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PubMed1984

Nocturnal cough in patients with chronic bronchitis and emphysema.

Patients with respiratory disease commonly report that their sleep is disrupted by nocturnal cough. We have recorded cough during the night in 10 patients with severe chronic bronchitis and emphysema (forced expiratory volume in one second, 1.0 +/- SEM 0.1/L) who complained of nocturnal cough and correlated cough with electroencephalographic sleep stage and arterial oxygenation. Cough was recorded using a directional microphone and an auto-editing tape recorder system. Each cough was subsequently verified by a listener. There was a mean of 14.6 +/- 4.5 bouts of coughing per patient per night, each bout lasting on average 3.9 +/- 0.2 s. Eighty-five percent of coughing bouts occurred during electroencephalographically confirmed wakefulness (p less than 0.02 versus sleep), and coughs during true sleep were rare, with only 1 patient coughing during rapid eye movement sleep and none during Stages 3 and 4 sleep. Cough was only once followed by arousal. There was no correlation between cough and either apneas or hypoxemia during sleep. We conclude that spontaneous cough is suppressed during sleep and only rarely awakens patients.

Adult↗
PubMed1994

Cough induced by quinapril with resolution after changing to fosinopril.

OBJECTIVE: To report a case of chronic, nonproductive cough secondary to the angiotensin-converting enzyme (ACE) inhibitor quinapril, with complete resolution after switching to another ACE inhibitor, fosinopril. DATA SOURCES: All relevant articles from January 1985 through February 1993 were identified, primarily through MEDLINE search and review of pertinent articles' bibliographies. CASE SUMMARY: A 68-year-old woman developed a dry, irritating cough within one month of starting quinapril therapy for the treatment of essential hypertension. The patient was a nonsmoker with no respiratory illnesses. The cough continued for the duration of therapy with quinapril. One month after changing to fosinopril therapy, the patient reported complete resolution of the cough. She remains cough-free to date. DISCUSSION: Cough induced by ACE inhibitors is a frequently documented adverse effect. It is severe enough to require discontinuation of therapy in 1-10 percent of patients. The cough is considered to be a class-related adverse effect with cross-reactions between ACE inhibitors routinely reported. At this time, changing to another ACE inhibitor or additive therapy with nonsteroidal antiinflammatory drugs is not recommended. Discontinuation of the ACE inhibitor results in rapid alleviation of the cough, although this is not always necessary, as most patients may experience a cessation or decrease in cough. We report a case of cough following the administration of quinapril, with complete resolution after changing to the alternative ACE inhibitor fosinopril in a patient with essential hypertension. CONCLUSIONS: Cough has been encountered commonly after the administration of ACE inhibitors. Frequency of cough is variable and although this complication has been described as a class effect, patients with a persistent, severe ACE inhibitor-induced cough may benefit from a trial of fosinopril therapy. This may be particularly useful in patients unable to tolerate an alternative class of antihypertensive agents.

Aged↗
PubMed2003

Cough augmentation with mechanical insufflation/exsufflation in patients with neuromuscular weakness.

Adults and children with neuromuscular disease exhibit weak cough and are susceptible to recurrent chest infections, a major cause of morbidity and mortality. Mechanical insufflation/exsufflation may improve cough efficacy by increasing peak cough flow. It was hypothesised that mechanical insufflation/exsufflation would produce a greater increase in peak cough flow than other modes of cough augmentation. The acceptability of these interventions was also compared. Twenty-two patients aged 10-56 yrs (median 21 yrs) with neuromuscular disease and 19 age-matched controls were studied. Spirometry was performed and respiratory muscle strength measured. Peak cough flow was recorded during maximal unassisted coughs, followed in random order by coughs assisted by physiotherapy, noninvasive ventilation, insufflation and exsufflation, and exsufflation alone. Subjects rated strength of cough, distress and comfort on a visual analogue scale. In the neuromuscular disease group, mean +/- SD forced expiratory volume in one second was 0.8 +/- 0.6 L x s(-1), forced vital capacity 0.9 +/- 0.8 L, maximum inspiratory pressure 25 +/- 16 cmH2O, maximum expiratory pressure 26 +/- 22 cmH2O and unassisted peak cough flow 169 +/- 90 L x min(-1). The greatest increase in peak cough flow was observed with mechanical insufflation/exsufflation at 235 +/- 111 L x min(-1) (p<0.01). All techniques showed similar patient acceptability. Mechanical insufflation/exsufflation produces a greater increase in peak cough flow than other standard cough augmentation techniques in adults and children with neuromuscular disease.

