- Email: [email protected]
Clinical posters discussion: Summary
Pulmonary Pharmacology & Therapeutics 24 (2011) 341e343
Contents lists available at ScienceDirect
Pulmonary Pharmacology & Therapeutics journal homepage: www.elsevier.com/locate/ypupt
Clinical posters discussion: Summary Omar S. Usmani a, *, Lorcan P.A. McGarvey b a b
National Heart & Lung Institute, Imperial College London and Royal Brompton Hospital, Airway Disease Section, Dovehouse Street, London SW3 6LY, UK Department of Medicine, The Queen’s University of Belfast, Grosvenor Road, Belfast BT12 6BJ, N Ireland, UK
a r t i c l e i n f o
a b s t r a c t
Article history: Received 24 August 2010 Accepted 23 September 2010
At the Sixth International Cough Symposium, eleven clinical posters were presented at the podium in a formal symposium session. Here we summarize the posters and the discussions. Ó 2010 Elsevier Ltd. All rights reserved.
Keyword: Cough
1. Introduction For the first time this year, the posters presented at the Sixth International Cough Symposium were divided into clinical and basic research sessions and each poster was delivered at the podium in their own dedicated session. The summary presented here is a commentary of the clinical poster session and discussion, which covered a wide array of important topics in cough related to; physiology and pathophysiology, gastro-oesophageal reflux, respiratory infections and upper airways. 2. Physiology and pathophysiology The physiological mechanisms underlying cough and urinary incontinence were explored by Addington and colleagues (Addington, WR, Stephens, RE, Phelipa, MM, Ockey, RR, Fontana, G, Widdicombe, JG: Cough and urinary incontinence; observations and an hypothesis). Their paper compared the effect of voluntary cough (VC, patients instructed to take deep breath in then cough maximally) and the laryngeal expiration reflex (LER, patients instructed to breathe out then inhale nebulized tartaric acid) in female patients with stress urinary incontinence (SUI). They observed LER induced incontinence in a greater proportion of patients than VC, a larger number of leaks with LER and, incontinence was more likely to occur after the first expiratory phase of LER compared with VC. The authors previously showed that the inspiratory phase of VC was associated with guarding of the urethral sphincter [1] and they hypothesised for this study, that the first expiratory phase of LER occurred against a relaxed * Corresponding author. Tel.: þ44 207 351 8051; fax: þ44 207 351 8937. E-mail addresses: [email protected] (O.S. Usmani), [email protected] (L.P.A. McGarvey). 1094-5539/$ e see front matter Ó 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.pupt.2010.09.007
urethral sphincter, leading to greater incontinence compared to the manoeuvre of VC. In their paper, Dicpinigaitis and colleagues investigated the sensitivity of the cough reflex during an acute upper respiratory tract infection (URTI) in healthy non-smoking adults (Dicpinigaitis, P, Tibb, A, Hull, D, Qu, A: Stability of cough reflex sensitivity during acute viral upper respiratory tract infection (common cold)). Subjects underwent capsaicin cough challenge testing on two consecutive days within the first eight days of an acute URTI illness and were tested again, after 4e8 weeks, in the post-recovery phase. The authors observed cough reflex sensitivity remained stable in the acute phase of an URTI, as judged by C5 (the capsaicin concentration required to induce five coughs). Their data also confirmed previous findings [2] of a transient increase of cough reflex sensitivity during an URTI compared to healthy baseline levels. The demonstration of stability of cough reflex sensitivity during the early stages of an URTI may be relevant to potential investigators planning to evaluate the effect of antitussive treatment during an URTI. The discussion raised unanswered questions on; what was considered a clinically significant difference in C5 with regards to clinical efficacy of an antitussive agent, whether the cough reflex sensitivity remained stable over a longer period of time during an URTI and, if patients with an urge to cough followed a similar pattern. Continuing the theme on the physiological exploration of the cough reflex, Lapi and colleagues reported their paper on monitoring respiratory movements and the motor pattern of cough (Lapi, S, Calzolai, M, Fontana, GA, Biagi, E, Borgioli, G, Masotti, L: Monitoring of cardiorespiratory rates and respiratory expulsive efforts by an accelerometer in awake and sleeping humans). In their assessment, they used a portable, accelerometer-based device to monitoring breathing frequency, heart rate, voluntary expulsive respiratory efforts and postural body position in healthy subjects.
