Management Of Chronic Cough Research Articles

Management of chronic cough

Management of chronic cough

The discovery and development of gefapixant as a novel antitussive therapy

ABSTRACT Introduction Gefapixant, a P2X 3 receptor antagonist, shows considerable potential in managing refractory or unexplained chronic cough. Clinical trials have consistently demonstrated its efficacy in significantly reducing cough frequency and alleviating associated symptoms. However, its adverse effect profile, particularly taste disturbances such as dysgeusia and hypogeusia, the incidence of which is dose-dependent, poses a significant challenge to patient compliance and overall treatment satisfaction. Areas covered The authors review the mechanism of action of gefapixant, the dose-dependent nature of its adverse effects and the findings from various clinical trials, including Phase 1, Phase 2, and Phase 3 studies. The authors also cover its regulatory status, post-marketing data, and its main competitors. Expert opinion Gefapixant represents a significant advancement in treating chronic cough. However, balancing efficacy and tolerability is crucial. Lower effective doses and potential combination therapies may mitigate taste disturbances. Patient education and close monitoring during treatment are also important for optimal outcomes. Further research is needed to refine dosing strategies to minimize side effects while maintaining therapeutic efficacy. This research and personalized treatment approaches are key to optimizing gefapixant therapy, ensuring improved management of chronic cough while reducing adverse effects. However, pharmaceutical trials and proposals must be adapted to align with each regulatory body’s specific requirements and concerns.

Divergences in chronic cough management among healthcare professionals in Southern Italy: A comprehensive survey

Divergences in chronic cough management among healthcare professionals in Southern Italy: A comprehensive survey

Chronic cough diagnosis, treatment, and referral practices among family physicians in the United States: a survey study

BackgroundCough is one of the most common presenting problems for patients in primary care and is largely managed in primary care clinical settings. Family physicians’ familiarity with chronic cough guidelines and the extent to which these guidelines translate into everyday practice have not been well described. The objective of this study was to characterize current diagnosis, treatment, and referral practices among family physicians and to identify potentially impactful strategies to optimize chronic cough management in primary care.MethodsWe conducted a cross-sectional survey of 5,000 family physicians to explore diagnosis, treatment, and referral practices related to chronic cough management in adults in primary care. Respondents completed the survey via paper or online. The outcome measures were self-reported numeric ratings and responses related to the survey elements.Results588 surveys were completed (11.8% response rate). About half (49.6%) of respondents defined chronic cough in a manner consistent with the American College of Chest Physicians (ACCP) chronic cough guidelines, with the rest differing in opinion primarily regarding duration of symptom presentation. Respondents reported trying to rule out most common causes of chronic cough themselves before referring (mean 3.41 on a 4-point scale where 4 is “describes me completely”) and indicated a desire for more resources to help them manage and treat chronic cough. Years in practice and rural/urban setting influenced diagnosis and referral practices.ConclusionsFamily physicians see chronic cough as a complicated condition that can be and is often diagnosed and treated entirely in a primary care setting. They also value the ability to refer in complex cases. Our results support that family physicians provide evidence-based management of chronic cough.

A survey of UK respiratory specialists' opinion on the management of chronic cough.

Chronic cough is a common presentation to respiratory specialists. Here, we survey their opinion on diagnosis, investigation and management. Whilst investigations were appropriate, treatments were not guideline-based. Further education is needed. https://bit.ly/4a7W7Ay.

Cerebellar ataxia, neuropathy and vestibular areflexia syndrome: a neurogenic cough prototype.

Chronic cough is a frequent disorder that is defined by cough of more than 8 weeks duration. Despite extensive investigation, some patients exhibit no aetiology and others do not respond to specific treatments directed against apparent causes of cough. Such patients are identified as having unexplained or refractory chronic cough. Recently, a high proportion of patients with chronic cough in the context of cerebellar ataxia, neuropathy and vestibular areflexia syndrome (CANVAS) was highlighted. CANVAS is a rare neurological disorder with a biallelic variation in the replication factor C subunit 1 (RFC1) gene corresponding mostly to an intronic AAGGG repeat expansion. Chronic cough in patients with CANVAS shares similar characteristics with cough hypersensitivity syndrome. The high prevalence of chronic cough in CANVAS gives the opportunity to better understand the neurogenic mechanism of chronic cough. In this review, we will describe the characteristics and mechanisms of CANVAS. We will also address the potential mechanisms responsible for chronic cough in CANVAS. Finally, we will address chronic cough management in the context of CANVAS.