Adolescent↗
PubMed1997

A noninvasive electromyographic study on threshold and intensity of cough in humans.

The assessment of cough threshold and intensity is important in respiratory medicine. We have developed a method for objectively and noninvasively assessing cough threshold and intensity of expiratory muscle efforts in response to inhalation of ultrasonically nebulized distilled water (UNDW). Thirty (83%) out of 36 volunteers studied coughed in response to UNDW inhalation. Cough threshold was taken as the lowest nebulizer output (mL x min(-1)) that induced cough in two challenges performed at a 30 min interval. At threshold level, repeatability of peak and slope of the integrated electromyographic (IEMG) activity of abdominal muscles was evaluated. Short- and long-term repeatability of cough threshold were evaluated in 15 subjects following a 3 h and a 6-9 month interval, respectively. Dose-response relationships between nebulizer outputs and IEMG-related variables were also investigated, as were the correlations between the latter and expiratory flow during voluntary coughing. The median (1st and 3rd quartile) cough threshold value was 0.89 (0.40 and 1.54) mL x min(-1). At threshold level, peak and slope of IEMG activity were highly reproducible. Cough threshold displayed a high degree of short- and long-term repeatability. Peak and slope of IEMG activity displayed a clear trend to increase (p<0.01) following inhalation of progressively higher UNDW outputs. Maximum flow during voluntary coughs of varying intensity correlated with the peak (p<0.05) and, more closely, with the slope (p<0.01) of abdominal IEMG activity. The assessment of cough threshold as well as the evaluation of the intensity of cough efforts by abdominal integrated electromyographic recordings may represent useful and reliable tools for cough research in humans.

Abdominal Muscles↗
PubMed2005

Chronic idiopathic cough: a discrete clinical entity?

STUDY OBJECTIVES: Despite the success of specialist cough clinics, there is increasing recognition of a subgroup of chronic coughers in whom a diagnosis cannot be made even after thorough, systematic investigation. We call this condition chronic idiopathic cough (CIC). The aim of this study is to compare the clinical characteristics of CIC patients with those of coughers in whom a diagnosis has been established (non-CIC) to see if there is a recognizable clinical pattern that distinguishes CIC from non-CIC. DESIGN: Retrospective analysis of the medical records of chronic cough patients. SETTING: The Royal Brompton Hospital Chronic Cough Clinic, London. PATIENTS: One hundred patients with chronic cough referred to the Royal Brompton Hospital Cough Clinic between October 2000 and February 2004. RESULTS: Seventy-one percent of all patients were female. Median age was 57 years (range, 19 to 81 years), with a median duration of symptoms of 48 months (range, 2 to 384 months). The primary diagnoses were CIC (42%), postnasal drip syndromes (22%), gastroesophageal reflux disease (16%), asthma (7%), and others (13%). In CIC patients, the median age at referral, age at onset of cough, and proportion of females did not differ significantly from non-CIC patients. CIC patients had a longer median duration of cough (72 months vs 24 months, p = 0.002), were more likely to report an upper respiratory tract infection (URTI) as the initial trigger of their cough (48% vs 24%, p = 0.0014), and had a significantly lower cough threshold in response to capsaicin (log concentration of capsaicin required to induce five or more coughs, - 0.009 vs 0.592, p = 0.032) than non-CIC patients. CONCLUSIONS: Patients with CIC commonly describe a URTI that initiates their cough, which then lasts for many years, and they demonstrate an exquisitely sensitive cough reflex. We believe that CIC may be a distinct clinical entity with an as-yet unidentified underlying pathology.

