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