Virtual assessment and management of chronic cough: A scoping review.

Chronic cough is a frequent reason for seeking consultation with primary care providers. The recent widespread adoption of virtual care offers a promising alternative that can be used to optimize the assessment and management of this condition. The objective of this review was to map and identify the strategies used to assess and/or manage chronic cough virtually, and to explore their impact on cough severity and patient satisfaction with virtual care. A scoping review was conducted in MEDLINE, EMBASE, and CINAHL in May 2023. Research questions were defined based on the Population, Concept, Context mnemonic, and literature search was conducted using a three-step approach. Study selection involved the steps of identification, screening, eligibility, and inclusion. A descriptive synthesis was performed, and quantitative variables were presented as absolute and relative frequencies. A total of 4953 studies were identified and seven met the inclusion criteria. The following mHealth and telehealth strategies were identified: diagnostic website, specialized online clinic, online speech language therapy, and remote follow-up to assess the effectiveness of in-person interventions. Results indicated that these virtual strategies can be useful to assess chronic cough, treat, and track chronic cough symptoms. Overall, patients were satisfied with the approaches. Although literature is scarce, evidence suggests that virtual strategies for the assessment and management of chronic cough may be effective and are well-received by patients. However, further research is needed to identify the type and characteristics of virtual approaches leading to optimize and facilitate the care of patients with this condition. This will also help develop a strong body of evidence to support their incorporation into guidelines and clinical practice.

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

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. 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. 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.

Evaluation and management of chronic cough in adults

Background: Chronic cough (CC), a cough that lasts > 8 weeks, has an overall prevalence of 5‐11% in adults, peaking between 60 and 80 years of age. Of the 15% of patients who remain undiagnosed or refractory to treatment, two thirds are women. Objective: The objective was to present an updated evidence-based algorithmic approach for evaluating and managing CC, with emphasis on treatment modalities for refractory CC. Methods: A literature search was conducted of medical literature data bases for guidelines, position papers, systematic reviews, and clinical trials from January 2022 to June 2023, on the evaluation and management of CC. Results: The initial assessment should be limited to a detailed history, physical examination, chest radiograph, spirometry, exhaled nitric oxide, blood eosinophil count, and measurement of cough severity and quality of life by using validated instruments. The top diagnoses to consider are asthma, chronic obstructive pulmonary disease, nonasthmatic eosinophilic bronchitis, gastroesophageal reflux disease, and upper airway cough syndrome. Additional studies are only obtained when red flags are present or the patient fails to respond after avoidance of high-risk factors, e.g., smoking and angiotensin-converting enzyme inhibitors, and 4‐6 weeks of empiric treatment for the most likely respiratory and gastrointestinal diseases. When diagnostic tests and/or specific directed treatments fail to control CC, low-dose morphine (preferred), gabapentin, pregabalin, and/or cough control therapy are recommended. Non-narcotic purinergic 2×3 (P2×3) receptor antagonists, gafapixant and campilixant, are currently being studied for CC. Conclusion: For the evaluation and management of patients with CC, clinicians should use an algorithmic approach and identify “red flags,” reduce high-risk factors, and use empiric treatment for the five top diagnoses before extensive diagnostic testing. Current treatment for refractory cough is limited to symptomatic management.

Consensus goals and standards for specialist cough clinics: the NEUROCOUGH international Delphi study.