Adult↗
PubMed2006

Chronic cough due to chronic bronchitis: ACCP evidence-based clinical practice guidelines.

BACKGROUND: Chronic bronchitis is a disease of the bronchi that is manifested by cough and sputum expectoration occurring on most days for at least 3 months of the year and for at least 2 consecutive years when other respiratory or cardiac causes for the chronic productive cough are excluded. The disease is caused by an interaction between noxious inhaled agents (eg, cigarette smoke, industrial pollutants, and other environmental pollutants) and host factors (eg, genetic and respiratory infections) that results in chronic inflammation in the walls and lumen of the airways. As the disease advances, progressive airflow limitation occurs, usually in association with pathologic changes of emphysema. This condition is called COPD. When a stable patient experiences a sudden clinical deterioration with increased sputum volume, sputum purulence, and/or worsening of shortness of breath, this is referred to as an acute exacerbation of chronic bronchitis as long as conditions other than acute tracheobronchitis are ruled out. The purpose of this review is to present the evidence for the diagnosis and treatment of cough due to chronic bronchitis, and to make recommendations that will be useful for clinical practice. METHODS: Recommendations for this section of the review were obtained from data using a National Library of Medicine (PubMed) search dating back to 1950, performed in August 2004, of the literature published in the English language. The search was limited to human studies, using the search terms "cough," "chronic bronchitis," and "COPD." RESULTS: The most effective way to reduce or eliminate cough in patients with chronic bronchitis and persistent exposure to respiratory irritants, such as personal tobacco use, passive smoke exposure, and workplace hazards is avoidance. Therapy with a short-acting inhaled beta-agonist, inhaled ipratropium bromide, and oral theophylline, and a combined regimen of inhaled long-acting beta-agonist and an inhaled corticosteroid may improve cough in patients with chronic bronchitis, but there is no proven benefit for the use of prophylactic antibiotics, oral corticosteroids, expectorants, postural drainage, or chest physiotherapy. For the treatment of an acute exacerbation of chronic bronchitis, there is evidence that inhaled bronchodilators, oral antibiotics, and oral corticosteroids (or in severe cases IV corticosteroids) are useful, but their effects on cough have not been systematically evaluated. Therapy with expectorants, postural drainage, chest physiotherapy, and theophylline is not recommended. Central cough suppressants such as codeine and dextromethorphan are recommended for short-term symptomatic relief of coughing. CONCLUSIONS: Chronic bronchitis due to cigarette smoking or other exposures to inhaled noxious agents is one of the most common causes of chronic cough in the general population. The most effective way to eliminate cough is the avoidance of all respiratory irritants. When cough persists despite the removal of these inciting agents, there are effective agents to reduce or eliminate cough.

Bronchitis, Chronic↗
PubMed2006

Causes and clinical features of subacute cough.

STUDY OBJECTIVES: Cough lasting > 3 weeks has been defined as chronic cough. However, it might be more persuasive to divide cough into subacute, lasting 3 to 8 weeks, and chronic, lasting > 8 weeks. We evaluated the causes and clinical courses of subacute cough, and the value of the bronchoprovocation test and induced sputum examination (IS). METHODS: Nonsmoking patients with cough of 3 to 8 weeks duration were enrolled into the study. Patients with dyspnea, basal FEV1 of < 70% predicted, abnormal findings on a plain chest radiograph or physical examination were excluded. We prescribed an antihistamine-decongestant for patients who were suspected to have postinfectious cough or postnasal drip. If patients had positive results on a bronchoprovocation test or IS, therapy with inhaled corticosteroids was substituted according to an algorithmic approach. RESULTS: One hundred eighty-four patients (77 men and 107 women) were evaluated; the mean age of the study group was 47.5 years. Eighty-nine of 184 patients had postinfectious cough. Cough resolved without treatment in 62 patients. Twenty-nine of 43 patients with positive bronchoprovocation test results had cough-variant asthma. CONCLUSIONS: Postinfectious cough was the most common cause of subacute cough. The spontaneous resolution of cough was frequent in patients with subacute cough. Unless asthma was strongly suspected, the performance of the bronchoprovocation test could be delayed until after empirical treatment had been administered.

