Cough desensitization treatment for patients with refractory chronic cough: results of a second pilot randomized control trial.

OBJECTIVE: The purpose of this study was to collect pilot efficacy data on a novel treatment for refractory chronic cough (RCC), which we call cough desensitization treatment (CDT). DESIGN AND METHODS: In this parallel cohort, sham-controlled, randomized controlled trial, 21 adults with RCC were randomly assigned to 12 sessions of either CDT (progressive doses of aerosolized capsaicin while behaviorally suppressing cough; n = 11) or a sham treatment (repeated exposure to aerosolized saline; n = 9). The Leicester Cough Questionnaire (LCQ) was the primary outcome measure. Perceived cough severity with a visual analogue scale and cough challenge testing (for measuring cough-reflex sensitivity) were secondary outcome measures. Data were analyzed with mixed effects linear regression and follow-up contrasts. RESULTS: Results on all measures favored CDT. Excluding one sham participant, whose baseline LCQ scores were deemed unreliable, mean change in LCQ at 3-weeks post treatment was 6.35 and 2.17 in the CDT and sham groups, respectively. There was moderate to strong evidence of a greater improvement in the CDT group in total LCQ score (p = .058) and LCQ Psychological domain (p = .026) and Physical domain (p = .045) scores. Strong evidence was found for a greater reduction in urge-to-cough during CCT in the CDT group (p = .037) and marginal for a reduction in the capsaicin cough-reflex sensitivity (p = .094). There was weak evidence of a greater reduction in cough severity in the CDT group (p = .103). DISCUSSION: Although the study is limited due to the small sample size, the data provide additional evidence supporting further research on CDT. CDT resulted in a greater change in the primary efficacy measure (LCQ) than both pharmaceutical and behavioral treatments currently found in the literature. TRIAL REGISTRATION: This trial (NCT05226299) was registered on Clinicaltrials.gov on 07/02/2022.

Severe chronic cough relating to post-COVID-19 interstitial lung disease: a case report.

Cough is a common symptom occurring in patients with acute coronavirus disease 2019 (COVID-19) infection as well as during the post-COVID-19 period. The post-COVID-19 cough can improve over time and the incidence of sustained post-COVID-19 chronic cough is low. Approaching post-COVID-19 cough is challenging to clinicians including pulmonologists and allergists due to a diverse set of etiologies and the lack of published guidance on effective treatments. A 60-year-old male ex-smoker presented to the outpatient long COVID-19 clinic because of a prolonged cough for 4 months after a severe COVID-19 infection. His cough was so violent that he had suffered a spontaneous pneumothorax on 2 occasions. In addition, he also complained of exertional breathlessness. Due to concerns over ongoing systemic inflammation from COVID-19 or thromboembolism, a serum C-reactive protein and d-dimer where checked and were normal. Chest computed tomography (CT) images revealed diffuse ground glass opacities combined with scattered emphysema in the bilateral upper lobes and several small bullae located close to the pleura. His diagnosis was post-COVID-19 interstitial lung disease (ILD) and he was treated with methylprednisolone 32 mg/day. After 2 weeks of treatment, he showed improvement with near cessation of cough and a significant decline in dyspnea. The follow-up chest CT also showed improvement in the ground glass opacities. Severe chronic cough could be a manifestation of post-COVID-19 ILD. This case demonstrates the use of systemic corticosteroid to improve both post-COVID-19 ILD and its associated chronic cough.

European Respiratory Society - 32nd International Congress

The 32nd European Respiratory Society (ERS) International Congress was held again in person at the FIRA Barcelona Gran Via Conference Center in Spain, as well as online. On-site attendance was limited to 10,000 delegates, with the spaces selling out before the conference began. The program included live streamed presentations, thematic poster discussion sessions, oral presentations, mini-symposia, industry exhibitors and skills workshops to discuss major respiratory fields that included thoracic oncology, respiratory infections, interstitial lung diseases, respiratory critical care, sleep and breathing disorders and pulmonary vascular diseases. This report will cover some of the most interesting presentations related to respiratory disease treatment. Copyright © 2022 Clarivate.

