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Lung cancer is the malignant tumor with the highest incidence and mortality in China, and cough is the most common symptom in lung cancer patients, which seriously affects patients' treatment compliance and quality of life. The number of guidelines and consensuses on the management of lung cancer-related cough in the world is small and slow to update; there is no consensus on guidelines for the management of lung cancer-related cough in mainland China. Therefore, the assessment, diagnosis and treatment process and rational use of lung cancer-related cough urgently need to be standardized management.
Recently, the Cancer Rehabilitation and Palliative Care Professional Committee of the Chinese Anti-Cancer Association released an expert consensus on lung cancer-related cough management, let's take a look at what wonderful content there is
Content Overview
First, the mechanism and harm of lung cancer-related cough
2. Evaluation plan for lung cancer-associated cough
3. Diagnostic protocol for lung cancer-related cough
4. Treatment options for lung cancer-related cough
▌ Definitions
Lung cancer-associated cough is defined as cough caused by tumors, tumor complications, and tumor treatment in lung cancer patients.
▌ Mechanism of occurrence: direct stimulation, secondary obstructive pneumonia, neurogenic inflammation, anti-tumor therapy related adverse reactions.
▌ Hazards: stress urinary incontinence, exacerbated pain, rib fractures, anxiety, etc.
Both types of scales of symptom intensity and quality of life can be used for assessment.
1 cough symptom points
Clinical assessment of cough severity and efficacy. Studies are currently developing a new cough symptom score assessment scale, divided into daytime and nocturnal scores, but are not easily distinguishable between different levels (see Table 1).
Table 1: Lung Cancer-associated Cough Symptoms Integral Scale
2 VAS
Patients should mark the corresponding scale on the straight line marked 0 to 10 cm according to their own feelings to indicate the degree of cough, or the 0 to 100 mm mark can be used.
3 NRS
Because patients with lung cancer-associated cough often have other symptoms that require supportive care, such as pain, NRS is more likely to be widely used in the scoring scale (see Table 2).
Table 2: Numerical grading scale for lung cancer-associated cough
4 Cough quality of life assessment
Chinese version of the Leicester Cough Questionnaire (LCQ-MC) is widely used and has been shown to be reliable, repeatable and sensitive.
It is recommended to choose one of the VAS and NRS scoring methods for cough intensity assessment. Chinese version of LCQ-MC can be evaluated from multiple dimensions, has the characteristics of conciseness and ease of use, and is recommended for the assessment of cough quality of life.
Figure 1: Schematic diagram of the diagnostic process for lung cancer-associated cough
▌ Diagnosis
Lung cancer patients with no previous history of respiratory disease, no symptoms other than dry cough, and cough from other causes other than laboratory and imaging tests should be considered for diagnosis of lung cancer-associated cough. Cough that occurs after surgery in lung cancer patients, except for other diseases on chest CT, and there is no evidence of asthma or retronasal drip syndrome, etc., can be used for therapeutic diagnosis with methasulfast. Patients with lung cancer who have coughs that occur after chemoradiotherapy for tumors and who have no other evidence of coughing can be treated with corticosteroids.
After anti-cancer treatment and/or antitussive therapy, the cough of lung cancer patients is completely relieved, indicating that the diagnosis of lung cancer-related cough is clear and the treatment plan is correct; if it is not completely relieved, the causes affecting the efficacy and other causes that may be combined should be re-evaluated for differential diagnosis.
▌ Differential diagnosis
Patients with lung cancer who have an acute cough should first exclude a severe disease such as acute myocardial infarction, left cardiac insufficiency, pneumonia, pneumothorax, pulmonary embolism, and foreign body inhalation.
Excluding tumor factors, the most common cough cause in patients with lung tumors is a respiratory disease such as chronic obstructive pulmonary disease (COPD), chronic bronchitis, or co-infection. Dry cough is mainly seen in patients with noninfectious cough, and patients with high sputum and purulent sputum should be considered for concomitant respiratory infectious disease, and blood routine and chest CT can usually be distinguished. Asthma, chronic bronchitis, COPD and other pre-existing diseases aggravated or acute onset, may also be the cause of cough in lung cancer patients, by asking the patient's medical history in detail can be preliminarily differentiated, lung function tests, laboratory tests and imaging tests can further confirm the diagnosis.
1. Cough that occurs after taking angiotensin-converting enzyme inhibitor (ACE Inhibitor) in lung tumor patients, considering the drug caused, the replacement of drugs can be identified.