Acute Disease↗
PubMed2003

[Assessment of cough threshold in patients with gastroesophageal reflux disease].

The aim of this study was the assessment of citric acid cough threshold in patients with chronic cough due to GERD, confirmed by 24-hour esophageal pH- monitoring, with other reasons of chronic cough excluded. Thirty subjects with chronic cough due to GERD and 15 healthy volunteers underwent cough challenge with doubling concentrations of citric acid using Asthma Provocation System (Jaeger). The cough threshold was defined as the first concentration of citric acid that induced cough. Spirometric parameters (FEV, PEF and FVC) were measured before and 10 minutes after cough challenge in all groups. A day and night cough score diaries (verbal category descriptive score) were completed in all subjects. The cough threshold was significantly lower in GERD patients in comparison with healthy volunteers. In GERD patients the negative correlation was found between day cough score measurements and cough threshold. Citric acid cough challenge did not cause bronchoconstriction or any significant change of spirometric parameters.

Administration, Inhalation↗
PubMed2006

[An epidemiologic study of cough in young college students in Guangzhou].

OBJECTIVE: To study the prevalence of cough and its risk factors in young college students in Guangzhou. METHODS: Using a questionnaire with uniform scheme, a cluster-randomized sampling survey was conducted among young college students in Guangzhou. Fluoroscopy of chest was performed in subjects with persisted cough longer than 8 weeks. RESULTS: There were 1087 cases with complete data from 1091 people including 648 males, 439 females with an average age of 21.16 years old. The total prevalence of cough was 10.9%. Difference in prevalence of cough between males and females showed no significance (10.3% vs. 11.9%, P > 0.05). There were also no significant differences between male and female in prevalence rates of acute cough (6.9% vs. 8.7%, P > 0.05) and chronic cough (3.4% vs. 3.2%, P > 0.05). Under chronic cough condition, cough was more likely to be the only or major symptom than under acute cough condition (77.8% vs. 44.6%, chi(2) = 11.166, P < 0.01). Nasal disease was an important risk factor to the development of chronic cough, which was found in 33.3% of the patients with chronic cough and when having chronic nasal diseases. CONCLUSION: Cough seemed a common disorder in young college student in Guangzhou and there was no significant difference in prevalence between males and females. Nasal disease was an important risk factor to chronic cough.

China↗
PubMed2006

"Post-nasal drip syndrome": most patients with purulent nasal secretions do not complain of chronic cough.

INTRODUCTION: Post-nasal drip syndrome (PNDS) is quoted as a common cause of chronic cough. However, there is little evidence to explain the mechanism by which PNDS may stimulate the cough reflex. This cohort study looks at patients with purulent nasal secretions, who may best represent any potential candidate for PNDS, and observes the frequency of symptomatic coughing. METHODS: One-hundred and eight consecutive patients referred to a rhinology clinic with symptoms of chronic infective rhinosinusitis, all with purulent nasal secretions identified on nasendoscopy, were observed through investigation and treatment. Patients were initially treated with broad-spectrum antibiotics and nasal douching. The frequency of coughing was recorded pre- and post- treatment. RESULTS: Eighty-nine percent of patients complained of post-nasal secretions. Twenty-three (21%) patients complained of cough. Eight had co-existing asthma, 3 had bronchiectasis, 1 had sarcoid and 2 had had a recent respiratory tract infection. Therefore 9 patients (8%) had purulent nasal secretions and a cough with no other discernable pathology. Cough improved in 8 of the 9 patients following treatment. Cough improved in 9 of the 14 patients with other possible co-existing causes for cough. CONCLUSIONS: Only a small proportion of patients with purulent rhinosinusitis without coexisting chest disease complain of cough. Although nasal disease may be a genuine cause for chronic cough it is unlikely to be as common a cause as has been reported. Postnasal secretions do not appear to be an adequate cause for cough and the term 'PNDS' should be replaced by rhinosinusitis when nasal disease is the cause of chronic cough.

