Evaluation of Occupational and Environmental Factors in the Assessment of Chronic Cough in Adults: A Systematic Review.

BACKGROUND: Several recent cough guidelines have advised consideration of occupational or environmental causes for chronic cough, but it is unclear how frequently this recommendation has been routinely applied. Therefore, we undertook a systematic review to address this aspect. METHODS: Cough guidelines and protocols were reviewed to identify recommendations for assessment of occupational and environmental aspects of chronic cough. The systematic search previously used to identify intervention fidelity to the use of protocols for diagnosis and management of chronic cough in adults was used for this review after extension to June 2015. PubMed, Scopus, and the Cochrane Library were searched using the same search terms and inclusion criteria as previously. Papers that met our criteria were then reviewed to identify methods used to assess occupational and environmental aspects of chronic cough and the outcomes of these assessments. RESULTS: Among the 10 general chronic cough guidelines and protocols identified, only the three published since 2006 included details advising detailed occupational and environmental assessments. One additional cough statement focused entirely on occupational cough. Of the 28 cohort studies of patients with chronic cough that specifically noted that they followed guidelines or protocols, none provided details of occupational and environmental assessments. CONCLUSIONS: Despite published recommendations, it is not apparent that occupational and environmental causes for chronic cough are addressed in detail during assessments of patients with chronic cough. This leaves open to speculation whether lack of recognition of an occupational cause may delay important preventive measures, put additional workers at risk, and/or be the reason why a chronic cough may remain unexplained.

Somatic Cough Syndrome (Previously Referred to as Psychogenic Cough) and Tic Cough (Previously Referred to as Habit Cough) in Adults and Children: CHEST Guideline and Expert Panel Report.

BACKGROUND: We conducted a systematic review on the management of psychogenic cough, habit cough, and tic cough to update the recommendations and suggestions of the 2006 guideline on this topic. METHODS: We followed the American College of Chest Physicians (CHEST) methodologic guidelines and the Grading of Recommendations, Assessment, Development, and Evaluation framework. The Expert Cough Panel based their recommendations on data from the systematic review, patients' values and preferences, and the clinical context. Final grading was reached by consensus according to Delphi methodology. RESULTS: The results of the systematic review revealed only low-quality evidence to support how to define or diagnose psychogenic or habit cough with no validated diagnostic criteria. With respect to treatment, low-quality evidence allowed the committee to only suggest therapy for children believed to have psychogenic cough. Such therapy might consist of nonpharmacologic trials of hypnosis or suggestion therapy, or combinations of reassurance, counseling, and referral to a psychologist, psychotherapy, and appropriate psychotropic medications. Based on multiple resources and contemporary psychologic, psychiatric, and neurologic criteria (Diagnostic and Statistical Manual of Mental Disorders, 5th edition and tic disorder guidelines), the committee suggests that the terms psychogenic and habit cough are out of date and inaccurate. CONCLUSIONS: Compared with the 2006 CHEST Cough Guidelines, the major change in suggestions is that the terms psychogenic and habit cough be abandoned in favor of somatic cough syndrome and tic cough, respectively, even though the evidence to do so at this time is of low quality.

Assessment of Intervention Fidelity and Recommendations for Researchers Conducting Studies on the Diagnosis and Treatment of Chronic Cough in the Adult: CHEST Guideline and Expert Panel Report.

