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

Podcast Transcript

Raed Dweik, MD:

Hello and welcome to the Respiratory Exchange Podcast. I'm Raed Dweik, Chief of the Integrated Hospital Care Institute at Cleveland Clinic. This podcast series of short digestible episodes is intended for healthcare providers, and covers topics related to respiratory health and disease. My colleagues and I will be interviewing experts, about timely and timeless topics, in the areas of lung health, critical illness, sleep, infectious disease, and related disciplines. We will share with you information that will help you take better care of your patients. I hope you enjoy today's episode.

Rachel Taliercio, DO:

Hello and welcome. My name is Rachel Taliercio. I am a pulmonologist, and a faculty member at Cleveland Clinic, and also a member of the Chronic Cough Team.

So, I wanna start this podcast by thanking you, the listener, for making time for this conversation, because it means that you care. It means that you care about patients with chronic cough. And what we tell residents and fellows, is that you can't run away from chronic cough. (Laughs). You will have a patient with chronic cough, no matter what area you specialize in, whether you are in general pulmonary medicine, whether you are in a subsection of pulmonary medicine. This is such a common chronic condition, so thank you for taking time to listen today, for caring about these patients, for being open to hearing about our suggestions. I'm really excited for this conversation, I am here with Michael Ghobrial, who is the director of our Chronic Cough clinic. Michael, can you tell us a little bit about yourself, and, and how long you've been here?

Michael Ghobrial, MD:

Sure. Thank you so much, Rachel. Thank you, guys, for joining. Thanks for having me. My name is Michael Ghobrial, and I have been with Cleveland Clinic for the last, probably, what, 15 years since I moved from Egypt. I did my year of research, residency, fellowship, and I've been on staff since 2018, and I'm happy to be co-directing this Chronic Cough clinic with Dr. Taliercio. Thanks for having me.

Rachel Taliercio, DO:

Wow, it's my pleasure. We're gonna talk about chronic cough. We're gonna cover a lot in the session today, we'll talk about what's new, what you're excited about in drug development, and cough monitors. And I wanna start by introducing terminology that many people are aware of and yet there's a need to create awareness in the medical community, because when we develop a common language, when we as pulmonologists can talk about chronic cough, in a way that everyone understands, and that patients understand, it allows us to evaluate, and manage these conditions better. So, can you tell me about the terminology, refractory chronic cough, and what this means to you?

Michael Ghobrial, MD:

Yeah. Setting the right language, and talking the same language is really important, because these patients usually have been through different providers, and they are hearing different terminologies, getting different diagnoses. So chronic cough, by definition, is a cough that lasts more than eight weeks. But we, as experts in chronic cough, identify another phenotype of chronic cough, which is kind of refractory. And it really represents what chronic cough really is. When you have a patient that's been coughing for probably months, or years, and you have not been able to find any solution for them, they have been refractory to different lines of treatment, for most common causes of chronic cough. These patients would then be labeled as refractory chronic cough. There hasn't been a consensus opinion yet, in regard to how long this would be, to call it refractory. But we are talking about patients we are seeing in clinic, who have been coughing for months, and years.

Rachel Taliercio, DO:

Yeah, most of these patients with refractory chronic cough, we think of at least a year of coughing. And I imagine what you're seeing in clinic is many years, if not decades, of coughing?

Michael Ghobrial, MD:

Correct. And studies have shown that probably about 40% of these patients, may have what we refer to as cough reflex hypersensitivity, which can make the diagnosis quite difficult, because there is no specific test you can provide to these patients, to diagnose them with this condition.

Rachel Taliercio, DO:

So when you're seeing these patients in clinic, whether you've heard the terminology refractory chronic cough, or if we're introducing this terminology to you, we invite you to use it, because it helps create that common language, and a platform, and a place to get started, in the evaluation, and management of these patients. You mentioned another terminology that can be confusing for clinicians, and that's cough hypersensitivity syndrome. This has been known by a lot of different terms, we try to explain this to patients in clinic and sometimes struggle with that. And we know that a lot of patients with refractory chronic cough, have cough hypersensitivity. Tell me about what that terminology means to you, and what it identifies.

