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Correspondence |

Chronic Idiopathic CoughResponse: Self-Sustaining? FREE TO VIEW

Jerome M. Reich, MD, FCCP
Author and Funding Information

Affiliations: Earl A. Chiles Research Institute, Portland, OR,  University of Massachusetts Medical School, Worcester, MA

Correspondence to: Jerome M. Reich, MD, FCCP, Earl A. Chiles Research Institute, 5251 NE Glisan, Building A, Portland, OR 97213-2967; e-mail: Reichje@dnamail.com



Chest. 2007;131(2):636-637. doi:10.1378/chest.06-2136
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Cough: A convulsion of the lungs, vellicated by some sharp serosity. It is pronounced coff.

Samuel Johnson

Unaided except by amanuenses, Johnson was justly famed for authoring the magisterial Dictionary of the English Language (1755), the source of this definition (vellicate = twitch or pluck; serosity = a serous surface). Until succeeded by the Oxford English Dictionary, it remained the acknowledged standard reference for more than a century. A nonsmoker, Johnson died a respiratory death; at autopsy, he was found to have emphysema and cor pulmonale.1 The severity of his cough and its potential contribution to his malady is conveyed by his vivid description of it as a “convulsion.”

In noting that “… the act of coughing itself may be responsible for the denudation and other histopathologic findings… ” in persons with chronic idiopathic cough, and that these findings were indistiguishable from bronchial biopsies in persons with defined intrapulmonary and extrapulmonary sources of cough, the authors2 assert the likelihood that these findings were the consequence, not the cause, of the observed cough. Implicit, I think, in this conclusion is the possibility that some instances of idiopathic chronic cough represent the tracheobronchial counterpart of neurodermatitis, ie, that chronic cough is self sustaining; that, mediated by respiratory trauma, it begets cough. If this interpretation is correct, it follows that a sustained trial of drug-induced cough suppression would be a valid diagnostic and therapeutic strategy.

The author has no conflicts of interest to disclose.

The author has reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reich, JM (1994) Convulsion of the lung: an historical analysis of the cause of Dr. Johnson’s fatal emphysema.J Roy Soc Med87,737-741. [PubMed]
 
Irwin, RS, Owmbey, R, Cagle, PT, et al Interpreting the histopathology of chronic cough.Chest2006;130,362-370. [PubMed] [CrossRef]
 
To the Editor:

There are three issues embodied within Dr. Reich’s letter that are deserving of comment. The first relates to his reference to Samuel Johnson, an important figure during the American revolutionary war period, who used language when describing and defining cough suggesting that the act of coughing had the potential to have severe and traumatic consequences and that this has been appreciated for at least hundreds of years.

The second issue could best be described as an English lesson for many of us who have never before used the word “amanuenses.” According to The American Heritage Dictionary, “amanuenses” is the plural of “amanuensis,” a noun, that is defined as “one who is employed to take dictation or to copy manuscript.”1While amanuensis is a Latin word that originated in ancient Rome to refer to a slave performing any command for his master, it has been used in academic contexts, for example, when an injured or disabled person is helped by an amanuensis at a written examination.2By referring to Samuel Johnson, quoting his definition of cough, and using the word “amanuenses,” Dr. Reich has not applied the razor of William of Occam, who wrote, “Pluritas non est ponenda sine necessitate [Entities should not be multiplied unnecessarily]” (ie, the principle of parsimony or, in the modern vernacular, “keep it simple” or “get to the point”).3

The third issue relates to the possibility that cough may “beget” cough. In suggesting this possibility, Dr. Reich refers to our recently published study,4which suggested that the airway inflammation associated with chronic cough may be due to the trauma of coughing, and that the characteristics of the inflammation from trauma may be indistinguishable from those of the underlying disease causing cough. The clinical and research implications of our findings are twofold: investigators must be cautious when imputing pathogenetic importance to observed inflammatory changes in the airways of coughing subjects; and, as suggested by Dr. Reich, studies should be performed to determine whether a sustained trial of cough suppression might eliminate chronic cough in patients whose cough is potentially perpetuated by the trauma of coughing itself. While it is an intriguing thought that a cough self-perpetuating cycle may potentially explain some of the causes of unexplained cough, cough suppression with a potent, potentially addicting agent such as a narcotic will probably be required and theoretically will work only if the original cause of cough has disappeared. Consequently, therapeutic trials with potent cough suppressants should be conducted for limited and finite periods of time. To test this hypothesis, future research will be needed to determine which, if any, cough suppressants might be of benefit5and to determine the time period of active cough suppression. Because there is a strong suspicion that a likely cause of chronic cough was actually present in many cases mislabeled as having an unexplained cough (ie, idiopathic cough) due to incomplete or inadequate evaluation or treatment,6 clinicians should diagnose chronic cough and treat patients according to the best available evidence, such as the ACCP cough guidelines,7 before considering a trial of potent cough suppressant therapy for a putative unexplained chronic cough.

References
 The American Heritage Dictionary of the English Language. Fourth ed. 2000; Houghton Mifflin Company. Boston MA:.
 
 Wikipedia, The Free Encyclopedia. Amanuensis. 2002; Free Software Foundation, Inc.. Boston, MA:.
 
Weg, JG, Irwin, RS Sounds like a PE to Me: response to letter to the editor.Chest1997;112,856
 
Irwin, RS, Ownbey, R, Cagle, PT, et al Interpreting the histopathology of chronic cough: a prospective, controlled, comparative study.Chest2006;130,362-370. [PubMed] [CrossRef]
 
Bolser, DC Cough suppressant and pharmacologic protussive therapy: ACCP evidence-based clinical practice guidelines.Chest2006;129(suppl),238S-249S
 
Pratter, MR Unexplained (idiopathic) cough: ACCP evidence-based clinical practice guidelines.Chest2006;129(suppl),220S-221S
 
Diagnosis and management of cough: ACCP evidence-based clinical practice guidelines.Chest2006;129(suppl),1S-292S
 

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References

Reich, JM (1994) Convulsion of the lung: an historical analysis of the cause of Dr. Johnson’s fatal emphysema.J Roy Soc Med87,737-741. [PubMed]
 
Irwin, RS, Owmbey, R, Cagle, PT, et al Interpreting the histopathology of chronic cough.Chest2006;130,362-370. [PubMed] [CrossRef]
 
 The American Heritage Dictionary of the English Language. Fourth ed. 2000; Houghton Mifflin Company. Boston MA:.
 
 Wikipedia, The Free Encyclopedia. Amanuensis. 2002; Free Software Foundation, Inc.. Boston, MA:.
 
Weg, JG, Irwin, RS Sounds like a PE to Me: response to letter to the editor.Chest1997;112,856
 
Irwin, RS, Ownbey, R, Cagle, PT, et al Interpreting the histopathology of chronic cough: a prospective, controlled, comparative study.Chest2006;130,362-370. [PubMed] [CrossRef]
 
Bolser, DC Cough suppressant and pharmacologic protussive therapy: ACCP evidence-based clinical practice guidelines.Chest2006;129(suppl),238S-249S
 
Pratter, MR Unexplained (idiopathic) cough: ACCP evidence-based clinical practice guidelines.Chest2006;129(suppl),220S-221S
 
Diagnosis and management of cough: ACCP evidence-based clinical practice guidelines.Chest2006;129(suppl),1S-292S
 
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