Full methacholine dose-response curves were performed on anesthetized tracheostomized Fischer 344... more Full methacholine dose-response curves were performed on anesthetized tracheostomized Fischer 344 adult rats treated neonatally with capsaicin (50 mg/kg) or with vehicle alone. Capsaicin, the hot extract of pepper, releases substance P (SP) from nonmyelinated sensory nerve endings and causes acute bronchoconstriction and airway microvascular leakiness. Chronic treatment with capsaicin leads to depletion of SP and other tachykinins from afferent C-fibers and can therefore be used as a tool to investigate the contribution of SP innervation to airway responses. The rats (9 controls and 6 treated with capsaicin) were paralyzed with succinylcholine and mechanically ventilated at a constant tidal volume and frequency. Airway resistance (RL) and dynamic compliance (Cdyn) were determined at each dose of methacholine from measurements of volume, flow, and transpulmonary pressure. Capsaicin-treated rats were found to have a significantly reduced baseline RL [0.150 +/- 0.039 (SD) vs. 0.225 +/-...
Albers, G. M., R. P. Tomkiewicz, M. K. May, O. E. Ramirez, and B. K. Rubin. Ring distraction tech... more Albers, G. M., R. P. Tomkiewicz, M. K. May, O. E. Ramirez, and B. K. Rubin. Ring distraction technique for measuring surface tension of sputum: relationship to sputum clearability. J. Appl. Physiol. 81(6): 2690–2695, 1996.—Poor sputum clearance has been related to sputum adhesion tension. In this study, we describe a modified du Noüy ring method for measuring the surface tension (γ) of small samples of sputum and for comparinge the calculated work of adhesion (Wad) for sputum specimens with the measured mucociliary transportability (MCTR) and cough transportability (CTR). The γ, as measured by this method, correlates with γ measured by sputum contact angle on a low-surface-energy solid ( R 2= 0.368, P = 0.03). There is a small but significant difference in measurements made by these two methods ( P = 0.03). Wad calculated from the surface tension ring method is inversely correlated with CTR ( R 2= 0.181, P = 0.004) but has no correlation with MCTR in this study. The miniaturized rin...
BACKGROUND: There is indirect evidence implicating viral respiratory tract infections in the path... more BACKGROUND: There is indirect evidence implicating viral respiratory tract infections in the pathogenesis of fatal asthma. However, it is unknown whether viruses are present within the lower respiratory tract in fatal asthma.OBJECTIVES: To apply a nine-virus polymerase chain reaction (PCR) panel to postmortem specimens of lower airway secretions and compare the prevalence of viral nucleic acid among patients who died of asthma, asthmatic patients who died of other causes and persons who died without lung disease.PATIENTS AND METHODS: Postmortem specimens of lower airway secretions from patients who died of asthma (fatal asthma [n=10]), asthmatic patients who died of other causes (n=4) and nonasthma controls (n=6) underwent PCR for nine common respiratory viruses. The prevalence of each virus was compared among the three groups.RESULTS: PCR was positive for at least one virus in 19 of 20 cases, and multiple viruses were detected in 14 of 20 cases. The prevalence of each virus was sim...
OBJECTIVE: To compare the biophysical properties of mucus from the left and right mainstem bronch... more OBJECTIVE: To compare the biophysical properties of mucus from the left and right mainstem bronchi in patients undergoing diagnostic bronchoscopy because of a unilateral radiological abnormality. It was hypothesized that abnormalities in the properties of mucus would be greater on the side with the lesion and that this would be most obvious in patients with unilateral lung cancer.PATIENTS AND METHODS: Bilateral paired samples of bronchial mucus were taken from 38 nonatopic patients (aged 59.8±12.6 years) including 16 nonsmokers, 14 current smokers and eight exsmokers (more than one year). Twenty of the 38 patients had a radiologically defined unilateral abnormality. Eight of these 20, including one nonsmoker, had lung cancer. The viscoelastic properties of the collected mucus were determined by magnetic microrheometry, and the analysis was carried out without knowledge of the histological diagnosis or source.RESULTS: The rheological properties of mucus strongly suggested which was t...
