Professional Documents
Culture Documents
Evidence-Based Medicine
Manuscript received June 18, 2014; revision accepted July 21, 2014;
originally published Online First September 4, 2014.
AFFILIATIONS: From the Johns Hopkins Asthma and Allergy Center
(Dr Canning), Baltimore, MD; the Queensland Childrens Respiratory
Centre (Dr Chang), Royal Childrens Hospital, Brisbane, QLD, Australia;
the Child Health Division (Dr Chang), Menzies School of Health,
Darwin, NT, Australia; the Department of Physiological Sciences (Dr
Bolser), University of Florida, Gainesville, FL; the Centre for Respiratory and Allergy (Dr Smith), University of Manchester, Manchester,
England; the School of Biomedical Sciences (Dr Mazzone), University
of Queensland, Brisbane, QLD, Australia; and the Centre for Infection
and Immunity (Dr McGarvey), The Queens University of Belfast, Belfast,
Northern Ireland.
FUNDING/SUPPORT: The American College of Chest Physicians was the
sole supporter of these guidelines, this article, and the innovations
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C-Fibers
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Figure 3 Structural organization of airway nerve terminals in guinea pigs and humans. A-A99, The arrangement of a cough receptor terminal in the
guinea pig airways. Heavy chain neurofilaments (A) are expressed in the cough receptor axon and major branch points, indicative of the myelinated
nature of these sensory nerve subtypes. These major branch points give rise to a more complex terminal structure (A9) that is defined by the expression
of an isozyme of the Na1/K1 ATPase containing the a3 subunit (a3 ATPase). B, Staining of nerve fibers innervating the human airways revealed using the
pan-neuronal marker protein gene product 9.5 (PGP9.5) (original magnification 3 20). C, Some of these fibers express heavy chain neurofilament proteins
and are comparable to the structures in guinea pigs that give rise to cough receptor terminals (original magnification 3 10). Scale bars represent 50 mm.
Infusion of fluid into the pharynx or pharyngeal stimulation with air puffs in awake or anesthetized human
subjects can initiate coughing or the urge to cough under
certain circumstances.83-86 The pharyngeal afferent
nerves regulating cough are either vagal in origin or
arise from the glossopharyngeal nerves or from nerve
branches emanating from the trigeminal ganglion.87 The
physiologic properties of the pharyngeal afferent nerves
regulating cough are poorly defined, but they may be
similar to the cough receptors innervating the larynx,
trachea, and bronchi. Thus, mechanical stimulation,
postnasal drip, and a water bolus placed into the pharynx
evoke vigorous coughing in human subjects and in
animals, whereas capsaicin may be unable to initiate
coughing when applied selectively to the pharynx.83-86
Cough Initiated From the Esophagus
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Conclusions
Coughing is directly evoked by stimulation of a subset
of bronchopulmonary C-fibers and a mechanically
sensitive, acid-sensitive subtype of myelinated airway
mechanoreceptors. Their activation may result directly
in coughing, whereas their coincident activation greatly
increases responsiveness to tussive stimuli. Cough can
also be modulated by other bronchopulmonary, vagal
afferent nerve subtypes and afferent nerves terminating
in extrapulmonary locations, including the upper
airways, pharynx, and esophagus.
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Acknowledgments
Author contributions: L. M. served as guarantor of the article and as
corresponding author. B. J. C., S. B. M., and L. M. wrote the first draft
of the manuscript; J. A. S. and S. B. M. prepared the figures and figure
legends; A. B. C., D. C. B., and J. A. S. refined the subsequent drafts of
the manuscript; and all contributors approved the final version.
Financial/nonfinancial disclosures: The authors have reported to
CHEST the following conflicts of interest: Dr Canning chairs a
scientific advisory board for Cerecor Inc, a company that has sought
development of new drugs for treating cough, including therapies
protected by patents held jointly by Cerecor Inc and by Dr Canning.
Dr Canning is also a member of the scientific advisory board for
Holaira, Inc and has recently served as a consultant for and/or
received research funding from Afferent Pharmaceuticals; Almirall S.A.;
Circuit Therapeutics, Inc; Eli Lilly and Company; GlaxoSmithKline;
Merck & Co, Inc; and Palatin Technologies, Inc. Dr Bolser receives no
financial compensation for participating in the Expert Cough Panel. He
has acted as a paid consultant for Merck & Co, Inc in the past year on
matters unrelated to the content of this manuscript. He also is a
cofounder of two startup companies, Sensory Integrated Solutions,
LLC and Airway Assistance, LLC. He holds an equity stake in each
but receives no financial compensation from these companies.
