Empirical Treatment Of Chronic Cough

BackgroundThe common causes of chronic cough includes postnasal drip syndrom(PNDS),cough-variant asthma(CVA), eosinophilic bronchitis(EB), gastroesophageal reflex-related cough(GERC), atopic cough(AC) . Because the patients with CVA, EB and AC are sensitive to glucocortisteroids, we name CVA, EB and AC as glucocortisteroids-sensitive cough (GCSC). The approach to"test all, then treat"is the most effective, but is the most expensive. However, economical condition of many patients and laboratory equipment in comminity hospitals are not very good in our country, it is impossible for each patient with chronic cough to get all etilogical examination. Empirical treatment should play an important role in chronic cough.ObjectiveTo explore and evaluated the stategy of empirical treating the chronic cough . MethodsAn empirical therapy protocol was used to treat patients who had a chronic cough and a normal CXR. Patients with a history of cough lasting not less than 8 weeks attending a respiratory clinic were recruited from July 2007 to March 2009. Cough symptom scores were recorded before and after each step in the protocol. We propose the following approach: 1. clinical history, physical examination, chest-X ray; 2. to exclude a cough secondary to an ACEI; 3. Accoding to the etiogical distribution of the chronic cough in south part of China, and their clinical charteristics,, the patiens were initially diagosised as GCSC, PNDS and GERC, then treated step by step. If the cough resolved, then the responsible factor was identified. If cough resolved or partly resolved, the treatment for other cause should be instituted next. In case of high clinical probability of post-nasal drip, antihistamine decongestants plus bronchodilators were taken in step one, corticosteroids in the second step, and a combination of a proton pump inhibitor and a prokinetic agent in the third step. In case of high clinical probability of gastro-oesophageal reflux, combination of a proton pump inhibitor and a prokinetic agent were taken in step one, a corticosteroids in the second step, and antihistamine decongestants plus bronchodilators in the third step. In case of high clinical probability of asthma or without the clinical probability of PNDS or GERC, corticosteroids were taken in step one, antihistamine decongestants plus bronchodilators in the second step, and a combination of a proton pump inhibitor and a prokinetic agent in the third step. The effective rate and the distribution of etiological diagnosis were observed two weeks after each empiricaltreatment.Results1. A number of 96 patients were recruited, with mean age 35.4±9.9 years and a mean course of cough of between 4 and 120 months, male 49cases and female 47cases. According to the clinical manifestation initially diagnosis were made as GCSC 53 cases(55.2%),GERC 7cases(6.3%) and PNDS 36cases(37.9%) respectively.2. After first period of empirical treatment, cough was eliminated or markedly improvement in 38 cases (39.6%), and partly improvement in 22 case (22.9%), with total efficiency of 62.5%. Of the 53 patients with GCSC, cough was eliminated or markedly improvement in 27 cases, and partly improvement in 10case, with the efficiency of 69.8% . Of the 36 patients with PNDS, cough was eliminated or markedly improvement in 7cases, and partly improvement in 12case, with the efficiency of 52.8%. Of the 7 cases of GERC, cough was eliminated or markedly improvement after first period of empirical treatment, with the efficiency of 57.1%.3. After the empirical treatment based on clinic manifestation, 78 cases were effective(81.3%) and 18 cases were ineffective(18.7%).Of the 78 cases, cough due to a single cause was found in 54 cases(56.3%) and due to multiple causes in 24 cases (25.0%). The final diagnosis distribution was that GCSC 35 cases (36.5%), PNDS 12 cases (12.5%), GERC 7cases (7.3%), GCSC+PNDS18 cases (18.8%%), GCSC+GERC3 cases (3.8%), and PNDS+GERC 3 cases (3.8%) respectively.4. Of the 78 patients who were effective to empirical treatment, there were no significant differences in age, gender, course of disease and the nature of cough. The VAS score in GCSC group is markedly higher than other groups. The incidence of nocturnal cough was 48.2% in GCSC group were significantly higher than those in others. The sensitivity and specificity of regurgitation associated symptom in GERC were 61.5% and 88.0%. The incidence of postnasal drip and rhinitis associated symptom in PNDS were36.4%and 69.7%, which were significantly higher than other groups, with a specificity of 96.8%, and 73.0% .5. 18 patients,cough disappeared in one patient after treating with antibiotics:Levofloxacin, in the other patient treated with high-dose intravenous corticosteroids, one patient was diagonosised as bronchial tuberculosis by bronchoscopy, tow patients was confirmed with bronchiectasis by CT, one patient suffered from premature ventricular complexes, one patient was diagnosed as nasopharyngeal carcinoma, cough disappeared after traditional Chinese medicine was administered in one patient., cough eliminated by itself in one patient, and the causes of chronic cough were not identified in 9 patients.ConclusionsWhen etiological diagnosis of chronic cough is not feasible, empiric trial is of some benefit, based upon total epidemiological data of common causes underlying chronic cough as well as clinical features of the patients.