Cardiac tamponade as the first presentation of thymoma: A case report during COVID-19 pandemic

We report a case of neoplastic cardiac tamponade, a life-threatening condition, as the initial presentation of an anterior mediastinal malignancy. A 69-year-old gentleman with no known history of malignancy presented to the emergency department with shortness of breath, reduced effort tolerance and chronic cough. Clinically, he was not in distress but tachycardic. He was subjected to echocardiography which revealed large pericardial effusion with tamponade effect. Pericardiocentesis drained 1.5 L of haemoserous fluid. CECT thorax, abdomen and pelvis revealed an anterior mediastinal mass with intrathoracic extension complicated with mass effect onto the right atrium and mediastinal vessels. Ultrasound-guided biopsy histopathology examination revealed thymoma. Due to locally advanced disease, tumour resection was not possible, and patient was referred to oncology team for chemoradiotherapy. We report this case study not only due to the rarity of the case but also to highlight its diagnostic challenge due to the COVID-19 pandemic. Copyright © The Author(s) 2022.

A Potential Novel Treatment for Chronic Cough in Long COVID Patients: Clearance of Epipharyngeal Residual SARS-CoV-2 Spike RNA by Epipharyngeal Abrasive Therapy.

A major target of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the epipharyngeal mucosa. Epipharyngeal abrasive therapy (EAT) is a Japanese treatment for chronic epipharyngitis. EAT is a treatment for chronic epipharyngitis in Japan that involves applying zinc chloride as an anti-inflammatory agent to the epipharyngeal mucosa. Here, we present a case of a 21-year-old man with chronic coughing that persisted for four months after a diagnosis of mild coronavirus disease 2019 (COVID-19), who was treated by EAT. We diagnosed chronic epipharyngitis as the cause of the chronic cough after the SARS-CoV-2 infection. SARS-CoV-2 spike RNA had persisted in the epipharyngeal mucosa of this Long COVID patient. EAT was performed once a week for three months, which eliminated residual SARS-CoV-2 RNA and reduced epipharyngeal inflammation. Moreover, a reduction in the expression of proinflammatory cytokines was found by histopathological examination. We speculate that the virus was excreted with the drainage induced by EAT, which stopped the secretion of proinflammatory cytokines. This case study suggests that EAT is a useful treatment for chronic epipharyngitis involving long COVID.

Effect of Behavioral Cough Suppression Therapy Delivered via Telehealth.

OBJECTIVES/HYPOTHESIS: Behavioral cough suppression therapy (BCST) has demonstrated up to 88% effectiveness at treating refractory chronic cough (RCC). With onset of the COVID-19 pandemic, along with many other medical services, BCST shifted to telehealth delivery. Our group hypothesized that BCST delivered via telemedicine by a specialized Speech-Language Pathologist would be comparable to previously reported response to treatment for in-person settings. STUDY DESIGN: Retrospective review. METHODS: An Emory IRB approved, retrospective review of electronic medical records was completed for RCC patients who received BCST via telehealth from March 2020 through January 2022 at Emory Voice Center. Patients were included in the study if they had a diagnosis of RCC, were referred for BCST, were seen for at least one therapy session in the telehealth setting, and provided Cough Severity Index (CSI) data pre and post-treatment. Patients were excluded if they had incomplete datasets, a known pulmonary condition, structural laryngeal disorders, smoking history, dysphagia, and ACE-inhibitor use. Change in CSI score pre- and post-treatment was calculated to determine treatment effect. Paired-samples t-tests were conducted to compare pre-and post-treatment CSI score change. RESULTS: Fifty-one RCC patients were included in this study; 88% were female with an average age of 60 years (SD = 12.68). Post-treatment CSI scores were significantly lower than pretreatment CSI scores (P < 0.0001). These findings are comparable to historical documented CSI change achieved with in-person BCST. CONCLUSIONS: This study provides preliminary evidence of the efficacy of BCST via telehealth for treating RCC. The findings of this study support the continued flexibility in speech-language pathology service delivery to include in-person and telehealth platforms for RCC beyond the COVID-19 pandemic.