(05:08 minutes)

Michael Ghobrial, MD:

Yes. It's very important, because patients have been told so many different things. Um, earlier it was called neurogenic cough, or habitual cough, or neuropathic cough. And this can imply to some providers, or patient that, oh, the cough is in your head, stop coughing. Uh, try to suppress it. And some patients were even blamed for coughing, and it was quite frustrating to patients, and their families too. So the idea that for some patients who have been having chronic cough, their cough reflexes have become quite hypersensitive. So stimuli that normally should not be stimulating their cough reflex, all of a sudden is causing them to have a cough, and they could develop, what we call allotussia, which is coughing just by talking, or if someone is exposed to cold drinks, or ice cream, or cold air, or just talking, they may be coughing.

And this can be related or attributed to cough reflex hypersensitivity. We caution providers from just labeling patients with cough reflex hypersensitivity, before providing patients with thorough evaluation, thorough testing, and thorough treatment. Typically, this is the diagnosis of exclusions. This is not the most common cause of refractory chronic cough, but it can play a role in refractory chronic cough, or why the chronic cough is being refractory. We typically would like to identify a cause; we like to optimize its treatment. If there is some degree of refractoriness for this cough, then we would work on this cough reflex hypersensitivity pathway as a possible cause for the refractory part of the chronic cough.

Rachel Taliercio, DO:

That's a critical point in this: patients whom we see with refractory chronic cough, with features of cough hypersensitivity. And these features, this condition of cough hypersensitivity, is a diagnosis of exclusion. You wanna make sure that you've done your due diligence. It can also be a factor, it can be a characteristic of cough in patients with asthma, or patients with other, you know, common causes of chronic cough. So it can be present in those conditions as well. And knowing what questions to ask in clinic can be a key part to how you help diagnose these features. In addition, I wanna highlight something you said, about patients telling us how they often feel dismissed, that either the cough is something that they have to live with, that it's a symptom, and, and what labeling something, or giving something a terminology like refractory chronic cough, cough hypersensitivity syndrome, not only does that create a common language, it is validation for the patient, and recognition that this is a condition, that this is something that other people struggle with, and suffer from.

Michael Ghobrial, MD:

That's critically important. We hear quite a lot from patients that you are the first one to listen to my symptoms. You are the first one to believe that I, I have a chronic cough, or a chronic condition, and how impactful this is affecting my life. So active listening, and validating patient's symptoms, understanding how it really affects their physical health, their social life, their psychological wellbeing, how it affects their sleep, how it affects their participation in activities. All these are critical areas in your success for evaluating and treating patients with this chronic condition.

Rachel Taliercio, DO:

Absolutely. You run a chronic cough clinic, and while you get patients that self-refer, that hear about the clinic, you also see a lot of patients that are referred by colleagues, by pulmonologists, colleagues of ours, both within Cleveland Clinic, and outside of Cleveland Clinic. When you think about seeing these patients in clinic, and getting these referrals, what do you want our colleagues to know about these patients? Who is the right patient to refer to a chronic cough clinic?

Michael Ghobrial, MD:

That's important. So patients who you have evaluated, and treated, and you could not really meet success, patients are quite frustrated. It's been, what, three, six months in your evaluation process, as a pulmonologist, and you have not been able to get this cough under good control. It's not a bad idea to pick on someone, to dig deeper into it, and provide more specialized evaluation for this chronic cough. So, people who did not have a clear etiology, people who have not responded to your treatment, I would say these would benefit from early referrals. 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. We have seen patients who have had surgeries for this chronic cough, and they really, maybe didn't need it, or definitely did not benefit from it. So it can ... earlier referrals can avoid this risk. Also, it's associated with reduction of time to diagnosis, and treatment, and reduction of overall healthcare-related costs.

(10:32 minutes)

Rachel Taliercio, DO:

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, a lot of different specialists. They undergo sometimes 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?