We compared the physical and transport properties of tracheal mucus collected from 16 asymptomati... more We compared the physical and transport properties of tracheal mucus collected from 16 asymptomatic smokers and from 18 nonsmokers. The smokers produced a larger volume of mucus (wet weight 18.6 versus 11.2 mg; p = 0.04) with a lower solids content (11.5 versus 16.3%; p = 0.02) and a lower modulus of rigidity (log G* 2.37 versus 2.62; p = 0.04). Although the smokers mucus had a 40% faster mucociliary transport rate on the frog palate (p = 0.04), the cough clearability was nearly identical to the mucus from nonsmokers. The differences are similar to those observed in rats or dogs chronically exposed to cigarette smoke. These data suggest both a quantitative and a qualitative difference in the composition of mucus from asymptomatic smokers. The increased volume of a watery mucus with increased mucociliary clearability may help to protect the airways from the injurious effects of inhaled smoke.
We collected the respiratory mucus coating the endotracheal tubes used during short surgical proc... more We collected the respiratory mucus coating the endotracheal tubes used during short surgical procedures in 27 patients with no clinical evidence of respiratory disease. Twelve were male and 15 were female, and they ranged from 1 to 64 yr of age (mean, 28.7 yr). The viscoelastic properties, frog palate transport rate, and percent solid composition were in the normal range reported for both canine and human mucus collected using the bronchoscopy brush technique. There were no significant differences noted between male and female patients, and there were no changes in mucus or transport properties seen with aging. Mucus was also collected separately from the inside of the tube exposed to constant gas flow (13 patients), and from the outside of the endotracheal tubes in 25 patients. Although there were no significant differences in viscoelastic properties between inside and outside mucus, there was a greater thread formation (filance, 45 versus 26 mm; p less than 0.005) and a higher percentage of solids in mucus from the inside of the endotracheal tube (15.9 versus 11.4%; p less than 0.05), which is compatible with reduced hydration. The duration of anesthesia ranged from 25 to 195 min (mean, 85 min). There was no effect of duration of anesthesia on any of the measured mucus properties. This technique for mucus collection allows us to study alterations in mucus properties in patients with and without pulmonary disease at the time of incidental surgery.(ABSTRACT TRUNCATED AT 250 WORDS)
Canadian Journal of Physiology and Pharmacology, 1995
The clearance of airway secretions is vital in protecting the mammalian lung from pollution and i... more The clearance of airway secretions is vital in protecting the mammalian lung from pollution and infection. Diverse animal models have been used to study lung diseases associated with impaired secretion clearance. The extrapolation of data from animal models to humans is based on the assumption that there are structural and functional similarities in the airway epithelium and secretions. This manuscript reviews regulation of mucus secretion as well as the physical and transport properties of respiratory mucus. As tracheal size increases, the rigidity of airway secretions decreases, and rigidity is inversely correlated with mucociliary transportability. These differences are placed in the context of previously reported species and regional differences in transepithelial potential difference and the tracheobronchial epithelial cell population. Tracheal mucus transport velocity varies with the species studied and has been shown to positively correlate with tracheal surface area. A progr...
We studied the effects of substances P administration on tracheal mucus viscoelasticity, water co... more We studied the effects of substances P administration on tracheal mucus viscoelasticity, water content, clearability and secretion rate. Six neutered adult male ferrets (weight 1.1-1.5 kg) were studied, on four occasions each. They were anaesthetized with ketamine and xylazine, and intubated shallowly. Control mucus (pre- and post-Ringer instillation) was compared with the mucus obtained following instillation of 200 microliters of 10(-6), 10(-5), and 10(-4) M substance P (SP), and 10(-4) M methacholine chloride as a reference. Tracheal mucus was collected by inserting a soft-bristled cytology brush to the level of the carina, and leaving it in contact with the mucosa for 30 min. After withdrawing the brush, the adherent mucus was quickly scraped off and layered with paraffin oil to prevent evaporation. The mucus was analysed for viscoelasticity by magnetic rheometry and solids content by evaporation to dryness. Mucus transportability was assessed by comparison with model gels, and ...
