MARZO 2001




Tos Crónica

Respir Med 2000 Dec;94(12):1166-70
Effects of anti-reflux surgery on chronic cough and asthma in patients with gastro-oesophageal reflux disease.
Ekstrom T, Johansson KE
Department of Pulmonary Medicine, University Hospital, Linkoping, Sweden.
This two-group prospective study evaluated the effect of anti-reflux surgery (fundoplication) on 24 patients with severe gastro-oesophageal reflux disease (GORD) and concomitant asthma (n=13) or chronic cough (n=11). Twenty-four hour oesophageal pH monitoring and lung function tests (FEV1, FVC) were done before and within 1 year after anti-reflux surgery. A diary was kept by the patient during the 4-week period prior to surgery and during 4-week periods 6 and 12 months postoperatively, with daily monitoring of peak expiratory flow rate, respiratory and reflux symptoms and medication. In non-asthmatic patients, coughing was reduced by 47% and 80% during the day and night, respectively, 12 months after surgery (P < 0.01). Concomitant hoarseness and expectoration were also significantly reduced (P<0.05). No effect on lung function was seen. In patients with asthma, small, non-significant reductions in asthma symptom scores and consumption of rescue medication were seen. Twenty-two patients were completely free from their GORD symptoms after surgery. In conclusion, anti-reflux surgery in patients with GORD had a more favourable effect on concomitant cough than concomitant asthma.
Publication Types:
  Evaluation studies

Am J Med 2000 Feb;108(2):179
The association of chronic cough with the risk of myocardial infarction: The Framingham Heart Study.
Hahn DL, McBride PE, Pasternak AV
Publication Types:

Eur Respir J 2000 Oct;16(4):633-8
Chronic cough and gastro-oesophageal reflux: a double-blind placebo-controlled study with omeprazole.
Kiljander TO, Salomaa ER, Hietanen EK, Terho EO 
Dept. of Pulmonary Diseases, Turku University Central Hospital, Finland.
Gastro-oesophageal reflux (GOR) is an important cause of chronic cough. There has been a lack of placebo-controlled trials treating GOR related chronic cough with antireflux therapy. The aim of this study was to determine the efficacy of omeprazole on GOR related chronic cough. After excluding other common causes of cough, oesophageal pH monitoring was performed on 48 patients with chronic cough. Twenty-nine patients found to have GOR were randomized in a double-blind fashion to receive omeprazole 40 mg o.d. or placebo for 8 weeks. After a 2-week washout period, patients were crossed over to the other treatment. Symptoms were recorded daily in a diary. Twenty-one patients completed both treatment periods. Cough (p=0.02) and gastric symptoms (p=0.003) improved significantly during the omeprazole treatment in twelve patients who received placebo during the first and omeprazole during the second 8-week period. In nine patients who received omeprazole during the first 8-week period, amelioration in cough reached statistical significance only after cessation of omeprazole. Gastric symptoms also remained minor during placebo in these nine patients. Omeprazole 40 mg o.d. seems to improve chronic cough in patients with gastrooesophageal reflux and the effect of omeprazole in ameliorating both cough and reflux symptoms continues after treatment ceases.

Am J Gastroenterol 2000 Aug;95(8 Suppl):S9-14
Gastroesophageal reflux and chronic cough.
Irwin RS, Richter JE
Division of Pulmonary, Allergy and Critical Medicine, University of Massachusetts Medical School, Worcester, USA.
Publication Types:
  Review, tutorial