Dr Smith is a named inventor on a patent owned by the University
Hospital of South Manchester, which describes novel techniques for
detecting cough from sound recordings. This patent is licensed to a
medical device company, but Dr Smith has not received any financial
rewards as a result. Dr Smith's institution has received grant funding
from Afferent Pharmaceuticals. Dr McGarvey receives university grant
References
1. Fleming PJ, Bryan AC, Bryan MH. Functional immaturity of
pulmonary irritant receptors and apnea in newborn preterm
infants. Pediatrics. 1978;61(4):515-518.
2. Schramm CM. Current concepts of respiratory complications of
neuromuscular disease in children. Curr Opin Pediatr. 2000;12(3):
203-207.
3. Mosconi P, Langer M, Cigada M, Mandelli M; Intensive Care Unit
Group for Infection Control. Epidemiology and risk factors of
pneumonia in critically ill patients. Eur J Epidemiol. 1991;7(4):320-327.
4. Niimi A, Matsumoto H, Ueda T, et al. Impaired cough reflex in
patients with recurrent pneumonia. Thorax. 2003;58(2):152-153.
5. Irwin RS, Baumann MH, Bolser DC, et al. Diagnosis and management
of cough executive summary: ACCP evidence-based clinical practice
guidelines. Chest. 2006;129(1_suppl):1S-23S.
6. Chung KF, Pavord ID. Prevalence, pathogenesis, and causes of
chronic cough. Lancet. 2008;371(9621):1364-1374.
7. Widdicombe JG. Afferent receptors in the airways and cough.
Respir Physiol. 1998;114(1):5-15.
8. Karlsson JA. The role of capsaicin-sensitive C-fibre afferent nerves
in the cough reflex. Pulm Pharmacol. 1996;9(5-6):315-321.
9. Canning BJ, Mori N, Mazzone SB. Vagal afferent nerves regulating
the cough reflex. Respir Physiol Neurobiol. 2006;152(3):223-242.
10. Canning BJ, Chou YL. Cough sensors. I. Physiological and pharmacologicalproperties of the afferent nerves regulating cough. Handb
Exp Pharmacol. 2009;(187):23-47.
11. Ho CY, Gu Q, Lin YS, Lee LY. Sensitivity of vagal afferent endings to
chemical irritants in the rat lung. Respir Physiol. 2001;127(2-3):113-124.
12. Widdicombe J. Airway receptors. Respir Physiol. 2001;125(1-2):3-15.
13. Coleridge JC, Coleridge HM. Afferent vagal C fibre innervation of
the lungs and airways and its functional significance. Rev Physiol
Biochem Pharmacol. 1984;99:1-110.
14. Lee LY, Pisarri TE. Afferent properties and reflex functions of
bronchopulmonary C-fibers. Respir Physiol. 2001;125(1-2):47-65.
15. Undem BJ, Chuaychoo B, Lee MG, Weinreich D, Myers AC,
Kollarik M. Subtypes of vagal afferent C-fibres in guinea-pig lungs.
J Physiol. 2004;556(pt 3):905-917.
16. Nassenstein C, Taylor-Clark TE, Myers AC, et al. Phenotypic
distinctions between neural crest and placodal derived vagal
C-fibres in mouse lungs. J Physiol. 2010;588(pt 23):4769-4783.
17. Taylor-Clark TE, Undem BJ. Sensing pulmonary oxidative stress by
lung vagal afferents. Respir Physiol Neurobiol. 2011;178(3):406-413.
18. Nassenstein C, Kwong K, Taylor-Clark T, et al. Expression and
function of the ion channel TRPA1 in vagal afferent nerves
innervating mouse lungs. J Physiol. 2008;586(6):1595-1604.
19. Birrell MA, Belvisi MG, Grace M, et al. TRPA1 agonists evoke
coughing in guinea pig and human volunteers. Am J Respir Crit
Care Med. 2009;180(11):1042-1047.
20. Grace M, Birrell MA, Dubuis E, Maher SA, Belvisi MG. Transient
receptor potential channels mediate the tussive response to
prostaglandin E2 and bradykinin. Thorax. 2012;67(10):891-900.