Cough is a common symptom experienced by athletes, particularly after exercise. We performed a sy... more Cough is a common symptom experienced by athletes, particularly after exercise. We performed a systematic review to assess the following in this population: (1) the main causes of acute and recurrent cough, either exercise-induced or not, (2) how cough is assessed, and (3) how cough is treated in this population. From the systematic review, suggestions for management were developed. This review was performed according to the CHEST methodological guidelines and Grading of Recommendations Assessment, Development and Evaluation framework until April 2015. To be included, studies had to meet the following criteria: participants had to be athletes and adults and adolescents aged ≥ 12 years and had to complain of cough, regardless of its duration or relationship to exercise. The Expert Cough Panel based their suggestions on the data extracted from the review and final grading by consensus according to a Delphi process. Only 60 reports fulfilled the inclusion criteria, and the results of our analysis revealed only low-quality evidence on the causes of cough and how to assess and treat cough specifically in athletes. Although there was no formal evaluation of causes of cough in the athletic population, the most common causes reported were asthma, exercise-induced bronchoconstriction, respiratory tract infection (RTI), upper airway cough syndrome (UACS) (mostly from rhinitis), and environmental exposures. Cough was also reported to be related to exercise-induced vocal cord dysfunction among a variety of less common causes. Although gastroesophageal reflux disease (GERD) is frequent in athletes, we found no publication on cough and GERD in this population. Assessment of the causes of cough was performed mainly with bronchoprovocation tests and suspected disease-specific investigations. The evidence to guide treatment of cough in the athlete was weak or nonexistent, depending on the cause. As data on cough in athletes were hidden in a set of other data (respiratory symptoms), evidence tables were difficult to produce and were done only for cough treatment in athletes. The causes of cough in the athlete appear to differ slightly from those in the general population. It is often associated with environmental exposures related to the sport training environment and occurs predominantly following intense exercise. Clinical history and specific investigations should allow identification of the cause of cough as well as targeting of the treatment. Until management studies have been performed in the athlete, current guidelines that exist for the general population should be applied for the evaluation and treatment of cough in the athlete, taking into account specific training context and anti-doping regulations.
Cough is common in pulmonary tuberculosis (TB) and other chronic respiratory infections. Identify... more Cough is common in pulmonary tuberculosis (TB) and other chronic respiratory infections. Identifying features that predict whether pulmonary TB is the cause would help target appropriate individuals for rapid and cost-effective screening, potentially limiting disease progression, and preventing transmission to others. A systematic literature search for individual studies to answer 8 Key questions (KQ) was conducted according to established Chest Organization methods using the following databases: MEDLINE via PubMed, EMBASE, Scopus and the Cochrane Database of Systematic Reviews from 1/1/1984 to April 2014. Searches for KQ1 and KQ3 were updated in February 2016. An updated KQ 2 search was undertaken in March 2017. Even where TB prevalence is greatest, most individuals with cough do not have pulmonary TB. There was no evidence that one, 3 or 4 weeks' duration were better predictors than cough lasting ≥2 weeks to screen for pulmonary TB. In people living with HIV infection (PLWHIV)...