342
O.S. Usmani, L.P.A. McGarvey / Pulmonary Pharmacology & Therapeutics 24 (2011) 341e343
They demonstrated that simultaneous recordings of these parameters could be made with the portable device. It was commented that the device may be useful to study cough in awake ambulatory patients during the day and also explore the effect of postural body changes on cough. The ideal positioning of the accelerometer-based device to pick up changes in posture was discussed as, in the study, the device picked up only short periods of recordings that corresponded to changes in body position. Matsumoto and colleagues presented their paper on the triggers of cough in patients with chronic cough and explored their relation to underlying disease aetiology (Matsumoto, H, Niimi, A, Inoue, H, Ito, I, Otsuka, K, Takeda, T, Oguma, T, Nakaji, H, Tajiri, T, Iwata, T, Jinnai, M, Yamaguchi, M, Mishima, M: Triggers of cough in patients with prolonged or chronic cough and their relation to pathophysiology). They identified cough-provoking triggers in their all-cause cough population and undertook factor analysis to investigate the association of these cough triggers with causes of cough. They observed; cold air provoked cough more often in asthmatic coughers than in non-asthmatic coughers, spicy food induced cough more often in gastro-oesophageal reflux coughers than other causes of cough, patients with cold air provoked cough showed enhanced airway sensitivity to inhaled methacholine and, patients with post-nasal drip showed higher exhaled nitric oxide levels. Interestingly, in their study, cough sensitivity did not associate with any cough-provoking trigger. The data support the growing recognition of the typical irritants and noxious stimuli that aggravate cough, which may be characteristically grouped into chemical, thermal or mechanical, that can damage airway sensory nerves leading to a sensitized cough [3]. 3. Gastro-oesophageal reflux An interesting paper by Lavorini and colleagues explored a possible causative relationship between gastro-oesophageal reflux and deflation cough (Lavorini, F, Fontana, G, Chellini, E, Magni, C, Widdicombe, J: Effect of expiratory loading on changes in oesophageal pH during coughing evoked by maximal lung emptying (“deflation cough”)). They undertook simultaneous recordings of oesophageal pH and deflation cough (DC, determined through visual inspection of respiratory flow and volume tracings) during unloaded slow vital capacity manoeuvres and also during full expiration with added expiratory flow loads (2, 3 and 5 cmH2O). They observed that the appearance of DC (¼ maximal lung emptying) was usually accompanied by a fall in oesophageal pH. The most important finding was that the oesophageal pH drop preceded (by half-a second) the appearance of DC, reinforcing the notion of a causative relationship between the events. It was also observed that expiratory loading inhibited DC frequency and inhibited oesophageal acidification and that the physiological mechanisms and processes behind this needed further exploration and understanding. In their paper, Pecova and colleagues investigated the role of gastro-oesophageal reflux (GOR) on capsaicin cough reflex sensitivity in asthmatic children (Pecova, R, Michnova, T, Fabry, J, Miskovska, M, Klco, P, Tatar, M: Cough reflex sensitivity in gastrooesophageal reflux and asthma children). They compared children (i) with asthma and GOR and (ii) with asthma but no GOR. Although they found a heightened cough reflex sensitivity in both groups, there was no significant difference in cough reflex sensitivity between the groups. Although study groups were matched for gender, the median age in the GOR group was higher and subsequent discussion centred on the influence of age and gender on cough reflex sensitivity. In contrast to males cough reflex sensitivity increases in females during adolescence [4]. There was an acknowledgement of a need for better standardization of the
methodology of cough challenge testing in children, similar to that undertaken in adults [5]. 4. Respiratory infections Ogawa and Fujimura described allergic fungal cough as a possible discrete clinical entity to consider in the differential diagnosis of cough patients (Ogawa, H, Fujimura, M: Allergic fungal cough (AFC): a more severe type of fungus-associated chronic cough (FACC)). In their paper they described AFC as a unique subset of FACC [6], where AFC is characterized by sensitization with Bjerkandera adusta (B. adusta), one of the basidiomycetous (BM) fungi. BM fungi in induced sputum has been implicated in patients with idiopathic cough [7]. The authors undertook a retrospective analysis of patients with FACC, where the diagnosis of AFC was undertaken with bronchoprovocation testing and lymphocyte stimulation test using the antigenic solution of B. adusta. They observed AFC patients took longer time to achieve cough remission, but also had a greater reoccurrence of their cough compared to