Current guidelines on the management of chronic cough do not provide recommendations for the operation of specialist cough clinics. The objective of the present study was to develop expert consensus on goals and standard procedures for specialist cough clinics. We undertook a modified Delphi process, whereby initial statements proposed by experts were categorised and presented back to panellists over two ranking rounds using an 11-point Likert scale to identify consensus. An international panel of 57 experts from 19 countries participated, with consensus reached on 15 out of 16 statements, covering the aims, roles and standard procedures of specialist cough clinics. Panellists agreed that specialist cough clinics offer optimal care for patients with chronic cough. They also agreed that history taking should enquire as to cough triggers, cough severity rating scales should be routinely used, and a minimum of chest radiography, spirometry and measurements of type 2 inflammatory markers should be undertaken in newly referred patients. The importance of specialist cough clinics in promoting clinical research and cough specialty training was acknowledged. Variability in healthcare resources and clinical needs between geographical regions was noted. The Delphi exercise provides a platform and guidance for both established cough clinics and those in planning stages.

Advances in clinical studies of chronic cough

Chronic cough is a common complaint in respiratory specialist clinics, with a significant impact on cough-specific quality of life and psychophysiological health. The diagnosis, treatment and management of chronic cough remains a major challenge. We summarized a series of recent advances from clinical studies in the epidemiology, diagnosis and management of chronic cough over the past year.

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.

Efficacy and safety of pharmacotherapy for refractory or unexplained chronic cough: a systematic review and network meta-analysis

Refractory chronic cough (RCC) has a significant impact on patient's health-related quality of life and represents a challenge in clinical management. However, the optimal treatment for RCC remains controversial. This study aimed to investigate and compare the efficacy and safety of the current pharmacological therapeutic options for RCC. A systematic review was performed by searching PubMed, Web of Science, Embase, and Ovid databases from January 1, 2008 to March 1, 2023. All randomised control trials (RCTs) reporting outcomes of efficacy or/and safety were included in the Bayesian network meta-analysis. Here, we compared the effects on Leicester Cough Questionnaire (LCQ), Visual Analogue Scale (VAS), and objective cough frequency of patients with RCC. Besides, we also compared the incidence of adverse events (AEs) for analysis of safety. PROSPERO registration: CRD42022345940. 19 eligible RCTs included 3326 patients and 7 medication categories: P2X3 antagonist, GABA modulator, Transient Receptor Potential (TRP) modulator, NK-1 agonist, opioid analgesic, macrolide, and sodium cromoglicate. Compared with placebo, mean difference (MD) of LCQ and 24 h cough frequency for P2X3 antagonist relief were 1.637 (95% CI: 0.887-2.387) and-11.042 (P=0.035). Compared with placebo, effect sizes (MD for LCQ and cough severity VAS) for GABA modulator were 1.347 (P=0.003) and-7.843 (P=0.003). In the network meta-analysis, gefapixant is the most effective treatment for patients with RCC (The Surface Under the Cumulative Ranking Curves (SUCRA) is 0.711 in LCQ, 0.983 in 24 h cough frequency, and 0.786 in cough severity VAS). Lesogaberan had better efficacy than placebo (SUCRA: 0.632 vs. 0.472) in 24 h cough frequency. Eliapixant and lesogaberan had better efficacy than placebo in cough severity VAS. However, TRP modulator had worse efficacy than placebo. In the meta-analysis of AEs, the present study found P2X3 antagonist had a significant correlation to AEs (RR: 1.129, 95% CI: 1.012-1.259), especially taste-related AEs (RR: 6.216, P<0.05). In this network meta-analysis, P2X3 antagonist showing advantages in terms of efficacy is currently the most promising medication for treatment of RCC. GABA modulator also showed potential efficacy for RCC but with AEs of the central system. Nevertheless, the role of TRP modulator needed to be revisited. Further research is needed to determine the potential beneficiary population for optimizing the pharmacological management of chronic cough. National Natural Science Foundation of China (81870079), Guangdong Science and Technology Project (2021A050520012), Incubation Program of National Science Foundation for Distinguished Young Scholars (GMU2020-207).

