Relieving the Chronic Cough Burden: From Expert Evaluation to Emerging Therapies (Podcast)

Chronic cough can have a significant impact on quality of life, not just for patients with the condition, but also for their loved ones. Due to its complexity and heterogeneity, chronic cough management and treatment require providers to go beyond symptom management and provide personalized care to their patients.

“We tell residents and fellows you can't run away from chronic cough. You will have a patient with chronic cough, no matter what area you specialize in, whether you are in general pulmonary medicine or whether you are in a subsection of pulmonary medicine,” says Rachel Taliercio, DO, co-Director of the Chronic Cough Clinic at Cleveland Clinic.

In a recent episode of Respiratory Exchange, Dr. Taliercio and Michael Ghobrial, MD, the other co-Director of the Chronic Cough Clinic, discuss how early referral to a specialized chronic cough clinic can reduce unnecessary testing, avoid treatment delays and uncover treatable causes that are often missed.

“There have been some proven benefits from early referral: high patient satisfaction, avoiding unnecessary or repeated testing, avoiding unnecessary or medical treatments, or even surgical interventions,” explains Dr. Ghobrial. “We have seen patients who have had surgeries for their chronic cough, and they definitely did not benefit from it. So, earlier referrals can avoid this risk. Also, it's associated with reduction of time to diagnosis, treatment and reduction of overall healthcare-related costs.”

In addition to discussing the Chronic Cough Clinic, they also touch on:

• How thoughtful history-taking and using guideline-based diagnostics can improve outcomes.
• The need for more precise language and terminology to ensure consistent evaluations and communication across specialties.
• Promising new medication trials on the horizon.
• The impact of AI-powered cough monitoring and behavioral cough suppression therapy on care.
• Different types of coughs and their significance.

Click the podcast player above to listen to the episode now, or read on for a short, edited excerpt. Check out more Respiratory Exchange episodes at https://my.clevelandclinic.org/podcasts/respiratory-exchange or wherever you get your podcasts.

Excerpt from the podcast

Dr. Taliercio: Let's talk about the evaluation. You mentioned what we can describe as a “healthcare burden” that these patients suffer from. They often see their primary care physician, and then a lot of different specialists. They sometimes undergo unnecessary testing and procedures. What is the standard of care for testing in patients? What should these patients be undergoing, in terms of testing and evaluation?

Dr. Ghobrial: So whenever a patient is being referred, or a patient is self-referring to the Chronic Cough Clinic, the first thing we do is to try to gather as many records as possible. We want to really dig deeper, go back through years of complaints, records and office visits with other providers, from pulmonology, primary care, ENT, GI, to understand what has been done, how long this has been going on, and what treatments were prescribed in the past.

So, we do a lot of reviewing of records before patients come in. This also enables us to identify if a patient would benefit from seeing pulmonary medicine in the chronic cough clinic alone or if we need to collaborate with other subspecialties during their visit as well.

The second thing we do is to order preliminary testing. This would typically include chest X-ray, spirometry with bronchodilator, along with exhaled nitric oxide. This would give us a clear idea, or a preliminary idea, of what could be causing this chronic cough. If there is a common cause that we can pinpoint to their chronic cough, this is typically followed up on during their visit, with a thorough history gathering and a physical examination.

It is critically important that we let patients talk and just let them talk. They will fill you with so much information, way more than what you probably need to ask them. You just have to let them talk, give you all the history, all what they needed to, to tell you, and they will give you typical clues, for what their chronic cough could be related to, especially when they mention to you, when did it start, what makes it get worse, what makes it get better, what exacerbates it, what type of treatments they may have received in the past? And it's important to review what kind of medications they are on at any point in time.

Afterward, if we need to do more testing or if we need to refer patients to our colleagues from different specialties, this will typically follow towards the end of their evaluation.

Dr. Taliercio: You mentioned something important there – the patients know their cough. They have an intimate relationship with it. Let's be honest about that. They are the best historians. So, it's a combination of reviewing the records, seeing what's been done, and knowing what questions to ask the patient. Then, allowing them to talk without interruption and tell the story of their cough, essentially. Recognizing that and taking the time to hear them out will be beneficial in the end, right? Because patients are often helping us figure out what the underlying cause is.

Dr. Ghobrial: I fully agree. And I would just add, too, it's important to listen to our patients' families who are coming with them. So, I remember one patient I'm seeing, and she's telling me about her cough. I'm asking, ‘OK, can you please tell me about your cough?’ And the husband responds and says, ‘It's our cough, it's not her cough. Let me tell you about what's going on here.’

So, this represents how impactful this is not just for the patient, but also for the family. People may sleep in different beds because of the cough, which is causing disturbed sleep at night. So, it's quite impactful, and when you listen, you can really understand the magnitude of this condition that you're taking care of.

Dr. Taliercio: You're absolutely right. We would often talk amongst ourselves that a majority of the chronic cough referrals, especially the self-referrals, the spouse, or the partner, were the ones who was reaching out for help.