Unexplained Chronic Cough

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. 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

9. 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

10. Depressive symptoms in chronic cough 60 50 40 CES-D Score > 16 (%) 30 20 10 0 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. 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 HRQOL: The LCQ Birring S et al, Thorax 2003; 58:339-343

16. Cough frequency & QOL 100 80 Cough frequency c/hr 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

17. Gender differences in QOL * 5.5 * 5 4.5 MALES LCQ SCORE 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: 199-201

24. 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

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 p=0.012 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

31. Chest physiotherapy for refractory chronic cough n=23 *p=0.003 *p<0.001 *p=0.03 7 6 5 Before 4 After LCQ Domain Score 3 2 1 0 Physical Psychological Social Patel A et al; Chronic Resp Dis 2011;8:253-8

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

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