non-AFC patients. This important paper highlighted that AFC should be considered in patients with difficult-to-manage or idiopathic cough [8], particularly as there is a good clinical response to antifungal drugs. The prevalence of the bacterium Mycoplasma pneumoniae (MP) in children with persistent cough was investigated in the paper from Wang and colleagues (Wang, K, Harnden, A, Chalker, V, Harrison, T, Mant, D: Mycoplasma pneumoniae in children with persistent cough: a retrospective cohort study). The authors undertook a retrospective cohort study to examine cough duration, estimate the prevalence of MP and assess the diagnostic value of clinical symptoms in the detection of MP in children with persistent cough in UK general practice settings in Oxfordshire. They found a 14e28-day history of cough and the presence of headache on initial presentation in primary care suggested a diagnosis of MP and that the duration of cough was significantly shorter in children with MP than with pertussis infection. The discussion acknowledged that MP was an important cause of persistent cough, which could be found in 1 in 8 children during local epidemic periods (approximately every 4 years). 5. Upper airways Sundar and Daly presented their paper investigating the relationship between chronic cough and treatment for sleep apnoea (Sundar, KM, Daly, SE: Clinical profile of chronic cough patients improving with therapy for sleep apnoea). A causal link between the two conditions has been suggested by recent reports [9,10] and the authors undertook a retrospective analysis on their cohort of chronic cough patients to determine the characteristics, if any, of those patients with sleep apnoea that were most vulnerable to chronic cough. They reviewed data on the clinical profiles of patients whose chronic cough resolved following usage of nocturnal positive pressure, in addition to other therapies. They observed patients with sleep apnoea and chronic cough did not have any unique clinical characteristics for gender, gastro-oesophageal reflux, medical comorbidities and upper airway disease. The authors advocated that screening for sleep disordered breathing in patients with chronic cough should be considered in all middle aged adults with chronic cough. Two papers from the same academic group presented new ongoing work on the role of speech pathology intervention in cough [11]. Ryan and colleagues specifically investigated the effects of speech pathology intervention on the cough reflex in patients with refractory chronic cough (Ryan, NM, Vertigan, AE, Bone, S, Gibson, PG: Cough reflex sensitivity improves with speech-language pathology management of refractory chronic cough). Patients were assessed
O.S. Usmani, L.P.A. McGarvey / Pulmonary Pharmacology & Therapeutics 24 (2011) 341e343
before, during and after speech pathology intervention for refractory chronic cough. There were 4 treatment sessions. Following treatment, there was a significant improvement in cough related quality of life and objective automated cough frequency. Early improvements in urge to cough and capsaicin cough reflex sensitivity were also observed, that progressively decreased throughout the treatment program. In the discussion it was acknowledged that speech pathology management was an important intervention to consider for patients with refractory chronic cough and the mechanism behind cough improvement could be due to reduced laryngeal irritation. In the second paper, having identified that access to speechlanguage pathologists was limited, Vertigan and Gibson ascertained the effectiveness of a brief speech pathology treatment intervention for chronic refractory cough patients (Vertigan, AE, Gibson, PG: Development of a brief speech pathology intervention for chronic refractory cough). The intervention was based on a computer presentation education and two advising sessions with the speechlanguage pathologist. The authors observed nearly a third of patients experienced a significant reduction in their cough (judged by quality of life cough scale, cough scores, visual analogue scale, and total symptom score) and could be discharged following the initial intervention. A further 45% demonstrated improvement but required ongoing speech pathology intervention. The results demonstrated that a brief intervention may be sufficient for a proportion of patients referred to speech pathology with chronic cough. It was commented in the discussion, for both papers, that a longer term follow-up study would be very helpful to determine the duration of effect after speech pathology intervention. 6. Conclusion The papers presented were excellent and covered a diverse area of cough. They stimulated good discussion, highlighting several
343
important clinical research questions requiring further research efforts. The new format of podium presentation in a formal session was appreciated by both presenters and audience alike and is one that will be adopted for future symposia.