Adolescent↗
PubMed1994

[Capsaicin-induced cough. Tachyphylaxis and the effect of anaesthesia on the pharynx].

We examined the reproducibility of capsaicin-induced cough thresholds and the influence of pharynx anaesthesia used to treat the cough. We performed cough threshold tests on ten patients with bronchial asthma and ten patients with chronic cough. The lowest level of capsaicin-induced cough threshold was defined as ten coughs. Tachyphylaxis in cough thresholds was examined three times at intervals of 30 minutes and 120 minutes after the initial test. We measured cough thresholds before and after pharynx anaesthesia with xylocainbiscus. There was no change in cough thresholds among the three times; nor was them any change in the thresholds before and after pharynx anaesthesia. But in five patients with acute pharyngitis, the cough thresholds after pharynx anaesthesia were greater than before. It was suggested that cough threshold tests had reproducibility 30 minutes and 120 minutes after indicating that tachyphylaxis did not exist. Furthermore it was suggested that pharynx anaesthesia influenced the cough threshold in patients with acute inflammation of the pharynx, but anesthesia had no influence on cough thresholds in patients without acute inflammation of the pharynx.

Adult↗
PubMed1996

[The effect of experimental gastroesophageal reflux on the cough reflex in anesthetized cats].

BACKGROUND: Gastroesophageal reflux (GER) is a common cause of chronic cough. It has been suggested that GER most often causes chronic cough by stimulating the distal oesophagus. Possible mechanisms of this interactive process are: a) an oesophageal-tracheobronchial reflex, b) acid reflux seems to be only a cofactor of cough; it decreases cough threshold. AIM: To evaluate the effects of experimental GER on the cardiorespiratory parameters and on the cough induced by mechanical stimulation of airways mucosa in anaesthetised cats. METHODS: In 10 adults cats of either sex, mean body weight 2.4 +/- 0.2 kg, anaesthetised with pentobarbitone sodium (30 mg/kg b.w., i.p.), oesophageal pressure, blood pressure, and volume tidal were recorded. 2 ml 0.1 N HCl was instilled into the isolated thoracic oesophagus with preserved innervation over a period of 5 minutes. The cough was induced by the insertion of nylon fibre into the airways and its intensity was evaluated from the changes in oesophageal pressure. Cough challenge was also repeated during intraesophageal instillation of 2 ml capsaicin (350 mumol/l). The parameters of cough intensity elicited during experimental GER were compared with the control cough parameters obtained during intraesophageal instillation of 2 ml physiological saline. RESULTS: Intraesophageal instillation of either HCl or capsaicin was accompanied by the contractions of oesophageal wall and by the fluctuations in volume tidal. These changes were more pronounced after capsaicin challenge. There was no induction of either cough or other respiratory reflexes with forced expiration during the experimental GER. In other part of this study there were not obtained any significant differences of the intensity of mechanically-induced cough during intraesophageal instillation of physiological saline, HCl, and capsaicin. CONCLUSION: The oesophageal-tracheobronchial reflex mechanism for either induction or modulation of cough is not present in healthy anaesthetised cats. We agree with previous data that GER alone is not trigger agent of cough. (Fig. 5, Ref. 17.)

Anesthesia↗
PubMed1997

Interpretation of positive results of a methacholine inhalation challenge and 1 week of inhaled bronchodilator use in diagnosing and treating cough-variant asthma.

