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

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

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 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

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

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

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; 31:1013-1018

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 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

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

IMPACT OF COUGH

IMPACT OF COUGH

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

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; 58:339-343

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

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

Cough Intensity Oesophageal pressure Flow rate Abdominal EMG activity Cough sound

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

Cough Sound Explosive Voiced Intermediate

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

Unexplained cough or cause yet to be identified? Enlarged tonsils Birring et al, Eur Resp J 2004; 23: 199-201

Birring et al, Thorax 2003;58:533-6 Birring et al, Resp Med 2004; 98: 242-6 Birring et al. Thorax 2005;60:249-253

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

Unexplained cough: profile 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

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

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 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

Chest physiotherapy for refractory chronic cough 7 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

PSALTI Trial Placebo Observation Screen Physiotherapy Randomisation DAY -7 0 7 14 28 56 84 T1 T4 T3 T2 Treatment VAS QOL(post) Screen VASQOL VAS QOL VAS QOL CM CRS VAS QOLCM CRS

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

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

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