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PubMed2004

The pharmacology of cough.

Cough is an indispensable defensive reflex. Although generally beneficial, cough is also a common symptom of diseases such as asthma, chronic obstructive pulmonary disease (COPD) and lung cancer. Cough remains a major unmet medical need and, although the centrally acting opioids have remained the antitussive drug of choice for decades, such opioids possess many unwanted side-effects. However, new research into the behaviour of airway sensory nerves has provided greater insight into the mechanisms of cough and new avenues for the discovery of novel non-opioid antitussive drugs. In this article, the pathophysiological mechanisms of cough and the implications of this research for the development of novel antitussive drugs will be discussed. A poster depicting the pharmacology of cough is available online and in print as to this article.

Antitussive Agents↗
PubMed1997

A comparison of ultrasonographically detected cervical changes in response to transfundal pressure, coughing, and standing in predicting cervical incompetence.

OBJECTIVE: Our purpose was to compare various noninvasive stress techniques for their ability to elicit ultrasonographic cervical changes and to determine their efficacy in detecting ultrasonographic cervical incompetence. STUDY DESIGN: Eighty-nine patients at risk for pregnancy loss and preterm birth underwent ultrasonographic evaluation of the cervix at least twice between 15 and 24 weeks of gestation. With use of a transvaginal probe, the funnel width, funnel length, and endocervical canal length were measured in millimeters with the patient in the supine position. These measurements were repeated after three stress tests: transfundal pressure, coughing, and standing. The difference between the baseline measurements and those obtained after the stress tests were determined. A positive response to stress was defined as any decrease in endocervical canal length accompanied by an increase in funnel width and length. Improvement was defined by any increase in endocervical canal length accompanied by a decrease in funnel width and length. Cervical incompetence was defined as the presence of progressive cervical changes on ultrasonographic examinations with final endocervical canal length measurements below 26 mm. Results are reported as median (range). RESULTS: The number of positive cervical responses to transfundal pressure (19%, 17/89) was significantly greater than to coughing (3.3%, 3/89) and standing (9.0%, 8/89). The status of the cervix improved with standing in three cases, whereas this was not seen with transfundal pressure or coughing. There was no case where there was a positive response to standing or coughing and not to transfundal pressure. When the changes in funnel width and length and endocervical canal length as a result of transfundal pressure and standing in the 17 cases that responded to transfundal pressure, transfundal pressure resulted in a significantly greater increase in funnel width and length and a decrease in endocervical canal length. The efficacy of transfundal pressure in detecting the cervix that had subsequent progressive changes on ultrasonography was as follows: sensitivity 83.3%, specificity 97.2%, and positive and negative predictive values 88.2% and 95.8%, respectively. The efficacy of coughing was sensitivity 16.7%, specificity 100%, and positive and negative predictive values 100% and 85.5%, respectively. The efficacy of standing was sensitivity 33.3%, specificity 97.2%, and positive and negative predictive values 75% and 85.2%, respectively. Similar results were obtained when the analysis was confined to 37 patients who had a prior history of a midtrimester miscarriage. CONCLUSION: Transfundal pressure was the most effective technique in eliciting cervical changes during the active assessment of the cervix during pregnancy and the most sensitive in detecting the cervix that had progressive second-trimester cervical shortening during pregnancy, compared with coughing or standing position.

Adolescent↗
PubMed2000

Role of substance P and tachykinin receptor antagonists in citric acid-induced cough in pigs.

The purpose of this work was to investigate the role of tachykinins in cough induced by citric acid (0.8 M) in pigs. With this object, we have studied the effect of citric acid on substance P content in the tracheo-bronchial tree and the effects of substance P and of tachykinin receptor antagonists on citric acid-induced cough. Citric acid exposure significantly increased substance P concentration in both broncho-alveolar and tracheal lavage fluids, while it decreased significantly the substance P content in tracheal mucosa. Substance P did not elicit cough, but significantly potentiated the citric acid-induced cough frequency. Tachykinin NK(1), NK(2) or NK(3) receptor antagonists, SR 140333 (nolpitantium), SR 48968 (saredutant) and SR 142801 (osanetant), respectively, significantly inhibited citric acid-induced cough. The same inhibitory effect of tachykinin receptor antagonists was observed, when substance P was nebulised before citric acid challenge. We conclude that citric acid induces in pigs a release of substance P in the tracheo-bronchial tree, which plays a sensitising role on the cough reflex. The involvement of tachykinin NK(1), NK(2), NK(3) receptors are also demonstrated in this reflex.