Michael Ghobrial, MD (10:58):

That's great, so whenever a patient is being referred, or a patient's self-referring to the Chronic Cough clinic, the first thing we do is to try to gather as many records as possible. We wanna really dig deeper, and go back in years of complaints, and records, office visits with other providers, from pulmonology, primary care, ENT, GI, to kind of understand what has been done, how long this has been going on, 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 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, and 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. And if there is a common cause, common is common in medicine. If there is a common cause that we can pinpoint to their chronic cough, this is typically followed 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 may 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.

Afterwards, 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.

Rachel Taliercio, DO:

Yeah. You mentioned something important. The patients know this cough. (laughs) 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, and allowing them to talk without interruption, and tell the story of their cough, essentially. And, and recognizing that taking the time to hear them out will be beneficial in the end, right. 'Cause patients are often helping us figure out what the underlying cause is.

Michael Ghobrial, MD:

I fully agree. And I would just add, too, it's important to listen to patient's families who are coming with them. So, I remember, one patient I'm seeing, and she's telling me about her cough, and simply I'm asking, okay, can you please tell me about your cough? And the husband responds and say, "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 on not just the patient, but also the family. People may sleep in different beds because of the cough, that's causing disturbed sleep at night. So, it's quite impactful, and when you provide this attempt of listening, you can really understand what the magnitude of this condition that you're taking care of.

Rachel Taliercio, DO:

You're absolutely right. We, we would often talk amongst ourselves, that a majority of the chronic cough referrals, especially the self-referrals, the spouse, the partner, was the one that was reaching out for help.

Michael Ghobrial, MD:

Sure.

Rachel Taliercio, DO:

So that, when you say it's our cough, that really-

Michael Ghobrial, MD:

Yeah.

(14:57 minutes)

Rachel Taliercio, DO:

... that really speaks to me. So, we talked about the need to, if we can prevent duplication of testing, and what I'm hearing from you, and what we tell patients, is that the cause of a chronic cough, especially a cough that's been there for years, can change over time. So, at a minimum, patients can expect, definitely a chest X-ray within the past year, an updated pulmonary function testing, including exhaled nitric oxide, to help determine whether or not the cough is inflammatory in nature. When do you think about doing a CAT scan of the chest? When do you think about proceeding with bronchoscopy, in patients with refractory chronic cough?

Michael Ghobrial, MD:

Yeah, these are all important diagnostics that we often order in our clinic. You just need to listen to patients first. So, you have someone with refractory chronic cough, and the chest X-ray is necessarily normal. That's, that's probably a reason why you need to get a CAT scan, because you wanna better visualize the airways. You wanna see if there's any areas that you may target with a bronchoscopy, when you go into evaluate, and take a look. If patient is having productive cough, you wanna probably get a sputum sample, and investigate what could be there, in regard to inflammatory cells, or if there is any possibly infection in there. I would say this is determined on a case-by-case basis.

Sometimes we may wanna order a methacholine challenge test or testing to evaluate for high airflow resistance. I would say these are tests that we would perform on a case-by-case basis. I can't say these are, like, the umbrellas that everyone will get. At the end of the day, we understand that these patients are coming, and they have had years of testing, and you wanna really explain to them why you are ordering this test? What are you looking for? How is this gonna affect your management, and change your management for them?

Rachel Taliercio, DO:

You mentioned productive cough, and that being one of the reasons to order a CAT scan of the chest, in that, you are looking for structural airway disease, looking for bronchiectasis, which isn't necessarily seen on a plain chest X-ray. Are there features of the cough in, in the office visit? If you do get an opportunity to hear the patient cough, are there features of that cough which would also make you think that a CAT scan might be necessary?

Michael Ghobrial, MD:

Yeah, so there is this, what we call seal barking cough, where patients are typically a little overweight. They have been having chronic upper respiratory tract infections or at least labeled as chronic upper respiratory tract infections. And oftentimes these patients would raise your suspicion, for a condition called tracheobronchomalacia, or excessive dynamic airway collapse. We perform a dynamic CT scan, and typically we would follow it with bronchoscopy, to evaluate and diagnose these patients with this condition. And if so, we refer them to the tracheobronchomalacia clinic, here at the clinic.

