Faruqi S, Fahim A, Morice A. European Respiratory Journal. 2012 Oct;40(4):1049-1050.
OBJECTIVES: We describe a patient with OSA and chronic cough who responded well to CPAP. Objective and subjective assessments of cough on treatment with CPAP, off CPAP and on follow-up as well as pharyngeal pH monitoring suggest a possible mechanism for this association.
RESULTS: OSA is characterised by recurrent episodes of upper airway narrowing during sleep with or without associated symptoms of daytime somnolence, morning headache and unrefreshing sleep. The prevalence of OSA is estimated to be 3–9% if defined as AHI .5 events h-1 with at least one symptom of OSA syndrome [2]. We report a case of OSA who presented with cough. There were two aspects to the patient’s cough. First, a chronic cough related to gastro-oesophageal reflux and secondly, cough related to OSA. There was some improvement in cough following acid suppression but the institution of CPAP produced a dramatic reduction in cough frequency and improvement in his quality of life. We have demonstrated that CPAP therapy in OSA is associated with a reduction in cough sensitivity, along with clinical improvement in cough-related quality of life. We believe that the possible mechanism of cough resolution with CPAP is through reduction of cough reflex sensitivity and improvement in reflux episodes. The baseline cough sensitivity was high but the patient had been on CPAP for only 2 months. Short-term cessation of CPAP did not cause change in cough sensitivity. However, at 1-yr follow-up, no coughs could be elicited by tussive challenge. We have previously demonstrated the disconnect between cough reflex sensitivity and symptoms [3]. We suggest in this case, cough reflex sensitivity lagged behind symptomatic improvement.
Resolution of cough with CPAP has been demonstrated in a case series of four patients who had objective cough recording and LCQ scores obtained pre- and post-CPAP therapy [4]. There was a significant improvement in both parameters in all patients. However, inhalational cough challenge was not performed in any of the patients.
CONCLUSION: Cough associated with OSA is probably under-recognised as there are only limited studies with small numbers of patients evaluating the prevalence of OSA as a cause of chronic cough. In a retrospective review, 44% of patients with chronic cough had OSA with 93% demonstrating significant improvement in cough with CPAP [5]. However, it is difficult to ascribe this benefit solely to CPAP as the majority of these patients had multiple therapeutic interventions for their cough. In a prospective series of 108 patients being evaluated for sleep disordered breathing, co-existent cough was documented in 33% [6]. Our case report evaluates the effect of CPAP on cough in a prospective and systematic manner and looks at a possible mechanism of this association.
The aetiology of cough in OSA could be multifactorial. First, OSA is associated with heightened cough sensitivity similar to patients with eosinophilic bronchitis. Obesity, a known risk factor for OSA, as well having as an association with chronic cough, is known to be associated with airway inflammation. This heightened cough sensitivity seen in OSA is likely to be related to cough receptor sensitisation secondary to increased inflammatory mediators in the upper airways and airway epithelial damage [7]. Furthermore, sensory dysfunction at upper airway correlates with the degree of OSA as measured by AHI and oxygen desaturation [8]. We propose that the mechanism of this airway inflammation is through reflux as there is evidence of a high prevalence of gastro-oesophageal reflux disease in patients with OSA and commencement of CPAP results in improvement in transthoracic pressure and reflux [9]. Secondly, there is objective evidence of impaired swallowing in OSA, which could predispose these patients to reflux, microaspiration and cough [10].
To our knowledge, this is the first clinical demonstration of reversibility of cough reflex sensitivity in OSA with CPAP therapy. This case highlights an interesting association and mechanism of chronic cough with OSA, likely to be under-recognised in cough clinics as a cause of chronic cough. Furthermore, it emphasises the value of thorough and systematic clinical evaluation in the management of patients with chronic cough.
Bree has been an integral part of Restech from the very beginning. She holds a Masters in Public Health from George Washington University, a BFA from The University of Kansas in Visual Communications, and is a National Board Certified Health & Wellness Coach. Her command of marketing, public health/health delivery systems, and human health behavior change gives her a unique perspective in developing effective marketing strategies for the company.