BACKGROUND: Successful management of chronic cough has varied in the primary research studies in the reported literature. One of the potential reasons relates to a lack of intervention fidelity to the core elements of the diagnostic and/or therapeutic interventions that were meant to be used by the investigators. METHODS: We conducted a systematic review to summarize the evidence supporting intervention fidelity as an important methodologic consideration in assessing the effectiveness of clinical practice guidelines used for the diagnosis and management of chronic cough. We developed and used a tool to assess for five areas of intervention fidelity. Medline (PubMed), Scopus, and the Cochrane Database of Systematic Reviews were searched from January 1998 to May 2014. Guideline recommendations and suggestions for those conducting research using guidelines or protocols to diagnose and manage chronic cough in the adult were developed and voted upon using CHEST Organization methodology. RESULTS: A total of 23 studies (17 uncontrolled prospective observational, two randomized controlled, and four retrospective observational) met our inclusion criteria. These articles included 3,636 patients. Data could not be pooled for meta-analysis because of heterogeneity. Findings related to the five areas of intervention fidelity included three areas primarily related to the provider and two primarily related to the patients. In the area of study design, 11 of 23 studies appeared to be underpinned by a single guideline/protocol; for training of providers, two of 23 studies reported training, and zero of 23 reported the use of an intervention manual; and for the area of delivery of treatment, when assessing the treatment of gastroesophageal reflux disease, three of 23 studies appeared consistent with the most recent guideline/protocol referenced by the authors. For receipt of treatment, zero of 23 studies mentioned measuring concordance of patient-interventionist understanding of the treatment recommended, and zero of 23 mentioned measuring enactment of treatment, with three of 23 measuring side effects and two of 23 measuring adherence. The overall average intervention fidelity score for all 23 studies was poor (20.74 out of 48). CONCLUSIONS: Only low-quality evidence supports that intervention fidelity strategies were used when conducting primary research in diagnosing and managing chronic cough in adults. This supports the contention that some of the variability in the reporting of patients with unexplained or unresolved chronic cough may be due to lack of intervention fidelity. By following the recommendations and suggestions in this article, researchers will likely be better able to incorporate strategies to address intervention fidelity, thereby strengthening the validity and generalizability of their results that provide the basis for the development of trustworthy guidelines.

Tools for assessing outcomes in studies of chronic cough: CHEST guideline and expert panel report.

BACKGROUND: Since the publication of the 2006 American College of Chest Physicians (CHEST) cough guidelines, a variety of tools has been developed or further refined for assessing cough. The purpose of the present committee was to evaluate instruments used by investigators performing clinical research on chronic cough. The specific aims were to (1) assess the performance of tools designed to measure cough frequency, severity, and impact in adults, adolescents, and children with chronic cough and (2) make recommendations or suggestions related to these findings. METHODS: By following the CHEST methodologic guidelines, the CHEST Expert Cough Panel based its recommendations and suggestions on a recently published comparative effectiveness review commissioned by the US Agency for Healthcare Research and Quality, a corresponding summary published in CHEST, and an updated systematic review through November 2013. Recommendations or suggestions based on these data were discussed, graded, and voted on during a meeting of the Expert Cough Panel. RESULTS: We recommend for adults, adolescents (≥ 14 years of age), and children complaining of chronic cough that validated and reliable health-related quality-of-life (QoL) questionnaires be used as the measurement of choice to assess the impact of cough, such as the Leicester Cough Questionnaire and the Cough-Specific Quality-of-Life Questionnaire in adult and adolescent patients and the Parent Cough-Specific Quality of Life Questionnaire in children. We recommend acoustic cough counting to assess cough frequency but not cough severity. Limited data exist regarding the performance of visual analog scales, numeric rating scales, and tussigenic challenges. CONCLUSIONS: Validated and reliable cough-specific health-related QoL questionnaires are recommended as the measurement of choice to assess the impact of cough on patients. How they compare is yet to be determined. When used, the reporting of cough severity by visual analog or numeric rating scales should be standardized. Previously validated QoL questionnaires or other cough assessments should not be modified unless the new version has been shown to be reliable and valid. Finally, in research settings, tussigenic challenges play a role in understanding mechanisms of cough.

Methodologies for the development of the management of cough: CHEST guideline and expert panel report.