Laparoscopic Surgical Management of an Huge Diaphragmatic Hernia

Introduction: Diaphragmatic hernias (DH) in most cases are the consequence of a diaphragmatic trauma causing a missed injury. Less frequently, DHs are congenital. Case Presentation: A 52 years old patient came to our attention due to a worsening severe dyspnea. A chest CT scan were performed, showing an extensive left-side DH.We present the video of the surgical procedure. The patient mentioned a severe left hemithorax trauma occurred almost twenty years before due to a motorbike accident. Possibly, a diaphragmatic injury was not diagnosed at the time. Subsequently, a Covid-19-related chronic cough resulting in a persistently increased intra abdominal pressuremayhave caused the herniation of abdominal viscera. The surgical procedure was laparoscopic. The whole greater omentum and most of the transverse colon were herniated and, after a thorough adhesiolysis between the herniated tissues and the left diaphragmatic crus, the DH was reduced. It was confirmed the presence of a 8 cm defect of the left hemidiaphragm, it was repaired with a absorbable continuous suture. A 08x10 cm Bio-A patch was positioned over. The herniated tissues were meticulously examined and showed no signs of damage. Conclusion(s): Diaphragm's injuries are unfortunately difficult to diagnose in an acute setting, thus remaining often unbeknownst to the surgeon. Some patients never develop any symptoms because of such missed diaphragmatic injuries. Some others instead, due to an increase in the intra abdominal pressure, may develop symptomatic DHs. In the latter case, surgical management becomes mandatory.

GRANULOMATOUS-LYMPHOCYTIC INTERSTITIAL LUNG DISEASE AS THE NONINFECTIOUS COMPLICATION OF COMMON VARIABLE IMMUNODEFICIENCY

SESSION TITLE: Difficult Diffuse Lung Disease SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 10:15 am - 11:10 am INTRODUCTION: Common Variable Immunodeficiency (CVID) is one of the most common humoral immunodeficiency disorders and usually manifests as infectious complications. However, noninfectious complications such Granulomatous-Lymphocytic Interstitial Lung Disease (GLILD) can convey a much poorer prognosis in patients with CVID. In this case report, we present a patient with GLILD who presented with cough and shortness of breath. CASE PRESENTATION: A 66 year old female with past medical history of provoked DVT (off anticoagulation), cervical cancer (s/p resection) presented to pulmonology clinic with complaints of chronic cough and shortness of breath on exertion. She had a negative smoking history and no occupational exposures. She was up to date on vaccinations and COVID was negative. Vitals were stable and physical exam was normal including clear breath sounds. CXR revealed emphysema and hazy opacities in the lung bases. PFTs demonstrated moderate obstructive pattern with no response to bronchodilator, normal lung volumes, and DLCO of 76%. Due to lack of improvement in her cough, CT Chest was done which revealed diffuse pulmonary nodules, bronchiectasis with possible atelectasis or scarring in the RML and lingula, and a prominent subcarinal lymph node. EBUS TBNA of station 7 returned negative for malignancy. Culture showed polymicrobial growth with negative AFB and fungi. Patient was treated without antibiotics, but due to family history of immunodeficiency, immunoglobulin panel was sent which returned low IgG subclasses. She then received IVIG. However, given the centrilobular nodules and lack of response to IVIG, repeat bronchoscopy with TBBx and BAL was performed. BAL revealed lymphocytic predominance and tissue biopsy showed non-caseating granulomas and negative cultures. Eventually patient was diagnosed with GLILD and started on 6 weeks of prednisone 40 mg daily along with PJP prophylaxis. However, her symptoms remained same and rituximab was prescribed with improvement in the symptoms. DISCUSSION: Although recurrent sinopulmonary infections are common in CVID patients, if clinical response to IVIG is minimal to none, GLILD should be considered on the differential. Centrilobular nodules and ground glass opacities should raise suspicion of GLILD and tissue sample should be obtained in these patients to confirm the diagnosis. Appropriate treatment with prednisone or rituximab along with IVIG improves GLILD patient symptoms and yields better outcomes in terms of morbidity and quality of life. CONCLUSIONS: Appropriate treatment with prednisone or rituximab along with IVIG improves GLILD patient symptoms and yields better outcomes in terms of morbidity and quality of life. Reference #1: Hurst JR, Verma N, Lowe D, Baxendale HE, Jolles S, Kelleher P, et al. British lung foundation/United Kingdom primary immunodeficiency network consensus statement on the definition, diagnosis, and management of granulomatous-lymphocytic interstitial lung disease in common variable immunodeficiency disorders. J Allergy Clin Immunol Pract. (2017) 5:938– 45. doi: 10.1016/j.jaip.2017.01.021 DISCLOSURES: No relevant relationships by Benjamin Butler No relevant relationships by Abdulmetin Dursun No relevant relationships by Badri Giri No relevant relationships by Emily Smallwood