Rachel Taliercio, DO:

So in these cases, what I'm hearing, is that the CAT scan can serve as a way to kind of screen for tracheobronchomalacia excessive dynamic airway collapse, when patients are doing forced expiration during a dynamic CT scan. If there is a suggestion of excessive dynamic airway collapse, that would be an indication for bronchoscopy.

Michael Ghobrial, MD:

That's correct.

Rachel Taliercio, DO:

Tell me about your thoughts on when to involve other specialties. So we, you know, we're very blessed here, that we have colleagues in gastroenterology, and allergy, and otolaryngology, that we can lean on, because of course, as pulmonologists, we're not the only one seeing patients with chronic cough. And a lot of times patients are going to other subspecialty clinics first, before they come to us. So when do you think about referring patients to other subspecialty care, during the evaluation and management of chronic cough?

Michael Ghobrial, MD:

So that's true. You mentioned earlier that patients will tell you about their cough. So just listen to their complaints, to their symptoms. And most common causes for chronic cough or refractory chronic cough, with asthma, upper airway cough syndrome, and gastroesophageal reflux disease, there is also condition, when there is more of an eosinophilic inflammation in the airways. We call it non-asthmatic eosinophilic bronchitis. So one key part of success that I have found with, with, with the chronic cough clinic, here at the Cleveland Clinic, is the availability of providers from different specialties, who are willing to take on these patients, and would also provide them with evaluation for their chronic cough. It's not that you are going to see an ear, nose and throat specialist, who really doesn't wanna do anything with chronic cough, or a gastroenterologist who only manages certain other conditions, in the gastroenterology system.

He or she would be more willing to investigate your symptoms from a chronic cough point of view. So having a consortium of providers, from different specialties, who you can just pick up the phone and reach out to them and say, "Hey, I need you to see this patient. They are having this chronic cough, and I think it is related to gastroesophageal reflux disease, or related to post-nasal drip, or related to significant allergic process going on their airways." And their availability to see these patients, and report back to you, with their evaluation, and their management is, has been a critical part in this chronic cough clinic's success.

(20:23 minutes)

Rachel Taliercio, DO:

So what I'm hearing is, when possible, if you have the ability to do this, develop relationships with other specialists, who identify themselves as somebody who is expert in the management of chronic cough?

Michael Ghobrial, MD:

Correct. We heard from patients coming in, that when they were seeing a provider somewhere, the provider really didn't want to take care of chronic cough, they would refer them. And this was quite a waste of a visit, waste of time, waste of resources, because some providers aren't really willing to provide the time and the care for these types of complaints.

Rachel Taliercio, DO:

Managing chronic cough can be difficult, because you are managing a condition that is not getting better, and that has sometimes high emotion associated with it. You mentioned the impact that chronic cough, especially refractory chronic cough, can have on patients. It can be disabling. You mentioned the impact that it can have on other people in the household, and friends as well. You know this extends into different relationships, patients often report feeling isolated. So let's spend some time talking about what a colleague of ours calls the pain cave, right, (laughs).

Michael Ghobrial, MD:

(Laughs).

Rachel Taliercio, DO:

Right? The pain cave is this, we've looked for every cause of the cough, we can't find it. We've either looked for, and treated empirically, for common causes of cough. It's a mostly nonproductive, or fully nonproductive cough, with features of cough hypersensitivity. Right now, we don't have any FDA approved treatments for this type of refractory chronic cough. So a cough with significant features of cough hypersensitivity. And we do have off-label therapy that can be successful. So tell me about your approach to management in these patients.

Michael Ghobrial, MD:

Right, so as you mentioned, there is no currently FDA approved treatment for refractory chronic cough. However, our approach has to be guideline based. And the Chest Society has provided guidelines for management of chronic cough. I would just summarize it in for providers is, one, try to avoid the kitchen sink approach. Do not prescribe three, four different treatments, and which one would work, which one gives side effects, no one would know. The other thing is, try to provide one treatment at a time, and provide short-term follow-up with patients, to report to you how they are feeling on this treatment, in regards to success, in regards to side effects. And it's important to set expectations, it's, if someone has been coughing for so many years, you don't have this magic pill that you will give to them, and it'll make the cough disappear right away.

