Unexplained Chronic Unexplained Chronic CoughCough
Dr Surinder BirringConsultant Respiratory PhysicianHonorary Senior Lecturer
King’s College Hospital & King’s College LondonLondon
OutlineOutlineCase 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
Causes of chronic cough
•Lung cancer
•COPD
•TB
•Fibrosis
•Heart failure
•Sarcoidosis
•Foreign body
Abnormal:
•Examination
•CXR
•Spirometry
Case studyCase study64 year old ladySeen by 3 respiratory consultantsReferred to cough clinic by GPTickly dry cough 2003Post nasal dripRefluxNever smoked
InvestigationsInvestigationsCXR/CT normalFEV1 normalPost Nasal DripENT review/nasal steroid/antihistamineAsthmaOral / inhaled corticosteroidsGOR3month+ omeprazole24-hr oes pH study -ve
Unexplained chronic Unexplained chronic coughcoughIdiopathic coughRefractory coughPersistent coughPsychogenic coughTic coughSensory neuropathic cough
Is she coughing?24 Hour cough monitor: LCM
Ambulatory Single coughs 24 Hours
Birring et al, ERJ 2008; 31:1013-1018
Hidden Markov Models
Automated
Adverse impact of chronic cough
Worried about serious illness 77%
Concerned something is wrong 72%
Frequent nausea 56%
Exhaustion 54%
Others think something is wrong with me 53%
Embarrassment 49%
Self-consciousness 46%
Difficulty speaking on the telephone 39%
Urine incontinence 30%
Absence from work 11%
French C et al, Arch Intern Med 1998; 158:1657
Depressive symptoms in chronic cough
0
10
20
30
40
50
60
Asthm
a
Chronic
cough
Sever
e COPD
Heart
Failu
re
Diabet
es IHD
Hyper
tensi
onCE
S-D
Sco
re >
16
(%)
Dicpinigaitis P et al, Chest 2006; 130:1839
Anxiety: HAD and STAI Anxiety: HAD and STAI scoresscores
Mc Garvey L et al, Cough 2006; 2:4
IMPACT OF COUGHIMPACT OF COUGH
IMPACT OF COUGHIMPACT OF COUGH
QOL questionnairesQOL questionnaires
KBILD
KSQ
COUGH Birring S et al, Thorax 2003; 58:339-343
ILD Patel A et al, Thorax 2012; 67:804
SARCOIDOSIS Patel A et al, Thorax 2012; In press
HRQOL: The LCQHRQOL: The LCQ
PhysicalChest pains
Sputum
Tired
Paints/fumes
Sleep
Frequency
Hoarse Voice
Energy
PsychologicalEmbarrassed
Anxious
In control
Frustrated
Fed up
Serious illness
Other people
SocialConversation
Annoy family
Job
Enjoyment
Birring S et al, Thorax 2003; 58:339-343
Cough frequency & QOL
0
20
40
60
80
100
4 6 8 10 12 14 16 18 20
LCQ scores
Co
ug
h f
req
uen
cy c
/hr
r = -0.6
Birring et al, Resp Med 2006; 100:1105-9
Gender differences in QOL
3
3.5
4
4.5
5
5.5
PHYSICAL PSYCHOLOGICAL SOCIAL
MALES
FEMALESLCQ SCORE
*p<0.05
**
Birring et al, ATS 2003
Oesophageal pressure
Abdominal EMG activity
Flow rate
Cough sound
Cough Intensity
Female patients cough Female patients cough harder during max harder during max voluntary coughvoluntary cough
Thoracic pressure Cough flow
Explosive
Intermediate
Voiced
Cough Sound
Maximum frequency
Energy
Cough Sound: a novel objective marker of Cough Sound: a novel objective marker of intensity?intensity?
Birring et al, Eur Resp J 2004; 23: 199-201
Unexplained cough or cause yet to be identified?
Enlarged tonsils
Birring et al, Resp Med 2004; 98: 242-6
Birring et al, Thorax 2003;58:533-6
Birring et al. Thorax 2005;60:249-253
Birring et al, Thorax 2003;58:1066-70
Morice et al, ERJ 2004; 24:481-92
Unexplained cough: prevalence
Most recent reports: 40%
Unexplained cough: Unexplained cough: profileprofile
•Female 70%•Onset around menopause•Cough duration, many >5 years•Poor QOL•High levels anxiety, depressive and obsessive traits
Mrs X: Treatment options for unexplained cough
•Amitriptyline
•Gabapentin
•Morphine
•Physiotherapy/Speech therapy
12
13
14
15
16
LC
Q s
core
1 2 3 4 5Visit number
Placebo Gabapentin
p=0.012
Full Treatment Period
Gabapentin: randomised controlled Gabapentin: randomised controlled trialtrial
Ryan N et al, Lancet 2012:380:1583
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 Psychology and the cough clinicclinic 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
*p=0.003 *p<0.001 *p=0.03
0
1
2
3
4
5
6
7
Physical Psychological Social
LC
Q D
om
ain
Sco
re
BeforeAfter
Chest physiotherapy for refractory chronic cough
n=23
Patel A et al; Chronic Resp Dis 2011;8:253-8
Placebo
Observation
Physiotherapy
DAY -7 0 7 14 28 56 84
Screen
Randomisation
T1 T4T3T2
VAS QOL(post)
Screen VASQOL
VAS QOL
VAS QOL CM CRS
VAS QOLCM CRS
VAS QOL(post)
Treatment
PSALTI Trial PSALTI Trial
Lee K and Birring SS. Medicine 2012;4:173-6
SummarySummaryChronic cough is a commonFrequently unexplainedHigh physical and mental health morbidityFew drug treatment optionsIntegrated physical and mental health approach
neededFuture research
-illness perception/behaviour
-Early detection of mental health problems
-Develop cough specific behavioural therapies
-Increase awareness of psychological morbidity
AcknowledgementsAcknowledgementsKing’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