INTERSTITIAL LUNG DISEASE EXACERBATED BY NON-NOVEL SARS-COV-2

SESSION TITLE: Variety in Chest Infections Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Viruses are thought to trigger acute exacerbation of interstitial lung disease (AE-ILD) [1]. AE-ILD results in significant morbidity and mortality [1]. We report a case of AE-ILD due to non-SARS CoV2 viral infection in the era of the COVID-19 pandemic. CASE PRESENTATION: A 61 year-old African-American male with a history of hypertension, diabetes mellitus, and smoking crack cocaine presented with acute onset of dyspnea, fever, and worsening of his chronic cough. He was diagnosed with ILD suspected to be idiopathic pulmonary fibrosis (IPF) 9 months prior to hospitalization and needed 3 L supplemental oxygen at baseline. He had received 3 doses of COVID-19 vaccination. He was tachycardic, tachypneic, hypoxemic and arrived on a non-rebreather mask to the ED. Physical examination revealed bilateral coarse inspiratory crackles. Laboratory workup revealed leukocytosis, neutrophilia, and lymphopenia. Procalcitonin, lactic acid, BNP, and troponin were normal. CXR showed significantly increased bilateral interstitial markings compared to prior imaging. The patient was not stable for a chest CT. Respiratory pathogen panel was negative for SARS-CoV2, but positive for Coronavirus OC43. Sputum culture grew normal respiratory flora. He continued to have increased work of breathing and was placed on NIV support. He received methylprednisolone, bronchodilators, and ceftriaxone with azithromycin. Antibiotics were discontinued after negative sputum cultures. The patient continued to worsen despite supportive care, he wished to transition the goals of care to comfort only. He was transitioned to hospice care and died within 24 hours. DISCUSSION: Viruses are identified in 10-20% of cases of AE-ILD, in which the virus may be acting as an extrinsic trigger [2]. Efficacious antiviral agents are lacking. Currently, there are no strong evidence based guidelines for the treatment of AE-ILD. Corticosteroids are empirically used to manage exacerbation, however response is variable and particularly worse in the IPF variant of ILD [3]. An effort should be made to identify a treatable infectious etiology in all cases of AE-ILD with any worsening symptoms. Our case highlights that the "common cold” may have fatal consequences for at-risk patients. Care for patients with AE-ILD often goes beyond medications and should encompass emotional and family support. CONCLUSIONS: Hand hygiene and mask wearing are beneficial for ILD patients, in addition to pneumococcal, COVID-19, and influenza vaccinations. In patients with IPF, antifibrotics may help prevent exacerbations [2]. There remains a need for clinical trials to aid in establishing efficacious treatment in AE-ILD. Reference #1: Charokopos A, Moua T, Ryu JH, Smischney NJ. Acute exacerbation of interstitial lung disease in the intensive care unit. World J Crit Care Med 2022;11(1): 22-32 [DOI: 10.5492/wjccm.v11.i1.22] Reference #2: Kreuter M, Polke M, Walsh SLF, et al. Acute exacerbation of idiopathic pulmonary fibrosis: international survey and call for harmonisation. Eur Respir J 2020;55: 1901760 [https://doi.org/ 10.1183/13993003.01760-2019 Reference #3: Jang HJ, Yong SH, Leem AY, et al. Corticosteroid responsiveness in patients with acute exacerbation of interstitial lung disease admitted to the emergency department. Sci Rep. 2021;11(1):5762. Published 2021 Mar 11. doi:10.1038/s41598-021-85539-1 DISCLOSURES: No relevant relationships by Ibukun Fakunle No relevant relationships by Prajwal Shanker No relevant relationships by Aashish Valvani