References [1] Addington WR, Stephens RE, Phelipa MM, Widdicombe JG, Ockey RR. Intra-abdominal pressures during voluntary and reflex cough. Cough 2008; 4:2. [2] O’Connell F, Thomas VE, Studham JM, Pride NB, Fuller RW. Capsaicin cough sensitivity increases during upper respiratory infection. Respir Med 1996;90: 279e86. [3] McGarvey L, McKeagney P, Polley L, MacMahon J, Costello RW. Are there clinical features of a sensitized cough reflex? Pulm Pharmacol Ther 2009;22: 59e64. [4] Varechova S, Plevkova J, Hanacek J, Tatar M. Role of gender and pubertal stage on cough sensitivity in childhood and adolescence. J Physiol Pharmacol 2008; 6:719e26. [5] Morice AH, Fontana GA, Belvisi MG, Birring SS, Chung KF, Dicpinigaitis PV, et al. ERS guidelines on the assessment of cough. Eur Respir J 2007;29: 1256e76. [6] Ogawa H, Fujimura M, Takeuchi Y, Makimura K. Is Bjerkandera adusta important to fungus-associated chronic cough as an allergen? eight cases’ reports. J Asthma 2009;46:849e55. [7] Ogawa H, Fujimura M, Takeuchi Y, Makimura K. The importance of basidiomycetous fungi cultured from the sputum of chronic idiopathic cough: a study to determine the existence of recognizable clinical patterns to distinguish CIC from non-CIC. Respir Med 2009;103:1492e7. [8] Haque RA, Usmani OS, Barnes PJ. Chronic idiopathic cough: a discrete clinical entity? Chest 2005;127:1710e3. [9] Chan KK, Ing AJ, Laks L, Cossa G, Rogers P, Birring SS. Chronic cough in patients with sleep-disordered breathing. Eur Respir J 2010;35:368e72. [10] Sundar KM, Daly SE, Pearce MJ, Alward WT. Chronic cough and obstructive sleep apnea in a community-based pulmonary practice. Cough 2010; 6:2. [11] Vertigan AE, Theodoros DG, Gibson PG, Winkworth AL. Efficacy of speech pathology management for chronic cough: a randomised placebo controlled trial of treatment efficacy. Thorax 2006;61:1065e9.
Contents lists available at ScienceDirect
Pulmonary Pharmacology & Therapeutics journal homepage: www.elsevier.com/locate/ypupt
Clinical posters discussion: Summary Omar S. Usmani a, *, Lorcan P.A. McGarvey b a b
National Heart & Lung Institute, Imperial College London and Royal Brompton Hospital, Airway Disease Section, Dovehouse Street, London SW3 6LY, UK Department of Medicine, The Queen’s University of Belfast, Grosvenor Road, Belfast BT12 6BJ, N Ireland, UK
a r t i c l e i n f o
a b s t r a c t
Article history: Received 24 August 2010 Accepted 23 September 2010
At the Sixth International Cough Symposium, eleven clinical posters were presented at the podium in a formal symposium session. Here we summarize the posters and the discussions. Ó 2010 Elsevier Ltd. All rights reserved.
