Diagnostic accuracy of fractional exhaled nitric oxide measurement in predicting cough-variant asthma and eosinophilic bronchitis in adults with chronic cough: A systematic review and meta-analysis

Song, Woo Jung; Kim, Hyun Jung; Shim, Ji Su; Won, Ha Kyeong; Kang, Sung Yoon; Sohn, Kyung Hee; Kim, Byung Keun; Jo, Eun Jung; Kim, Min Hye; Kim, Sang Heon; Kim, Sun Sin; Chang, Yoon Seok; Morice, Alyn H.; Lee, Byung‐Jae; Cho, Sang Heon

doi:10.1016/j.jaci.2016.11.037

Cited by 88 publications

(71 citation statements)

References 35 publications

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“…Exhaled nitric oxide can be used as a surrogate marker of eosinophilic airway inflammation and steroid responsiveness in classic asthma, but its role in asthma and chronic cough is questioned (see later). A meta-analysis of observational studies showed exhaled nitric oxide to have a relatively high specificity of 0.85 in predicting asthma among adult patients with chronic cough [46]; however, there is still no consensus on the cut-off level for the diagnosis. Blood eosinophilia is a simple and readily available measure, but is characterised by diurnal and seasonal variability [47], so multiple assessments should be made [48].…”

Section: Phenotypes Of Chronic Coughmentioning

confidence: 99%

ERS guidelines on the diagnosis and treatment of chronic cough in adults and children

et al. 2019

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These guidelines incorporate the recent advances in chronic cough pathophysiology, diagnosis and treatment. The concept of cough hypersensitivity has allowed an umbrella term that explains the exquisite sensitivity of patients to external stimuli such a cold air, perfumes, smoke and bleach. Thus, adults with chronic cough now have a firm physical explanation for their symptoms based on vagal afferent hypersensitivity. Different treatable traits exist with cough variant asthma (CVA)/eosinophilic bronchitis responding to anti-inflammatory treatment and non-acid reflux being treated with promotility agents rather the anti-acid drugs. An alternative antitussive strategy is to reduce hypersensitivity by neuromodulation. Low-dose morphine is highly effective in a subset of patients with cough resistant to other treatments. Gabapentin and pregabalin are also advocated, but in clinical experience they are limited by adverse events. Perhaps the most promising future developments in pharmacotherapy are drugs which tackle neuronal hypersensitivity by blocking excitability of afferent nerves by inhibiting targets such as the ATP receptor (P2X3). Finally, cough suppression therapy when performed by competent practitioners can be highly effective. Children are not small adults and a pursuit of an underlying cause for cough is advocated. Thus, in toddlers, inhalation of a foreign body is common. Persistent bacterial bronchitis is a common and previously unrecognised cause of wet cough in children. Antibiotics (drug, dose and duration need to be determined) can be curative. A paediatric-specific algorithm should be used.

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Section: Phenotypes Of Chronic Coughmentioning

confidence: 99%

ERS guidelines on the diagnosis and treatment of chronic cough in adults and children

et al. 2019

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“…Type 2 airway inflammation contributes to cough hypersensitivity at peripheral levels and is frequent in asthma. Thus, the detection of type 2 airway inflammation using objective tools, such as induced sputum analyses or fractional exhaled nitric oxide tests,85 may help relieve asthma-related cough in chronic cough patients 86. However, cough in asthma appears to have more complex nature than expected, particularly among asthmatic patients already receiving asthma-specific treatment.…”

Section: Clinical Implication Of Cough Hypersensitivity In Various Comentioning

confidence: 99%

Cough Hypersensitivity Syndrome: A Few More Steps Forward

Song

Morice

2017

Allergy Asthma Immunol Res

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115

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Cough reflex is a vital protective mechanism against aspiration, but when dysregulated, it can become hypersensitive. In fact, chronic cough is a significant medical problem with a high degree of morbidity. Recently, a unifying paradigm of cough hypersensitivity syndrome has been proposed. It represents a clinical entity in which chronic cough is a major presenting problem, regardless of the underlying condition. Although it remains a theoretical construct, emerging evidence suggests that aberrant neurophysiology is the common etiology of this syndrome. Recent success in randomized clinical trials using a P2X3 receptor antagonist is the first major advance in the therapeutics of cough in the past 30 years; it at last provides a strategy for treating intractable cough as well as an invaluable tool for dissecting the mechanism underpinning cough hypersensitivity. Additionally, several cough measurement tools have been validated for use and will help assess the clinical relevance of cough in various underlying conditions. Along with this paradigm shift, our understanding of cough mechanisms has improved during the past decades, allowing us to continue to take more steps forward in the future.

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“…Cough due to asthma can be classifi ed as cough-variant asthma, in which cough is the sole symptom; cough-predominant asthma, which can include dyspnea and wheezing; and cough that persists despite therapy with corticosteroids and beta agonists. 4,5 Of note, while variable airfl ow obstruction is classically detected in asthmatic patients, some patients exhibit no abnormal spirometry results. 6,7 Therefore, additional pulmonary tests are often needed, such as methacholine challenge and fraction of exhaled nitric oxide (FeNO) measurement.…”

Section: Diagnostic Testsmentioning

confidence: 99%