BACKGROUND: In diagnosing cough due to asthma, methacholine chloride inhalation challenge (MIC) interpreted in a traditional fashion has been shown to have positive predictive values from 60% to 82%. OBJECTIVE: To determine whether any features of positive results of an MIC or the results of a 1-week trial of inhaled beta-agonist therapy were helpful in predicting when the cough was due to asthma. METHODS: The study design was a prospective, randomized, double-blind, placebo-controlled, crossover format performed in adult, nonsmoking subjects, who were referred for diagnosis and treatment of chronic cough. The subjects had no other respiratory complaints or medical conditions for which they were taking medications, the results of baseline spirometry and chest roentgenograms were normal, and the results of MIC were positive. After obtaining baseline data, including MICs on 2 separate days, objective cough counting, and self-assessment of cough severity using a visual analog scale, subjects were randomized to receive 2 inhalations (1.3 mg) of metaproterenol sulfate or placebo by metered dose inhaler attached to a spacer device every 4 hours while awake. At 1 week, data identical to baseline were collected, and subjects received the other metered dose inhaler for 7 days. At 1 week, data identical to baseline were collected. After completion of the protocol, subjects were followed up in the clinic to observe the final response of the cough to specific therapy. RESULTS: Based on the disappearance of the cough with specific therapy, the cough was due to asthma in 9 of 15 subjects and nonasthma in 6 of 15 subjects. Baseline data were similar between groups. With respect to MICs, there were no significant differences between groups in the cumulative dose of methacholine that provoked a 20% decrease in forced expiratory volume in 1 second from the postsaline baseline value (PD20 values), slopes of dose-response curves, and maximal-response plateaus. Cough severity significantly improved after 1 week of metaproterenol use compared with the severity of the cough at baseline (P = .03) and with placebo (P = .02) only in subjects with asthma. CONCLUSIONS: No matter how the results are analyzed, positive MIC results, without observing response to therapy, are only consistent with asthma as the cause of the cough. The results are only diagnostic of asthma when they are followed by a favorable response to asthma therapy. After 1 week of inhaled beta-agonist, only the cough due to cough-variant asthma is significantly better.

Administration, Inhalation↗
PubMed2005

Evaluation of an ambulatory system for the quantification of cough frequency in patients with chronic obstructive pulmonary disease.

BACKGROUND: To date, methods used to assess cough have been primarily subjective, and only broadly reflect the impact of chronic cough and/or chronic cough therapies on quality of life. Objective assessment of cough has been attempted, but early techniques were neither ambulatory nor feasible for long-term data collection. We evaluated a novel ambulatory cardio-respiratory monitoring system with an integrated unidirectional, contact microphone, and report here the results from a study of patients with COPD who were videotaped in a quasi-controlled environment for 24 continuous hours while wearing the ambulatory system. METHODS: Eight patients with a documented history of COPD with ten or more years of smoking (6 women; age 57.4 +/- 11.8 yrs.; percent predicted FEV1 49.6 +/- 13.7%) who complained of cough were evaluated in a clinical research unit equipped with video and sound recording capabilities. All patients wore the LifeShirt system (LS) while undergoing simultaneous video (with sound) surveillance. Video data were visually inspected and annotated to indicate all cough events. Raw physiologic data records were visually inspected by technicians who remained blinded to the video data. Cough events from LS were analyzed quantitatively with a specialized software algorithm to identify cough. The output of the software algorithm was compared to video records on a per event basis in order to determine the validity of the LS system to detect cough in COPD patients. RESULTS: Video surveillance identified a total of 3,645 coughs, while LS identified 3,363 coughs during the same period. The median cough rate per patient was 21.3 coughs.hr-1 (Range: 10.1 cghs.hr(-1) - 59.9 cghs.hr(-1)). The overall accuracy of the LS system was 99.0%. Overall sensitivity and specificity of LS, when compared to video surveillance, were 0.781 and 0.996, respectively, while positive- and negative-predictive values were 0.846 and 0.994. There was very good agreement between the LS system and video (kappa = 0.807). CONCLUSION: The LS system demonstrated a high level of accuracy and agreement when compared to video surveillance for the measurement of cough in patients with COPD.

Journal Article↗
PubMed2006

Anti-histamines for prolonged non-specific cough in children.