Eur Respir J 2000 Jul;16(1):108-11
Chlamydia pneumoniae infection in adults with chronic cough compared with healthy blood donors.
Birkebaek NH, Jensen JS, Seefeldt T, Degn J, Huniche B, Andersen PL, Ostergaard L
Dept of Pediatrics, Skejby Hospital, Arhus, Denmark.
In a small uncontrolled study, persistent cough has recently been found to be associated with serological evidence of acute Chlamydia pneumoniae infection. In order to assess whether C. pneumoniae plays a role in chronic cough, the prevalence of C. pneumoniae infection in 201 adult patients with chronic cough was compared with the prevalence in 106 healthy blood donors without respiratory tract symptoms in the preceding 3 months. A microimmunofluorescence antibody test was used to determine C. pneumoniae antibodies in the immunoglobulin (Ig)M, IgG and IgA fractions. Further, nasopharyngeal aspirates from the 201 patients were examined for C. pneumoniae deoxyribonucleic acid by polymerase chain reaction (PCR). As judged by serology, nine patients (4%) and one control (1%) had acute C. pneumoniae infection, and 92 patients (46%) and 42 controls (40%) had previous or chronic C. pneumoniae infection. Of the nine patients with acute infection, three were C. pneumoniae PCR positive, and they all had an IgM antibody titre response. The remaining six patients had either an IgG antibody titre of > or =512 (five patients) or an IgA antibody titre of > or =512 (one patient). None of these six patients had detectable IgM antibodies. The mean cough period for the five IgG positive patients (10.8 weeks) was significantly longer than the mean cough period for the remaining patient population (6.4 weeks; p=0.004). It is concluded that Chlamydia pneumoniae infection was not statistically significantly more prevalent in patients with chronic cough than in healthy blood donors, and that Chlamydia pneumoniae appears to have a minor role in patients with chronic cough. Direct detection of Chlamydia pneumoniae by polymerase chain reaction on nasopharyngeal aspirates is highly correlated with detectable immunoglobulin M antibodies, but in the late stages of prolonged cough serological testing of immunoglobulin G and immunoglobulin A may be more beneficial for obtaining a microbiological diagnosis.

Chest 2000 Jul;118(1):278-9
Chronic cough revisited.
Paul TW
Publication Types:

Arch Bronconeumol 2000 Apr;36(4):208-20
[Study and diagnosis of chronic cough in adults].
[Article in Spanish]
de Diego Damia A, Perpina Tordera M
Servicio de Neumologia, Hospital Universitario La Fe, Valencia.
Publication Types:
  Review, tutorial

Chest 2000 Apr;117(4):1215-6
A possible pathologic link between chronic cough and sleep apnea syndrome through gastroesophageal reflux disease in older people.
Teramoto S, Ouchi Y
Publication Types:

Am J Med 2000 Mar 6;108 Suppl 4a:126S-130S
Anatomical diagnostic protocol in evaluating chronic cough with specific reference to gastroesophageal reflux disease.
Irwin RS, Madison JM
Department of Medicine, University of Massachusetts Medical School, Worcester, USA.
Using the anatomic, diagnostic protocol, the cause of chronic cough can be determined 88% to 100% of the time, leading to specific therapy with success rates of 84% to 98%. Gastroesophageal reflux disease (GERD), along with postnasal drip syndrome (PNDS) and asthma, is one of the three most common causes of chronic cough in all age groups. When GERD is the cause of chronic cough, there may be no gastrointestinal (GI) symptoms up to 75% of the time, and, in these cases, the term "silent GERD" is used. The most sensitive and specific test for GERD is 24-hour esophageal pH monitoring. In interpreting this test, it is essential not only to evaluate the duration and frequency of the reflux episodes but also to determine the temporal relationship between reflux and cough events. Patients with normal standard reflux parameters still may have reflux diagnosed as the likely cause of cough if a temporal relationship exists. The definitive diagnosis of cough resulting from GERD can only be made if cough goes away with antireflux therapy. When 24-hour esophageal pH monitoring cannot be done, an empiric trial of antireflux medical therapy is appropriate when GERD is a likely cause of chronic cough. It is likely in the following settings: patients with prominent GI symptoms consistent with GERD and/or those with no GI complaints and normal chest x-rays, who are not taking angiotensin-converting enzyme inhibitors and who are not smoking, and in whom asthma and PNDS have been excluded. However, if empiric treatment fails, it cannot be assumed that GERD has been ruled out as a cause of chronic cough; rather, objective investigation for GERD is recommended, because the empiric therapy may not have been intensive enough or it may have failed. In treating patients with chronic cough resulting from GERD, cough has been reported to resolve with medical therapy 70% to 100% of the time. Mean time to recovery may take as long as 161 to 179 days, and patients may not start to get better for 2 to 3 months. In patients who fail to respond to maximal medical therapy, antireflux surgery can be successful.
Publication Types:
  Review, tutorial