But we are looking for at least a certain degree of improvement in their chronic cough, and we can build on that. Next, as you mentioned, there are off-label treatments, and when ... it's important to tell the patients that these are off-label treatments, they are associated with some side effects. And the more you prescribe these off-label treatments, the more you will see side effects, and you will feel bad that you probably did this or caused this to patients. So before you provide this off-label treatment, do your due diligence in trying to identify the true cause for their cough, and start with a low dose, and evaluate. You can up-titrate the dosage as the patients need, and as their symptoms are, are improving, and you can down-titrate treatment as well, when they have been doing very well for quite some time, it's not treatment that you'll prescribe, and leave them on it the rest of their life.

But these treatments are associated with side effects, especially when we are talking about older population. We also wanna caution providers about, to avoid narcotics, and these cough syrups. Yes, there is some data for these treatments, but they significantly have more side effects, than probably benefits. Their treatment, their benefits are typically short-term, patients with developed tolerance, and definitely would be associated with side effects. The guidelines also advise against empiric treatment with protein pump inhibitors, or treatment for acid reflux, for patients who don't have evidence of acid reflux in testing, or those who do not have clinical symptoms of acid reflux. So we have not seen that these patients typically would respond with treatment for acid reflux. And it's important to ask if they have been given empiric treatment. If they didn't improve on it first, they are unlikely to improve on it, on a second, third, second time.

(25:00 minutes)

It's important to review their medications. I would say, not just the ACE inhibitors, and ARBs, that are associated with chronic cough, but we have detected different cases of patients who have been on certain treatments for multiple sclerosis, breast cancer, certain treatments for common variable immunodeficiency. So there are different treatments. If a patient is on a treatment that you aren't very familiar with, it doesn't hurt to do a literature search and see if there is any reported evidence of cough, or airway inflammation. It really takes a lot of time, sometimes, to dig and find what could be the true cause for this patient's chronic cough.

Rachel Taliercio, DO:

And the investigation is worth it, because ultimately your evaluation will be optimized, your ability to help these patients with chronic cough will be improved. And what I'm hearing in terms of your approach to pharmacologic therapy, in some ways less is more.

Michael Ghobrial, MD:

Sure.

Rachel Taliercio, DO:

You have this tendency to just, let's shoot for all the common things, give patients a couple of medications at once. Again, the intention is in the right place. You want to help these patients, you want to relieve the burden, but you don't necessarily know if the cough gets better, what they're responding to. There are significant side effects with medications, and there's a cost associated with these medicines, as well.

Michael Ghobrial, MD:

Very true. So, to be honest with you, what I have heard and understood from patients over time is they aren't really looking for, oftentimes, treatment. See, they are looking for answers, and they are, they wanna know why am I coughing? And it's not, they will trust you more, probably when you aren't just prescribing three, four different medications. But when you are being more specific in your thought process, in your evaluation process, and when you are telling them, I'm giving you this medication, because I expect this, or I am thinking of that, and I want you to respond to me in couple of weeks, with how you interacted with this medication. They would be way more satisfied than just going home with three, four different medications for their chronic cough.

Rachel Taliercio, DO:

Aw, thank you for mentioning that, Michael. It's such an important point. We talk about cough hypersensitivity syndrome, and it shares features of chronic pain, and, and that's why neuromodulator therapy can be a successful way to help manage refractory cough with hypersensitivity. I also think of the parallels that we can make, in patients who suffer from chronic pain, and patients who suffer from chronic cough. When they come and see us in the office, they're not expecting the cough to go from a 10 to a zero. (laughs).

Michael Ghobrial, MD:

Correct. Correct.

Rachel Taliercio, DO:

They are hoping that you can relieve the burden of the cough, and these patients are realistic. They understand, and appreciate, that this can be something difficult, and they want you to pause. They want you to pause and really think and investigate the cough. They're not necessarily looking for answers that day, or you know, they're hoping, but if they don't get it, it's all about the way that you frame it.