BACKGROUND: Non-specific cough is defined as non-productive cough in the absence of identifiable respiratory disease or known aetiology. It is commonly seen in paediatric practice. These children are treated with a variety of therapies including anti-histamines. Also, anti-histamines are advocated as an empirical treatment in adults with chronic cough. OBJECTIVES: To evaluate the effectiveness of anti-histamines in treating children with prolonged non-specific cough. SEARCH STRATEGY: The Cochrane Register of Controlled Trials (CENTRAL), MEDLINE, OLDMEDLINE and EMBASE databases were searched by the Cochrane Airways Group. The latest searches were performed in November 2005. SELECTION CRITERIA: All randomised controlled trials comparing anti-histamines with a placebo or placebo-like medication with cough as an outcome, where cough is not primarily related to an underlying respiratory disorder such as cystic fibrosis, asthma, or suppurative lung disease. DATA COLLECTION AND ANALYSIS: Results of searches were reviewed against pre-determined criteria for inclusion. Two independent reviewers selected, extracted and assessed data for inclusion. Three eligible trials were identified. MAIN RESULTS: The three included studies varied in age of subjects, sample size, inclusion criteria, type of anti-histamine and length of intervention. These 3 studies included 182 randomised subjects with 162 completing the trials although in one study, children with recurrent wheeze were also included. Clinical heterogeneity was evident and limited data prevented combining data for meta-analysis. The two larger studies described significant improvement in both the intervention and the placebo/placebo-like arms with no significant difference between the two groups. In the study with the smallest sample size, cetirizine (a second generation anti-histamine) was significantly more efficacious than placebo in reducing chronic cough in children associated with seasonal allergic rhinitis, and the effect was seen within 2 weeks of therapy. AUTHORS' CONCLUSIONS: This review has significant limitations. However, our finding of uncertain efficacy of anti-histamines for chronic cough are similar to that for acute cough in children. In contrast to recommendations in adults with chronic cough, anti-histamines cannot be recommended as empirical therapy for children with chronic cough. If anti-histamines were to be trialled in these children, current data suggest a clinical response (time to response) occurs within 2 weeks of therapy. However the use of anti-histamines in children with non-specific cough has to be balanced against the well known risk of adverse events especially in very young children.

Child↗
PubMed1994

Angiotensin-converting enzyme inhibitors and cough: a prospective evaluation in hypertension and in congestive heart failure.

Angiotensin-converting enzyme inhibitors (ACE-I) have become the mainstem of antihypertensive therapy and first-choice agents for vasodilatation in congestive heart failure (CHF). A typical dry cough is the main cause for discontinuation of ACE-I therapy. Data about the incidence, course, and clinical significance of this side effect are conflicting. This study determined the incidence of cough in ACE-I treated patients with hypertension and with CHF and to appreciate its clinical significance; 268 ACE-I treated patients, 164 with hypertension and 104 with CHF were prospectively followed for at least 1 year and specifically questioned about cough and other side effects. In those in whom cough developed, a second and then a third ACE-I were tried. Cough developed in 50 (18.6%) of the 268 patients; 23 patients with hypertension (14%) had coughs 24.7 +/- 17.1 (SD) weeks after initiation of therapy; 27 patients with CHF (26%) had coughs 12.3 +/- 12 (SD) weeks after the start of ACE-I therapy (P = 0.005). All but three patients had coughs also on the second and third ACE-I. The time from the beginning of therapy to the onset of cough was significantly shorter with the second than the first drug. ACE-I agents had to be discontinued in 50% of the patients in whom coughs developed, most of them in the CHF group. In the others, cough was well tolerated or disappeared during subsequent months. The incidence of cough, which necessitated discontinuation of ACE-I treatment, was 4% among patients with hypertension and 18% among patients with CHF (P < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed2002

Extrathoracic airway responsiveness in children with asthma-like symptoms, including chronic persistent cough.