TRACHEOBRONCHIAL ASPIRATION IN THE ELDERLY

CASE: A 68-year-old male with a past medical history of hypertension and null smoking history presented with insidious onset dyspnea for the past three days. On physical exam, he had inspiratory rhonchi and was hypoxic, saturating to 88% in room air, requiring 6L oxygen. Laboratory studies were unremarkable, including a negative COVID PCR test. Chest X-ray demonstrated right-sided hilar prominence, and CT of the chest revealed an 8 mm endobronchial. On the day of his bronchoscopy evaluation, the patient expectorated a brownish undercooked pea while receiving nebulizer treatment and repeat chest CT revealed the resolution of the previous endobronchial lesion. IMPACT/DISCUSSION: Foreign body aspiration (FBA) has a bimodal presentation with a second peak in adults above 50 years. Although FBA most commonly presents with abrupt onset cough and dyspnea, the immediate presentation may not be evident in the geriatric population given the lack of cough reflex and cognitive decline. A retrospective study performed with data from 140 patients with FBA noted that 44.3% of patients did not present to the emergency in the first 24 hours of aspiration. Physical exam findings depend on the location of foreign body(FB) dislodgement, but around half the time, the exam could be unremarkable. A radiograph could reveal the object if the aspirated FB is radiopaque;hence a negative radiograph does not rule out the diagnosis of FBA. However, when present, the most common radiographic findings are inspiratory-expiratory abnormalities. High clinical suspicion is required to diagnose FBA to prevent chronic respiratory manifestations. An undiagnosed FB could travel distally and present as pneumonia, bronchiectasis, atelectasis, asthma/COPD-like illness. However, our patient presented with an endobronchial mass that was suspicious for malignancy. We found a similar presentation described by Bader et al. in a case about a 41-year-old woman who underwent chest CT for chronic cough, revealing a mass lesion in the right main bronchus. Bronchoscopic examination showed no growth;instead, the team found a plastic foreign body. The patient admitted aspirating this plastic object in her early 20s. If FBA is suspected, bronchoscopy is the study of choice to evaluate the airway, and extraction of FB can be performed with flexible or rigid bronchoscopy. Although flexible bronchoscopy requires only local anesthesia and a rigid bronchoscopy requires general anesthesia, the latter is safer in preventing damage to the airway. Given that each case of FBA can present unique challenges and might occasionally need endotracheal intubation or tracheostomy, only experts should perform bronchoscopic extraction of FB. CONCLUSION: In this COVID era, it is very reasonable to be anchored to a diagnosis of COVID for every patient who presents with dyspnea. FBA should be one of the differential diagnoses for geriatric patients presenting with newonset respiratory symptoms even when no physical or radiographic signs are evident.

Stepwise Validation Program for Developing the Algorithm for Chronic Cough with Remote e-stethoscope Platform RESP

