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• W2294839194 abstract "FOR RELATED ARTICLE SEE PAGE 639Various terms are used to describe a chronic cough that has no obvious medical explanation; these terms include chronic refractory cough, chronic idiopathic cough, and chronic persistent cough. The terminology in this topic is challenging and a general problem in scientific reports, all of which describe a condition that is often misdiagnosed and unsuccessfully treated. FOR RELATED ARTICLE SEE PAGE 639 Unexplained chronic cough (UCC) is a frustrating condition not only for the patients but also for physicians involved in efforts to treat these patients. Although non-life-threatening, chronic cough influences social activity and quality of life.1Irwin R.S. French C.T. Fletcher K.E. Quality of life in coughers.Pulm Pharmacol Ther. 2002; 15: 283-286Crossref PubMed Scopus (44) Google Scholar Most patients with significant symptoms have been extensively examined and have tried a variety of asthma, COPD, and cough medications. Treatment failure is more the rule than the exception, despite evident links between a number of respiratory conditions and aspects of coughing. In recent years, a new concept of cough hypersensitivity as a clinically useful paradigm has been developed to categorize patients with chronic cough under the “umbrella” of cough hypersensitivity syndrome (CHS). CHS comprises patients who have a chronic cough that is often triggered by low levels of thermal, mechanical, or chemical exposure, with or without pathologic medical findings.2Morice A.H. Millqvist E. Belvisi M.G. et al.Expert opinion on the cough hypersensitivity syndrome in respiratory medicine.Eur Respir J. 2014; 44: 1132-1148Crossref PubMed Scopus (212) Google Scholar CHS is closely related to the condition described as laryngeal hypersensitivity syndrome.3Vertigan A.E. Bone S.L. Gibson P.G. Laryngeal sensory dysfunction in laryngeal hypersensitivity syndrome.Respirology. 2013; 18: 948-956Crossref PubMed Scopus (73) Google Scholar The key to successful management of chronic cough may be to disregard old concepts (eg, use of asthma medications such as β2-agonists and inhaled steroids) as cures for UCC. There is growing evidence that in many cases, UCC is not caused by eosinophilic asthmatic inflammation (which we have developed an expertise in treating during the last decades) or the neutrophilic inflammation found in COPD. Instead, assessing how similar conditions in other organ systems are explained and managed could lead to greater treatment success. Chronic pain and chronic itch may be the result of various neuropathic disorders and have several similarities to chronic cough.4Ji R.R. Neuroimmune interactions in itch: Do chronic itch, chronic pain, and chronic cough share similar mechanisms?.Pulm Pharmacol Ther. 2015; 35: 81-86Crossref PubMed Scopus (52) Google Scholar As a parallel to the treatment of pain and itch, UCC should now perhaps be treated as a sensory neuropathic disorder, in concordance with earlier findings of neurogenic inflammation in such cough.5Chung K. McGarvey L. Mazzone S. Chronic cough as a neuropathic disorder.Lancet Respir Med. 2013; 1: 412-422Abstract Full Text Full Text PDF Scopus (159) Google Scholar, 6Niimi A. Torrego A. Nicholson A.G. Cosio B.G. Oates T.B. Chung K.F. Nature of airway inflammation and remodeling in chronic cough.J Allergy Clin Immunol. 2005; 116: 565-570Abstract Full Text Full Text PDF PubMed Scopus (121) Google Scholar Transient receptor potential (TRP) ion channels on airway sensory nerves are key players in the cough reflex,7Caterina M.J. Schumacher M.A. Tominaga M. Rosen T.A. Levine J.D. Julius D. The capsaicin receptor: a heat-activated ion channel in the pain pathway.Nature. 1997; 389: 816-824Crossref PubMed Scopus (7050) Google Scholar and the TRPs have gained much interest during the last decade as possible targets for various airway conditions, among them chronic cough following cough reflex sensitization and increased expression of TRPs.8Kaneko Y. Szallasi A. Transient receptor potential (TRP) channels: a clinical perspective.Br J Pharmacol. 2014; 171: 2474-2507Crossref PubMed Scopus (251) Google Scholar Although the current results are not in unison, research regarding TRP inhibitors in the treatment of cough is quickly developing.9Bonvini S.J. Birrell M.A. Smith J.A. Belvisi M.G. Targeting TRP channels for chronic cough: from bench to bedside.Naunyn Schmiedebergs Arch Pharmacol. 