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Unexplained Chronic Cough Dr Surinder Birring Consultant Respiratory Physician Honorary Senior Lecturer Kings College Hospital & Kings College London.

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Presentation on theme: "Unexplained Chronic Cough Dr Surinder Birring Consultant Respiratory Physician Honorary Senior Lecturer Kings College Hospital & Kings College London."— Presentation transcript:


2 Unexplained Chronic Cough Dr Surinder Birring Consultant Respiratory Physician Honorary Senior Lecturer Kings College Hospital & Kings College London London

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

4 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

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

6 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

7 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

8 Unexplained chronic cough Idiopathic cough Refractory cough Persistent cough Psychogenic cough Tic cough Sensory neuropathic cough

9 Is she coughing? 24 Hour cough monitor: LCM AmbulatorySingle coughs24 Hours Birring et al, ERJ 2008; 31: Hidden Markov Models Automated

10 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

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

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



15 QOL questionnaires KBILD KSQ COUGH Birring S et al, Thorax 2003; 58: ILD Patel A et al, Thorax 2012; 67:804 SARCOIDOSIS Patel A et al, Thorax 2012; In press

16 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 Birring S et al, Thorax 2003; 58:

17 Cough frequency & QOL LCQ scores Cough frequency c/hr r = -0.6 Birring et al, Resp Med 2006; 100:1105-9

18 Gender differences in QOL PHYSICALPSYCHOLOGICALSOCIAL MALES FEMALES LCQ SCORE * p<0.05 * * Birring et al, ATS 2003

19 Oesophageal pressure Abdominal EMG activity Flow rate Cough sound Cough Intensity

20 Female patients cough harder during max voluntary cough Thoracic pressureCough flow

21 Explosive Intermediate Voiced Cough Sound

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


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

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

26 Morice et al, ERJ 2004; 24: Unexplained cough: prevalence Most recent reports: 40%

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

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

29 p=0.012 Full Treatment Period Gabapentin: randomised controlled trial Ryan N et al, Lancet 2012:380:1583

30 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

31 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

32 *p=0.003 *p<0.001 *p= PhysicalPsychologicalSocial LCQ Domain Score Before After Chest physiotherapy for refractory chronic cough n=23 Patel A et al; Chronic Resp Dis 2011;8:253-8

33 Placebo Observation Physiotherapy DAY Screen Randomisation T1T4T3T2 VAS QOL (post) ScreenVAS QOL VAS QOL CM CRS VAS QOL (post) Treatment PSALTI Trial

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

35 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

36 Acknowledgements Kings 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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