BACKGROUND: This series of guidance documents on cough, which will be published over time, is a hybrid of two processes: (1) evidence-based guidelines and (2) trustworthy consensus statements based on a robust and transparent process. METHODS: The CHEST Guidelines Oversight Committee selected a nonconflicted Panel Chair and jointly assembled an international panel of experts in each clinical area with few, if any, conflicts of interest. PICO (population, intervention, comparator, outcome)-based key questions and parameters of eligibility were developed for each clinical topic to inform the comprehensive literature search. Existing guidelines, systematic reviews, and primary studies were assessed for relevance and quality. Data elements were extracted into evidence tables and synthesized to provide summary statistics. These, in turn, are presented to support the evidence-based graded recommendations. A highly structured consensus-based Delphi approach was used to provide expert advice on all guidance statements. Transparency of process was documented. RESULTS: Evidence-based guideline recommendations and consensus-based suggestions were carefully crafted to provide direction to health-care providers and investigators who treat and/or study patients with cough. Manuscripts and tables summarize the evidence in each clinical area supporting the recommendations and suggestions. CONCLUSIONS: The resulting guidance statements are based on a rigorous methodology and transparency of process. Unless otherwise stated, the recommendations and suggestions meet the guidelines for trustworthiness developed by the Institute of Medicine and can be applied with confidence by physicians, nurses, other health-care providers, investigators, and patients.

Overview of the management of cough: CHEST Guideline and Expert Panel Report.

This overview will demonstrate that cough is a common and potentially expensive health-care problem. Improvement in the quality of care of those with cough has been the focus of study for a variety of disciplines in medicine. The purpose of the Cough Guideline and Expert Panel is to synthesize current knowledge in a form that will aid clinical decision-making for the diagnosis and management of cough across disciplines and also identify gaps in knowledge and treatment options.

Interdisciplinary collaboration: the slogan that must be achieved for models of delivering critical care to be successful.

There is wide acceptance of the concept that interdisciplinary collaboration is an essential building block for successful health-care teams. This belief is grounded in our understanding of how teams function to address complex care needs that change with acute illness or injury. This general agreement has been validated in studies that have reported favorable outcomes associated with successfully implementing interdisciplinary models of health-care delivery in non-critical care settings. The very short time frames over which the care needs of critically ill or injured adults change and the team approach taken by nearly all ICUs strongly suggest that interdisciplinary collaboration is also beneficial in this setting. In this commentary, we define interdisciplinary collaboration and share the story of how we successfully redesigned and transformed our system-wide, interdisciplinary collaborative model for delivering critical care in order to share the lessons we learned as the process evolved with those who are about to embark on a similar challenge. We anticipate that those health-care systems that successfully implement interdisciplinary collaboration will be ahead of the curve in providing high-quality care at as low a cost as possible. Such institutions will also potentially be better positioned for improving teaching and providing a better foundation for critical care research in their institutions.

A prospective global measure, the Punum Ladder, provides more valid assessments of quality of life than a retrospective transition measure.

OBJECTIVES: We assessed the reliability and validity of two measures of change, one retrospective (the Global Rating of Change Scale [GRCS]) and one prospective (the Punum Ladder), and the relative utility of the two methods of assessing change and establishing the minimal important difference (MID) of the Cough Quality of Life Questionnaire (CQLQ), a reliable and valid cough-specific quality-of-life (QoL) instrument. STUDY DESIGN AND SETTING: A prospective, longitudinal study assessing the change in cough-related QoL over 6 months in participants with chronic cough was carried out in a tertiary care cough clinic. Before seeing a physician, subjects completed eight Punum Ladders and the CQLQ. At 1 and 6 months, eight Punum Ladders, the CQLQ, and seven GRCSs were completed. Punum Ladders and GRCSs were psychometrically tested, and MIDs were calculated. RESULTS: Reliability and validity of GRCSs and Punum Ladders were acceptable. However, closer analysis of the relation between change scores and CQLQ pretest and posttest scores showed that the GRCS was only related to patient's present state, whereas the Punum Ladder was associated with both initial and present states. This compromises the validity of the GRCS. Crosstab comparisons revealed that GRCS ratings made more liberal estimates of change in the CQLQ than the Punum Ladder; this is reflected in their respective MIDs (10.58+/-10.63 vs. 21.89+/-15.38). CONCLUSION: The prospective Punum Ladder is likely to be more useful, because it reflects the actual change in QoL over time in a less biased and more accurate way than the retrospective GRCS.