21. Baluk P, Nadel JA, McDonald DM. Substance P-immunoreactive
sensory axons in the rat respiratory tract: a quantitative study of
their distribution and role in neurogenic inflammation. J Comp
Neurol. 1992;319(4):586-598.
22. Hunter DD, Undem BJ. Identification and substance P content of
vagal afferent neurons innervating the epithelium of the guinea pig
trachea. Am J Respir Crit Care Med. 1999;159(6):1943-1948.
23. Mazzone SB, Reynolds SM, Mori N, et al. Selective expression of a
sodium pump isozyme by cough receptors and evidence for its
essential role in regulating cough. J Neurosci. 2009;29(43):13662-13671.
24. Ricco MM, Kummer W, Biglari B, Myers AC, Undem BJ. Interganglionic segregation of distinct vagal afferent fibre phenotypes in
guinea-pig airways. J Physiol. 1996;496(pt 2):521-530.
25. Lundberg JM, Hkfelt T, Martling CR, Saria A, Cuello C. Substance
P-immunoreactive sensory nerves in the lower respiratory tract of
various mammals including man. Cell Tissue Res. 1984;235(2):251-261.
26. Lamb JP, Sparrow MP. Three-dimensional mapping of sensory
innervation with substance p in porcine bronchial mucosa: comparison
with human airways. Am J Respir Crit Care Med. 2002;166(9):
1269-1281.
27. Groneberg DA, Niimi A, Dinh QT, et al. Increased expression of
transient receptor potential vanilloid-1 in airway nerves of chronic
cough. Am J Respir Crit Care Med. 2004;170(12):1276-1280.
28. Dey RD, Altemus JB, Zervos I, Hoffpauir J. Origin and colocalization
of CGRP- and SP-reactive nerves in cat airway epithelium. J Appl
Physiol (1985). 1990;68(2):770-778.
29. Forsberg K, Karlsson JA. Cough induced by stimulation of capsaicinsensitive sensory neurons in conscious guinea-pigs. Acta Physiol
Scand. 1986;128(2):319-320.
30. Widdicombe JG. Respiratory reflexes from the trachea and bronchi
of the cat. J Physiol. 1954;123(1):55-70.
31. Widdicombe JG. Receptors in the trachea and bronchi of the cat.
J Physiol. 1954;123(1):71-104.
32. Widdicombe JG. Respiratory reflexes excited by inflation of the
lungs. J Physiol. 1954;123(1):105-115.
33. Canning BJ, Mazzone SB, Meeker SN, Mori N, Reynolds SM,
Undem BJ. Identification of the tracheal and laryngeal afferent
neurones mediating cough in anaesthetized guinea-pigs. J Physiol.
2004;557(pt 2):543-558.
34. Canning BJ, Mori N. An essential component to brainstem cough
gating identified in anesthetized guinea pigs. FASEB J. 2010;24(10):
3916-3926.
35. Canning BJ, Mori N. Encoding of the cough reflex in anesthetized
guinea pigs. Am J Physiol Regul Integr Comp Physiol. 2011;300(2):
R369-R377.
journal.publications.chestnet.org
36. Barnes NC, Piper PJ, Costello JF. Comparative effects of inhaled
leukotriene C4, leukotriene D4, and histamine in normal human
subjects. Thorax. 1984;39(7):500-504.
37. Joos G, Pauwels R, van der Straeten M. Effect of inhaled substance
P and neurokinin A on the airways of normal and asthmatic
subjects. Thorax. 1987;42(10):779-783.
38. Fujimura M, Sakamoto S, Kamio Y, Matsuda T. Effects of methacholine induced bronchoconstriction and procaterol induced
bronchodilation on cough receptor sensitivity to inhaled capsaicin
and tartaric acid. Thorax. 1992;47(6):441-445.
39. Shinagawa K, Kojima M, Ichikawa K, Hiratochi M, Aoyagi S,
Akahane M. Participation of thromboxane A(2) in the cough response
in guinea-pigs: antitussive effect of ozagrel. Br J Pharmacol. 2000;
131(2):266-270.
40. Jeffery PK. Remodeling in asthma and chronic obstructive lung
disease. Am J Respir Crit Care Med. 2001;164(10 pt 2):S28-S38.
41. Baluk P, Gabella G. Afferent nerve endings in the tracheal muscle of
guinea-pigs and rats. Anat Embryol (Berl). 1991;183(1):81-87.