As the first paper in this Journal Conference on intensive care unit controversies, the editors w... more As the first paper in this Journal Conference on intensive care unit controversies, the editors wished
PURPOSE To update the section on complications associated with coughing in the 2006 CHEST cough g... more PURPOSE To update the section on complications associated with coughing in the 2006 CHEST cough guidelines to address 2 aims: systematically identify and thematically categorize the diverse complications of cough providing a guide for future studies and identify gaps in the literature for future research. METHODS To guide our literature search, we asked the following key clinical question: What are the potential complications associated with the act of coughing that have been reported in infants, children, adolescents and adults? A scoping review was performed using PubMed and SCOPUS databases that were searched from their beginning until September 6, 2019. RESULTS 247 publications met our inclusion criteria. To these, we added 38 articles from the 2006 complications paper not identified in the literature search plus the paper itself for a final total of 286 publications that formed the basis of this review. Since 2006, 3 new categories of complications have been reported: ear, nose and throat; disease transmission; and laboratory testing. Multiple additional complications that fall outside of these 3 categories have also been identified and included in the following categories: cardiovascular, constitutional symptoms, dermatological, gastrointestinal, genitourinary, musculoskeletal, neurological, ophthalmological, psychosocial/quality of life, and respiratory. Not previously highlighted is that some of the complications led to serious morbidity including death, especially in patients with comorbid conditions and potentially resulted in harm to others when cough resulted in a motor vehicle accident. CONCLUSIONS Our work identified a large number of cough complications that we thematically categorized primarily by organ system so that future studies of each system or each complication can be conducted. The gap in the literature that future studies should address is to identify the frequency of the complications and the strength of their association with cough. Only then will one be able to describe the findings in a manner that allows specific recommendations for avoiding these complications. In the meantime, patients with cough should be evaluated and managed according to evidence-based guidelines to mitigate or prevent the myriad of potential complications associated with coughing.
As the first paper in this Journal Conference on intensive care unit controversies, the editors w... more As the first paper in this Journal Conference on intensive care unit controversies, the editors wished us to set the tone for the debate by discussing the ethics of medical "adventurism" in the intensive care unit. More life-or-death decisions are made in the intensive care unit than elsewhere in the hospital, and the critical care specialist often sees himself or herself as a warrior in a battle with death. This adrenaline-charged calling attracts highly intelligent, hard-working, and compassionate caregivers, as well as fiercely independent clinicians. The result of this is that critical care specialists passionately debate about the meaning and application of published "evidence" and this leads to thoughtful debate, as exemplified by the papers in this and the next issue of Respiratory Care, as well as thoughtless and often dangerous disregard for evidence-based medicine. Physicians are morally obligated to provide the best and most appropriate care possible f...
Full methacholine dose-response curves were performed on anesthetized tracheostomized Fischer 344... more Full methacholine dose-response curves were performed on anesthetized tracheostomized Fischer 344 adult rats treated neonatally with capsaicin (50 mg/kg) or with vehicle alone. Capsaicin, the hot extract of pepper, releases substance P (SP) from nonmyelinated sensory nerve endings and causes acute bronchoconstriction and airway microvascular leakiness. Chronic treatment with capsaicin leads to depletion of SP and other tachykinins from afferent C-fibers and can therefore be used as a tool to investigate the contribution of SP innervation to airway responses. The rats (9 controls and 6 treated with capsaicin) were paralyzed with succinylcholine and mechanically ventilated at a constant tidal volume and frequency. Airway resistance (RL) and dynamic compliance (Cdyn) were determined at each dose of methacholine from measurements of volume, flow, and transpulmonary pressure. Capsaicin-treated rats were found to have a significantly reduced baseline RL [0.150 +/- 0.039 (SD) vs. 0.225 +/-...
Albers, G. M., R. P. Tomkiewicz, M. K. May, O. E. Ramirez, and B. K. Rubin. Ring distraction tech... more Albers, G. M., R. P. Tomkiewicz, M. K. May, O. E. Ramirez, and B. K. Rubin. Ring distraction technique for measuring surface tension of sputum: relationship to sputum clearability. J. Appl. Physiol. 81(6): 2690–2695, 1996.—Poor sputum clearance has been related to sputum adhesion tension. In this study, we describe a modified du Noüy ring method for measuring the surface tension (γ) of small samples of sputum and for comparinge the calculated work of adhesion (Wad) for sputum specimens with the measured mucociliary transportability (MCTR) and cough transportability (CTR). The γ, as measured by this method, correlates with γ measured by sputum contact angle on a low-surface-energy solid ( R 2= 0.368, P = 0.03). There is a small but significant difference in measurements made by these two methods ( P = 0.03). Wad calculated from the surface tension ring method is inversely correlated with CTR ( R 2= 0.181, P = 0.004) but has no correlation with MCTR in this study. The miniaturized rin...
