Congratulations to North East Thames trainee Dr Richard Turner, who has co-authored a review article in Primary Care Respiratory Medicine from the Nature group with Prof Graham Bothamley. They report a retrospective cohort study which examined the investigations necessary and the final diagnoses of people with chronic (>8wks) cough referred to a specialist cough clinic. They conclude “Most cases of chronic cough referred to secondary care could be managed with a simple and systematic approach, which is potentially transferrable to a community setting.” There are learning points not only for GPs, but also Respiratory physicians outside of specialist cough clinics, with reassurance that in the majority of cases a systematic approach leads to diagnosis and improved symptoms.
Richard argues that there are benefits to the patient and the wider health system from treatment in primary rather than secondary care, and that there is evidence that referral to secondary care for chronic cough occurs prematurely. Among 266 patients, the most frequent diagnoses were asthma (29%), gastro-oesophageal reflux (22%) and angiotensin-converting enzyme inhibitor use (14%). In all, 12% had unexplained chronic cough.
“The approach of the cough clinic followed that advocated by British Thoracic Society guidelines, with emphasis on 8- to 12-week trials of treatment before detailed investigation…. As the last step in the algorithm, options for persistent cough of unknown cause included referral to a respiratory physiotherapist for behavioural cough-suppression training, a trial of gabapentin or tertiary referral for entry into a clinical trial. For smokers, once serious pathology and airway disease were excluded, management was smoking cessation. From mid-2013, the clinic assessed patient-reported cough severity and cough-related quality at clinic visits with a 0–100 VAS and the LCQ, respectively.”
“We demonstrated good patient outcomes in a secondary-care cough clinic over a median of only two clinic visits. Although ENT referral contributed to the diagnosis in 17%, we undertook very few investigations which were not available to GPs in the UK. Skin tests were commonly performed but were not essential for diagnosis. The majority (>80%) of cases of chronic cough referred from primary to secondary care could therefore be managed in a systematic and simple way.”
Read the full text article here:
- Richard D Turner & Graham H Bothamley. Chronic cough and a normal chest X-ray – a simple systematic approach to exclude common causes before referral to secondary care: a retrospective cohort study. npj Primary Care Respiratory Medicine 26:15081 (2016) doi:10.1038/npjpcrm.2015.81
Brush up on your knowledge of the BTS guidelines on cough here:
- Morice, A. H., L. McGarvey, and I. Pavord. “Recommendations for the management of cough in adults.” Thorax 61.suppl 1 (2006): i1-i24.
Have a look at the clinic aide-memoire on cough in the resources section, which is based on these guidelines and the approach used in Prof Bothamley’s clinic.