Asthma-like symptoms, including chronic persistent cough, are not always specific for classical asthma. In order to investigate whether assessment of extrathoracic airway hyperresponsiveness (EAHR) during methacholine bronchial challenge helped in the evaluation of pediatric patients with asthma-like symptoms such as chronic cough, we examined 133 consecutive, unselected patients (mean age, 10.06 +/- 2.16 years) who had neither established asthma nor bronchial obstruction previously. We recorded the forced mid-inspiratory flow (FIF(50)) as an index of extrathoracic airway narrowing. In addition, a 25% decrease in FIF(50) (PD(25)FIF(50)) below the cutoff concentration of < or = 8 mg/mL methacholine was assumed to indicate EAHR. According to the methacholine response, 81 patients had EAHR, and 41 of them had combined EAHR and bronchial hyperresponsiveness (BHR); 39 patients had only BHR. Airway hyperresponsiveness was not demonstrated in 13 patients and not in any of the control children. When patients with cough as the sole presenting symptom (60.9%) were compared with those with cough and wheeze (20.3%), those with cough alone had a significantly greater probability of having EAHR (OR, 4.16; 95% CI, 1.32-13.13) and a lower probability of having BHR (OR, 0.70; CI, 0.25-1.95) than those with cough and wheeze. Patients with cough, wheeze, and dyspnea (18.8%) had a significantly greater chance of having BHR than those with cough alone (OR, 5.08; CI, 1.55-16.64). Patients with cough and wheeze as compared with those with cough, wheeze, and dyspnea had significantly greater probability of having both EAHR and BHR (OR, 4.71; CI, 1.94-11.47). In order to ascertain the clinical relevance of EAHR, we assessed in the second part of the study whether the effects of treatment of the underlying disease would result in relief of airway hyperresponsiveness. Rhinosinusitis and perennial allergic rhinitis accounted for EAHR in 71 patients, and 34 of them also demonstrated BHR. They received specific therapy for their upper airway diseases for 4 weeks. Compared with values before treatment, FIF(50) and forced expiratory volume in 1 sec (FEV(1)) did not change significantly. The dose of methacholine causing a 20% fall in FEV(1) (PD(20)FEV(1)) and PD(25)FIF(50) values were significantly increased from 2.40 +/- 1.39 to 4.22 +/- 1.13 mg /mL (P < 0.001) and from 1.03 +/- 1.75 to 8.71 +/- 1.21 mg /mL (P < 0.0001), respectively. We conclude that measurements of EAHR and BHR are the most important ways to evaluate children with asthma-like symptoms, including chronic persistent cough when chest X-rays and pulmonary function tests remain within normal limits. Therefore, empirical treatment is not necessary when these investigations are available. Our results suggest that specific treatment of inflammation in the upper airways reversed persistant cough, and may play an important role in modulating lower airways responsiveness in patients with concomitant BHR.

Adolescent↗
PubMed2002

Water aerosols and cough.

Inhalation of ultrasonically nebulised distilled water (fog) induces cough; however, the receptor type(s) mediating this reflex are poorly defined. In humans, cough threshold can be determined by inhalation of progressively increasing fog concentrations; the intensity of the associated motor response can be indexed in terms of flow-related variables as well as of the peak and slope of the integrated electromyographic activity of the abdominal muscles. We have evaluated coughing in patients with Parkinson's disease who show a high incidence of serious chest infections. These patients turned out to have a normal cough threshold but reduced expiratory muscle force during reflex coughing; this suggests an impairment in the central mechanisms subserving muscle activation possibly leading to inefficient airway clearing. Recurrent chest infections also affect laryngectomised patients. These patients have a normal cough threshold but reduced muscle force during coughing in response to threshold stimuli. Voluntary coughing is preserved in these patients, and this should be used to facilitate mucus removal. In normal subjects, fog inhalation causes cough and increases in respiratory drive and minute ventilation, mainly accounted for by increases in tidal volume, possibly due to activation of airway rapidly adapting receptors. Nedocromil sodium administration increases cough threshold and attenuates the ventilatory responses. The assessment of sensory and motor components of coughing may represent a useful tool for those investigating cough in humans.

Aerosols↗