BACKGROUND: There is indirect evidence implicating viral respiratory tract infections in the path... more BACKGROUND: There is indirect evidence implicating viral respiratory tract infections in the pathogenesis of fatal asthma. However, it is unknown whether viruses are present within the lower respiratory tract in fatal asthma.OBJECTIVES: To apply a nine-virus polymerase chain reaction (PCR) panel to postmortem specimens of lower airway secretions and compare the prevalence of viral nucleic acid among patients who died of asthma, asthmatic patients who died of other causes and persons who died without lung disease.PATIENTS AND METHODS: Postmortem specimens of lower airway secretions from patients who died of asthma (fatal asthma [n=10]), asthmatic patients who died of other causes (n=4) and nonasthma controls (n=6) underwent PCR for nine common respiratory viruses. The prevalence of each virus was compared among the three groups.RESULTS: PCR was positive for at least one virus in 19 of 20 cases, and multiple viruses were detected in 14 of 20 cases. The prevalence of each virus was sim...
OBJECTIVE: To compare the biophysical properties of mucus from the left and right mainstem bronch... more OBJECTIVE: To compare the biophysical properties of mucus from the left and right mainstem bronchi in patients undergoing diagnostic bronchoscopy because of a unilateral radiological abnormality. It was hypothesized that abnormalities in the properties of mucus would be greater on the side with the lesion and that this would be most obvious in patients with unilateral lung cancer.PATIENTS AND METHODS: Bilateral paired samples of bronchial mucus were taken from 38 nonatopic patients (aged 59.8±12.6 years) including 16 nonsmokers, 14 current smokers and eight exsmokers (more than one year). Twenty of the 38 patients had a radiologically defined unilateral abnormality. Eight of these 20, including one nonsmoker, had lung cancer. The viscoelastic properties of the collected mucus were determined by magnetic microrheometry, and the analysis was carried out without knowledge of the histological diagnosis or source.RESULTS: The rheological properties of mucus strongly suggested which was t...
We compared the physical and transport properties of tracheal mucus collected from 16 asymptomati... more We compared the physical and transport properties of tracheal mucus collected from 16 asymptomatic smokers and from 18 nonsmokers. The smokers produced a larger volume of mucus (wet weight 18.6 versus 11.2 mg; p = 0.04) with a lower solids content (11.5 versus 16.3%; p = 0.02) and a lower modulus of rigidity (log G* 2.37 versus 2.62; p = 0.04). Although the smokers mucus had a 40% faster mucociliary transport rate on the frog palate (p = 0.04), the cough clearability was nearly identical to the mucus from nonsmokers. The differences are similar to those observed in rats or dogs chronically exposed to cigarette smoke. These data suggest both a quantitative and a qualitative difference in the composition of mucus from asymptomatic smokers. The increased volume of a watery mucus with increased mucociliary clearability may help to protect the airways from the injurious effects of inhaled smoke.
