Benefits of an Established Chronic Cough Clinic in Providing Quality Care to Patients

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Dr. Blaiss:
Hello, I'm Dr. Michael Blaiss, Clinical Professor at the Medical College of Georgia at Augusta University in Augusta, Georgia. And I wanted to present to you benefits of an established chronic cough clinic and providing quality care to patients. What is a chronic cough, and why the need for a chronic cough clinic? We tended to find cough related to duration, and in fact the most common cause and one of the main reasons that patients see a clinician is an acute cough, a cough that lasts than less than three weeks, usually related to an upper respiratory tract infection. Here, chronic cough, we're talking about a cough that lasts for greater than eight weeks. Unfortunately, many patients that we see with these symptoms of cough have it in fact for months or years, and this leads to a major impact on their quality of life. Patients tell us they have sleep loss related this condition, they can't do the normal activities with families and friends. So, because of the numerous causes of chronic cough, a standalone chronic cough clinic can in fact be the best approach for workup in management of these patients.

So, what are the most common causes of chronic cough? And this is just some of them. We can see allergic or non-allergic rhinitis, sinusitis. Pulmonary conditions like asthma, COPD, non-asthmatic eosinophilic bronchitis. Gastroesophageal reflux disease, or GERD. Upper respiratory tract infections. Pneumonia, smoking, certain medications like ACE inhibitors. We can have a cardiac condition like congestive heart failure, laryngeal sensory neuropathy. We can see different cancers like lung cancer causing a chronic cough. Interstitial lung disease, and a group of patients that we call refractory and unexplained chronic cough. Refractory is, we find a cause, but even with treatment, the cough doesn't go away. Unexplained are those patients we can find no cause for their cough. Empiric treatment does not work. They continue to have problems.

So, when we look at the experience of patients with chronic cough, with the number of conditions that can lead to chronic cough, it's not uncommon for these patients to go to one physician after another. They tend to get numerous testing and unfortunately, in many cases, no diagnosis. And many times, when we see these patients, they're extremely frustrated, they're irritable, and they can be angry. And all of this can lead to a general mistrust of the medical profession. So, what are the benefits of a chronic cough clinic? Well, by having this chronic cough clinic to refer patients, we have a single location for an extensive evaluation with all the needed specialist and ancillary staff. So, this type of clinic can lead to a quicker diagnosis in many cases, and appropriate management for that sufferer. Now, many times, and we see this, patients just aren't taken serious for their chronic cough. But in a chronic cough clinic, they're always going to hear an empathetic voice and support needed to help cure or at least help control their condition.

So, what is unique about a chronic cough clinic? Well, it's a true multidisciplinary approach cause as we saw, there are so many different types of causes for this condition. So, we have allergists, pulmonologists, gastroenterologists, otolaryngologists, and speech and language pathologists to work up the patient. So, what is that approach for work-up in management a chronic cough clinic? One, to try to get that diagnosis, one needs to start with an extensive history, looking at cough duration, impact triggers, family history, environmental history. Look for issues that we call red flags. Serious conditions like malignancies, infections. We need a detailed medical history, family histories we mentioned, smoking history. We need to assess cough severity and quality of life. We can do that by visual analog scale for cough severity. Quality of life, we commonly use the Lester cough questionnaire, and there are others. These patients need a very broad comprehensive physical examination, and the initial evaluation should always include a chest x-ray and spirometry.

Now, what if nothing is found so far? Then we need to look for what's called the big four, the most common things that are seen when nothing is figured out in the history and physical exam, and the routine evaluation. So, things like upper airway cough syndrome, which include allergic and non-allergic rhinitis and sinusitis. Asthma, non-asthmatic eosinophilic bronchitis, and gastroesophageal reflux disease. So, with these things, we may want to do further testing, and this can be done in a chronic cough clinic. Things like allergy testing, CT scans of the sinuses, the chest. We may need to do bronchoscopy of the lungs, rhinoscopy, laryngoscopy, sputum eosinophils. We may need an extensive GI workup, acid reflux, pH, impedance testing in our patient population.

What if no cause for the chronic cough is found? So, this gets back to refractory or unexplained chronic cough. And management is limited, but there are things that can be done in a chronic cough clinic, things like speech and language evaluation. Different treatments of the neuronal pathway. Off-label use of things like gabapentin, pregabalin, amitriptyline, and in certain cases, low-dose morphine to try to help control the condition. One of the other benefits of a chronic cough clinic is that these clinics are usually involved in clinical studies with new treatments for chronic cough. And therefore, many of the patients in these particular clinics may qualify for these studies, which hopefully may improve their cough and hopefully lead to new improved treatments for all patients suffering with chronic cough.

So, in conclusion, chronic cough can lead to frustration, irritability, and anger for the patient. Chronic cough clinics, with their multidisciplinary approach, can lead to a comprehensive evaluation and work-up with the hope to find a cause that can be treated or at least lead to improvement in symptomatology. Very importantly, the patient gets validation that they have a medical condition from an empathetic group of clinicians, whose one goal is care for these patients. Thank you.

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