RATIONALE: There has been a sustained interest in chronic cough, defined as 8 to 12 weeks of daily coughing (adults) or 4 weeks (children). The interest was initially driven by discrimination of cough based on etiology and response to therapy, and the proposed diagnosis of refractory chronic cough when other major etiologies have been excluded. Perhaps not coincidentally, the convergence of cough counting as a valid method of assessing response to therapy (necessary and sufficient) with the clinical development of first generation P2X3 inhibitors has led to the emergence of a number of patient-oriented devices that claim to count coughs. The emergence of “COVID cough” and “post COVID cough” have heightened the interest in cough. METHODS: The Strados Labs RESPTM has been validated to count coughs. Presented are three methods to count coughs in a continuous recording, in order of increased automation. Each validated method has been confirmed to be within +/- 10% of the true cough count for the gold standard recordings. Each method is validated using >6 patients (>48 hours) of continuous recordings. Number of coughs are annotated by trained professionals and are then reviewed by clinical professionals. This is the gold standard cough count. Cough Counting Methods:1.Multiple trained labelers listen to the recordings and agree on if a sound is a cough or not. The number of agreed upon coughs are added together to determine a total cough count. 2.A highly sensitive machine learning algorithm highlights samples that have a probable likelihood of a cough. Multiple trained labelers listen to recordings and agree if a cough or not. 3.Fully automated machine learning algorithm. RESULTS: In comparison with the gold standard, the highly sensitive method was (>98% sensitivity, and the fully automated machine learning algorithm is >90% specific and >90% accurate and reports the number of coughs. CONCLUSIONS: The process shown here is both necessary and sufficient to validate cough data collection using the RESP. However, unlike other approaches, the RESP provides significant quantitative and qualitative data beyond counting coughs. The RESP provides spectrograms and chest wall motion as well as archival recordings so that parsing coughs into single, multiple and spasms can be reclassified as the data set and science expand. Cough architecture can be evaluated to differentiate intrathoracic from extra-thoracic cough, cough onset in inspiration versus expiration, and response to therapy in real time and with increased anatomic certainty.

Allergic shiners in a patient with cough-variant asthma: a case report.

BACKGROUND: Chronic cough, with a duration of coughing of more than 8 weeks in adults, affects 5-10% of the general population. One of the most common causes of chronic cough is cough-variant asthma, which accounts for approximately one-third of cases. This phenotype of asthma is characterized by extreme sensitivity of the neuronal pathways mediating cough to environmental irritants, which results in an urge to cough. This case is an example of cough-variant asthma presenting with allergic shiners due to her severe cough. CASE PRESENTATION: A 38-year-old Iranian woman, who was well before the start of the coronavirus disease 2019 pandemic, presented with a nonproductive hacking cough that had begun after excessive use of antiseptic solutions. The only positive finding on physical examination was a reddish-purple rash on and around the eyelids mimicking a heliotrope rash, which had probably evolved due to the severity of the cough. The results of the pulmonary function test were within normal limits. Methacholine challenge test and chest x-ray were both normal. Chest high-resolution computed tomography revealed hyperinflation and tree-in-bud opacities. All other laboratory tests were normal. Because of the reversibility in her pulmonary function test, despite normal baseline parameters, asthma treatment was initiated, resulting in disappearance of the cough and the eye discoloration, being indicative of the correct diagnosis and proper treatment. CONCLUSION: Patients with cough-variant asthma may often have no other classic symptoms of asthma other than cough.

WAO-ARIA consensus on chronic cough - Part III: Management strategies in primary and cough-specialty care. Updates in COVID-19.

Background: Chronic cough management necessitates a clear integrated care pathway approach. Primary care physicians initially encounter the majority of chronic cough patients, yet their role in proper management can prove challenging due to limited access to advanced diagnostic testing. A multidisciplinary approach involving otolaryngologists and chest physicians, allergists, and gastroenterologists, among others, is central to the optimal diagnosis and treatment of conditions which underly or worsen cough. These include infectious and inflammatory, upper and lower airway pathologies, or gastro-esophageal reflux. Despite the wide armamentarium of ancillary testing conducted in cough multidisciplinary care, such management can improve cough but seldom resolves it completely. This can be due partly to the limited data on the role of tests (eg, spirometry, exhaled nitric oxide), as well as classical pharmacotherapy conducted in multidisciplinary specialties for chronic cough. Other important factors include presence of multiple concomitant cough trigger mechanisms and the central neuronal complexity of chronic cough. Subsequent management conducted by cough specialists aims at control of cough refractory to prior interventions and includes cough-specific behavioral counseling and pharmacotherapy with neuromodulators, among others. Preliminary data on the role of neuromodulators in a proof-of-concept manner are encouraging but lack strong evidence on efficacy and safety. Objectives: The World Allergy Organization (WAO)/Allergic Rhinitis and its Impact on Asthma (ARIA) Joint Committee on Chronic Cough reviewed the recent literature on management of chronic cough in primary, multidisciplinary, and cough-specialty care. Knowledge gaps in diagnostic testing, classical and neuromodulator pharmacotherapy, in addition to behavioral therapy of chronic cough were also analyzed. Outcomes: This third part of the WAO/ARIA consensus on chronic cough suggests a management algorithm of chronic cough in an integrated care pathway approach. Insights into the inherent limitations of multidisciplinary cough diagnostic testing, efficacy and safety of currently available antitussive pharmacotherapy, or the recently recognized behavioral therapy, can significantly improve the standards of care in patients with chronic cough.

