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Syncope: a complication of chronic cough

Jenny King, Sarah Hennessey, James Wingfield Digby, Jaclyn Ann Smith, Paul Marsden
Breathe 2021 17: 210094; DOI: 10.1183/20734735.0094-2021
Jenny King
1The University of Manchester, Faculty of Allergy, Immunology and Respiratory Medicine, Wythenshawe Hospital, Wythenshawe, Manchester, UK
2Manchester University NHS Foundation Trust, North West Lung Centre, Wythenshawe Hospital, Wythenshawe, Manchester, UK
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  • ORCID record for Jenny King
  • For correspondence: jenny.king@manchester.ac.uk
Sarah Hennessey
2Manchester University NHS Foundation Trust, North West Lung Centre, Wythenshawe Hospital, Wythenshawe, Manchester, UK
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James Wingfield Digby
1The University of Manchester, Faculty of Allergy, Immunology and Respiratory Medicine, Wythenshawe Hospital, Wythenshawe, Manchester, UK
2Manchester University NHS Foundation Trust, North West Lung Centre, Wythenshawe Hospital, Wythenshawe, Manchester, UK
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Jaclyn Ann Smith
1The University of Manchester, Faculty of Allergy, Immunology and Respiratory Medicine, Wythenshawe Hospital, Wythenshawe, Manchester, UK
2Manchester University NHS Foundation Trust, North West Lung Centre, Wythenshawe Hospital, Wythenshawe, Manchester, UK
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Paul Marsden
1The University of Manchester, Faculty of Allergy, Immunology and Respiratory Medicine, Wythenshawe Hospital, Wythenshawe, Manchester, UK
2Manchester University NHS Foundation Trust, North West Lung Centre, Wythenshawe Hospital, Wythenshawe, Manchester, UK
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Figures

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  • Figure 1
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    Figure 1

    Slices from CT of the thorax.

  • Figure 2
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    Figure 2

    Lung function testing (Ref: reference value; Pre: measured value; Post: post-bronchodilator value, not performed). Results are shown in table 1.

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    Figure 3

    Results of 14-day cardiac monitoring, revealing occasional ventricular ectopics (VEs), and an unsustained episode of ventricular tachycardia (VT). HR: heart rate; WCT: wide complex tachycardia; SDNN: standard deviation of the normal-to-normal RR intervals; SVE: supraventricular ectopic beats; AF: atrial fibrillation.

  • Figure 4
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    Figure 4

    Proposed set of investigations in all patients reporting cough syncope.

Tables

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  • Table 1

    Result of the lung function testing for this 54-year-old Caucasian male

    SpirometryMeasurement% of referenceSR
    FEV1, L2.6682–1.16
    FVC, L3.7693–0.45
    FEV1/FVC, %71
    DLCO, mmol·min−1·kPa−19.11000.02
    KCO, mmol·min−1·kPa−1·L−11.671201.02
    TLC (box), L5.5185–1.42
    RV (box), L1.6374–1.37
    RV/TLC, %29

    SR: standard residuals (the deviation from predicted values (recorded−predicted)/residual standard deviation), FEV1: forced expiratory volume in 1 s; FVC: forced vital capacity; DLCO: diffusing capacity of the lung for carbon monoxide; KCO: transfer coefficient of the lungs for carbon monoxide; TLC: total lung capacity; RV: residual volume.

    • Table 2

      Bronchoalveolar lavage (BAL) results

      Differential cell count
       Macrophages 83%
       Neutrophils 1%
       Lymphocytes 6%
       Eosinophils 1%
       Others9%
      Microscopic descriptionNo malignant cells recognised

      Total cell count: 0.11 million cells per mL.

      • Table 3

        EU standards for driving with recurrent cough syncope and DVLA guidance for group 1 (motorcycles, passenger cars and other small vehicles) and 2 (vehicles over 3.5 tonnes or vehicles designed for the carriage of more than nine passengers) drivers for patients with cough syncope

        EU standards [11]Group 1 driversDriving allowed if no recurrence in 6 months
        Group 2 driversPermanent ban
        UK DVLA guidelines [12]Group 1 DriversMust not drive for 6 months following a single episode and for 12 months following multiple episodes and must notify DVLA
        Group 2 Drivers (bus and lorry)Must not drive for 12 months following a single episode and for 5 years following multiple episodes and must notify DVLA

        If more than one episode of cough syncope occurs within a 24-h period, this will be counted as a single event. However, if the episodes of cough syncope are more than 24 h apart, these are considered as multiple episodes. Adapted from [11, 12].

        • Table 4

          Adverse features in the history suggestive of alternative diagnoses

          Chest painHeadache
          PalpitationsExertional onset
          Protracted loss of consciousness >1–2 minSyncope whilst supine or sitting
          Significant history of structural heart diseasePolyuria/polydipsia
          Significant breathlessnessWeight loss
        • Table 5

          Conditions that may mimic or exacerbate cough syncope

          CardiacAtrioventricular block
          Pulmonary hypertension
          Constrictive pericarditis
          Carotid sinus syndrome
          Postural hypotension
          Aortic stenosis
          Structural heart disease [16]
          NeurologicalEpilepsy
          Intracranial tumours [17]
          Subclavian steel syndrome [18]
          Autonomic dysfunction
          OthersDrug induced (vasodilators, diuretics)
          Diabetes (resulting in autonomic dysfunction)

          Information from [15].

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          Syncope: a complication of chronic cough
          Jenny King, Sarah Hennessey, James Wingfield Digby, Jaclyn Ann Smith, Paul Marsden
          Breathe Dec 2021, 17 (4) 210094; DOI: 10.1183/20734735.0094-2021

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          Syncope: a complication of chronic cough
          Jenny King, Sarah Hennessey, James Wingfield Digby, Jaclyn Ann Smith, Paul Marsden
          Breathe Dec 2021, 17 (4) 210094; DOI: 10.1183/20734735.0094-2021
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