Animals↗
PubMed2003

Augmentation of spontaneous cough by enalapril through up-regulation of bradykinin B1 receptors in guinea pigs.

Studies of angiotensin-converting enzyme inhibitor-induced cough have involved extensive use of experimental models in which guinea pigs are exposed to an inhaled stimulus such as capsaicin or citric acid. In the present study, we examined enalapril-induced potentiation of spontaneous cough in guinea pigs, without an inhaled stimulus. Daily oral administration of enalapril (3 mg/kg) for 20 to 30 days enhanced spontaneous cough. This enhancement of cough was inhibited by the bradykinin B(1) receptor antagonist des-Arg(10)-[Leu(9)]kallidin, but not by the bradykinin B(2) receptor antagonist icatibant. The amount of the bradykinin B(1) receptor agonist [3H]des-Arg(10)-kallidin specifically bound to membrane fractions from the trachea and larynx was increased by prolongation of the enalapril treatment, and positively correlated well with coughing frequency. In conclusion, the present results indicate that enalapril-induced cough is mediated by up-regulation of bradykinin B(1) receptors.

Animals↗
PubMed1997

Effect of 5-HT1A receptor agonist, 8-OH-DPAT, on cough responses in the conscious guinea pig.

We have studied the role for 5-hydroxytryptamine (5-HT) in the modulation of the cough reflex by examining the effect of a selective 5-HT1A receptor agonist, 8-hydroxy-2-(di-n-propylamino) tetralin (8-OH-DPAT) on cough and respiratory rate in conscious guinea pigs. Animals were placed in a box and exposed to the tussive agent citric acid (0.5 M) for 10 min, 3 min after terbutaline (0.05 mg/kg i.p.) was administered to prevent bronchoconstriction. 8-OH-DPAT inhibited at low doses (0.008 and 0.016 mg/kg) but potentiated at high doses (0.25 and 0.5 mg/kg) the citric acid-induced number of coughs, but dose-dependently increased respiratory rate. Methysergide (0.05-5 mg/kg), a 5HT1 and 5HT2 receptor antagonist, and ketanserin (0.005 mg/kg), a 5HT2 receptor antagonist, had no effects on cough or respiratory rate. Methysergide inhibited the increased cough responses and respiratory rate induced by 8-OH-DPAT at high doses, while ketanserin was without effect. These results suggest that 8-OH-DPAT may induce both in inhibition and activation of the cough reflex, the latter involving central 5HT1-receptor activation.

8-Hydroxy-2-(di-n-propylamino)tetralin↗
PubMed2000

Differential effects of cough, valsalva, and continence status on vesical neck movement.

OBJECTIVE: We tested the null hypothesis that vesical neck descent is the same during a cough and during a Valsalva maneuver. We also tested the secondary null hypothesis that differences in vesical neck mobility would be independent of parity and continence status. METHODS: Three groups were included: 17 nulliparous continent (31.3 +/- 5.6; range 22-42 years), 18 primiparous continent (30.4 +/- 4.3; 24-43), and 23 primiparous stress-incontinent (31.9 +/- 3.9; 25-38) women. Measures of vesical neck position at rest and during displacement were obtained by ultrasound. Abdominal pressures were recorded simultaneously using an intravaginal microtransducer catheter. To control for differing abdominal pressures, the stiffness of the vesical neck support was calculated by dividing the pressure exerted during a particular effort by the urethral descent during that effort. RESULTS: The primiparous stress-incontinent women displayed similar vesical neck mobility during a cough effort and during a Valsalva maneuver (13.8 mm compared with 14.8 mm; P =.49). The nulliparous continent women (8.2 mm compared with 12.4 mm; P =. 001) and the primiparous continent women (9.9 mm compared with 14.5 mm; P =.002) displayed less mobility during a cough than during a Valsalva maneuver despite greater abdominal pressure during cough. The nulliparas displayed greater pelvic floor stiffness during a cough compared with the continent and incontinent primiparas (22.7, 15.5, 12.2 cm H(2)O/mm, respectively; P =.001). CONCLUSION: There are quantifiable differences in vesical neck mobility during a cough and Valsalva maneuver in continent women. This difference is lost in the primiparous stress-incontinent women.

