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Year : 2015  |  Volume : 32  |  Issue : 6  |  Page : 668-669  

Chronic cough: An Indian perspective

1 Department of Respiratory Medicine, Castle Hill Hospital, The Hull and East Yorkshire Hospitals NHS Trust, Cottingham, United Kingdom
2 Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea

Date of Web Publication23-Oct-2015

Correspondence Address:
Shoaib Faruqi
Department of Respiratory Medicine, Castle Hill Hospital, The Hull and East Yorkshire Hospitals NHS Trust, Cottingham
United Kingdom
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0970-2113.168108

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How to cite this article:
Faruqi S, Song WJ. Chronic cough: An Indian perspective. Lung India 2015;32:668-9

How to cite this URL:
Faruqi S, Song WJ. Chronic cough: An Indian perspective. Lung India [serial online] 2015 [cited 2021 Jan 21];32:668-9. Available from: https://www.lungindia.com/text.asp?2015/32/6/668/168108


We read with great interest the recent excellent review article on the management of chronic dry cough.[1]

We support the use of the concept of "cough hypersensitivity syndrome" in routine clinical use. Other than suggesting a universal mechanistic explanation for chronic cough, it also offers a novel therapeutic target.[2],[3] Capsaicin cough challenge tests unfortunately neither have the requisite sensitivity nor specificity to aid in the diagnosis of cough hypersensitivity,[4] as alluded to in the review. Although as a group, patients with chronic cough are clearly more sensitive as compared to healthy volunteers, there is a wide variation in the cough group as well as in healthy volunteers precluding the use of capsaicin cough challenge as a diagnostic test.[5] Indeed, any of the common tussive challenges evaluated (capsaicin, citric acid, tartaric acid, and distilled water) do not offer a "diagnostic test" and this is a very important, as yet unmet, clinical need.

There are some merits in regarding chronic cough as a neuropathic disorder.[6] Extrapolating its use in chronic pain where the suggested pathogenesis is similar to "cough hypersensitivity," Ryan et al. demonstrated successful outcomes in the treatment of chronic cough with gabapentin.[7] This was a double-blind, randomized, placebo-controlled trial. Gabapentin is a familiar drug to most physicians and is now a medication that may be considered for use in chronic refractory cough. P2X3 receptors are expressed by airway vagal afferent nerves and may contribute to cough hypersensitivity. In a very promising study, it has been recently demonstrated that afirst-in-class oral P2X3 antagonist, AF-219, markedly reduces cough frequency. This was based on an objective cough recording.[8] This drug is currently being evaluated in a large multicentric trial and hopefully the results should be available soon.

Concomitantly, we may also need to take an India-specific perspective. In our recent systematic review and meta-analysis on the global epidemiology of chronic cough in general adult populations, we had identified four studies that met the requisite criteria for inclusion from India. Compared to the pooled global prevalence of 9.6%, that from India was less than 5%.[9] It would be erroneous to draw any definitive conclusions regarding the relatively lower prevalence; this needs a multinational prospective survey with a standardized protocol. Several studies have suggested the risk factors that are particularly applicable to India such as the use of biomass fuel, outdoor air pollution and beedi smoking.[10],[11],[12],[13],[14],[15] Respiratory symptoms, including cough, are more commonly reported by beedi smokers as compared to cigarette smokers.[16] There could be many other determinant factors for chronic cough epidemiology that are specific to the Indian population.

The etiology of cough from the tropics can also be different. Nadri and D'Souza prospectively evaluated 87 consecutive patients presenting with cough based on the suggested "anatomic diagnostic protocol" and reported their results in this journal. In 8% of the cases, Löffler syndrome or tropical pulmonary eosinophilia was diagnosed. Pulmonary tuberculosis (TB) was diagnosed in 5% of the cases.[17] In a cross-sectional, community-population survey, the presence of cough for more than 1 week was evaluated as a possible marker of undiagnosed TB and paragonimiasis cases across 63 remote villages from two states in Northeast India. Over 4,000 subjects were included in the study. The prevalence of cough in the states of Arunachal Pradesh and Assam studied was 37.4% and 23.5%, respectively. Among those with cough, pulmonary TB was diagnosed in 2.64% and 11.6% of the cases and paragonimiasis, based on serology, was confirmed in 7.6% and 1.2% of the cases, respectively, from the two states.[18] These findings warrant additional consideration from clinicians in making differential diagnoses of chronic cough.

