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Communications to the Editor |

Clinical Significance of Cough as a Defense Mechanism or a Symptom in Elderly Patients With Aspiration and Diffuse Aspiration Bronchiolitis FREE TO VIEW

Shinji Teramoto, MD, FCCP; Takeshi Matsuse, MD; Yasuyoshi Ouchi, MD
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Department of Geriatric Medicine Tokyo University Hospital, Japan



Chest. 1999;115(2):602. doi:10.1378/chest.115.2.602
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To the Editor

Although cough is the most common symptom for adult patients seeking medical attention from primary care physicians in the United States and is associated with deterioration in patients’ quality of life,1the concise and distinct guideline is not available. Thus, the recent consensus report, “Managing Cough as a Defense Mechanism and as a Symptom”2is very helpful and meaningful for chest physicians. However, age-related changes in cough reflex and the protective roles of cough as the defense mechanism of aspiration in older patients are not argued in the report. Owing to the increasing number of the aged population, many pulmonologists and geriatricians recognized that silent aspiration might be very important for the pathogenesis of aspiration pneumonia and nosocomial pneumonia in older patients.3,,4,,5,,6,,7,,8,,9 Because pneumonia is in principle prevented by the defense mechanisms, such as upper airway reflexes, mucociliary clearance, and phagocytosis by alveolar macrophages, age-dependent declines of upper airway reflexes may be one of the pathophysiologic features of aspiration pneumonia in older subjects.7,,8,,9 Aged persons appear to have slowed clearance of particles from the airway probably due to impaired mucociliary function that accompanies aging. However, in our experiences, cough reflexes rather than swallowing reflex or mucociliary clearance are utmost important for preventing aspiration in elderly patients. In fact, a marked decreased cough reflex was observed in elderly patients with aspiration pneumonia.8 Therefore, cough is a particularly important defense mechanism, and it also is important as a symptom for detection of silent aspiration. We have recently demonstrated that recurrent silent aspiration causes diffuse aspiration bronchiolitis (DAB), which is characterized as a chronic inflammation of bronchioles accompanying a foreign body reaction.3,,4 The patients with DAB mostly demonstrated signs of bronchorrhea, cough, bronchospasm, and dyspnea in the case of food intake.3 In addition to the age-dependent decline in cough reflexes, depression of airway reflexes by sedatives and hypnotics are considered to be a major risk for aspiration pneumonia in older patients.9 The clinical significance of cough reflex in older patients should be carefully considered by all physicians. Hopefully, the next consensus report will include the clinical significance of cough reflex in older patients with pneumonia and DAB.

Correspondence to: Shinji Teramoto, MD, FCCP, Department of Geriatrics, University of Tokyo, 7-3-1 Hongo Bunkyo-ku, Tokyo University Hospital 113–8655, Japan

References

French, CL, Irwin, RS, Curley, FJ, et al (1998) Impact of chronic cough on quality of life.Arch Intern Med158,1657-1661. [PubMed] [CrossRef]
 
Irwin, RS, Boulet, LP, Cloutier, MM, et al Managing cough as a defense mechanism and as a symptom.Chest1998;114(Suppl),133S-181S
 
Matsuse, T, Oka, T, Kida, K, et al Importance of diffuse aspiration bronchiolitis caused by chronic occult aspiration in the elderly.Chest1996;110,1289-1293. [PubMed]
 
Matsuse, T, Teramoto, S, Matsui, H, et al Widespread occurrence of diffuse aspiration bronchiolitis, in patients with dysphagia irrespective of age [letter].Chest1998;114,350-351
 
Teramoto, S, Matsuse, T, Ouchi, Y Foreign body aspiration into the lower airways may not be unusual in older adults [letter].Chest1998;113,1733-1734. [PubMed]
 
Gleeson, K, Eggli, DF, Maxwell, SL Quantitative aspiration during sleep in normal subjects.Chest1997;111,1266-1272. [PubMed]
 
Pontopiddan, H, Beecher, HK Progressive loss of protective reflexes in the airway with the advancing age.JAMA1960;174,2209-2013. [PubMed]
 
Sekizawa, K, Ujiie, Y, Itabashi, S, et al Lack of cough reflex in patients with aspiration pneumonia [letter]. Lancet. 1997;;335 ,.:1228
 
Huxley, EJ, Viroslav, J, Gray, WR, et al Pharyngeal aspiration in normal subjects and patients with depressed consciousness.Am J Med1978;64,564-586. [PubMed]
 

Figures

Tables

References

French, CL, Irwin, RS, Curley, FJ, et al (1998) Impact of chronic cough on quality of life.Arch Intern Med158,1657-1661. [PubMed] [CrossRef]
 
Irwin, RS, Boulet, LP, Cloutier, MM, et al Managing cough as a defense mechanism and as a symptom.Chest1998;114(Suppl),133S-181S
 
Matsuse, T, Oka, T, Kida, K, et al Importance of diffuse aspiration bronchiolitis caused by chronic occult aspiration in the elderly.Chest1996;110,1289-1293. [PubMed]
 
Matsuse, T, Teramoto, S, Matsui, H, et al Widespread occurrence of diffuse aspiration bronchiolitis, in patients with dysphagia irrespective of age [letter].Chest1998;114,350-351
 
Teramoto, S, Matsuse, T, Ouchi, Y Foreign body aspiration into the lower airways may not be unusual in older adults [letter].Chest1998;113,1733-1734. [PubMed]
 
Gleeson, K, Eggli, DF, Maxwell, SL Quantitative aspiration during sleep in normal subjects.Chest1997;111,1266-1272. [PubMed]
 
Pontopiddan, H, Beecher, HK Progressive loss of protective reflexes in the airway with the advancing age.JAMA1960;174,2209-2013. [PubMed]
 
Sekizawa, K, Ujiie, Y, Itabashi, S, et al Lack of cough reflex in patients with aspiration pneumonia [letter]. Lancet. 1997;;335 ,.:1228
 
Huxley, EJ, Viroslav, J, Gray, WR, et al Pharyngeal aspiration in normal subjects and patients with depressed consciousness.Am J Med1978;64,564-586. [PubMed]
 
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