Michael Ghobrial, MD:

True. So it's very important during this visit, to build a relationship, build up a trust with them. And this would be provided by really listening to them. Let them just give you all what they need to continue. They have been dealing with this for years, they don't typically see people who want to listen to it. Even close family members sometimes are just frustrated with their cough, and they are trying to stay away, because they don't wanna hear the cough. Validate their symptoms, give them reassurance based on the amount of workups that you have done, and give them hope that this will get better, even if it's not completely resolved on the initial evaluation, but it will get better. And set the right expectations when you meet with them.

Rachel Taliercio, DO:

Absolutely. And when you respond and, and validate, acknowledge the emotion, you can then move into the, let's talk about how we're gonna help you feel better, or let's talk about how we're gonna help manage this cough.

Michael Ghobrial, MD:

Specifically for patients, you are right, specifically for patients with productive coughs. So sometimes I tell them, "Listen, cough is treatment for you. You have mucus related, or mucus produced, related to either an inflammatory process in your airways, or an infection in your airways. I would be doing you a disservice if I'm suppressing or getting rid of your cough. Cough is a good treatment for you. We just need to get rid of the mucus, get rid of the inflammation, and then the cough will improve." So it's not about just, oh, you are coughing, I'm gonna give you a cough suppressant, or I'm gonna get rid of this cough. No, actually, cough is sometimes not the disease, but it's actually a way your body's treating you, or helping you to get better.

Rachel Taliercio, DO:

I love that. Let's talk about what you're excited for, in research of chronic cough, in drug development, how you're currently managing these patients. We'll talk a little bit about cough monitors.

(30:05 minutes)

Michael Ghobrial, MD:

Yeah, that's a really exciting time for the chronic cough community. Typically for patients, but also for providers. We have been left for so long, with no consensus on definition, we don't have FDA approved medications. So to see that there are some medications in clinical trials, in Phase Three clinical trials, meaning that they have shown promising effects in earlier phases of clinical trials, is quite exciting. So one medication, targeting certain receptors in the airways, called P2X3, is in phase 3 clinical trials. We are expecting to see some data by the end of this year. We are very excited about it. There's another medication that targets certain opioid receptors. It has very specific and unique mode of action. It's an agonist on the Kappa-opioid receptors, and then antagonist on the mu-opioid receptors. So these are the receptors that morphine is agonist to, and being an antagonist to it makes it less addictive, less likely to develop tolerance.

This medication has shown significant improvement in cough, by about 50% in the patients, with idiopathic pulmonary fibrosis. We are super excited that this medication might provide these patients with good relief. Additionally, there has been several exploratory trials, about some inhaled therapies, that would target central receptors, mainly the GABA receptors, and also some peripheral receptors, like the NMDA or TRP-IV, et cetera. This has not really shown significant impact, but there's also ongoing studies. So from a drug development [perspective], it's an exciting time, because there's some interest for more, and new, pharmaceuticals, in this chronic condition, with more awareness about how impactful this is. And probably there are close to 10% of the population dealing with chronic cough, which is quite remarkable. From a diagnostic perspective, and from monitoring, as you mentioned, we talked about validation. When patients come to see you in the office, and you've been spending about, what, an hour with them, and they haven't had a cough.

And you wonder in your head, where is the cough? We have been talking for an hour, and they didn't cough. Is this really a true thing? So there are more now, software that is available on apps, on the phones. And also there are some watches and some necklaces that patients can wear, that would quantify what we call these cough bursts. Cough bursts are group of four or more coughs, that can happen within five second period, and could be really exhausting to patients, could be painful for patients, and in patients with some lung conditions, like pulmonary fibrosis, could be associated with drop in their oxygen saturation, and it could be quite frightening. So there are more tools now that we can use to quantify and assess the cough burden. It gives you how often you have been coughing for week to week, day to day, month to month. And within a 24-hour period, when is your cough the worst or is more prominent.

