Diagnosis and Treatment of Chronic

Cough

March 3, 2017

Eric M. Davis, MD
Division of Pulmonary and Critical Care Medicine
University of Virginia Health System
Presenter disclosure:

• I have no relevant financial interests to disclose

Four learning objectives

• Review the morbidity of cough and underlying pathophysiology

• New guidelines and an algorithmic approach to chronic cough

• Understand the treatment options for cough associated with reflux

disease

• Define unexplained chronic cough and review therapeutic strategies

Cough morbidity and impact:

• Why do we cough?

• How do we cough?

• Has anyone seen a patient with cough this week?

Chronic Cough - pathophysiology

• Coughing is good for the

survival of the species

• Clear the upper airway of

secretions:
– Mucus, noxious substances,
foreign particles, and infectious
organisms

• It is a complicated process:
– Inspiratory phase
– Forced expiratory effort against
closed glottis
– Opening of the glottis with rapid
expiration(sound)

Chung KJ and Pavord ID Lancet 2008

Chronic Cough - pathophysiology

• The cough reflex:

– Transient receptor potential vanilloid-1 (TRPV-1) is a capsaicin receptor

Chung KJ and Pavord ID Lancet 2008

Chronic Cough – Definitions:

• Chronic cough (> 8 weeks duration) impacts 8-10% of the adult

population

• #1 medical reason for outpatient visit in 2001-2002 as per CDC

records:

Schappert SM and Burt CW Vital Health Stat 2006 from CDC

Chung KJ and Pavord ID Lancet 2008
Gibson PG and Vertigan AE. BMJ 2015;351:h5590
Chronic Cough – Age and sex are risk factors:

• A worldwide survey of 11 cough clinics (10,000 patients)

– Female preponderance
– Females may have heightened cough reflex sensitivity

Morice AH et al. ERJ 2014

Chronic Cough – Smoking and pollution are risk factors:

• Swiss smokers cough (SAPALDIA cross-sectional study):

• Never smokers were found to have greatest risk of chronic

cough in response to environmental pollution

Zemp et al. Am J Respir Crit Care Med 1999

Chronic Cough – Why do we care?

• Chronic cough can last 6+ years on average

• It impacts quality of life: It is expensive:

Irwin RS et al. Chest 2014

French CL et al. Arch Intern Med 1998
Chronic Cough – Why do we care?

• Treatment can help with quality of life

French CL et al. Arch Intern Med 1998

Chronic Cough – What are the most common causes:

• Cough hypersensitivity syndrome (coined by Alyn Morice)

Iyer VN and Lim KG Mayo Clin Proc 2013

Gibson P and Vertigan AE BMJ 2015
Chronic Cough – How to treat?

• We often treat the 3 most common causes:

– Asthma

– Upper airway cough syndrome (post nasal drip)

– Reflux

• We often do not treat long enough.

• Patients don’t always get better!

Gibson P and Vertigan AE BMJ 2015

Chronic Cough – Are there guidelines?
Chronic Cough - Guidelines:

Gibson PG and Vertigan AE BMJ 2015

The ACCP (Chest) is in the process of updating the
cough guidelines:

Irwin RS et al Chest 2014

Approach cough with an algorithm:
Approach cough with an algorithm:

Gibson P et al. Chest 2016; 149(1):27-44

Approach cough with an algorithm:

Gibson P et al. Chest 2016; 149(1):27-44

Approach cough with an algorithm:

Gibson P et al. Chest 2016; 149(1):27-44 Kardos P and the German Respiratory Society, Pneumologie 2010
Approach cough with an algorithm:

Iyer VN and Lim KG Mayo Clin Proc 2013

Gibson P et al. Chest 2016; 149(1):27-44 Kardos P and the German Respiratory Society, Pneumologie 2010
Approach cough with an algorithm:

Unexplained chronic cough

Approach cough with an algorithm:

Iyer VN and Lim KG Mayo Clin Proc 2013 Gibson PG and Vertigan AE BMJ 2015
Approach cough with an algorithm:

• These three make up 70-90% of all chronic coughs

• Treat sequentially based on clues from history and physical
• Give yourself at least 3 months to see improvements

• Asthma
– Corticosteroids, Bronchodilators, Anticholinergics,
Avoiding triggers
• Upper airway cough syndrome (post nasal drip)
– Decongestants, Antihistamines, Anticholinergics, Nasal
steroids
• Reflux
– Diet and exercise, Lifestyle modifications, Acid
suppressing medication (?)
Gibson PG and Vertigan AE BMJ 2015
Cough and Reflux Case:

• A 42 year old man presents with dry cough for 3 months duration.
He denies any reflux symptoms or wheezing. He endorses a diet
heavy with caffeine, chocolate, and alcohol.

• On exam, he has a body mass index of 29 kg/m2, central adiposity,

and clear lung fields.

• We suspect he has reflux related cough.