Keyword: Cough
1. Introduction For the first time this year, the posters presented at the Sixth International Cough Symposium were divided into clinical and basic research sessions and each poster was delivered at the podium in their own dedicated session. The summary presented here is a commentary of the clinical poster session and discussion, which covered a wide array of important topics in cough related to; physiology and pathophysiology, gastro-oesophageal reflux, respiratory infections and upper airways. 2. Physiology and pathophysiology The physiological mechanisms underlying cough and urinary incontinence were explored by Addington and colleagues (Addington, WR, Stephens, RE, Phelipa, MM, Ockey, RR, Fontana, G, Widdicombe, JG: Cough and urinary incontinence; observations and an hypothesis). Their paper compared the effect of voluntary cough (VC, patients instructed to take deep breath in then cough maximally) and the laryngeal expiration reflex (LER, patients instructed to breathe out then inhale nebulized tartaric acid) in female patients with stress urinary incontinence (SUI). They observed LER induced incontinence in a greater proportion of patients than VC, a larger number of leaks with LER and, incontinence was more likely to occur after the first expiratory phase of LER compared with VC. The authors previously showed that the inspiratory phase of VC was associated with guarding of the urethral sphincter [1] and they hypothesised for this study, that the first expiratory phase of LER occurred against a relaxed * Corresponding author. Tel.: þ44 207 351 8051; fax: þ44 207 351 8937. E-mail addresses: [email protected] (O.S. Usmani), [email protected] (L.P.A. McGarvey). 1094-5539/$ e see front matter Ó 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.pupt.2010.09.007
urethral sphincter, leading to greater incontinence compared to the manoeuvre of VC. In their paper, Dicpinigaitis and colleagues investigated the sensitivity of the cough reflex during an acute upper respiratory tract infection (URTI) in healthy non-smoking adults (Dicpinigaitis, P, Tibb, A, Hull, D, Qu, A: Stability of cough reflex sensitivity during acute viral upper respiratory tract infection (common cold)). Subjects underwent capsaicin cough challenge testing on two consecutive days within the first eight days of an acute URTI illness and were tested again, after 4e8 weeks, in the post-recovery phase. The authors observed cough reflex sensitivity remained stable in the acute phase of an URTI, as judged by C5 (the capsaicin concentration required to induce five coughs). Their data also confirmed previous findings [2] of a transient increase of cough reflex sensitivity during an URTI compared to healthy baseline levels. The demonstration of stability of cough reflex sensitivity during the early stages of an URTI may be relevant to potential investigators planning to evaluate the effect of antitussive treatment during an URTI. The discussion raised unanswered questions on; what was considered a clinically significant difference in C5 with regards to clinical efficacy of an antitussive agent, whether the cough reflex sensitivity remained stable over a longer period of time during an URTI and, if patients with an urge to cough followed a similar pattern. Continuing the theme on the physiological exploration of the cough reflex, Lapi and colleagues reported their paper on monitoring respiratory movements and the motor pattern of cough (Lapi, S, Calzolai, M, Fontana, GA, Biagi, E, Borgioli, G, Masotti, L: Monitoring of cardiorespiratory rates and respiratory expulsive efforts by an accelerometer in awake and sleeping humans). In their assessment, they used a portable, accelerometer-based device to monitoring breathing frequency, heart rate, voluntary expulsive respiratory efforts and postural body position in healthy subjects.
342
O.S. Usmani, L.P.A. McGarvey / Pulmonary Pharmacology & Therapeutics 24 (2011) 341e343
They demonstrated that simultaneous recordings of these parameters could be made with the portable device. It was commented that the device may be useful to study cough in awake ambulatory patients during the day and also explore the effect of postural body changes on cough. The ideal positioning of the accelerometer-based device to pick up changes in posture was discussed as, in the study, the device picked up only short periods of recordings that corresponded to changes in body position. Matsumoto and colleagues presented their paper on the triggers of cough in patients with chronic cough and explored their relation to underlying disease aetiology (Matsumoto, H, Niimi, A, Inoue, H, Ito, I, Otsuka, K, Takeda, T, Oguma, T, Nakaji, H, Tajiri, T, Iwata, T, Jinnai, M, Yamaguchi, M, Mishima, M: Triggers of cough in patients with prolonged or chronic cough and their relation to pathophysiology). They identified cough-provoking triggers in their all-cause cough population and undertook factor analysis to investigate the association of these cough triggers with causes of cough. They observed; cold air provoked cough more often in asthmatic coughers than in non-asthmatic coughers, spicy food induced cough more often in gastro-oesophageal reflux coughers than other causes of cough, patients with cold air provoked cough showed enhanced airway sensitivity to inhaled methacholine and, patients with post-nasal drip showed higher exhaled nitric oxide levels. Interestingly, in their study, cough sensitivity did not associate with any cough-provoking trigger. The data support the growing recognition of the typical irritants and noxious stimuli that aggravate cough, which may be characteristically grouped into chemical, thermal or mechanical, that can damage airway sensory nerves leading to a sensitized cough [3]. 