Am J Gastroenterol 1999 Nov;94(11):3131-8
A prospective evaluation of esophageal testing and a double-blind, randomized study of omeprazole in a diagnostic and therapeutic algorithm for chronic cough.
Ours TM, Kavuru MS, Schilz RJ, Richter JE
Center for Swallowing and Esophageal Disorders, Department of Gastroenterology, The Cleveland Clinic Foundation, Ohio 44195, USA.
OBJECTIVE: Recent studies suggest an association between chronic cough and gastroesophageal reflux. Our study aims were 1) to define the prevalence of acid reflux induced cough in the general community, 2) to examine the ability of esophageal testing to identify gastroesophageal reflux related cough, and 3) to assess the utility of omeprazole in a chronic cough algorithm. METHODS: Patients with chronic cough of unknown etiology, who were mostly from the community, were evaluated. Subjects underwent a chest x-ray, methacholine challenge test, and empiric trial of postnasal drip therapy, and completed daily cough symptom diaries subjectively evaluating cough frequency and severity on a graded scale of 0-4 (combined maximum 8). After excluding other causes of cough, the remaining patients underwent esophageal and pH testing. Those testing positive were randomized to omeprazole 40 mg b.i.d. or placebo for 12 weeks. Follow-up was 1 yr. RESULTS: A total of 71 patients were screened; 48 were excluded. Twenty-three patients were evaluated for gastroesophageal reflux disease; six (26%) were eventually determined to have an acid-related cough. Of these patients, 17 had a positive pH test, six (35%) of whom showed a striking improvement or resolution of their cough during omeprazole treatment which was sustained for up to 1 yr. Six had a negative pH test, none of whom responded to omeprazole therapy. No significant differences were seen between responders (n = 6) and nonresponders (n = 11) for demographic factors, baseline symptom frequency and duration, or physiological parameters (motility/pH). CONCLUSIONS: Acid-related chronic cough was present in 26% (six of 23) of patients evaluated for gastroesophageal reflux disease. Esophageal testing does not reliably identify patients with acid induced chronic cough responsive to proton pump inhibitor therapy. We suggest that the best diagnostic and therapeutic approach, after excluding asthma and postnasal drip syndrome, is empiric treatment for 2 wk with a high dose proton pump inhibitor.
Publication Types:
  Clinical trial
  Randomized controlled trial

Chest 1999 Nov;116(5):1287-91
The role of sinus imaging in the treatment of chronic cough in adults.
Pratter MR, Bartter T, Lotano R
Division of Pulmonary and Critical Care Medicine, Cooper Hospital/University Medical Center, University of Medicine and Dentistry of New Jersey/Robert Wood Johnson Medical School at Camden, NJ, USA.
PRIMARY STUDY OBJECTIVE: To determine the appropriate role and timing of sinus imaging studies in the evaluation and treatment of chronic cough. DESIGN: Prospective study of chronic cough. All patients underwent sinus imaging, the results of which identified prospectively the following: (1) fluid in sinuses, with or without opacification, and (2) mucosal thickening. Patients then were treated using an algorithm that sequentially addresses the etiologies of chronic cough. Patients whose sinus imaging studies had demonstrated fluid were treated initially for sinusitis, but mucosal abnormalities alone were not considered an indication to change the algorithm. After workup, relationships between abnormalities on sinus imaging studies and diagnoses were determined. SETTING: University hospital pulmonary outpatient clinic. PATIENTS: Thirty-six patients (31 women, 5 men; mean age, 58.4 years). Cough duration averaged 5.2 years (range, 4 weeks to 30 years). RESULTS: Diagnoses were made in 100% of patients, and cough resolved in 86%. Mucosal thickening correlated with sinusitis as a cause of cough in only 29% of cases. CONCLUSIONS: Mucosal thickening is not diagnostic of sinusitis as a cause of chronic cough; in most patients, cough will resolve without treatment for sinusitis. Given this lack of specificity, it is reasonable to delay sinus imaging until after efforts at treating rhinitis have failed and, in the absence of complaint or findings of postnasal drip, until after completion of evaluation for asthma. The principles of diagnosis and treatment of chronic cough remain simple: go sequentially from the most common to the least common cause; use tools that begin with the most available and least expensive and invasive modality; then move as needed to tools that are more expensive and invasive.
Publication Types:
  Clinical trial