• He asks the following:

– How could this be reflux associated cough if I don’t have
heartburn?
– Is my weight related?
– Can I just take a proton pump inhibitor?
Gastro-esophageal reflux triggers the cough pathway

• Reflux irritates cough receptors (even if no GI symptoms)

• Sensory receptors in the esophagus form part of the afferent limb

of an esophageal tracheobronchial cough reflex

• Giving HCL in the esophagus leads to cough

Ing et al. Am J Respir Crit Care Med 1994

Gastro-esophageal reflux triggers the cough pathway

• Reflux irritates cough receptors (even if no GI symptoms)

• Sensory receptors in the esophagus form part of the afferent limb

of an esophageal tracheobronchial cough reflex

• Even saline (without acid) can cause cough in patients

Ing et al. Am J Respir Crit Care Med 1994

Weight correlates with cough severity

• Being overweight is a risk factor for gastro-esophageal reflux and

cough.

• High calorie and fat diets associated with worse baseline cough
scores in a small weight loss clinical trial:

Higher LCQ score = Less coughing Higher LCQ score = Less coughing

Smith et al. Cough 2013

Weight loss has been shown to improve cough severity
scores

• Weight loss effectively treats cough symptoms in GERD even in

absence of PPI

• Each arm had a significant change in a cough questionnaire score

of 3.6 units or 2.5 units

Smith et al. Cough 2013

What about the role for acid suppressing medications?
Chronic Cough – PPI

• Chronic cough > 8 weeks, non smokers and no asthma

• Baseline 24h pH study, methacholine challenge test, laryngoscopy

• Esomeprazole 40 mg bid or placebo 12 weeks

• Primary outcome cough-specific quality of life questionnaire (CQLQ)

Shaheen et al. Aliment Pharmacol Ther. 2011

Chronic Cough – PPI

• 39 to 45% of patients had a positive pH study

Shaheen et al. Aliment Pharmacol Ther. 2011

Chronic Cough – PPI

• No difference in cough questionnaire between the groups at 12 weeks

Shaheen et al. Aliment Pharmacol Ther. 2011

Chronic Cough – PPI

• No difference in outcomes even when isolating the “high acid” groups

Shaheen et al. Aliment Pharmacol Ther. 2011

Proton pump inhibitors have a strong placebo effect

• Mixed results in the randomized controlled trials with strong

placebo effect of PPI therapy particularly in patients with normal
esophageal pH.

Kahrilas et al. Chest 2013

Chronic cough and reflux:

• Any trial which included weight loss and/or lifestyle modifications

had greatest impact.

• One such RCT showed that lifestyle modifications (elevate head of

bed, no food for 2h before bed, avoidance of fatty
meals/alcohol/caffeine/tobacco) and weight loss counseling
worked in PPI and control group:

Steward DL et al. Otolaryngol Head Neck Surg 2004

Chronic cough and reflux:

• ACCP updated guidelines 2016:

Summary
• Healthy weight loss
• Lifestyle modifications and reflux precautions
• PPI if the patient has heartburn or regurgitation symptoms
• No PPI if no GI symptoms

Kahrilas et al. Chest 2016

Approach cough with an algorithm:

• Asthma
– Corticosteroids, Bronchodilators, Anticholinergics,
Avoiding triggers
• Upper airway cough syndrome (post nasal drip)
– Decongestants, Antihistamines, Anticholinergics, Nasal
steroids
• Reflux
– Diet and exercise, Lifestyle modifications, Acid
suppressing medication (?)

Gibson PG and Vertigan AE BMJ 2015

Approach cough with an algorithm:

Unexplained chronic cough

Approach cough with an algorithm:

Unexplained chronic cough

Unexplained Chronic Cough Case:

• A 38 year old woman presents with chronic cough for almost 2

years. She has been treated sequentially for suspected asthma,
gastro-esophageal reflux, and post-nasal drip.

• Exam is notable for a normal BMI, normal HEENT and pulmonary

examination. She is on no medications. Chest x-ray and PFTs have
been normal.

• She wants to know the following:

– What is my diagnosis?
– Do I need therapy?
– Is there a magic pill for this cough?
Chronic cough - guidelines:

• Systemic review of RCTs

– What is the efficacy of treatment compared with usual care for
cough severity, cough frequency, and cough-related quality of life
in patients with unexplained chronic cough

• 11 RCTs, 5 systematic reviews included

Gibson P et al. Chest 2016; 149(1):27-44

Chronic cough - definition:

• CHEST Expert Cough Panel:

– Unexplained chronic cough:
– Refractory chronic cough:

Gibson P et al. Chest 2016; 149(1):27-44

Chronic cough - guidelines:

• ACCP proposed algorithm:

Gibson PG and Vertigan AE BMJ 2015 Gibson P et al. Chest 2016; 149(1):27-44
Chronic cough - guidelines:

Gibson P et al. Chest 2016; 149(1):27-44

Chronic cough - guidelines:

• There is 1 good randomized controlled trial of 87

patients.

• 4 sessions of speech therapy vs healthy lifestyle

education

Vertigan et al Thorax 2006

Chronic cough - guidelines:

• There is 1 good randomized controlled trial of 87

patients.

• 4 sessions of speech therapy vs healthy lifestyle

education

Vertigan et al Thorax 2006

Chronic cough - guidelines:

• There is 1 good randomized controlled trial of 87

patients.