42. Yu J. Spectrum of myelinated pulmonary afferents. Am J Physiol
Regul Integr Comp Physiol. 2000;279(6):R2142-R2148.
43. Schelegle ES, Green JF. An overview of the anatomy and physiology
of slowly adapting pulmonary stretch receptors. Respir Physiol.
2001;125(1-2):17-31.
44. Widdicombe J. Functional morphology and physiology of pulmonary
rapidly adapting receptors (RARs). Anat Rec A Discov Mol Cell Evol
Biol. 2003;270(1):2-10.
45. Jonzon A, Pisarri TE, Coleridge JC, Coleridge HM. Rapidly adapting
receptor activity in dogs is inversely related to lung compliance.
J Appl Physiol (1985). 1986;61(5):1980-1987.
46. Pack AI, DeLaney RG. Response of pulmonary rapidly adapting
receptors during lung inflation. J Appl Physiol. 1983;55(3):955-963.
47. Yu J, Wang YF, Zhang JW. Structure of slowly adapting pulmonary
stretch receptors in the lung periphery. J Appl Physiol (1985). 2003;
95(1):385-393.
48. Matsumoto S. The activities of lung stretch and irritant receptors
during cough. Neurosci Lett. 1988;90(1-2):125-129.
49. Nishino T, Sugimori K, Hiraga K, Hond Y. Influence of CPAP on
reflex responses to tracheal irritation in anesthetized humans.
J Appl Physiol (1985). 1989;67(3):954-958.
50. Lavorini F, Fontana G, Chellini E, Magni C, Pistolesi M, Widdicombe J.
The Fontana paradoxical reflex? Chest. 2011;140(3):586-588.
51. Bolser DC, Davenport PW. Volume-timing relationships during cough
and resistive loading in the cat. J Appl Physiol (1985). 2000;89(2):
785-790.
52. Smith JA, Aliverti A, Quaranta M, et al. Chest wall dynamics during
voluntary and induced cough in healthy volunteers. J Physiol. 2012;
590(pt 3):563-574.
53. Canning BJ, Reynolds SM, Mazzone SB. Multiple mechanisms of
reflex bronchospasm in guinea pigs. J Appl Physiol (1985). 2001;
91(6):2642-2653.
54. Richardson CA, Herbert DA, Mitchell RA. Modulation of pulmonary
stretch receptors and airway resistance by parasympathetic efferents.
J Appl Physiol. 1984;57(6):1842-1849.
55. Lowry R, Wood A, Johnson T, Higenbottam T. Antitussive properties
of inhaled bronchodilators on induced cough. Chest. 1988;93(6):
1186-1189.
56. Mazzone SB, Lim LH, Wagner EM, Mori N, Canning BJ. Sympathetic
nerve-dependent regulation of mucosal vascular tone modifies airway
smooth muscle reactivity. J Appl Physiol (1985). 2010;109(5):1292-1300.
57. Barnes PJ. Neurogenic inflammation in the airways. Respir Physiol.
2001;125(1-2):145-154.
58. Lundberg JM, Saria A, Brodin E, Rosell S, Folkers K. A substance P
antagonist inhibits vagally induced increase in vascular permeability
and bronchial smooth muscle contraction in the guinea pig. Proc
Natl Acad Sci U S A. 1983;80(4):1120-1124.
59. Basoglu OK, Pelleg A, Essilfie-Quaye S, Brindicci C, Barnes PJ,
Kharitonov SA. Effects of aerosolized adenosine 59-triphosphate
vs adenosine 59-monophosphate on dyspnea and airway caliber in
healthy nonsmokers and patients with asthma. Chest. 2005;128(4):
1905-1909.
1645
60. Beijer S, Gielisse EA, Hupperets PS, et al. Intravenous ATP infusions
can be safely administered in the home setting: a study in preterminal cancer patients. Invest New Drugs. 2007;25(6):571-579.
61. Abdulqwai R, McCarthy B, Layton G, Woodcock A, Ford A, Smith
JA. Inhibition of ATP-gated P2X3 channels by AF-219: an effective
anti-tussive mechanism in chronic cough. Abstract 1965. Presented
at: European Respiratory Society Annual Congress; September 7-11,
2013; Barcelona, Spain.
62. Mazzone SB, Canning BJ. Central nervous system control of the
airways: pharmacological implications. Curr Opin Pharmacol. 2002;
2(3):220-228.
63. Kubin L, Alheid GF, Zuperku EJ, McCrimmon DR. Central pathways
of pulmonary and lower airway vagal afferents. J Appl Physiol (1985).