Clin Infect Dis 1999 Nov;29(5):1239-42
Bordetella pertussis and chronic cough in adults.
Birkebaek NH, Kristiansen M, Seefeldt T, Degn J, Moller A, Heron I, Andersen PL, Moller JK, Ostergard L
Department of Pediatrics, Skejby Hospital, University of Arhus,
Brendstrupgardsvej, Denmark.
To evaluate Bordetella pertussis as a cause of persistent cough in adults, we examined 201 patients who had a cough for 2-12 weeks and no pulmonary disease. We obtained the following at presentation: medical history, chest radiograph, respiratory function measurement, nasopharyngeal aspirate for polymerase chain reaction (PCR), nasopharyngeal swab specimen for culture, and a blood sample (acute serum). Four weeks later a second blood sample (convalescent serum) was obtained. Control sera were obtained from 164 age-matched healthy blood donors with no history of cough during the previous 12 weeks. Four patients were B. pertussis culture-positive; 11 (including the culture-positive patients) were B. pertussis PCR-positive; and 33, including 10 of the 11 PCR-positive patients, had serological evidence of recent B. pertussis infection. Pertussis-positive and -negative patients could not be discriminated by a history of cough. We conclude that B. pertussis infection is a common cause of persistent cough in adults. This is of concern, because these patients may be B. pertussis reservoirs from which transmission may occur to infants, in whom the disease can be devastating.

Can Respir J 1999 Jul-Aug;6(4):323-30
Nonasthmatic chronic cough: No effect of treatment with an inhaled corticosteroid in patients without sputum eosinophilia.
Pizzichini MM, Pizzichini E, Parameswaran K, Clelland L, Efthimiadis A, Dolovich J, Hargreave FE
University of Santa Catarina (UFSC), Florianopolis, Brazil.
BACKGROUND: Inhaled corticosteroids are effective in suppressing a chronic cough without asthma associated with sputum eosinophilia. OBJECTIVE: To investigate the inflammatory characteristics in the induced sputum of patients with a chronic cough without asthma or known cause and the effects of budesonide treatment on chronic cough in those patients. PATIENTS AND METHODS: Forty-four adults (mean [minimu, maximum] age of 45 years [20,75], 28 women, 17 atopic subjects and 32 nonsmokers], with a daily bothersome cough for at least one year and who had no evidence of asthma or other known cause for the cough, were consecutively enrolled. The trial was a randomized, double-blind, controlled parallel group trial of budesonide 400 mg twice daily for two weeks versus placebo. Patients then received open administration of the same dose of budesonide for a further two weeks. Sputum was induced before and at the end of each treatment period. Cough severity was documented by a visual analogue scale. RESULTS: Thirty-nine (89%) patients produced mucoid sputum after induction on at least one study visit. At baseline, the majority (59%) had a mild elevation in the median proportion of neutrophils (65%). All had elevated fluid phase levels of fibrinogen (3200 mg/L) and albumin (880 mg/L), and high levels of interleukin-8 and substance P. Interleukin-8 correlated with neutrophils (rho=0.72, P<0.001), fibrinogen (rho=0.65, P<0.001), albumin (rho=0.67, P=0. 001) and eosinophil cationic protein (rho=0.60, P=0.001). Substance P correlated with albumin (rho=0.60, P=0.006). No subject had an increase in eosinophils. Treatment with budesonide did not affect cough or sputum measurements. CONCLUSIONS: Patients with nonasthmatic chronic cough enrolled in this study had evidence of a mild neutrophilia and/or microvascular leakage. Chronic cough did not respond to treatment with budesonide, perhaps because the cause was not associated with sputum eosinophilia.
Publication Types:
  Clinical trial
  Randomized controlled trial