Adult↗
PubMed1995

Relationship between ultrasonically nebulized distilled water-induced bronchoconstriction and acetic acid-induced cough in asthmatic children.

BACKGROUND: Although wheezing and cough are the most common complaints in asthmatic persons, the mechanisms of hyperresponsiveness to bronchoconstriction and cough are nevertheless still unclear. OBJECTIVE: To investigate the common mechanisms between them, we studied the relationship between ultrasonically nebulized distilled water (UNDW) inhalation challenge and acetic acid (AA) inhalation challenge. In addition, we evaluated the effect of inhaled furosemide on both provocation tests by means of a placebo-controlled study. METHOD: In study 1 the UNDW, AA, and histamine inhalation challenges were performed in 40 asthmatic children (26 boys, aged from 7 to 16 years; mean +/- SD, 11.2 +/- 2.0 years). In study 2, 12 of the study 1 subjects (9 boys, 11.3 +/- 2.4 years) were subjected to each challenge test after inhalation of furosemide (10 mg/body square meters), or placebo (0.9% saline solution) on separate days. RESULTS: There was a good correlation between the provocative dose causing a 20% fall in forced expiratory volume in 1 second in the UNDW inhalation challenge (UNDW-PD20) and threshold dose causing cough in the AA inhalation challenge (R = 0.527; p < 0.001). There was no relationship either between UNDW-PD20 and the provocative concentration causing a 20% fall in the histamine inhalation challenge (histamine-PC20)(R = 0.384; p > 0.1), or between histamine-PC20 and the cough threshold (R = 0.308; p > 0.05). In study 2 neither bronchoconstriction nor bronchodilation after inhalation of furosemide was observed. Inhaled furosemide exerted a protective effect on UNDW-PD20 and cough threshold of the AA inhalation challenge (p < 0.01 and p < 0.01, respectively), but did not attenuate histamine-PC20 (p > 0.1). CONCLUSION: These data suggest that a common mechanism may cause hyperresponsiveness against both UNDW-induced bronchoconstriction and AA-induced cough in asthmatic children.

Acetates↗
PubMed1996

Effect of acetazolamide on cough induced by low-chloride-ion solutions in normal subjects: comparison with furosemide.

BACKGROUND: The antitussive activity of inhaled furosemide has been attributed to its blocking effect on the Na(+)-2Cl(-)-K+ cotransporter. It is likely that the antitussive activity of inhaled diuretics is more complex because amiloride, a diuretic that has no effect on the Na(+)-2Cl(-)-K+ cotransporter, also shows a significant effect against cough induced by low-chloride-ion solutions. Apart from pharmacokinetics of inhaled diuretics, this activity could also depend on the inhibition of carbonic anhydrase. OBJECTIVES: We therefore studied the effect of inhaled acetazolamide, a selective inhibitor of carbonic anhydrase activity, on cough induced by the inhalation of different chloride ion solutions in a group of normal subjects. This was compared with the antitussive effect of furosemide. In addition, we attempted to determine whether the effect of acetazolamide is dose-dependent. METHODS: Cough challenge consisted of consecutive inhalations of four solutions having decreasing concentrations of chloride ions (150, 75, 37.5 and 0 mmol/L). Nine normal subjects underwent the cough challenge 5 minutes after the inhalation of saline placebo, acetazolamide (500 mg), and furosemide (30 mg) according to a randomized, double-blind study design. A group of six subjects were challenged according to the same procedure and study design, after the inhalation of saline placebo and of two doses of acetazolamide (250 mg and 500 mg). RESULTS: Inhaled acetazolamide significantly reduced cough response to 37.5 and 0 mmol/L chloride solutions compared with placebo (p less than 0.015 and p less than 0.015, respectively). Furosemide showed a similar protective effect (p less than 0.015 and p less than 0.025, respectively). Acetazolamide provided a significantly better protective effect than furosemide (p less than 0.025 and p less than 0.015, respectively). The antitussive activity of the two doses of acetazolamide was not statistically different. CONCLUSION: These results demonstrate that inhaled acetazolamide, a selective inhibitor of carbonic anhydrase, attenuates cough induced by low-chloride-ion solutions in normal subjects. At the applied doses, its antitussive activity is slightly greater than furosemide. This finding suggests that the inhibition of carbonic anhydrase activity is likely involved in modulating changes caused by absence of a chloride ion in the airway microenvironment of human beings.

