Chronic refractory cough

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Classification according to ICD-10
J44 Other chronic obstructive pulmonary disease
R5 to cough
ICD-10 online (WHO version 2019)

Chronic refractory cough , and CRC (for c hronic r efractory c ough) one will tease coughing called, continue to suffer from the patient - despite a careful diagnosis and consistent treatment of possible causes. An unexplained cough is when the cause of the cough is definitely not found. A cough is referred to as refractory if the treatment of a cause of the cough has not brought about any improvement.

Persistent coughing affects the quality of life enormously. Patients are under great stress because they can prevent concerts and theater visits, cause stress incontinence or even headaches . It disrupts conferences or meetings and often also disturbs sleep. In the past, a psychological cause was often discussed in a refractory cough . Today, a hypersensitivity syndrome with peripheral and central sensitization analogous to a chronic pain syndrome is assumed.

Definitions

A chronic cough is when the cough lasts for more than eight weeks. After clarifying the underlying cause, a distinction is made between two different types:

  • Chronic refractory cough , when the cough persists despite adequate therapy for the underlying disease.
  • chronic idiopathic cough , if a diagnostic exclusion of possible causes has been made (exclusion diagnosis).

Clarification of the chronic cough

The symptom-related history and physical examination are very important for clarifying an unexplained cough. For most patients, they allow an initial diagnostic classification.

Possible underlying diseases in chronic refractory cough are: rhinosinusitis (Upper Airway Cough Syndrome), gastroesophageal reflux disease (GERD) , asthma , allergy and / or COPD .

The following diagnostics can be used to clarify possible underlying diseases: pulmonary function test , chest x-ray , ENT examination , electrocardiogram , neurology , drugs as the cause (e.g. ACE inhibitors ; a common undesirable side effect ), diagnostics for gastroesophageal reflux disease, possibly thorax CT and / or bronchoscopy .

Since probatory , i. H. Trial therapies include, a clear separation is often difficult.

Probatory therapies

Bronchial hyperresponsiveness

The bronchial hyperreactivity is characterized by a dry and excruciating persistent cough - often following a respiratory tract infection ; In contrast to asthma, however, there are no bouts of shortness of breath and normal lung function is found . An inhaled corticosteroid can lead to an improvement in the first week and has reasonably few side effects. However, if the cough does not improve after four to six weeks with this probatory therapy, bronchial hyperreactivity is rather unlikely and further investigation must be carried out.

Reflux esophagitis

A reflux oesophagitis (gastroesophageal reflux) can with a gastroscopy or a 24-hour pH value be detected measurement. However, no technical examination can provide evidence that gastroesophageal reflux is also the cause of the cough. Therefore, if reflux and cough are known, probatory therapy with a proton pump inhibitor is carried out. Double the standard dosage - over two to three months - may be necessary here.

Rhinitis and / or sinusitis

If you have symptoms of rhinitis or sinusitis , you may have Upper Airway Cough Syndrome (UACS). The UACS covers all diseases of the upper respiratory tract that cause cough: chronic sinusitis , chronic (allergic) rhinitis and nasal polyps . Secretions and inflammatory stimuli from the nasopharynx are the triggers of a chronic cough. If there is uncertainty about the differential diagnosis , a CT or MRI examination of the paranasal sinuses is the gold standard . A trial therapy with oral antihistamines is possible, decongestant nasal drops or sprays can be used as an alternative. However, since these should not be used for longer than seven days, they are of limited therapeutic use. If chronic sinusitis is suspected, a nasal spray containing corticosteroids should be prescribed.

Non-drug treatments

As non-drug therapy approaches, physiotherapeutic and speech therapy treatment concepts were investigated, which are intended to reduce the increased urge to cough.

Drug treatments

Various substances, such as As gabapentin , pregabalin , morphine and amitriptyline were in randomized trials investigated. To baclofen and ipratropium bromide exist case reports . However, there is no approval for any of the preparations in this indication. In terms of application, this means off-label use (regulation without approval).

Adenosine triphosphate can lead to hypersensitivity of the airways and thus to a chronic cough. A subtype of the ATP receptor could be a point of attack to block the cough reflex: P2X receptor . A first drug, Gefapixant (MK-7264), acts as a P2X3 receptor antagonist and is currently being investigated in clinical trials (phase III) for the treatment of chronic refractory cough. The drug has not yet been approved.

Guidelines

literature

Web links

Individual evidence

  1. ↑ Chung KF et al .: Chronic 'cough hypersensitivity syndrome': a more precise label for chronic cough. In: Pulm Pharmacol Ther . tape 24 , no. 3 , June 2011, p. 267-271 ., Doi : 10.1016 / j.pupt.2011.01.012 .
  2. ^ Peter G Gibson et al .: Management of chronic refractory cough. In: BMJ . 351: h5590, December 14, 2015, doi : 10.1136 / bmj.h5590 .
  3. ↑ Guideline - Chronic Cough , German Society for General Medicine and Family Medicine (DEGAM), accessed on April 18, 2019
  4. ↑ Ryan NM, Birring SS, Gibson PG: gabapentin for refractory chronic cough: a randomized, double-blind, placebo-controlled trial. Lancet 2012; 380: 1583-1589.
  5. ↑ Vertigan AE, Kapela SL, Ryan NM et al .: pregabalin and speech pathology combination therapy for refractory chronic cough: a randomized controlled trial. Chest 2016; 149: 639-648.
  6. ↑ Morice AH, Menon MS, Mulrennan SA et al .: Opiate therapy in chronic cough. Am J Respir Crit Care Med 2007; 175: 312-315.
  7. ↑ Jeyakumar A, Brickman TM, haben M: Effectiveness of amitriptyline versus cough suppressants in the treatment of chronic cough resulting from postviral vagal neuropathy. Laryngoscope 2006; 116: 2108-2112.
  8. ↑ Dicpinigaitis PV Rauf K: Treatment of chronic, refractory cough with baclofen. Respiration 1998; 65: 86-88.
  9. ↑ Holmes PW, Barter CE, Pierce RJ: Chronic persistent cough: use of ipratropium bromide in undiagnosed cases following upper respiratory tract infection. Respir Med 1992; 86: 425-429.
  10. ↑ ClinicalTrials.gov: Phase 3 Study of Gefapixant (MK-7264) in Adult Participants With Chronic Cough (MK-7264-027) , accessed April 18, 2019.
  11. ↑ P. Kardos, QT Dinh, K.-H. Fuchs, A. Gillissen, L. Klimek, M. Koehler, H. Sitter, H. Worth: Guideline of the German Society for Pneumology and Respiratory Medicine for the Diagnosis and Therapy of Adult Patients with Cough In: Pneumology Volume 73, Number 3, 2019, Pp. 143-180, doi : 10.1055 / a-0808-7409 , accessed on April 4, 2019