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a Department of
Respiratory Medicine, b Department of Radiology, c Belfast City Hospital, Belfast, BT9 7AB, UK
Department of Medicine, Lagan Valley Hospital, d Department of ENT, Antrim
Area Hospital, e Department of
Clinical Biochemistry, The Queen's University of Belfast, Belfast
Correspondence to: Dr L P A McGarvey.
Received 8 December 1997; Returned to authors 9 February 1998; Revised version received 4 March 1998; Accepted for publication 6 March 1998
BACKGROUND
Asthma, post-nasal drip
syndrome (PNDS), and gastro-oesophageal reflux (GOR) account for many
cases of chronic non-productive cough (CNPC). Each may simultaneously
contribute to cough even when clinically silent, and failure to
recognise their contribution may lead to unsuccessful treatment.
MethodsPatients
(all lifetime non-smokers with normal chest radiographs and spirometric
measurements) referred with CNPC persisting for more than three weeks
as their sole respiratory symptom underwent histamine challenge, home
peak flow measurements, ear, nose and throat (ENT) examination, sinus
CT scanning, and 24 hour oesophageal pH monitoring. Treatment was
prescribed on the basis of diagnoses informed by investigation results.
RESULTSForty three
patients (29 women) of mean age 47.5 years (range 18-77) and mean
cough duration 67 months (range 2-240) were evaluated. On the basis of
a successful response to treatment, a cause for the cough was
identified in 35 patients (82%) as follows: cough variant asthma (CVA)
(10 cases), PNDS (9 cases), GOR (8 cases), and dual aetiologies (8 cases). Histamine challenge correctly predicted CVA in 15 of 17 (88%)
positive tests. ENT examination and sinus CT scans each had low
positive predictive values for PNDS (10 of 16 (63%) and 12 of 18 (67%) positive cases, respectively), suggesting that upper airways
disease frequently co-exists but does not always contribute to cough.
When negative, histamine challenge and 24 hour oesophageal pH
monitoring effectively ruled out CVA and GOR, respectively, as a cause
for cough.
CONCLUSIONThis
comprehensive approach aids the accurate direction of treatment and,
while CVA, PNDS and GOR remain the most important causes of CNPC to
consider, a group with no identifiable aetiology remains.
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