Management of cough in Canadian primary care and specialty practices: A survey of current knowledge of clinicians and allied health professionals

RATIONALE Cough is one of the most common causes for medical consultation. However, we do not know whether its management is optimal in Canada. Although guidelines are available, awareness of these and implementation of their recommendations are uncertain. OBJECTIVE The objective of this research was to evaluate the diagnostic approach and management of cough, as well as knowledge of cough guidelines in Canada. METHODS A cross-sectional online survey of general practitioners (GPs), specialists (SPs) and allied health professionals (AHPs) was conducted anonymously in Canada. Participants answered multiple-choice questions on etiology, diagnosis, follow-up and treatment (only physicians) of cough and knowledge and application of cough guidelines. MEASUREMENTS AND MAIN RESULTS A total of 248 respondents completed the survey (43 GPs, 27 SPs, and 178 AHPs). In the investigation of a patient with chronic cough, a chest radiograph was the most common test ordered by physicians (GPs: 51.2%, SPs: 59.3%) and spirometry with bronchodilator reversibility (61.2%) by AHPs. GPs most often treated cough of unknown etiology with combined inhaled corticosteroid (ICS)-long-acting β2-agonist (LABA) (25.8%) and SPs with a nasal corticosteroid (NCS)(29.8%). NCS was also the most often prescribed treatment for cough considered originating in the upper respiratory tract (GPs: 60.4%, SPs: 76.2%). When cough was believed to be due to asthma or gastroesophageal reflux disease, treatment was appropriate in most cases. Awareness of current cough guidelines content was poor in all groups (GPs: 14.0%, SPs: 51.9%, AHPs: 26.6%). CONCLUSIONS Physicians and AHPs’ knowledge and application of guidelines for the management of chronic cough remains poor.

Does hiatal hernia impact gastro-oesophageal reflux-related chronic cough?

Hiatal hernia may coexist with gastro-oesophageal reflux (GOR)-related chronic cough. This study aimed to evaluate whether the presence of hiatal hernia was related to chronic cough severity and the response to antireflux therapy. This was a retrospective analysis of data on adults with GOR-related chronic cough managed in our cough centre between 2017 and 2021. Patients who had undergone chest computed tomography (CT) and in whom follow-up data were available were included. The presence and size of hiatal hernia were assessed based on thorax CT scanning. Patients were treated with modification of diet and proton pump inhibitors. The response to treatment was assessed by the change in quality of life (QOL) measured by Leicester Cough Questionnaire (LCQ) and cough severity was measured by 100-mm visual analogue scale. 45 adults (28 female, 17 male) were included. Hiatal hernia was demonstrated in 12 (26.6%) patients. Patients with hiatal hernia did not differ from those without hiatal hernia in clinical characteristics, cough duration and severity and cough-related QOL. We found moderate positive correlations between maximal sagittal diameter of hiatal hernia and cough severity (ρ=0.692, p=0.013) and duration (ρ=0.720, p=0.008). Patients without hiatal hernia responded better to antireflux therapy, with significant LCQ improvement. A strong negative correlation between sagittal diameter of hiatal hernia gate and increase in LCQ (ρ= -0.764, p=0.004) was demonstrated. The presence of hiatal hernia identified in chest CT may impact cough severity, duration and response to antireflux treatment in patients with GOR-related chronic cough. Further prospective studies are justified to confirm significance of hiatal hernia in the management of chronic cough.

Yardstick for managing cough, part 2: In children

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 respiratory specialists. 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 evidence-based guidelines most of which have been developed from high-quality systematic reviews on how best to manage cough of all durations in adults, adolescents, and children. Chronic cough in children is often benign and self-limiting. Using established and validated protocols and specific pointers (clues in history, findings on examination) can aid the clinician in identifying causes when present and improve outcomes. In this manuscript, part 2 of the 2-part series, we provide evidence-based, expert opinion recommendations on the management of chronic cough in the pediatric patient (<14 years of age).

Canadian Health Care Professionals' Familiarity with Chronic Cough Guidelines and Experiences with Diagnosis and Management: A Cross-Sectional Survey.