Deadly metastatic adenocarcinoma of the lung presenting as isolated chronic cough for “3 months”: A cautionary tale

Background: Lung cancer is the leading cause of cancer death worldwide. Adenocarcinoma accounts for 38.5% of all lung cancer cases. Case Study: A 70 year old nonsmoker female with chief complaints of dry cough since 3 months, no history of hemoptysis, chest pain, fever, weight loss, loss of appetite, jointpains, no past history of COVID-19. Chest X-ray showed bilateral nodular opacities.In view of persistent symptoms HRCT chest was done that revealed large nodular lesions and paraseptal emphysematous changes in the periphery of both lungs. PET scan was done with high index of suspicion of bronchogenic carcinoma with multiple bilateral lung secondaries that revealed multiple mass lesions in bilateral lungs with lymphangitis carcinomatosis, adrenal, skeletal and abdominal metastasis. CT guided biopsy from the mass lesion revealed adenocarcinoma. EGFR mutation was positive. Discussion: Lung cancer being the most common cause of cancer death warrants meticulous evaluation including chronic cough without constitutional symptoms. Conclusion: Initial clinical presentation and investigations can be deceptive. Patient should be re-evaluated if there is no improvement. Diagnosis of malignancy can be delayed due to low index of suspicion.

Coronavirus Disease 2019-Induced Tracheomegaly: A Case Report.

Tracheomegaly is a medical condition where the tracheal diameter is greater than the upper limits of normal. Tracheomegaly can be classified as primary or secondary. Primary tracheomegaly is usually congenital. Secondary tracheomegaly can be due to multiple causes, including connective tissue disease, infections, autoimmune diseases like sarcoidosis, and prolonged mechanical ventilation. Here, we describe the first reported case of tracheomegaly secondary to coronavirus disease 2019 (COVID-19) pneumonia and COVID-induced interstitial lung disease (ILD). While many cases of tracheomegaly are asymptomatic, patients can have symptoms like cough, dyspnea, hemoptysis, or even respiratory failure. Tracheomegaly is associated with a higher risk of recurrent lower respiratory tract infections, chronic cough, bronchiectasis, and tracheobronchomalacia. Early recognition of COVID-19-induced tracheomegaly can help initial early management and reduce the incidence of infections.

Phase 2B Study of Inhaled RVT-1601 for Chronic Cough in Idiopathic Pulmonary Fibrosis: A Multicenter, Randomized, Placebo-controlled Study (SCENIC Trial).