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Thomas previously worked as a polysomnographic technologist in the Virginia Mason system, before moving into sales with Restech in 2007. After spending 9 years working with distributors across Europe, he was moved into an organizational role at the head office in Houston. In this capacity he works closely with sales and marketing to provide clinical support, manages clinical studies, and provides clinical perspectives on business development. In his spare time Thomas plays rugby for Houston Athletic Rugby Club.
Jeff has over 30 years of experience in the medical device industry and previously worked in sales at companies such as Encision Inc., Interventional Therapies, LLC, Boston Scientific, and United States Surgical Corporation. He has been working as the VP of Sales for Mederi Therapeutics since 2009 and now brings his extensive expertise to Restech. Jeff was part of the team that bridged the Mederi asset sale to Restech. His clinical knowledge of the Stretta and Secca technologies is invaluable. Jeff has three decades of physician relations experience that he brings to Restech as part of the leadership team.
Ray joined Restech in May 2018 as the Vice President for Sales. He has been in the medical device, and specifically in the GERD space for more than 18 years. Starting in sales at Sandhill Scientific pH diagnostics, he moved on to Curon Medical when Stretta and Secca were first introduced to the market. He then worked for Given Imaging when Curon closed operations. When Stretta was relaunced he joined Mederi as VP of Sales. Ray was instrumental in keeping Stretta alive and the customer based informed when Mederi ceased operation and assets were purchased by Restech. He is part of the leadership team directing all product sales for Restech. Ray graduated from Old Dominion University in Norfolk with a BS in Marketing and Business Administration.
Mark is a seasoned professional and Certified Public Accountant in Texas who brings a unique blend of creative vision and financial expertise to any leadership team. He worked as a Senior Executive for 15 years on a leadership team which grew a private equity backed cash logistics company performing at negative EBITDA on $100 million revenue into an international industry leader with superior profitability on revenue exceeding $1.5 billion. In addition, he spent 10 years as a Senior Manager at Price Waterhouse delivering results-oriented merger & acquisition, audit and strategic consulting services to middle market clientele including over 40 manufacturing, distribution, service, nonprofit and technology clients. Mark currently serves as a Chief Financial Officer and consulting CFO (seven years) providing in-house and outsourced CFO and transactional services to the middle market.
Larry is the CTO for Restech and holds a B.S. in Computer Science. He is a software architect specializing in remote patient monitoring, medical sensors, and clinical trial software. Larry holds a patent on massively distributed computing and has worked for a number of major software startup companies including Sybase, Oracle, and Teradata. Larry was also the co-founder of a startup to deliver advanced clinical pathways to patients using mobile devices and medical sensors. Larry is truly a pioneer and now a veteran in the deployment.
Jeff has a breadth of experience with over 25 years in engineering and executive positions within major fortune 100 healthcare companies. He also has proven success in startup medical technology companies. Jeff provides leadership in securing and managing Restech’s patent portfolio. He also built Restech’s compliance platform that established regulatory acceptance in 25+ countries worldwide. Jeff’s scientific support and in-depth understanding of the device industry set the foundation for current and future commercial innovations at Restech.
With nearly 30 years of working with physician thought leaders developing novel and emerging technologies, Leo has played a key role in the development and evolution of balloon angioplasty and stent technologies that revolutionized the therapy of cardiac disease. His experience was instrumental in the development of the patented platform technology which drives the Restech sensor. Leo provides a vision and passion for effecting change in the diagnosis and management of atypical reflux.
With over 20 years of executive experience in both the private and public sector, Debra brings a broad understanding of healthcare delivery system. With experience managing products aimed at wide scale disease and population management for 20 million subscribers, Debra has extensive experience in effectively and efficiently developing models of delivery that address specific health issues. Debra has also been involved in the legislative process and served as the elected President of the Independent Physician Association of California. Debra is dedicated to bringing tools to the healthcare market that improve and support the clinical process.