3. Gastro-oesophageal reflux An interesting paper by Lavorini and colleagues explored a possible causative relationship between gastro-oesophageal reflux and deflation cough (Lavorini, F, Fontana, G, Chellini, E, Magni, C, Widdicombe, J: Effect of expiratory loading on changes in oesophageal pH during coughing evoked by maximal lung emptying (“deflation cough”)). They undertook simultaneous recordings of oesophageal pH and deflation cough (DC, determined through visual inspection of respiratory flow and volume tracings) during unloaded slow vital capacity manoeuvres and also during full expiration with added expiratory flow loads (2, 3 and 5 cmH2O). They observed that the appearance of DC (¼ maximal lung emptying) was usually accompanied by a fall in oesophageal pH. The most important finding was that the oesophageal pH drop preceded (by half-a second) the appearance of DC, reinforcing the notion of a causative relationship between the events. It was also observed that expiratory loading inhibited DC frequency and inhibited oesophageal acidification and that the physiological mechanisms and processes behind this needed further exploration and understanding. In their paper, Pecova and colleagues investigated the role of gastro-oesophageal reflux (GOR) on capsaicin cough reflex sensitivity in asthmatic children (Pecova, R, Michnova, T, Fabry, J, Miskovska, M, Klco, P, Tatar, M: Cough reflex sensitivity in gastrooesophageal reflux and asthma children). They compared children (i) with asthma and GOR and (ii) with asthma but no GOR. Although they found a heightened cough reflex sensitivity in both groups, there was no significant difference in cough reflex sensitivity between the groups. Although study groups were matched for gender, the median age in the GOR group was higher and subsequent discussion centred on the influence of age and gender on cough reflex sensitivity. In contrast to males cough reflex sensitivity increases in females during adolescence [4]. There was an acknowledgement of a need for better standardization of the
methodology of cough challenge testing in children, similar to that undertaken in adults [5]. 4. Respiratory infections Ogawa and Fujimura described allergic fungal cough as a possible discrete clinical entity to consider in the differential diagnosis of cough patients (Ogawa, H, Fujimura, M: Allergic fungal cough (AFC): a more severe type of fungus-associated chronic cough (FACC)). In their paper they described AFC as a unique subset of FACC [6], where AFC is characterized by sensitization with Bjerkandera adusta (B. adusta), one of the basidiomycetous (BM) fungi. BM fungi in induced sputum has been implicated in patients with idiopathic cough [7]. The authors undertook a retrospective analysis of patients with FACC, where the diagnosis of AFC was undertaken with bronchoprovocation testing and lymphocyte stimulation test using the antigenic solution of B. adusta. They observed AFC patients took longer time to achieve cough remission, but also had a greater reoccurrence of their cough compared to non-AFC patients. This important paper highlighted that AFC should be considered in patients with difficult-to-manage or idiopathic cough [8], particularly as there is a good clinical response to antifungal drugs. The prevalence of the bacterium Mycoplasma pneumoniae (MP) in children with persistent cough was investigated in the paper from Wang and colleagues (Wang, K, Harnden, A, Chalker, V, Harrison, T, Mant, D: Mycoplasma pneumoniae in children with persistent cough: a retrospective cohort study). The authors undertook a retrospective cohort study to examine cough duration, estimate the prevalence of MP and assess the diagnostic value of clinical symptoms in the detection of MP in children with persistent cough in UK general practice settings in Oxfordshire. They found a 14e28-day history of cough and the presence of headache on initial presentation in primary care suggested a diagnosis of MP and that the duration of cough was significantly shorter in children with MP than with pertussis infection. The discussion acknowledged that MP was an important cause of persistent cough, which could be found in 1 in 8 children during local epidemic periods (approximately every 4 years). 