• 4 sessions of speech therapy vs healthy lifestyle

education

Vertigan et al Thorax 2006

Chronic cough - guidelines:
Chronic cough - guidelines:

• 44 adults, age 45+

• 1 year of cough

• No asthma or otherwise known etiology

• Randomized and blinded to budesonide 400 mg

bid x2 weeks or placebo

• Results: nonasthmatic chronic cough had no

evidence of response to budesonide

Pizzichini et al. Can Respir J 1999

Chronic cough - guidelines:

• Cochrane review of 8 primary studies,

570 participants

• While ICS treatment resulted in a mean

decrease in cough score of 0.34
standard deviations, the quality of
evidence was low.

• International cough guidelines

recommend that a trial of ICS should
only be considered in patients with
evidence of asthma or eosinophilic
pulmonary disease

Johnstone KJ et al. Cochrane Airways Group 2013

Chronic cough - guidelines:

• Target neuronal pathways:

– Gabapentin
– Pregabalin

• Target microbiome and inflammatory

pathways:
– Azithromycin

• Target the cough reflex:

– AF-219
Unexplained chronic cough – Gabapentin:

• 62 patients randomly assigned to gabapentin (up to 1800 mg daily

dosage) or placebo

• Chronic cough > 8 weeks

– All participants had previously been treated for asthma, reflux, and rhinosinusitis
– Excluded smokers, chronic lung disease, ACE inhibitor usage, purulent sputum

• Treatment protocol:
– 5 visits over 16 weeks
– Start at 300 mg and titrate up until cough resolved or side effects intolerable

• Primary outcome was a change in cough score from baseline to 8

weeks
Ryan NM et al, Lancet 2012;380:1583-89
Unexplained chronic cough – Gabapentin:

• Cough scores were significantly improved in the gabapentin group

Ryan NM et al, Lancet 2012;380:1583-89

Unexplained chronic cough – Gabapentin:

• Side effects were more common in the gabapentin group

• 31% adverse effect rate with gabapentin (vs 10% in placebo)
• 1 patient in each arm withdrew due to side effects

Ryan NM et al, Lancet 2012;380:1583-89

Unexplained chronic cough – Pregabalin:

• Random allocation to speech therapy plus pregabalin (up to 300 mg

daily) or speech therapy plus placebo for 14 weeks

• Enrolled 40 patients with chronic cough

Vertigan AE et al. Chest 2016

Unexplained chronic cough – Pregabalin:

• Side effects were more common in the pregabalin group

Vertigan AE et al. Chest 2016

Unexplained chronic cough – Azithromycin:

• Randomized trial. 8 weeks of

treatment

• Asthmatic patients included if had

normal spirometry and no
improvement with prednisone.

• Treatment with azithromycin 500

mg daily x3 days then 250 mg
three times a week for 8 weeks

• Primary outcome was change in

cough questionnaire at week 8
Hodgson D et al. Chest 2016
Unexplained chronic cough – Azithromycin:

Hodgson et al, Chest 2016

Unexplained chronic cough – Azithromycin:

Hodgson et al, Chest 2016

Unexplained chronic cough – Emerging therapy options:

• P2X3 receptors are expressed by

airway vagal afferent nerves

• These receptors contribute to the

hypersensitization of sensory
neurons.

• Activation could lead to chronic

cough.

• AF-219 is an oral P2X3 antagonist

Abdulqawi et al. Lancet 2015
Unexplained chronic cough - guidelines:

• Take home points:

– Inhaled corticosteroids were found to be ineffective for UCC
– Proton pump inhibitors are ineffective for UCC without GERD
– Multimodality speech pathology intervention improved cough
severity
– Gabapentin is supported as a treatment recommendation

Gibson P et al. Chest 2016; 149(1):27-44

 Unexplained chronic cough case:

• A 38 year old woman presents with chronic cough for almost 2 years. She
has been treated sequentially for suspected asthma, gastro-esophageal
reflux, and post-nasal drip.

• Exam is notable for a normal BMI, normal HEENT and pulmonary

examination. She is on no medications. Chest x-ray and PFTs have been
normal.

• She wants to know the following:

– What is my diagnosis? Unexplained chronic cough
– Do I need therapy? Speech therapy may help
– Is there a magic pill for this cough? ? Gabapentin
Summary and Take Home Points:

1. Chronic cough carries significant morbidity and cost to our patients and
healthcare community

2. Asthma, upper airway cough syndrome (post-nasal drip), and reflux are
the most common causes of chronic cough

3. Trust your algorithm to guide your workup and treatment

4. The treatment of reflux cough syndrome involves diet, exercise, and

lifestyle modifications. Use of an acid suppressing medication should be
used only if dictated by GI symptoms

5. Unexplained chronic cough is difficult to treat. Longterm inhaled

corticosteroids and acid suppressing medication are not recommended.

6. Consider speech therapy and gabapentin for unexplained chronic cough.

Talk with patient about risks of gabapentin
 Thank you!
Questions or comments:

Eric M. Davis, MD
[email protected]
434-982-0405