We collected the respiratory mucus coating the endotracheal tubes used during short surgical proc... more We collected the respiratory mucus coating the endotracheal tubes used during short surgical procedures in 27 patients with no clinical evidence of respiratory disease. Twelve were male and 15 were female, and they ranged from 1 to 64 yr of age (mean, 28.7 yr). The viscoelastic properties, frog palate transport rate, and percent solid composition were in the normal range reported for both canine and human mucus collected using the bronchoscopy brush technique. There were no significant differences noted between male and female patients, and there were no changes in mucus or transport properties seen with aging. Mucus was also collected separately from the inside of the tube exposed to constant gas flow (13 patients), and from the outside of the endotracheal tubes in 25 patients. Although there were no significant differences in viscoelastic properties between inside and outside mucus, there was a greater thread formation (filance, 45 versus 26 mm; p less than 0.005) and a higher percentage of solids in mucus from the inside of the endotracheal tube (15.9 versus 11.4%; p less than 0.05), which is compatible with reduced hydration. The duration of anesthesia ranged from 25 to 195 min (mean, 85 min). There was no effect of duration of anesthesia on any of the measured mucus properties. This technique for mucus collection allows us to study alterations in mucus properties in patients with and without pulmonary disease at the time of incidental surgery.(ABSTRACT TRUNCATED AT 250 WORDS)
Canadian Journal of Physiology and Pharmacology, 1995
The clearance of airway secretions is vital in protecting the mammalian lung from pollution and i... more The clearance of airway secretions is vital in protecting the mammalian lung from pollution and infection. Diverse animal models have been used to study lung diseases associated with impaired secretion clearance. The extrapolation of data from animal models to humans is based on the assumption that there are structural and functional similarities in the airway epithelium and secretions. This manuscript reviews regulation of mucus secretion as well as the physical and transport properties of respiratory mucus. As tracheal size increases, the rigidity of airway secretions decreases, and rigidity is inversely correlated with mucociliary transportability. These differences are placed in the context of previously reported species and regional differences in transepithelial potential difference and the tracheobronchial epithelial cell population. Tracheal mucus transport velocity varies with the species studied and has been shown to positively correlate with tracheal surface area. A progr...
We studied the effects of substances P administration on tracheal mucus viscoelasticity, water co... more We studied the effects of substances P administration on tracheal mucus viscoelasticity, water content, clearability and secretion rate. Six neutered adult male ferrets (weight 1.1-1.5 kg) were studied, on four occasions each. They were anaesthetized with ketamine and xylazine, and intubated shallowly. Control mucus (pre- and post-Ringer instillation) was compared with the mucus obtained following instillation of 200 microliters of 10(-6), 10(-5), and 10(-4) M substance P (SP), and 10(-4) M methacholine chloride as a reference. Tracheal mucus was collected by inserting a soft-bristled cytology brush to the level of the carina, and leaving it in contact with the mucosa for 30 min. After withdrawing the brush, the adherent mucus was quickly scraped off and layered with paraffin oil to prevent evaporation. The mucus was analysed for viscoelasticity by magnetic rheometry and solids content by evaporation to dryness. Mucus transportability was assessed by comparison with model gels, and ...
Cough is a common symptom experienced by athletes, particularly after exercise. We performed a sy... more Cough is a common symptom experienced by athletes, particularly after exercise. We performed a systematic review to assess the following in this population: (1) the main causes of acute and recurrent cough, either exercise-induced or not, (2) how cough is assessed, and (3) how cough is treated in this population. From the systematic review, suggestions for management were developed. This review was performed according to the CHEST methodological guidelines and Grading of Recommendations Assessment, Development and Evaluation framework until April 2015. To be included, studies had to meet the following criteria: participants had to be athletes and adults and adolescents aged ≥ 12 years and had to complain of cough, regardless of its duration or relationship to exercise. The Expert Cough Panel based their suggestions on the data extracted from the review and final grading by consensus according to a Delphi process. Only 60 reports fulfilled the inclusion criteria, and the results of our analysis revealed only low-quality evidence on the causes of cough and how to assess and treat cough specifically in athletes. Although there was no formal evaluation of causes of cough in the athletic population, the most common causes reported were asthma, exercise-induced bronchoconstriction, respiratory tract infection (RTI), upper airway cough syndrome (UACS) (mostly from rhinitis), and environmental exposures. Cough was also reported to be related to exercise-induced vocal cord dysfunction among a variety of less common causes. Although gastroesophageal reflux disease (GERD) is frequent in athletes, we found no publication on cough and GERD in this population. Assessment of the causes of cough was performed mainly with bronchoprovocation tests and suspected disease-specific investigations. The evidence to guide treatment of cough in the athlete was weak or nonexistent, depending on the cause. As data on cough in athletes were hidden in a set of other data (respiratory symptoms), evidence tables were difficult to produce and were done only for cough treatment in athletes. The causes of cough in the athlete appear to differ slightly from those in the general population. It is often associated with environmental exposures related to the sport training environment and occurs predominantly following intense exercise. Clinical history and specific investigations should allow identification of the cause of cough as well as targeting of the treatment. Until management studies have been performed in the athlete, current guidelines that exist for the general population should be applied for the evaluation and treatment of cough in the athlete, taking into account specific training context and anti-doping regulations.