Although the currently accepted concepts of chronic cough are universally applicable, risk factors and causes of cough from a tropical perspective can be quite different from those reported from other parts of the world. This needs to be taken cognizance of when evaluating a patient presenting with cough.

   References Top

Mahashur A. Chronic dry cough: Diagnostic and management approaches. Lung India 2015;32:44-9.  Back to cited text no. 1
[PUBMED]  Medknow Journal  
Morice AH, Jakes AD, Faruqi S, Birring SS, McGarvey L, Canning B, et al.; Chronic Cough Registry. A worldwide survey of chronic cough: A manifestation of enhanced somatosensory response. Eur Respir J 2014;44:1149-55.  Back to cited text no. 2
Song WJ, Chang YS. Cough hypersensitivity as a neuro-immune interaction. Clin Transl Allergy 2015;5:24.  Back to cited text no. 3
Morice AH, Millqvist E, Belvisi MG, Bieksiene K, Birring SS, Chung KF, et al. Expert opinion on the cough hypersensitivity syndrome in respiratory medicine. Eur Respir J 2014;44:1132-48.  Back to cited text no. 4
Spinou A, Birring SS. An update on measurement and monitoring of cough: What are the important study endpoints? J Thorac Dis 2014;6(Suppl 7):S728-34.  Back to cited text no. 5
Chung KF, McGarvey L, Mazzone SB. Chronic cough as a neuropathic disorder. Lancet Respir Med 2013;1:414-22.  Back to cited text no. 6
Ryan NM, Birring SS, Gibson PG. Gabapentin for refractory chronic cough: A randomised, double-blind, placebo-controlled trial. Lancet 2012;380:1583-9.  Back to cited text no. 7
Abdulqawi R, Dockry R, Holt K, Layton G, McCarthy BG, Ford AP, et al. P2×3 receptor antagonist (AF-219) in refractory chronic cough: A randomised, double-blind, placebo-controlled phase 2 study. Lancet 2015;385:1198-205.  Back to cited text no. 8
Song WJ, Chang YS, Faruqi S, Kim JY, Kang MG, Kim S, et al. The global epidemiology of chronic cough in adults: A systematic review and meta-analysis. Eur Respir J 2015;45:1479-81.  Back to cited text no. 9
Behera D, Jindal SK. Respiratory symptoms in Indian women using domestic cooking fuels. Chest 1991;100:385-8.  Back to cited text no. 10
Norboo T, Yahya M, Bruce NG, Heady JA, Ball KP. Domestic pollution and respiratory illness in a Himalayan village. Int J Epidemiol 1991;20:749-57.  Back to cited text no. 11
Prasad R, Singh A, Garg R, Giridhar GB. Biomass fuel exposure and respiratory diseases in India. Biosci Trends 2012;6:219-28.  Back to cited text no. 12
Kumar R, Sharma M, Srivastva A, Thakur JS, Jindal SK, Parwana HK. Association of outdoor air pollution with chronic respiratory morbidity in an industrial town in northern India. Arch Environ Health 2004;59:471-7.  Back to cited text no. 13
Chowgule RV, Shetye VM, Parmar JR, Bhosale AM, Khandagale MR, Phalnitkar SV, et al. Prevalence of respiratory symptoms, bronchial hyperreactivity, and asthma in a megacity. Results of the European community respiratory health survey in Mumbai (Bombay). Am J Respir Crit Care Med 1998;158:547-54.  Back to cited text no. 14
Singh V, Sharma BB, Yadav R, Meena P. Respiratory morbidity attributed to auto-exhaust pollution in traffic policemen of Jaipur, India. J Asthma 2009;46:118-21.  Back to cited text no. 15
Chhabra SK, Rajpal S, Gupta R. Patterns of smoking in Delhi and comparison of chronic respiratory morbidity among beedi and cigarette smokers. Indian J Chest Dis Allied Sci 2001;43:19-26.  Back to cited text no. 16
Nadri F, D'Souza G. Investigation of chronic cough in tropics: A cost effective analysis. Lung India 2007;24:11.  Back to cited text no. 17
  Medknow Journal  
Rekha Devi K, Narain K, Mahanta J, Deori R, Lego K, Goswami D, et al. Active detection of tuberculosis and paragonimiasis in the remote areas in North-Eastern India using cough as a simple indicator. Pathog Glob Health 2013;107:153-6.  Back to cited text no. 18


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