5. Upper airways Sundar and Daly presented their paper investigating the relationship between chronic cough and treatment for sleep apnoea (Sundar, KM, Daly, SE: Clinical profile of chronic cough patients improving with therapy for sleep apnoea). A causal link between the two conditions has been suggested by recent reports [9,10] and the authors undertook a retrospective analysis on their cohort of chronic cough patients to determine the characteristics, if any, of those patients with sleep apnoea that were most vulnerable to chronic cough. They reviewed data on the clinical profiles of patients whose chronic cough resolved following usage of nocturnal positive pressure, in addition to other therapies. They observed patients with sleep apnoea and chronic cough did not have any unique clinical characteristics for gender, gastro-oesophageal reflux, medical comorbidities and upper airway disease. The authors advocated that screening for sleep disordered breathing in patients with chronic cough should be considered in all middle aged adults with chronic cough. Two papers from the same academic group presented new ongoing work on the role of speech pathology intervention in cough [11]. Ryan and colleagues specifically investigated the effects of speech pathology intervention on the cough reflex in patients with refractory chronic cough (Ryan, NM, Vertigan, AE, Bone, S, Gibson, PG: Cough reflex sensitivity improves with speech-language pathology management of refractory chronic cough). Patients were assessed
O.S. Usmani, L.P.A. McGarvey / Pulmonary Pharmacology & Therapeutics 24 (2011) 341e343
before, during and after speech pathology intervention for refractory chronic cough. There were 4 treatment sessions. Following treatment, there was a significant improvement in cough related quality of life and objective automated cough frequency. Early improvements in urge to cough and capsaicin cough reflex sensitivity were also observed, that progressively decreased throughout the treatment program. In the discussion it was acknowledged that speech pathology management was an important intervention to consider for patients with refractory chronic cough and the mechanism behind cough improvement could be due to reduced laryngeal irritation. In the second paper, having identified that access to speechlanguage pathologists was limited, Vertigan and Gibson ascertained the effectiveness of a brief speech pathology treatment intervention for chronic refractory cough patients (Vertigan, AE, Gibson, PG: Development of a brief speech pathology intervention for chronic refractory cough). The intervention was based on a computer presentation education and two advising sessions with the speechlanguage pathologist. The authors observed nearly a third of patients experienced a significant reduction in their cough (judged by quality of life cough scale, cough scores, visual analogue scale, and total symptom score) and could be discharged following the initial intervention. A further 45% demonstrated improvement but required ongoing speech pathology intervention. The results demonstrated that a brief intervention may be sufficient for a proportion of patients referred to speech pathology with chronic cough. It was commented in the discussion, for both papers, that a longer term follow-up study would be very helpful to determine the duration of effect after speech pathology intervention. 6. Conclusion The papers presented were excellent and covered a diverse area of cough. They stimulated good discussion, highlighting several
343
important clinical research questions requiring further research efforts. The new format of podium presentation in a formal session was appreciated by both presenters and audience alike and is one that will be adopted for future symposia.
References [1] Addington WR, Stephens RE, Phelipa MM, Widdicombe JG, Ockey RR. Intra-abdominal pressures during voluntary and reflex cough. Cough 2008; 4:2. [2] O’Connell F, Thomas VE, Studham JM, Pride NB, Fuller RW. Capsaicin cough sensitivity increases during upper respiratory infection. Respir Med 1996;90: 279e86. [3] McGarvey L, McKeagney P, Polley L, MacMahon J, Costello RW. Are there clinical features of a sensitized cough reflex? Pulm Pharmacol Ther 2009;22: 59e64. [4] Varechova S, Plevkova J, Hanacek J, Tatar M. Role of gender and pubertal stage on cough sensitivity in childhood and adolescence. J Physiol Pharmacol 2008; 6:719e26. [5] Morice AH, Fontana GA, Belvisi MG, Birring SS, Chung KF, Dicpinigaitis PV, et al. ERS guidelines on the assessment of cough. Eur Respir J 2007;29: 1256e76. [6] Ogawa H, Fujimura M, Takeuchi Y, Makimura K. Is Bjerkandera adusta important to fungus-associated chronic cough as an allergen? eight cases’ reports. J Asthma 2009;46:849e55. [7] Ogawa H, Fujimura M, Takeuchi Y, Makimura K. The importance of basidiomycetous fungi cultured from the sputum of chronic idiopathic cough: a study to determine the existence of recognizable clinical patterns to distinguish CIC from non-CIC. Respir Med 2009;103:1492e7. [8] Haque RA, Usmani OS, Barnes PJ. Chronic idiopathic cough: a discrete clinical entity? Chest 2005;127:1710e3. [9] Chan KK, Ing AJ, Laks L, Cossa G, Rogers P, Birring SS. Chronic cough in patients with sleep-disordered breathing. Eur Respir J 2010;35:368e72. [10] Sundar KM, Daly SE, Pearce MJ, Alward WT. Chronic cough and obstructive sleep apnea in a community-based pulmonary practice. Cough 2010; 6:2. [11] Vertigan AE, Theodoros DG, Gibson PG, Winkworth AL. Efficacy of speech pathology management for chronic cough: a randomised placebo controlled trial of treatment efficacy. Thorax 2006;61:1065e9.