2006;101(2):618-627.
64. Mazzone SB, Canning BJ. Synergistic interactions between airway
afferent nerve subtypes mediating reflex bronchospasm in guinea
pigs. Am J Physiol Regul Integr Comp Physiol. 2002;283(1):R86-R98.
65. Mazzone SB, Mori N, Canning BJ. Synergistic interactions between
airway afferent nerve subtypes regulating the cough reflex in
guinea-pigs. J Physiol. 2005;569(pt 2):559-573.
66. Ma QP, Woolf CJ. Involvement of neurokinin receptors in the
induction but not the maintenance of mechanical allodynia in rat
flexor motoneurones. J Physiol. 1995;486(pt 3):769-777.
67. Woolf CJ, Salter MW. Neuronal plasticity: increasing the gain in
pain. Science. 2000;288(5472):1765-1769.
68. Canning BJ, Mazzone SB. Reflex mechanisms in gastroesophageal
reflux disease and asthma. Am J Med. 2003;115(suppl 3A):45S-48S.
69. Tatar M, Webber SE, Widdicombe JG. Lung C-fibre receptor activation
and defensive reflexes in anaesthetized cats. J Physiol. 1988;402:411-420.
70. Tatar M, SantAmbrogio G, SantAmbrogio FB. Laryngeal and
tracheobronchial cough in anesthetized dogs. J Appl Physiol (1985).
1994;76(6):2672-2679.
71. Tatr M, Korps J, Polcek H, Zhradn V. Changes induced by
severe hypoxia in respiratory defence reflexes in anaesthetized cats.
Respiration. 1986;49(2):114-121.
72. Eckert DJ, Catcheside PG, Stadler DL, McDonald R, Hlavac MC,
McEvoy RD. Acute sustained hypoxia suppresses the cough reflex in
healthy subjects. Am J Respir Crit Care Med. 2006;173(5):506-511.
73. Tomori Z, Sedkov V, Javorka K. Changes in blood gas tensions
and acid-base balance during respiratory reflexes. Physiol
Bohemoslov. 1973;22(3):305-314.
74. Nattie E. CO2, brainstem chemoreceptors and breathing. Prog
Neurobiol. 1999;59(4):299-331.
75. Tekdemir I, Aslan A, Elhan A. A clinico-anatomic study of the
auricular branch of the vagus nerve and Arnolds ear-cough reflex.
Surg Radiol Anat. 1998;20(4):253-257.
76. Nomura S, Mizuno N. Central distribution of primary afferent
fibers in the Arnolds nerve (the auricular branch of the vagus
nerve): a transganglionic HRP study in the cat. Brain Res. 1984;
292(2):199-205.
77. Plevkova J, Kollarik M, Brozmanova M, Revallo M, Varechova S,
Tatar M. Modulation of experimentally-induced cough by
stimulation of nasal mucosa in cats and guinea pigs. Respir Physiol
Neurobiol. 2004;142(2-3):225-235.
78. Plevkova J, Brozmanova M, Pecova R, Tatar M. Effects of intranasal
capsaicin challenge on cough reflex in healthy human volunteers. J
Physiol Pharmacol. 2004;55(suppl 3):101-106.
79. Buday T, Brozmanova M, Biringerova Z, et al. Modulation of cough
response by sensory inputs from the nose - role of trigeminal
TRPA1 versus TRPM8 channels. Cough. 2012;8(1):11.
80. Tatar M, Plevkova J, Brozmanova M, Pecova R, Kollarik M.
Mechanisms of the cough associated with rhinosinusitis. Pulm
Pharmacol Ther. 2009;22(2):121-126.
81. Plevkova J, Kollarik M, Poliacek I, Brozmanova M, Surdenikova L,
Tatar M, Mori N, Canning BJ. The role of trigeminal nasal
TRPM8-expressing afferent neurons in the antitussive effects of
menthol. J Appl Physiol (1985). 2013;115(2):268-274.
82. Morice AH, Marshall AE, Higgins KS, Grattan TJ. Effect of inhaled
menthol on citric acid induced cough in normal subjects. Thorax.
1994;49(10):1024-1026.
journal.publications.chestnet.org
128.
129.
130.
131.
132.
133.
134.
135.
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137.
138.
139.
140.
141.
142.
143.
144.
145.
146.
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148.
149.
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165.
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170.
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