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Am Fam Physician. 2007;76(8):1214-1217

Background: Chronic cough is one of the most common reasons for patients to seek a physician's advice. Current management guidelines for this condition emphasize history taking and physical examination followed by focused diagnostic testing and sequential empiric treatment. Although logical and cost-effective, this approach is time-consuming; for example, up to five months may be needed to sequentially treat the two most common sources of chronic cough (allergic rhinitis and gastric reflux). The guidelines also may not consider patient concerns about the condition, such as fear of a serious underlying cause, effect on quality of life, and the implications of refractory symptoms despite an extended treatment course. The impact of chronic cough on quality of life is reported to be similar to that of chronic pain or inflammatory bowel disease. Identifying how chronic cough specifically affects quality of life may have clinical implications and help address this issue from the patient's perspective.

The Study: Kuzniar and colleagues prospectively surveyed all patients presenting with chronic cough at Mayo Clinic Hospital over a four-month period. Patients had to have had a cough for more than three weeks to be included in the study. Researchers used an 18-point questionnaire to get data about the psychological, physical, social, and economic impact of chronic cough on the patients' quality of life.

Results: Of the 146 patients who completed the questionnaires, 136 met the inclusion criteria. The respondents had a median age of 63 years, and 65 percent were women. Overall, the most common problems reported were interference with lifestyle (109 patients [80 percent]); frustration, irritability, anger, and sleep disturbances (107 patients [79 percent]); and the need for frequent physician visits and testing (104 patients [76 percent]). The problems most likely to have a major impact on quality of life were frustration, irritability, and anger (58 patients [43 percent]); frequent physician visits and testing (56 patients [41 percent]); and sleep disturbances (52 patients [38 percent]). No difference was found in frequency of problems based on sex, age, or longer duration of cough.

Forty-three percent of patients reported that incontinence was a minor or major issue, and women were more likely than men to say it was a problem. Although two thirds of respondents reported anxiety about an underlying illness, only 21 percent said this had a major impact on their quality of life. The results of a cluster analysis revealed that anxiety was present independent of the physical and psychological symptoms reported by the patients.

Conclusion: The authors conclude that chronic cough is associated with a high frequency of somatic and psychological complaints. The need for frequent physician visits and testing was cited as negatively impacting quality of life. It is possible that the sequential testing and empiric treatment algorithm currently recommended to manage chronic cough may increase anxiety and concern about a serious underlying condition. Therefore, anxiety should be routinely assessed during chronic cough evaluation. Although the sequential process is more cost-effective in general, selected patients may benefit from focused therapy based on more comprehensive initial testing.

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