A comparison of gender differences in health-related quality of life in acute and chronic coughers.

STUDY OBJECTIVES: To determine whether the health-related quality of life (HRQOL) of women and men is adversely affected by acute cough (AC), affected differently by AC, or affected differently by AC and chronic cough (CC). DESIGN: Analysis of consecutively and prospectively collected AC data from two time periods, and previously prospectively and consecutively collected CC data that had not been previously analyzed. When no differences were found in the two cohorts of acute coughers, as was the case in the greatest majority of comparisons, the two samples were pooled, treated as one sample of acute coughers, and compared with chronic coughers. SETTINGS: Primary care and cough clinics in an academic, tertiary care medical center. PARTICIPANTS: Subjects prospectively seeking medical attention complaining of AC for < 3 weeks and CC for at least 8 weeks. MEASUREMENT: All subjects completed the cough-specific quality-of-life questionnaire (CQLQ) prior to contact with a physician and medical intervention. RESULTS: Of 62 acute coughers, 32 were women and 30 were men (p = 0.25). Total CQLQ scores for women were 59.9, and for men they were 59.2. (There was no difference in total CQLQ scores in the two cohorts of acute coughers.) The mean (+/- SD) combined total CQLQ score of women and men of 59.57 +/- 10.4 was higher (t90 = 11.39; p < 0.0001) than the score in an historical control group of women and men who were not complaining of cough (35.06 +/- 8.40). In acute coughers, there were no gender differences in the total or six subscale scores when the two cohorts were considered separately or combined. Of 172 chronic coughers, 116 were women and 56 were men (p < 0.0001). Women with CC rated themselves significantly higher than did women with AC on the total CQLQ and on five of the six subscales. Women with AC did not rate themselves higher on any of the CQLQ subscales. Total CQLQ scores for men with AC and CC were similar. Men with CC, compared with men with AC, scored significantly higher in two of six subscales (and significantly lower in one subscale) and scored similarly in three subscales. CONCLUSIONS: AC, like CC, adversely affected the HRQOL of women and men. Unlike CC, AC did not adversely affect the HRQOL of women more than men. The HRQOL of women is more adversely affected than the HRQOL of men, the longer a cough lasts.

Gender differences in health-related quality of life in patients complaining of chronic cough.

STUDY OBJECTIVES: To confirm that more women than men who complain of chronic cough seek medical attention, to determine whether the health-related quality of life (HRQOL) of these women is more adversely affected than men, and to determine whether there are gender differences in the ways that chronic cough adversely affects HRQOL. DESIGN: Analysis of previously, prospectively collected data, but not previously analyzed or reported data, plus additional prospectively collected data to enrich the database to make meaningful gender comparisons. SETTING: Cough clinic in an academic, tertiary care medical center. PARTICIPANTS: Subjects seeking medical attention complaining of cough of at least 8 weeks duration and a control group of smokers not complaining of cough. MEASUREMENTS: Assessment of chronic cough on HRQOL utilizing a valid and reliable cough-specific HRQOL instrument, the cough-specific quality-of-life questionnaire (CQLQ). INTERVENTIONS: All subjects completed the CQLQ prior to any contact with the cough specialist and medical intervention. RESULTS: In the original cohort of subjects, women (116 subjects) outnumbered the men (38 subject) by 3:1 (p < 0.0001). In the current study, total CQLQ scores for women were higher than for men (67.1 vs 59.7, respectively; p = 0.002). Women had higher scores than men in three of six subscales, as follows: physical complaints (21.6 vs 19.0, respectively; p = 0.004); psychosocial issues (14.7 vs 12.9, respectively; p = 0.002); and extreme physical complaints (8.9 vs 6.6, respectively; p < 0.001). Men and women had similar scores on the remaining subscales. Women scored significantly higher on 10 of the 28 items that make up the six subscales. The item that showed the greatest disparity and the most significant difference between women and men was wetting the pants (p < 0.001) as a result of chronic coughing. CONCLUSIONS: Women with chronic cough were probably more inclined to seek medical attention than men because their HRQOL was more adversely affected and because they were more apt to suffer from physical complaints such as stress incontinence, which provoked psychosocial issues such as becoming embarrassed.