Acetazolamide↗
PubMed1998

Upper airway motor outputs during sneezing and coughing in decerebrate cats.

The purposes of the present study were to determine which upper airway movements cause a difference in the expiratory airflow pathway between sneezing and coughing, and to develop a new animal model for studying the neural mechanism of sneezing in paralyzed animals, i.e. fictive sneezing. We compared the upper airway motor patterns of sneezing and coughing, induced by electrical stimulation of the anterior ethmoidal nerve (AEN) and superior laryngeal nerve, respectively, in non-paralyzed decerebrate cats. Respiratory and laryngeal motor patterns that consisted of an inspiration phase, compression phase, and expulsion phase were observed for both sneezing and coughing. The main difference was observed in the activity of the elevator of the back of the tongue, styloglossus (SG) muscle, which was explosively activated during the expulsion phase of sneezing, whereas it was virtually silent during coughing. The nasopharyngeal closers were weakly to moderately activated during sneezing. Their activities during coughing were weaker than during sneezing. Furthermore, the AEN-induced activities of the phrenic and abdominal nerves and the lateral branch of the hypoglossal nerve (lat-XII), which innervates the SG muscle, in paralyzed cats were consistent with the activities of the diaphragm, abdominal, and SG muscles during actual sneezing in non-paralyzed cats. Thus, we conclude that tongue movement is the main difference in the motor outputs between sneezing and coughing, which probably causes greater nasal airflow in sneezing, and that it is necessary to record the activity of the lat-XII to identify fictive sneezing in paralyzed cats.

Abdominal Muscles↗
PubMed2001

[Definition and nosological aspects of chronic cough in children].

Cough is a physiological reflex occurring when sensitive receptors located in upper airways and the larynx are activated. By definition a 'chronic cough' lasts at least 3 weeks. An analysis of clinical characteristics is essential for setting up the diagnosis and giving correct treatment. We can individualize three mainly clinical aspects: the young child of less than 3 years of age, the nocturnal cough and the productive cough. The 'variant of asthma' cough is a common problem among all ages that frequently goes unrecognized. Any patient with dry nocturnal coughing that lasts more than three weeks should have an empiric bronchodilator treatment. The prognosis is on the whole favourable.

Adolescent↗
PubMed2001

[Physiopathology of the cough].

Cough is initiated from organs innervated by the vagus nerve. The larynx and the lower airways are the main sites involved in cough initiation. Cough is mainly triggered by mechanical stimuli, especially at the laryngeal level, and also by inflammatory stimuli and chemical irritants. Two receptor types are involved in the cough reflex: the irritant receptors (IR) and the C fibers. IR are directly involved in cough initiation whereas stimulated C fibers act essentially through tachykinin release, which in turn activates IR. Cough in asthma was initially thought to be related to the bronchospasm reflex, but seems in fact mainly due to airway inflammation.

Bronchial Spasm↗
PubMed2004

Comparison of objective and subjective measurements of cough frequency in patients with seasonal allergic rhinitis.

BACKGROUND: Cough is a frequent complaint of patients with a variety of respiratory disorders, including seasonal allergic rhinitis (SAR), and it is often evaluated subjectively to determine disease status and response to treatment. However, it is not known whether subjective reports of cough from patients with SAR are accurate. OBJECTIVE: To compare a novel objective measurement with subjective reports of cough frequency in a subset of 28 patients (aged > or = 12 years) with active SAR who were enrolled in a large, multicenter trial examining the efficacy of an active treatment for SAR. METHODS: In this supplemental pilot study, subjective data were collected on a diary card and objective data were collected using home-based telemetry. Three 24-hour recording sessions were conducted with each patient: 2 consecutive baseline sessions (day 1 and day 2) and 1 session after randomization to placebo or active cough treatment (day 3). RESULTS: Strong correlations existed between cough frequency data for days 1 and 2 (Spearman correlation coefficient = 0.91; P < .001) and between subjective and objective data for days 1, 2, and 3 (daytime greater than nighttime) (Spearman correlation coefficient = 0.51; P < .001). CONCLUSION: These results have implications for the design and interpretation of results from clinical trials that evaluate cough frequency as a treatment outcome.

Adolescent↗
PubMed2003

Short- and long-term reproducibility of capsaicin cough challenge testing.