Am J Respir Crit Care Med 1999 Aug;160(2):406-10 [Texto completo]
Eosinophilic bronchitis is an important cause of chronic cough.
Brightling CE, Ward R, Goh KL, Wardlaw AJ, Pavord ID
Department of Respiratory Medicine, Glenfield Hospital, Leicester, United Kingdom.
Eosinophilic bronchitis presents with chronic cough and sputum eosinophilia, but without the abnormalities of airway function seen in asthma. It is important to know how commonly eosinophilic bronchitis causes cough, since in contrast to cough in patients without sputum eosinophilia, the cough responds to inhaled corticosteroids. We investigated patients referred over a 2-yr period with chronic cough, using a well-established protocol with the addition of induced sputum in selected cases. Eosinophilic bronchitis was diagnosed if patients had no symptoms suggesting variable airflow obstruction, and had normal spirometric values, normal peak expiratory flow variability, no airway hyperresponsiveness (provocative concentration of methacholine producing a 20% decrease in FEV(1) ([PC(20)] > 8 mg/ml), and sputum eosinophilia (> 3%). Ninety-one patients with chronic cough were identified among 856 referrals. The primary diagnosis was eosinophilic bronchitis in 12 patients, rhinitis in 20, asthma in 16, post-viral-infection status in 12, and gastroesophageal reflux in seven. In a further 18 patients a diagnosis was established. The cause of chronic cough remained unexplained in six patients. In all 12 patients with eosinophilic bronchitis, the cough improved after treatment with inhaled budesonide 400 micrograms twice daily, and in eight of these patients who had a follow-up sputum analysis, the eosinophil count decreased significantly, from 16.8% to 1.6%. We conclude that eosinophilic bronchitis is a common cause of chronic cough, and that sputum induction is important in the investigation of cough.

Am J Respir Crit Care Med 1999 Jun;159(6):1810-3 [Texto completo]
Exhaled nitric oxide as a noninvasive assessment of chronic cough.
Chatkin JM, Ansarin K, Silkoff PE, McClean P, Gutierrez C, Zamel N, Chapman KR
Divisions of Respiratory Medicine, University of Toronto, Toronto, Canada.
Exhaled nitric oxide (ENO) has been suggested as a marker of airway inflammation. This study aimed to evaluate the role of ENO in the investigation of chronic cough. We measured ENO in 38 adult patients reporting chronic cough, in 23 healthy control subjects, and in 44 asthmatics. In addition to the regular investigation, ENO was measured by a chemiluminescent analyzer using the restricted breath technique. In the chronic cough group, 30 were considered as nonasthmatic, whereas asthma was diagnosed in eight by a positive methacholine challenge. ENO values were significantly higher in patients with chronic cough attributable to asthma as compared with those with chronic cough not attributable to asthma and to healthy volunteers (75.0 ppb; 16.7 ppb; and 28.3 ppb, respectively). The sensitivity and specificity of ENO for detecting asthma, using 30 ppb as the ENO cutoff point, were 75 and 87%, respectively. The positive and negative predictive values were 60 and 93%, and the positive and negative likelihood ratios were 5.8 and 0.3, respectively. We conclude that ENO may have a role in the evaluation of chronic cough. In this group of patients, low ENO suggested little likelihood of asthma. The patients with chronic cough not attributable to asthma showed a low ENO value as compared with healthy volunteers and asthmatics.
Publication Types:
  Clinical trial

Hosp Pract (Off Ed) 1999 Apr 15;34(4):62-3
Diagnosing chronic cough.
Hoag S, Wentworth M
Publication Types:

Am J Respir Crit Care Med 1999 May;159(5 Pt 1):1533-40 [Texto completo]
Bronchoalveolar cell profiles in children with asthma, infantile wheeze, chronic cough, or cystic fibrosis.
Marguet C, Jouen-Boedes F, Dean TP, Warner JO
Paediatric Respiratory Disease Unit, Hopital Ch. Nicolle, Rouen, France.
Differential cell counts of bronchoalveolar lavage (BAL) have been reported in normal children but few data on cellular profiles in bronchial diseases in childhood are available. We determined the BAL cell profiles of 72 children divided into 5 groups: asthma (n = 14), chronic cough (n = 12), infantile wheeze (n = 26), cystic fibrosis (n = 10), and control (n = 10). The highest total cell, eosinophil, and neutrophil counts were found in children with cystic fibrosis. The cell profile of children with chronic cough was similar to that of control children. Asthma and infantile wheeze were characterized by a high median ratio of eosinophils (3%) and neutrophils (12%), respectively. In both diseases, epithelial shedding was suggested by an elevated epithelial cell count, 13.5 and 12%, respectively. Lymphocyte subset analysis showed a higher proportion of CD8 cells (58 versus 40%) and therefore a lower CD4/CD8 ratio (0.266 versus 0. 455) in children with asthma compared with infantile wheezers (p = 0. 02). Irrespective of the presence or absence of radiological abnormalities, a proportion of neutrophils > 10%, was found in one-third of the children with asthma and in half of the infantile wheezers, and was related to symptom severity. We suggest that neutrophil-mediated inflammation, with or without bacterial infection, may contribute to symptoms of asthma in childhood. Chronic cough, however, is not associated with the cell profiles suggestive of asthma and in isolation should not be treated with prophylactic antiasthma drugs.

Hosp Pract (Off Ed) 1999 Jan 15;34(1):53-60; quiz 129-30 [Texto completo]
Silencing chronic cough.
Irwin RS
University of Massachusetts, Worcester, USA.
The cause can almost always be identified. Postnasal drip syndrome, asthma, or gastroesophageal reflux disease account for most cases. The differential diagnosis also includes ACE inhibitor therapy, pertussis, and, in up to 80% of patients, multiple causes. Response to treatment may offer diagnostic confirmation but can be slow in coming.
Publication Types:
  Review, tutorial

Am Fam Physician 1998 Dec;58(9):2015-22 [Texto completo]
An office approach to the diagnosis of chronic cough.
Lawler WR
University of Texas Health Science Center, San Antonio, USA.
Chronic cough is a common problem in patients who visit family physicians. The three most common causes of chronic cough in those who are referred to pulmonary specialists are postnasal drip, asthma and gastroesophageal reflux. The initial treatment of patients with cough is often empiric and may involve a trial of decongestants, bronchodilators or histamine H2 antagonists, as monotherapy or in combination. If a therapeutic trial is not successful, sequential diagnostic testing including chest radiograph, purified protein derivative test for tuberculosis, computed tomography of the sinuses, methacholine challenge test or barium swallow may be indicated. By using a standard protocol for diagnosis and treatment, 90 percent of patients with chronic cough can be managed successfully in the family physician's office. However, in some cases it may take three to five months to determine a diagnosis and effective treatment. For the minority of patients in whom this diagnostic approach is unsuccessful, consultation with a pulmonary specialist is appropriate.
Publication Types: 
  Review, tutorial

Scand J Infect Dis 1998;30(3):227-9
Chronic cough in patients with HIV infection.
Wong KH, Cooper DA, Pigott P, Marriott DJ
AIDS Unit, Department of Health, Hong Kong.
We retrospectively studied the clinical spectrum, course and outcome of 26 patients with HIV infection and chronic cough. All except 2 were homo-/bisexual males. 22 (85%) had AIDS. They had cough for a mean of 75 d with sputum production (88%) and dyspnoea (77%) being the commonest associated symptoms. Sputum examination and chest X-ray were useful initial investigations. CT scan of the chest and sinuses had a high rate of abnormal results for selected patients (89-100%). Cause of cough was found in 21 patients (81%): bronchopulmonary infections (17), Kaposi's sarcoma (5) and sinus infections (3). Patients with sinopulmonary infections tended to have longer duration of cough. Overall, 4 patients (15%) had significant improvement in the illness with cough during the study period. Four patients with bronchopulmonary infections died. We concluded that chronic cough is a heterogeneous clinical problem in advanced HIV-infected patients, most commonly caused by an infective process. Extrapulmonary disease, such as sinusitis, has to be considered and investigated. The clinical course and outcome is unfavourable for most of the patients.