2. Serological antibody detection is helpful in identifying cough caused by Mycoplasma infection.
3. Cough caused by the common cold, patients often have nasal-related symptoms.
4. Bronchial provocative tests can help identify cough variant asthma.
5. Induced sputum eosinophilic examination helps in the diagnosis of eosinophilic bronchitis.
6. When considering gastroesophageal reflux cough, 24-hour esophageal pH monitoring helps to identify.
7. Most patients with upper airway cough syndrome/retronasal drip syndrome have nasopharyngeal symptoms, and CT of the sinuses helps to distinguish.
▌ Etiological treatment
Treatment should first be tailored to the patient's cause, and individualized treatment of the patient's tumor is the best option for relieving lung cancer-associated cough.
▌ Antitussive medication
1 Central antitussive drugs
Central cough drugs are the most effective drugs for the treatment of lung cancer-associated cough, and opioids are the most representative central cough drugs. Commonly used clinical central antitussive drugs include codeine, dextromethorphan, morphine, and forcodine.
(1) Forcodine recommends forcodine as the first choice for lung cancer antitussive drugs.
(2) Codeine Due to the large number of adverse reactions, priority is not recommended, and codeine is contraindicated in cough patients with multiple sputum.
(3) Dextromethorphan should consider its drug dependence risk in the treatment of lung cancer-associated cough.
(4) Morphine
There is no dose-dependent elevation, and morphine should be used if cough is not suppressed by other opioid derivatives or other means. Considering the high incidence of adverse reactions, for patients who have been treated with morphine for neobulis, their dose can be increased by 20%, the efficacy can be observed and the adverse reactions can be paid attention to.
2 Peripheral antitussive drugs
Peripheral cough drugs act on 1 or more sites in the afferent nerve, efferent nerve, or receptor of the cough reflex arc. Commonly used drugs include nacotin, levoxypropiperazine, and phenylpropiperine.
There is no clinical evidence of definitive lung cancer-associated cough with peripheral antitussive drugs. However, based on its potential benefits, it may be an option for lung cancer-associated cough therapy in the presence of contraindications to central antitussive drugs, or in the absence or intolerance of central antitussive drugs.
3 Compound antitussive drugs
In addition to antitussive drugs, expectorants, decongestants, and antihistamines are also common components of compound cough drugs.
In patients with sputum lung cancer-associated cough, patients with sputum may consider combined cough medications containing central cough drugs and expectors. The long-term safety of compound antitussive drugs is unclear, especially those containing antihistamines, and long-term use should be avoided as much as possible.
4 Local anesthetics
In cases where opioid cough is ineffective or intolerant and peripheral cough suppressants are ineffective, local anesthetics may be tried for cough suppression.
There is no clinical evidence of local anesthetics for the treatment of lung cancer-associated cough, so it is only used experimentally if both central and peripheral antitussive drugs are ineffective, and the risk of aspiration should be carefully assessed before use.
5 Other treatments
Corticosteroids are recommended for the treatment of cough caused by chemotherapy or radiation pneumonitis in lung cancer patients. Macrolides act as immunomodulators and can be used as adjunctive therapies or steroid protectors for steroid drug therapy.
Treatment of lung cancer-associated cough with corresponding specific drugs may be considered in specific patients. In patients who do not respond to both central and peripheral antitussive agents, the selection of antitussive agents based on clinical experience may be made on a trial basis after a full assessment of the benefits and risks.
6 Traditional Chinese medicine treatment
For patients with lung cancer-associated cough who are ineffective or intolerant to opioid therapy, multidisciplinary diagnosis and treatment (MDT) consultation can be conducted together with the Department of Traditional Chinese Medicine, and appropriate chinese medicine, Traditional Chinese medicine formula, proprietary medicine or acupuncture point patch are selected for adjuvant treatment or as part of multimodal treatment according to the theory of traditional Chinese medicine combined with the clinical experience of the hospital.
Figure 2: Schematic diagram of lung cancer-associated cough treatment flow
Table 3: Recommended table for the use of commonly used central and peripheral antitussive drugs
bibliography:
[1]
Cancer Rehabilitation and Palliative Care Professional Committee of Chinese Anti-Cancer Association. Chinese expert consensus on lung cancer-related cough diagnosis and treatment[J]. Chinese Medical Journal, 2021, 101(35): 2751-2759. DOI: 10.3760/cma.j.cn112137-20210603-01264.
This article was first published: Medical Oncology Channel
Body organization: Takayamako
This article was reviewed: Yu Jiangyong Beijing Hospital
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