2015; 388: 401-420Crossref PubMed Scopus (54) Google Scholar The findings of a cough reflex desensitization with the use of orally administered capsaicin indicate the possibility of improving both cough symptoms and cough reflex sensitivity, although it is not clear whether the effect mechanism is peripheral or central.10Ternesten-Hasseus E. Johansson E.L. Millqvist E. Cough reduction using capsaicin.Respir Med. 2015; 109: 27-37Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar Centrally acting drugs such as codeine and morphine can influence the central reflex control of coughing but are associated with well-known adverse effects. Cough hypersensitivity may occur at both the peripheral and central levels, or both; in accordance with the use of gabapentin for neuropathic pain, such medications in chronic cough also exerted positive effects on cough symptoms.11Ryan N.M. Birring S.S. Gibson P.G. Gabapentin for refractory chronic cough: a randomised, double-blind, placebo-controlled trial.Lancet. 2012; 380: 1583-1589Abstract Full Text Full Text PDF PubMed Scopus (301) Google Scholar In this issue of CHEST (see page 639), Vertigan et al12Vertigan A.E. Kapela S.L. Ryan N.M. Birring S.S. McElduff P. Gibson P.G. Pregabalin and speech pathology combination therapy for refractory chronic cough: a randomized controlled trial.Chest. 2016; 149: 639-648Abstract Full Text Full Text PDF PubMed Scopus (131) Google Scholar found that a combination of pregabalin and speech therapy improved cough severity, cough frequency, and cough quality of life in patients with UCC. The study included patients with earlier treatment failure and no obvious medical explanation for coughing. By using a cough monitor and measuring cough severity with validated instruments such as a visual analogue scale and the Leicester Cough Questionnaire, the authors produced reliable results supporting the treatment of chronic cough with a centrally acting neuromodulatory drug, together with speech therapy probably targeting peripheral mechanisms. The findings remind us to use nonpharmacologic methods as options for managing difficult-to-treat conditions. Although it is necessary to be aware of potential adverse effects when using centrally acting medications, the article by Vertigan et al12Vertigan A.E. Kapela S.L. Ryan N.M. Birring S.S. McElduff P. Gibson P.G. Pregabalin and speech pathology combination therapy for refractory chronic cough: a randomized controlled trial.Chest. 2016; 149: 639-648Abstract Full Text Full Text PDF PubMed Scopus (131) Google Scholar gives important signals for physicians to try new methods in cough treatment and the need for new guidelines in chronic cough. Such guidelines, suggesting a new way to assess and treat UCC, are now being developed based on a systematic review of randomized controlled clinical trials using CHEST organization methodology.13Gibson P. Wang G. McGarvey L. Vertigan A.E. Altman K.W. Birring S.S. Treatment of unexplained chronic cough: CHEST guideline and expert panel report.Chest. 2016; 149: 27-44Abstract Full Text Full Text PDF PubMed Scopus (182) Google Scholar An expert panel valued the efficacy of treatment compared with customary care on cough severity, cough frequency, and cough-related quality of life. Both speech pathology-based cough suppression and neuromodulatory drugs were suggested as treatment options. The guidelines also highlight our current limited knowledge and suggest UCC as an area for future research for determining uniformed terminology, methods of investigations, and treatment policy. Pregabalin and Speech Pathology Combination Therapy for Refractory Chronic Cough: A Randomized Controlled TrialCHESTVol. 149Issue 3PreviewChronic refractory cough (CRC) is a difficult problem to treat. Speech pathology treatment (SPT) improves symptoms but resolution is incomplete. Centrally acting neuromodulators also improve cough symptoms, but not cough reflex sensitivity, and the effect is short-lived. We hypothesized that combined SPT and centrally acting neuromodulators would have a superior outcome than SPT alone. Our goal was to determine whether combined pregabalin and SPT is more effective than SPT alone. Full-Text PDF" @default.
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• W2294839194 title "The Problem of Treating Unexplained Chronic Cough" @default.
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