1. Unexplained Chronic Cough
Dr Surinder Birring
Consultant Respiratory Physician
Honorary Senior Lecturer
King’s College Hospital & King’s College London
London

2. Outline Case study Impact on QOL Unexplained cough
Non-pharmacological therapy

3. 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

4. Causes of chronic cough
Lung cancer
COPD TB
Fibrosis
Heart failure
Sarcoidosis
Foreign body
Abnormal:
Examination
CXR
Spirometry

5. 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

6. 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

7. Unexplained chronic cough
Idiopathic cough
Refractory cough
Persistent cough
Psychogenic cough
Tic cough
Sensory neuropathic cough

8. 24 Hour cough monitor: LCM
Is she coughing?
24 Hour cough monitor: LCM
Hidden Markov Models
Ambulatory
Single coughs
Automated
24 Hours
Birring et al, ERJ 2008; 31:

9. Adverse impact of chronic cough
Worried about serious illness 77%
Concerned something is wrong 72%
Frequent nausea %
Exhaustion %
Others think something is wrong with me 53%
Embarrassment %
Self-consciousness %
Difficulty speaking on the telephone 39%
Urine incontinence %
Absence from work %
French C et al, Arch Intern Med 1998; 158:1657

10. Depressive symptoms in
chronic cough 60 50 40
CES-D Score > 16 (%) 30 20 10
IHD
Asthma
Heart Failure
Diabetes
Chronic cough
Severe COPD
Hypertension
Dicpinigaitis P et al, Chest 2006; 130:1839

11. Anxiety: HAD and STAI scores
Mc Garvey L et al, Cough 2006; 2:4

12. IMPACT OF COUGH

13. IMPACT OF COUGH

14. 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

15. HRQOL: The LCQ Physical Psychological Social 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
Birring S et al, Thorax 2003; 58:

16. Cough frequency & QOL Cough frequency c/hr LCQ scores r = -0.6
100 80
Cough frequency c/hr 60 40
r = -0.6 20 4 6 8 10 12 14 16 18 20
LCQ scores
Birring et al, Resp Med 2006; 100:1105-9

17. Gender differences in QOL
5.5 * * 5
4.5
LCQ SCORE
MALES
FEMALES 4
*p<0.05
3.5 3
PHYSICAL
PSYCHOLOGICAL
SOCIAL
Birring et al, ATS 2003

18. Cough Intensity Oesophageal pressure Flow rate Abdominal EMG activity
Cough sound

19. Female patients cough harder during max voluntary cough
Thoracic pressure
Cough flow

20. Cough Sound
Explosive
Voiced
Intermediate

21. Cough Sound: a novel objective marker of intensity?
Energy
Maximum frequency

23. Unexplained cough or cause yet to be identified?
Enlarged tonsils
Birring et al, Eur Resp J 2004; 23:

24. Birring et al, Thorax 2003;58:533-6
Birring et al, Resp Med 2004; 98: 242-6
Birring et al. Thorax 2005;60:

25. Unexplained cough: prevalence
Most recent reports: 40%
Morice et al, ERJ 2004; 24:481-92

26. Unexplained cough: profile
Female 70%
Onset around menopause
Cough duration, many >5 years
Poor QOL
High levels anxiety, depressive and obsessive traits

27. Mrs X: Treatment options for unexplained cough
Amitriptyline
Gabapentin
Morphine
Physiotherapy/Speech therapy

28. Gabapentin: randomised controlled trial
Cough quality of life measured by the Leicester cough questionnaire is represented on the y axis and again the visit number is presented on the x axis. For the LCQ there was a statistically significant improvement (p=0.012) and maximum effect of treatment on cough quality of life seen at Visit 3 (full dose). This effect was not statistically maintained (p=0.084) when the medication was reduced however a clinically significant effect (ΔLCQ>2.56) that was also seen at visit 2 remained. When the medication was withdrawn completely cough quality of life decreased and headed toward baseline value.
Full Treatment Period
Ryan N et al, Lancet 2012:380:1583

29. 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

30. 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
Covered as part of clinical physiotherapy
As we noticed with some of our chronic cough patients stress and anxiety exacerbated or sometimes triggered their cough, covering stress and anxiety has become a key element in the clinical cough suppression service that we treat our patients with her at Kings.
Jane Hutton, Helene Bellas and myself worked together to produce a booklet for our chronic cough patients on stress, anxiety and its impact on cough. It explains to the patients the effect anxiety has on the body and specifically how it can make cough worse by affecting concentration, so cough patients are less likely to identify their triggers, or remember to implement the cough suppression techniques we go through. Anxiety can also affect breathing pattern – causing us to take more swallow and fast breaths – which can also trigger cough. And anxiety can make our patients tend to focus more on coughing. Many of our cough patients are anxious or worried about going to public quite places like the cinema, for the fear they will cough which in turn tends to make them over-concentrate or focus on the cough – making them more likely to do so.
We explain this to patients as try not to think of a polar bear – more than likely a polar bear will pop into your mind.
Referral of chronic cough patients
In the past some of our chronic cough patients have been referred

31. Chest physiotherapy for refractory chronic cough7 6 5
Before 4
After
LCQ Domain Score 3 2 1
Physical
Psychological
Social
Patel A et al; Chronic Resp Dis 2011;8:253-8

32. PSALTI Trial Placebo Observation Screen Physiotherapy
Randomisation
DAY T1 T4 T3 T2
Treatment
VAS QOL(post)
Screen
VASQOL
VAS QOL
VAS QOL CM CRS
VAS QOLCM CRS

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

34. 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

35. 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