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.

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.

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.

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.

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.

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.