Rachel Taliercio, DO:

We have subjective ways of measuring cough. We have surveys. The objective piece of this is critical.

Michael Ghobrial, MD:

Sure.

Rachel Taliercio, DO:

And exactly what you stated, because we want to have an objective way of measuring the burden of the cough, developing, you know, what is the frequency. And then also measuring response to treatment, an objective way to do that. So there's a lot of exciting development in cough monitors. Tell me about artificial intelligence and chronic cough.

Michael Ghobrial, MD:

Yeah, that's very exciting, and that's what we are talking about, in regard to certain software and hardware that are primarily using artificial intelligence to quantify your cough. So if you are in a public environment and someone around you is coughing, artificial intelligence will be able to identify your cough, and count it, and would skip coughs that's happening in your environment. So it's quite exciting, because this is available anywhere you are, as long as the app, or as long as you are wearing this device it's able to capture your coughing. In research, in clinical research, there are devices that would accurately count your cough. And these are the devices that we are currently using in clinical trials, for chronic cough.

Rachel Taliercio, DO:

It's amazing. It's amazing. We've talked about a lot. Lastly, I want to hear about behavioral cough suppression therapy, because patients are asking us what they can do outside of medication. I mean they recognize the role of medication; they've often tried a lot of medicine that hasn't helped, and the benefit of behavioral cough suppression therapy in managing these patients.

(35:02 minutes)

Michael Ghobrial, MD:

That's great. So out of everything we have discussed when we talk about off-label treatments for chronic cough, the data for these treatments isn't that strong. However, behavioral cough suppression therapy has strong data by randomized controlled trials, to show that it has significant impact of reducing chronic cough in this patient population. Nowadays this can be done through in-person visits but also can be provided virtually. So patients do not have to go to a certain place, to get this line of treatment. And it is the one treatment that I tell patients, that really has no side effects. It's associated with quite degree of success, but if, if it didn't work for you, you really lost nothing, there is really no side effects that you will endure. But they will work with you, on trying to really suppress your cough, give you certain tools and certain techniques. I talked to some patients about this behavioral cough suppressive therapy during their office visit but getting an evaluation from speech-language pathology specialist, who again is very invested and interested in seeing and treating these patients with chronic cough, has shown quite an impact in this patient's journey.

Rachel Taliercio, DO:

And it helps patients in the moment, get control over their cough, something that they otherwise feel is so out of their control. And I appreciate that you've mentioned the opportunity for virtual visits, because not all of us have the benefit of speech-language pathologists that are trained in behavioral cough suppression therapy. So it's important to know that this can be done virtually.

Michael Ghobrial, MD:

That's correct. And within the clinic we have several providers in different locations. Some on the west, some on the east, some at main campus, who are dedicated and have the expertise to provide this kind of service, for patients with chronic cough.

Rachel Taliercio, DO:

And for our listeners outside of Northeast Ohio or Ohio in general, certainly this is something that they can look for. You know, find out who in their area, the speech-language pathologists, that have an interest in treating patients with chronic cough, that have experience in behavioral cough suppression therapy.

Michael Ghobrial, MD:

That's correct.

Rachel Taliercio, DO:

Well, Michael, I can't thank you enough. It's been so much fun to sit and talk with you. To finish out, to wind out our time together, tell me five takeaways.

Michael Ghobrial, MD:

Oh, great. Thank you so much again for having me. But what I would just try to summarize is first, listen to your patients and their families. Use a guideline-based approach, avoid the kitchen sink approach. Earlier referral to a specialized chronic cough clinic is a key, especially for those who fail to respond to treatment, and you really can't find answers for why they are having chronic cough. Provide reassurance, provide hope, set expectations, and use behavioral cough suppression therapy when appropriate.

Rachel Taliercio, DO:

Wonderful. Thank you so much.

Michael Ghobrial, MD:

Thank you.

Raed Dweik:

Thank you for listening to this episode of the Respiratory Exchange Podcast. For more stories, and information from the Cleveland Clinic Respiratory Institute, you can follow me on Twitter at RaedDweikMD.