Cough is common in pulmonary tuberculosis (TB) and other chronic respiratory infections. Identify... more Cough is common in pulmonary tuberculosis (TB) and other chronic respiratory infections. Identifying features that predict whether pulmonary TB is the cause would help target appropriate individuals for rapid and cost-effective screening, potentially limiting disease progression, and preventing transmission to others. A systematic literature search for individual studies to answer 8 Key questions (KQ) was conducted according to established Chest Organization methods using the following databases: MEDLINE via PubMed, EMBASE, Scopus and the Cochrane Database of Systematic Reviews from 1/1/1984 to April 2014. Searches for KQ1 and KQ3 were updated in February 2016. An updated KQ 2 search was undertaken in March 2017. Even where TB prevalence is greatest, most individuals with cough do not have pulmonary TB. There was no evidence that one, 3 or 4 weeks' duration were better predictors than cough lasting ≥2 weeks to screen for pulmonary TB. In people living with HIV infection (PLWHIV)...
As the first paper in this Journal Conference on intensive care unit controversies, the editors w... more As the first paper in this Journal Conference on intensive care unit controversies, the editors wished
PURPOSE To update the section on complications associated with coughing in the 2006 CHEST cough g... more PURPOSE To update the section on complications associated with coughing in the 2006 CHEST cough guidelines to address 2 aims: systematically identify and thematically categorize the diverse complications of cough providing a guide for future studies and identify gaps in the literature for future research. METHODS To guide our literature search, we asked the following key clinical question: What are the potential complications associated with the act of coughing that have been reported in infants, children, adolescents and adults? A scoping review was performed using PubMed and SCOPUS databases that were searched from their beginning until September 6, 2019. RESULTS 247 publications met our inclusion criteria. To these, we added 38 articles from the 2006 complications paper not identified in the literature search plus the paper itself for a final total of 286 publications that formed the basis of this review. Since 2006, 3 new categories of complications have been reported: ear, nose and throat; disease transmission; and laboratory testing. Multiple additional complications that fall outside of these 3 categories have also been identified and included in the following categories: cardiovascular, constitutional symptoms, dermatological, gastrointestinal, genitourinary, musculoskeletal, neurological, ophthalmological, psychosocial/quality of life, and respiratory. Not previously highlighted is that some of the complications led to serious morbidity including death, especially in patients with comorbid conditions and potentially resulted in harm to others when cough resulted in a motor vehicle accident. CONCLUSIONS Our work identified a large number of cough complications that we thematically categorized primarily by organ system so that future studies of each system or each complication can be conducted. The gap in the literature that future studies should address is to identify the frequency of the complications and the strength of their association with cough. Only then will one be able to describe the findings in a manner that allows specific recommendations for avoiding these complications. In the meantime, patients with cough should be evaluated and managed according to evidence-based guidelines to mitigate or prevent the myriad of potential complications associated with coughing.
As the first paper in this Journal Conference on intensive care unit controversies, the editors w... more As the first paper in this Journal Conference on intensive care unit controversies, the editors wished us to set the tone for the debate by discussing the ethics of medical "adventurism" in the intensive care unit. More life-or-death decisions are made in the intensive care unit than elsewhere in the hospital, and the critical care specialist often sees himself or herself as a warrior in a battle with death. This adrenaline-charged calling attracts highly intelligent, hard-working, and compassionate caregivers, as well as fiercely independent clinicians. The result of this is that critical care specialists passionately debate about the meaning and application of published "evidence" and this leads to thoughtful debate, as exemplified by the papers in this and the next issue of Respiratory Care, as well as thoughtless and often dangerous disregard for evidence-based medicine. Physicians are morally obligated to provide the best and most appropriate care possible f...
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Papers by Bruce Rubin