronic cough

Severe COPD

Hypertension

Dicpinigaitis P et al, Chest 2006; 130:1839


Anxiety had and stai scores

Anxiety: HAD and STAI scores

Mc Garvey L et al, Cough 2006; 2:4


Impact of cough

IMPACT OF COUGH


Impact of cough1

IMPACT OF COUGH


Qol questionnaires

QOL questionnaires

COUGH Birring S et al, Thorax 2003; 58:339-343

KBILD

ILD Patel A et al, Thorax 2012; 67:804

SARCOIDOSIS Patel A et al, Thorax 2012; In press

KSQ


Hrqol the lcq

Physical

Chest pains

Sputum

Tired

Paints/fumes

Sleep

Frequency

Hoarse Voice

Energy

Psychological

Embarrassed

Anxious

In control

Frustrated

Fed up

Serious illness

Other people

Social

Conversation

Annoy family

Job

Enjoyment

HRQOL: The LCQ

Birring S et al, Thorax 2003; 58:339-343


Unexplained chronic cough

Cough frequency & QOL

100

80

Cough frequency c/hr

60

40

r = -0.6

20

0

4

6

8

10

12

14

16

18

20

LCQ scores

Birring et al, Resp Med 2006; 100:1105-9


Unexplained chronic cough

Gender differences in QOL

*

5.5

*

5

4.5

MALES

LCQ SCORE

FEMALES

4

*p<0.05

3.5

3

PHYSICAL

PSYCHOLOGICAL

SOCIAL

Birring et al, ATS 2003


Unexplained chronic cough

Cough Intensity

Oesophageal pressure

Flow rate

Abdominal EMG activity

Cough sound


Female patients cough harder during max voluntary cough

Female patients cough harder during max voluntary cough

Thoracic pressure

Cough flow


Unexplained chronic cough

Cough Sound

Explosive

Voiced

Intermediate


Unexplained chronic cough

Cough Sound: a novel objective marker of intensity?

Energy

Maximum frequency


Unexplained chronic cough

Unexplained cough or cause yet to be identified?

Enlarged tonsils

Birring et al, Eur Resp J 2004; 23: 199-201


Unexplained chronic cough

Birring et al, Thorax 2003;58:533-6

Birring et al, Thorax 2003;58:1066-70

Birring et al, Resp Med 2004; 98: 242-6

Birring et al. Thorax 2005;60:249-253


Unexplained chronic cough

Unexplained cough: prevalence

Most recent reports: 40%

Morice et al, ERJ 2004; 24:481-92


Unexplained cough profile

Unexplained cough: profile

Female 70%

Onset around menopause

Cough duration, many >5 years

Poor QOL

High levels anxiety, depressive and obsessive traits


Unexplained chronic cough

Mrs X: Treatment options for unexplained cough

  • Amitriptyline

  • Gabapentin

  • Morphine

  • Physiotherapy/Speech therapy


Gabapentin randomised controlled trial

Gabapentin: randomised controlled trial

p=0.012

Full Treatment Period

Ryan N et al, Lancet 2012:380:1583


Unexplained chronic cough

Cough Suppression Physiotherapy

  • Education (avoid triggers, no benefit of excessive cough)

  • Laryngeal hygiene (reduce alcohol/caffeine, sips water, avoid mouth breathing, correct abnormal breathing pattern+ VCD)

  • Cough control (chew sweets, forced swallow, huff, distraction)

  • Counselling (reinforcement of techniques, modify behaviour, address adverse symptoms such as incontinence)

Patel A et al; Chronic Resp Dis 2011;8:253-8


Psychology and the cough clinic

Psychology and the cough clinic

  • As part of our clinical physiotherapy cough suppression service stress and anxiety is covered for our chronic cough patients

  • Booklet was designed by Dr Hutton, Helene Bellas and Sarah Chamberlain for chronic cough patients to cover stress and anxiety and how it affects their cough. Which covers:

    • The general affects cough has on the body

    • How anxiety can make cough worse as patients are:

      • Less likely to identify their cough triggers

      • Less likely to remember and implement the cough suppression techniques they have been taught

      • Affects their breathing pattern

      • If patients are anxious about coughing they tend to over focus on coughing


Unexplained chronic cough

Chest physiotherapy for refractory chronic cough

n=23

*p=0.003

*p<0.001

*p=0.03

7

6

5

Before

4

After

LCQ Domain Score

3

2

1

0

Physical

Psychological

Social

Patel A et al; Chronic Resp Dis 2011;8:253-8


Psalti trial

T1

T2

T3

T4

Screen

VAS QOL CM CRS

VASQOL

VAS QOL

VAS QOLCM CRS

VAS QOL(post)

VAS QOL(post)

PSALTI Trial

Placebo

Observation

Screen

Physiotherapy

Randomisation

DAY -7 0 7 14 28 56 84

Treatment


Unexplained chronic cough

Lee K and Birring SS. Medicine 2012;4:173-6


Summary

Summary

  • Chronic cough is a common

  • Frequently unexplained

  • High physical and mental health morbidity

  • Few drug treatment options

  • Integrated physical and mental health approach needed

  • Future research

    -illness perception/behaviour

    -Early detection of mental health problems

    -Develop cough specific behavioural therapies

    -Increase awareness of psychological morbidity


Acknowledgements

Acknowledgements

King’s College

Kai Lee

Sarah Chamberlain

Rachel Harding

Rachel Garrod

Jane Hutton

Aish Sinha

Jonathan La-Crette

Amit Patel

Helene Bellas

Alka Savani

John Moxham

Irene Higginson

Gerrard Rafferty

Tracey Fleming

Claire Woods

Lynne Morgan

Collaborators

Ian Pavord

Sergio Matos

David Evans

Gillian Watkins

Ben Prudon

Debbie Parker

Fan Chung

Alvin Ing

Kevin Chan

Nicole Ryan

Peter Gibson


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