Arch Intern Med 1998 Jun 8;158(11):1222-8
From a prospective study of chronic cough: diagnostic and therapeutic aspects in older adults.
Smyrnios NA, Irwin RS, Curley FJ, French CL
Department of Medicine, University of Massachusetts Medical School, Worcester, USA.
BACKGROUND: Cough is the most common complaint for which adults see a physician in the ambulatory setting in the United States. An anatomical diagnostic protocol has been used since 1981 to evaluate patients with chronic cough. It has been shown to be effective in diagnosing the cause of cough and leading to specific treatment in a variety of adult populations but has never been evaluated specifically in a population of older adults. OBJECTIVES: To question whether the spectrum and frequency of causes of chronic cough and the response to therapy would be different in older adults. METHODS: Thirty patients at least 64 years of age with a history of cough lasting at least 3 weeks were prospectively evaluated with a protocol designed to detect diseases that stimulate the afferent limb of the cough reflex. The final diagnosis of the cause of chronic cough required fulfillment of pretreatment criteria and having cough disappear with specific therapy. When more than one disease fulfilled pretreatment diagnostic criteria, therapy was instituted in the order that these were fulfilled. Probability statistics were used to describe the testing characteristics of individual components of the diagnostic protocol in terms of sensitivity, specificity, positive predictive value, and negative predictive value as they applied to chronic cough. RESULTS: Forty causes of chronic cough were identified in all 30 patients. Postnasal drip syndrome, gastroesophageal reflux disease, and asthma were the most common causes of chronic cough, accounting for 85% of all causes found. Among patients with normal chest radiograph findings who were not cigarette smokers and not taking an angiotensin-converting enzyme inhibitor, postnasal drip syndrome, gastroesophageal reflux disease, and asthma accounted for 100% of all causes found. Specific therapy was successful in eliminating chronic cough in 100% of the patients studied. Except for barium esophagography, all laboratory tests for which information was available had sensitivities and negative predictive values of 100%. CONCLUSIONS: Postnasal drip syndrome, gastroesophageal reflux disease, and asthma accounted for 85% of all causes of chronic cough in older adults. Chronic cough caused substantial physical and emotional morbidity among older patients. The major value of performing objective testing in evaluating chronic cough is its ability to rule out specific diseases as a diagnostic possibility. The following clinical profile consistently predicts patients with cough attributable to gastroesophageal reflux disease: the patient has cough that has been persistently troublesome for at least 3 weeks; does not smoke cigarettes; does not take an angiotensin-converting enzyme inhibitor; does not have or has not responded to therapy for postnasal drip syndrome and asthma; and has normal or nearly normal findings and stable chest radiograph. The differences between what we observed regarding chronic cough in older adults and observations by ourselves and others regarding chronic cough in general are minor.

Mayo Clin Proc 1997 Oct;72(10):957-9
Assessment of the patient with chronic cough.
Yu ML, Ryu JH
Division of Pulmonary and Critical Care Medicine and Internal Medicine, Mayo Clinic Rochester, Minnesota 55905, USA.
Chronic cough, defined as cough that persists for 3 weeks or longer, is one of the most common symptoms evaluated by a primary-care physician. With the exclusion of cigarette smoking, postnasal drip, asthma, and gastroesophageal reflux are responsible for more than 80% of the causes of chronic cough. Elicitation of a thorough history and performance of a physical examination will usually provide clues about the cause of chronic cough. The use of diagnostic tests including methacholine challenge, gastroesophageal reflux studies, and sinus imaging is based on clinical suspicion. Treatment of chronic cough is aimed at the underlying cause.