The tussive agent capsaicin has achieved common usage in clinical research because it induces cough in a safe, dose-dependent, and reproducible manner. However, the reproducibility of capsaicin challenge testing has been demonstrated only in the short term (study intervals of 20 min to 14 days). In the present study, evaluation of data from several hundred cough challenges performed in the author's laboratory yielded two groups of 40 subjects. In the short-term reproducibility group, subjects underwent cough challenge at an interval of 14 days. Subjects in the long-term reproducibility group were challenged at intervals of at least 6 months (mean 16.7+/-2.4 months, range 6-62 months). All subjects were healthy adult volunteers who underwent identical cough challenge testing, which involved inhalation of incremental, doubling concentrations (microM) of capsaicin until the concentrations inducing two or more (C(2)) and five or more coughs (C(5)) were reached. Results were evaluated in terms of the percentage of subjects whose repeat studies yielded C(2) and C(5) values within one and two doubling concentrations of the initial values. Overall, reproducibility was quite good, with 90-100% of challenges yielding C(2) and C(5) values within two doubling concentrations. Short-term reproducibility of C(5) was superior to that of C(2), suggesting that C(5) is the preferred end point for trials involving serial cough challenges performed within a 14-day period.

Administration, Inhalation↗
PubMed2003

Temporal correlation between chronic cough and gastroesophageal reflux disease.

Reflux disease (GERD) and chronic cough often coexist, but a temporal correlation using the symptom association probability has not been reported. Our aim was to determine if a temporal correlation exists between cough and GERD. Sixty-one patients with chronic cough had esophageal pH monitoring with sensors 5 and 20 cm above the LES. The symptom (SI) and symptom sensitivity (SSI) indices and the symptom association probability (SAP) were used to test cough-reflux association. Pathological reflux was defined as the percentage of time pH < 4 exceeded 4.2%. A significant temporal association between cough and distal reflux was made in 35% of patients by SAP compared with only 14.8% by SI and SSI alone (P < 0.002). Patients with pathologic reflux had a greater likelihood of a temporal symptom correlation (57.1%) when not on acid-blocking medications. In conclusion, a temporal association between cough and distal reflux exists in one third of patients, especially those with pathological reflux. The SAP is a more sensitive measure of temporal association than SI or SSI.

Cough↗
PubMed1983

Depressive effect of coughing on spinal monosynaptic reflexes in conscious man.

1. The relationship between coughing and spinal monosynaptic reflexes (SMR) in extensors and flexors was investigated in eight healthy subjects by using the Hoffmann technique. Coughing exerted major depression (81% in extensor and 83% in flexor SMR). This depressant effect began simultaneously with the first cough and lasted through the coughing phase. Complete recovery to initial values occurred an average of 40 s thereafter. 2. In comparison, mental tasks induced only a slight decrease in SMR amplitude. In contrast, the Mueller and Valsalva manoeuvres induced facilitation. 3. During coughing, large variations in extensor amplitudes were observed that were coupled with the ventilatory cycle. Slight facilitation was observed during inspiration, but expiration induced pronounced depression, occurring 0.20 s after the beginning of the expiratory period. Experiments performed during baseline breathing failed to show any change throughout inspiratory or expiratory phases. 4. Chemical stimulation of irritant receptors (inhalation of citric acid) produced no specific modification of extensor responses compared with the effect of placebo inhalation (distilled water). 5. These data suggest that coughing exerts a major depressant effect on motor activity via a loop that possibly includes cardiopulmonary receptors and inhibitory supraspinal descending pathways.

Adult↗
PubMed2003

Effect of the second-generation antihistamine, fexofenadine, on cough reflex sensitivity and pulmonary function.

