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

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
CES-D Score > 16 (%)
Depressive symptoms in
chronic cough
60
50
40
30
20
10
0
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
Does your cough stop you doing the things
you would like to do?
Frequently,
28%
Do you feel fed-up or depressed because of
your cough?
Never,
10%
Never,
22%
Yes,
55%
Sometimes,
50%
Sometimes,
35%
IMPACT OF COUGH
Does your cough disturb or worry your
partner, family or friends?
Does your cough affect your quality of
life?
Not at all, 5%
Never,
8%
Severely,
22%
Yes,
61%
Sometimes,
32%
A little,
40%
Moderately,
34%
QOL questionnaires
COUGH Birring S et al,Thorax 2003; 58:339-343
KBILD
KSQ
ILD Patel A et al,Thorax 2012; 67:804
SARCOIDOSIS Patel A et al,Thorax 2012; In press
HRQOL: The LCQ
Physical
Psychological
Social
Chest pains
Embarrassed
Conversation
Sputum
Anxious
Annoy family
Tired
In control
Job
Paints/fumes
Frustrated
Enjoyment
Sleep
Fed up
Frequency
Serious illness
Hoarse Voice
Other people
Energy
Birring S et al, Thorax 2003; 58:339-343
Cough frequency c/hr
Cough frequency & QOL
100
80
60
40
r = -0.6
20
0
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
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, Thorax 2003;58:1066-70
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
16
Gabapentin: randomised controlled trial
14
13
Full Treatment Period
12
LCQ score
15
p=0.012
1
2
3
Visit number
Placebo
4
5
Gabapentin
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
Chest physiotherapy for refractory chronic cough
n=23
*p=0.003
LCQ Domain Score
7
*p<0.001
*p=0.0
3
6
5
Before
After
4
3
2
1
0
Physical
Psychological
Social
Patel A et al; Chronic Resp Dis 2011;8:253-8
PSALTI Trial
Placebo
Observation
Screen
Physiotherapy
Randomisation
DAY
-7
Screen
0
7
14
28
T1
T2
T3
Treatment
T4
VAS
QOL
CM
CRS
VAS
QOL
VAS
QOL
VAS
QOL
CM
CRS
56
84
VAS
QOL
VAS
QOL
(post)
(post)
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