Am Fam Physician 1997 Oct 1;56(5):1395-404 [Texto completo]
Chronic cough.
Philp EB
Department of Family Medicine, University of Alabama School of Medicine, Tuscaloosa 35401, USA.
Chronic cough is defined as a cough that lasts for more than three weeks. More than 90 percent of cases of chronic cough result from five common causes: smoking, post-nasal drip, asthma, gastroesophageal reflux and chronic bronchitis. Although in most patients chronic cough has a single cause, in up to one fourth of patients, multiple disorders contribute to the cough. A stepwise evaluation in patients with chronic cough can minimize the invasiveness and expense of the work-up. Initial screening of patients with chronic cough should search for smoking, occupational exposure to an airway irritant, cough-inducing medications, airway hyperresponsiveness following upper respiratory infection, chronic bronchitis or any systemic symptoms suspicious for serious disease. Patients who are not diagnosed after an initial screening are evaluated or empirically treated in a stepwise fashion for postnasal drip, asthma and reflux. Bronchoscopy is reserved for use in the few patients still without a diagnosis after the previous steps have been completed.
Publication Types:
  Review, tutorial

Am J Respir Crit Care Med 1997 Jul;156(1):211-6 [Texto completo]
A systematic evaluation of mechanisms in chronic cough.
Carney IK, Gibson PG, Murree-Allen K, Saltos N, Olson LG, Hensley MJ
Airway Research Centre, John Hunter Hospital, New South Wales, Australia.
We tested the hypothesis that hyperresponsiveness of the upper airway (UAHR) is present in patients with chronic cough of diverse etiology. We determined the frequency of bronchial hyperresponsiveness (BHR), hyperresponsiveness of the upper airway, sputum eosinophilia, pulmonary aspiration, and psychological symptoms in adults with chronic cough. Consecutive adults (n = 30) presenting to a tertiary referral clinic with chronic cough were compared with a group of 20 asymptomatic adults. Measurements included histamine provocation testing with measurement of flow volume curves to determine inspiratory and expiratory airflow obstruction; hypertonic saline induced sputum for analysis of eosinophils, mast cells and lipid-laden macrophages; and a validated psychological symptom questionnaire. Symptomatic rhinitis and gastroesophageal reflux were common causes of chronic cough. BHR occurred in seven patients (23%) and in no control subjects (p < 0.05). UAHR occurred in 40% of patients with cough and in four (20%) control subjects (p > 0.05). Eosinophils were present in the sputum of more patients with cough than control subjects (50% versus 19%; p < 0.05). High degrees of eosinophilia were present in six patients with cough, including three without BHR. No subject had significant lipid-laden macrophages. There was greater somatization in patients with chronic cough; ten subjects scored in the clinically significant range (p < 0.05). Abnormalities in one or more of these tests were 7.67-fold (95% CI 1.83-34.52) more likely to occur in cough patients than control subjects. We conclude that chronic cough is a nonspecific symptom that is associated with several apparently unrelated mechanisms. These include UAHR, somatization, BHR, and eosinophilic bronchitis. UAHR cannot be implicated as a single unifying mechanism. These findings emphasize the need to systematically evaluate several different causes of cough in patients who present with chronic cough.

South Med J 1997 Mar;90(3):305-11 [Texto completo]
Twenty-four-hour ambulatory esophageal pH monitoring in the diagnosis of acid reflux-related chronic cough.
Vaezi MF, Richter JE
Division of Gastroenterology, University of Alabama at Birmingham, USA.
To define the role of ambulatory pH monitoring in evaluating chronic cough, we studied esophageal pH values of patients referred to a gastroenterology laboratory. Chronic cough was evaluated in 31 patients, who were grouped based on response to treatments; 11 patients (35.5%) had gastroesophageal reflux (GER)-related cough, 11 (35.5%) had pulmonary/otorhinolaryngologic-related cough (1 bronchitis, 6 asthma, 2 postnasal drip, 1 pneumonia), and 9 patients (29%) had cough of unknown etiology. Esophageal pH values of groups were compared. Excessive acid reflux distally (upright and supine) and proximally (upright) and cough symptom frequency related to acid reflux were significantly higher in patients with GER. Esophageal pH monitoring had good sensitivity (91%), specificity (82%), and positive (83%) and negative (90%) predictive values in identifying GER-related cough. In summary, ambulatory pH monitoring is an excellent test for identifying patients with GER-related cough.

Rev Clin Esp 1996 Jul;196(7):461-8
[Chronic cough in adults].
[Article in Spanish]
Cordero PJ, Benlloch E
Servicio de Neumologia, Hospital Universitario La Fe, Valencia.
Publication Types:
  Review literature

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