Rationale: Chronic cough remains a major and often debilitating symptom for patients with idiopathic pulmonary fibrosis (IPF). In a phase 2A study, inhaled RVT-1601 (cromolyn sodium) reduced daytime cough and 24-hour average cough counts in patients with IPF. Objectives: To determine the efficacy, safety, and optimal dose of inhaled RVT-1601 for the treatment of chronic cough in patients with IPF. Methods: In this multicenter, randomized, placebo-controlled phase 2B study, patients with IPF and chronic cough for ⩾8 weeks were randomized (1:1:1:1) to receive 10, 40, and 80 mg RVT-1601 three times daily or placebo for 12 weeks. The primary endpoint was change from baseline to end of treatment in log-transformed 24-hour cough count. Key secondary endpoints were change from baseline in cough severity and cough-specific quality of life. Safety was monitored throughout the study. Measurements and Main Results: The study was prematurely terminated owing to the impact of the coronavirus disease (COVID-19) pandemic. Overall, 108 patients (mean age 71.0 years, 62.9% males) received RVT-1601 10 mg (n = 29), 40 mg (n = 25), 80 mg (n = 27), or matching placebo (n = 27); 61.1% (n = 66) completed double-blind treatment. No statistically significant difference was observed in the least-square mean change from baseline in log-transformed 24-hour average cough count, cough severity, and cough-specific quality of life score between the RVT-1601 groups and the placebo group. The mean percentage change from baseline in 24-hour average cough count was 27.7% in the placebo group. Treatment was generally well tolerated. Conclusions: Treatment with inhaled RVT-1601 (10, 40, and 80 mg three times a day) did not provide benefit over placebo for the treatment of chronic cough in patients with IPF.

Cough in the Elderly During the COVID-19 Pandemic.

INTRODUCTION: The prevalence of chronic cough increases with age. However, data on the prevalence and background disorders of cough subtypes in the elderly are scarce. The objective of this study was to identify the point prevalence and risk factors of acute, subacute, and chronic cough in an elderly community-based population. METHODS: This was a cross-sectional email survey amongst 26,205 members of the Finnish Pensioners' Federation during the COVID-19 pandemic in spring 2021. RESULTS: The response rate was 23.6% (6189). 5983 subjects aged at least 64 years were included in the analyses (mean 72.6 years, 66.3% female). The point prevalence of daily acute, subacute, and chronic cough were 1.4%, 0.7%, and 9.6%, respectively. Only 0.4% of the subjects had a COVID-19 infection. In the multivariate analyses, chronic rhinosinusitis, and obstructive sleep apnoea were common risk factors for all cough subtypes. Chronic cough had several risk factors; Bronchiectasis (OR 5.79 (CI95% 2.70-12.41)), current asthma (2.67 (2.02-3.54)), chronic rhinosinusitis (2.51 (1.94-3.24)), somatic symptom score (1.13 per symptom (1.07-1.19)), family history of chronic cough (1.88 (1.54-2.30)), gastro-oesophageal reflux disease (1.86 (1.50-2.32)), advanced age (1.20 per decade (1.02-1.40)), chronic obstructive pulmonary disease (1.74 (0.99-3.05)), dog ownership (1.42 (1.07-1.89)), and obstructive sleep apnoea (1.41 (1.16-1.73)). CONCLUSION: Acute and subacute cough, as well as previous COVID-19 infection, were uncommon in this Finnish elderly population. The prevalence of chronic cough was higher than that previously found in younger adults. Chronic cough is a multifactorial disorder in the elderly.

The respiratory consequences of COVID-19 lasted for a median of 4 months in a cohort of children aged 2-18 years of age.

AIM: We focused on the clinical picture, severity and prognosis of children who experienced long-term respiratory issues after COVID-19. METHODS: This was a national Czech multicentre study of paediatric post-COVID syndrome, which used a standard protocol to evaluate structural and functional anomalies and exclude alternative diagnoses. From 6 January to 30 June 2021, 11 paediatric pulmonologists enrolled all paediatric referrals aged 2-18 years with persistent respiratory symptoms more than 12 weeks after COVID-19, namely cough, dyspnoea and chest pain. Medical histories were taken, and physical examinations, lung function testing, chest X-ray and blood tests were performed. RESULTS: The dominant symptoms in the 39 children (56.4% girls) were exertional dyspnoea (76.9%) and a chronic cough (48.7%), while dyspnoea at rest (30.8%) and chest pain (17.9%) were less prevalent. More than half (53.8%) reported more than 1 symptom, and 38.5% had abnormal results for 1 of the following tests: lung function, chest X-ray or D-dimers. The median age of the children was 13.5 years (interquartile range ±4.8 years), and the median recovery time was 4 months (range 1.5-8 months). CONCLUSION: Our initial data suggest that the long-term respiratory impact of COVID-19 was relatively mild in our cohort, with a favourable prognosis.