Quality of life in coughers.

As coughing can cause profound physical and psychosocial complications, it has the potential to lead to a decrease in health-related quality of life (HRQoL). Two studies have prospectively shown that cough can adversely affect HRQoL. The first utilized the Sickness Impact Profile, a non-illness specific measure of health-related dysfunction that measured the effect of patients' health dysfunction on usual daily activities; it has not been psychometrically tested to assess the effects of cough. The second utilized a cough specific quality of life questionnaire that assessed the 28 most common and important reasons why patients seek medical attention because of coughing. It has been found to be a reliable and valid tool for evaluating the impact of acute and chronic cough on adult patients and a valid method by which to assess the efficacy of cough therapies for chronic cough. Because HRQoL is of the highest importance to patients and a cough specific HRQoL instrument assesses the impact of cough in a way no other type of measure does, a cough specific HRQoL instrument should be considered for routine use to optimally evaluate the impact of cough on patients and assess the efficacy of cough modifying agents.

Effects of a multifaceted, multidisciplinary, hospital-wide quality improvement program on weaning from mechanical ventilation.

OBJECTIVE: To examine the effects of a mechanical ventilation weaning management protocol that was implemented as a hospital-wide, quality improvement program on clinical and economic outcomes. DESIGN: Prospective, before-and-after intervention study. Data from a preimplementation year are compared with those of the first 2 yrs after protocol implementation. PATIENTS AND SETTING: Patients older than 18 yrs in diagnosis-related group 475 and group 483, who were admitted to the adult medical, surgical, and cardiac intensive care units (ICU) in a university hospital. INTERVENTIONS: After the baseline year, a weaning management program was implemented throughout our institution. Primary endpoints were mortality, days on mechanical ventilation, ICU and hospital lengths of stay, hospital costs, and the percentage of patients requiring tracheostomy. MAIN RESULTS: The number of patients increased from 220 in the baseline year (year 0) to 247 in the first year (year 1), then to 267 in the second year (year 2). The mean Acute Physiology and Chronic Health Evaluation (APACHE) II score increased from 22.2 to 24.4 in year 1 (p =.006) and to 26.2 in year 2 (p <.0005). When year 0 was compared with year 1, mean days on mechanical ventilation decreased from 23.9 to 21.9 days (p =.608), hospital length of stay decreased from 37.5 to 31.6 days (p =.058), ICU length of stay decreased from 30.5 to 25.9 days (p =.133), and total cost per case decreased from $92,933 to $78,624 (p =.061). When year 0 was compared with year 2, mean days on mechanical ventilation decreased from 23.9 days to 17.5 days (p =.004), mean hospital length of stay decreased from 37.5 to 24.7 days, mean ICU length of stay decreased from 30.5 to 20.3 days, total cost per case decreased from $92,933 to $63,687, and percentage of patients requiring tracheotomy decreased from 61% to 41% (all p <.0005). There was also a reduction in the percentage of patients requiring more than one course of mechanical ventilation during the hospitalization from 33% to 26% (p =.039), a total cost savings of $3,440,787 and a decrease in mortality between all 3 yrs from 32% to 28% (p =.062). CONCLUSIONS: A multifaceted, multidisciplinary weaning management program can change the process of care used for weaning patients from mechanical ventilation throughout an acute care hospital and across multiple services. This change can lead to large reductions in the duration of mechanical ventilation, length of stay, and hospital costs, even at a time when patients are sicker.