AIMS: Current guidelines recommend the use of first-generation antihistamines for the treatment of cough due to rhinitis/postnasal drip syndrome. The antitussive activity of the second-generation antihistamine, fexofenadine, has not been investigated. Therefore, we evaluated the effect of fexofenadine on capsaicin-induced cough in healthy volunteers and in subjects with acute viral upper respiratory tract infection (URI). METHODS: Twelve healthy volunteers and 12 subjects with URI underwent pulmonary function testing and capsaicin cough challenge on two separate days, 2 h after ingesting 180 mg fexofenadine or matched placebo. Subjects inhaled single, vital-capacity breaths of capsaicin aerosol, administered in incremental doubling concentrations, until the concentration inducing five or more coughs (C5) was determined. RESULTS: In both subject groups, C5 was not significantly different after fexofenadine compared to placebo. In subjects with URI, pulmonary function studies were also similar. In healthy volunteers, however, FEV1 and FEF(25-75), pulmonary function parameters reflecting the degree of airway dilatation, were significantly increased after fexofenadine. Mean (95% CI) values for FEV1(L) after fexofenadine and placebo were 3.16 (2.77, 3.55) and 3.08 (2.69, 3.47), respectively (P = 0.017). Mean values for FEF(25-75)(L/s) were 3.49 (3.10, 3.88) and 3.26 (2.79, 3.72), respectively (P = 0.029). CONCLUSIONS: Fexofenadine demonstrated no antitussive activity against capsaicin-induced cough in healthy volunteers and subjects with URI. The ineffectiveness of fexofenadine in suppressing cough probably reflects the lack of anticholinergic activity and central nervous system penetrance that is characteristic of first-generation antihistamines. The mild bronchodilation induced by fexofenadine in healthy volunteers is of unclear clinical significance and requires further investigation.

Adolescent↗
PubMed2002

Persistent cough in children and the overuse of medications.

OBJECTIVE: Children referred for persistent cough were evaluated for the referring and final diagnosis, and the extent of the use of medications prior to referral and the side effects encountered. METHODS: Data on children seen by respiratory paediatricians for persistent cough (> or =4 weeks) in a tertiary respiratory setting were collected prospectively over 12 months. RESULTS: Of the 49 children, 61.2% were diagnosed with asthma at referral, with similar referral rates from general practitioners and paediatricians. Children with isolated cough were just as likely to have been diagnosed with asthma as children with cough and wheeze. Medication use (asthma, gastro-oesophageal reflux and antibiotics) prior to referral was high, asthma medications were most common, and of these 12.9% had significant steroid side effects. The most common abnormality found (46.9%) was a bronchoscopically defined airway lesion, and in 56.5% of these children, another diagnosis (aspiration, achalasia, gastro-oesophageal reflux) existed. No children had a sole final diagnosis of asthma and pre-referral medications were weaned in all children. CONCLUSION: Over diagnosis of asthma and the overuse of asthma treatments with significant side effects is common in children with persistent cough referred to a tertiary respiratory clinic. Children with persistent cough deserve careful evaluation to minimize the use of unnecessary medications and, if medications are used, assessment of response to treatment is important.

Adolescent↗
PubMed2002

Chronic cough at a non-teaching hospital: Are extrapulmonary causes overlooked?

OBJECTIVE: To estimate the prevalence, assess the diagnostic approach and to identify specific causes and treatment response of chronic persistent cough (CPC) in consecutive adult patients attending the chest clinic at a non-teaching hospital in Riyadh, Saudi Arabia. METHODOLOGY: Chronic persistent cough was defined as cough persisting for more than 3 weeks. Patients were assessed clinically and investigated according to the suspected diagnosis. The specific causes were confirmed by appropriate investigations, as well as response to specific therapy. Improvement in cough following therapy was assessed subjectively by patients on a scale from 0 to 100%. RESULTS: Of 1332 patients seen in the chest clinic, 136 (10.2%; 95% confidence interval 8.6-11.8%) presented with CPC as the main complaint. One hundred patients (55% males) were assessed, after excluding 36 patients who were lost to follow up. The common presenting diagnoses (for the 81 patients who had previously consulted a physician) were upper respiratory tract infection (17.1%), asthma (15.9%), bronchitis (9.8%) and unknown in 30.8% of patients. Final diagnoses (as a sole or contributory cause) were established in 96% of patients and included rhinosinusitis (RS; 60%), asthma (26%), gastro-oesophageal reflux (GERD; 9%), postinfectious cough (8%) and bronchiectasis (5%). The agreement between the presenting and final diagnoses was generally poor, especially for extrapulmonary causes, which was as low as 5.3%. All patients, except for one, had complete or substantial improvement in the severity of cough. CONCLUSIONS: In a non-teaching hospital setting, CPC is a common benign disorder that rarely requires specialized investigations and is easily treated once the causes are identified. The multiplicity of causes and extrapulmonary triggers of CPC, particularly RS, are often overlooked. The principal causes in our series remain the same as in studies elsewhere, namely RS, asthma and GERD.

Adult↗