Educational programs on chronic cough may improve patient care, but little is known about how Canadian physicians manage this common debilitating condition. We aimed to investigate Canadian physicians' perceptions, attitudes, and knowledge of chronic cough. We administered a 10-min anonymous, online, cross-sectional survey to 3321 Canadian physicians in the Leger Opinion Panel who managed adult patients with chronic cough and had been in practice for > 2years. Between July 30 and September 22, 2021, 179 physicians (101 general practitioners [GPs] and 78 specialists [25 allergists, 28 respirologists, and 25 ear/nose/throat specialists]) completed the survey (response rate: 5.4%). In a month, GPs saw a mean of 27 patients with chronic cough, whereas specialists saw 46. About one-third of physicians appropriately identified a duration of > 8weeks as the definition for chronic cough. Many physicians reported not using international chronic cough management guidelines. Patient referrals and care pathways varied considerably, and patients frequently experienced lost to follow-up. While physicians endorsed nasal and inhaled corticosteroids as common treatments for chronic cough, they rarely used other guideline-recommended treatments. Both GPs and specialists expressed high interest in education on chronic cough. This survey of Canadian physicians demonstrates low uptake of recent advances in chronic cough diagnosis, disease categorization, and pharmacologic management. Canadian physicians also report unfamiliarity with guideline-recommended therapies, including centrally acting neuromodulators for refractory or unexplained chronic cough. This data highlights the need for educational programs and collaborative care models on chronic cough in primary and specialist care.

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).

Current Pharmacological and Non-Pharmacological Therapies for Chronic Cough

Chronic cough, defined as cough lasting 8 weeks or longer, affects approximately 10% of adults globally, but with large global variations with prevalence estimates ranging from 2–18%. The prevalence of chronic cough in adults over the age of 45 in the Canadian Longitudinal Study of Ageing (CLSA) was 16%, the second highest in the world. Interestingly, the prevalence and incidence is higher in English speaking compared with French speaking participants. Cough is the leading cause for ambulatory and primary care visits to physicians and one of the most common reasons for referral to specialist care. Chronic cough is associated with aging, smoking, higher body mass index, use of an ACE-inhibitor, and airways diseases. More recently, novel data has shown that symptoms of depression and psychological distress independently increase the risk of developing chronic cough by approximately 20%. Data from clinical trials and observational cohort studies suggest that patients with chronic cough have a median cough frequency of 20 coughs/hr. This may lead to distressing physical, psychological and social consequences such as urinary incontinence, exhaustion, fatigue, anxiety, frustration, embarrassment and social isolation, which all impairs quality of life. Chronic cough can be challenging to treat, since most over-the-counter therapies are ineffective and current treatments for chronic cough are all considered ‘off-label’. Although most cases are due to a benign cause, chronic cough can represent a serious underlying condition. A recent Canadian consensus has identified a simplified approach which can aid in the management of chronic cough and provide treatment for refractory or unexplained chronic cough. The guiding principles of this approach include i) investigation to rule out serious underlying conditions, ii) objective testing to prevent over and under-diagnosis, iii) treatment of identifiable diseases and traits and iv) monitoring to ensure effectiveness of treatment, including minimization of side effects and appropriate titration of treatment.

Management and referral patterns for new-onset chronic cough in primary care patients.

Background: The diagnosis and management of chronic cough in primary care is challenging despite it being one of the most common chronic conditions. Objective: Clinical characterization of patients with new-onset chronic cough in the primary care setting. Methods: This was a retrospective study of adult patients (ages ≥ 18 years) with at least three visits with primary care providers (PCP) for new-onset cough, with at least 8 weeks between the first and third visits, within a tertiary-care center and affiliated clinics between January 1, 2010, and January 1, 2019 (N = 174). We calculated the frequency of primary care visits, diagnostic testing, specialist referrals, and prescribed medications up to 18 months after the third visit with a PCP for cough. Results: Of 174 patients who met the criteria of new-onset chronic cough, >50% had four or more primary care visits related to cough. Despite that, 91 (52.3%) did not receive a referral to a specialist, and 41 (23.5%) did not receive an order for a chest radiograph during the evaluation of the chronic cough. Antibiotics and systemic corticosteroids were prescribed to 106 (61%) and 63 (36%) of the patients, respectively, and 20% were prescribed opiates. No patients were prescribed central-neuromodulating agents, and angiotensin-converting enzyme inhibitors were discontinued in 48% of the patients who were taking them (12/25). Conclusion: We found considerable heterogeneity and discrepancies with clinical guideline recommendations in patients who presented with new chronic cough. There is a substantial unmet need to study chronic cough in the primary care setting to inform important stakeholders.