Chest
Volume 136, Issue 4, October 2009, Pages 1021-1028
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Original Research
Cough
Effect of the Management of Patients With Chronic Cough by Pulmonologists and Certified Respiratory Educators on Quality of Life: A Randomized Trial

https://doi.org/10.1378/chest.08-2399Get rights and content

Background

The role of certified respiratory educators (CREs) is to educate, assess, and help to manage patients with asthma and COPD in Canada. This study was undertaken to see whether CREs could assist pulmonologists (MDs) in managing patients with chronic cough.

Methods

An 8-week prospective, parallel design, randomized, controlled trial to determine whether CREs using a protocol-driven algorithmic approach could assist in the management of patients referred to a university tertiary care medical center for the assessment and treatment of chronic cough. Patients were randomly assigned to a CRE-led or MD study arm for the management of chronic cough. Patients were screened to exclude those patients whose cough was due to life-threatening conditions. The primary outcome was measured with the cough-specific quality-of-life questionnaire (CQLQ).

Results

A total of 198 patients were randomized, and 8-week results were available on 151 patients (mean [± SD] age, 49.8 ± 13.4 years; female gender, 70%; median cough duration, 16 months). At 8 weeks, total CQLQ scores improved in the CRE-led patients (score [± SD] range, 58.1 ± 14.9 to 50.0 ± 15.8; p = 0.0003). CQLQ scores improved in four of six domains but not in the physical or emotional domains. Improvements in CRE-led patients were similar to those in MD-managed patients (initial CQLQ score, p = 0.261 [CRE vs MD]; CQLQ score at 8 weeks, p = 0.42 [CRE vs MD]). In a composite analysis of both CRE and MD patient data, CQLQ scores improved in patients whose cough resolved (56.3 ± 13.6 to 41.5 ± 13.6; p < 0.0001), in those whose cough improved but did not disappear (60.9 ± 14.2 to 50.5 ± 13.9; p < 0.0001), but did not improve in those whose cough did not improve (58.1 ± 13.3 to 58.6 ± 12.7; difference not significant).

Conclusions

CREs can help to safely, economically, and effectively manage properly screened patients with chronic cough. The use of CREs may shorten wait times for specialist consultation for these patients.

Section snippets

Study Design

The study was an 8-week, prospective, randomized, parallel-group, clinical trial approved by the University of Calgary, Calgary Health Region Office of Medical Bioethics (Calgary, AB, Canada). Blinding was not feasible.

Outcome Measures

The primary objective was to determine whether CREs can improve the QOL of patients with chronic cough. The secondary objectives were to determine whether CREs could improve QOL in patients with chronic cough to the same extent as patients seen only by MDs, the effects on the

Results

After appropriate screening, 198 patients (44% of the patients attending the chronic cough clinic) were randomized to care by an MD or a CRE. Reasons for exclusion from the study were an abnormal chest radiograph finding or previously recognized lung disease (25%), other comorbidities (13%), or worrisome symptoms (9%) [Fig 2]. Only 9% of referred patients were unwilling to participate in this study, were unable to return for follow-up, or were excluded because of limited language skills.

Discussion

This study demonstrated that CQLQ improved in patients with chronic cough after 8 weeks of CRE management. The screening process identified patients who can be managed safely by CREs, and their outcomes were as good as those of patients with chronic cough managed by MDs. The use of CREs reduced wait times and was cost-effective.26 CREs are employed across Canada, and extending their mandate to include chronic cough should be feasible in other Canadian centers.

There were other differences

Acknowledgments

Author contributions: Dr. Field had full access to the data in the study, and takes responsibility for the integrity and accuracy of the data. Data were acquired and analyzed by Ms. Conley, Drs. Field, Leigh, and Cowie, and Mr. Thawer. Drs. Field and Cowie were responsible for the study concept and design. Dr. Field drafted the manuscript. All of the authors critically revised the manuscript. No medical writer was involved in the drafting or editing of the manuscript. All of the authors

References (0)

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Funding/Support: Innovation funding was provided by the Calgary Health Region Department of Medicine for salary support.

This article was presented at the American Thoracic Society International Meeting in May 2008.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/site/misc/reprints.xhtml).

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