Diagnosis and Management of Cough Executive Summary ACCP Evidence-Based Clinical Practice Guidelines Richard S. Irwin, MD, FCCP, Chair; Michael H. Baumann, MD, FCCP (HSP Liaison); Donald C. Bolser, PhD; Louis-Philippe Boulet, MD, FCCP (CTS Representative); Sidney S. Braman, MD, FCCP; Christopher E. Brightling, MBBS, FCCP; Kevin K. Brown, MD, FCCP; Brendan J. Canning, PhD; Anne B. Chang, MBBS, PhD; Peter V. Dicpinigaitis, MD, FCCP; Ron Eccles, DSc; W. Brendle Glomb, MD, FCCP; Larry B. Goldstein, MD; LeRoy M. Graham, MD, FCCP; Frederick E. Hargreave, MD; Paul A. Kvale, MD, FCCP; Sandra Zelman Lewis, PhD; F. Dennis McCool, MD, FCCP; Douglas C. McCrory, MD, MHSc; Udaya B.S. Prakash, MD, FCCP; Melvin R. Pratter, MD, FCCP; Mark J. Rosen, MD, FCCP; Edward Schulman, MD, FCCP (ATS Representative); John Jay Shannon, MD, FCCP (ACP Representative); Carol Smith Hammond, PhD; and Susan M. Tarlo, MBBS, FCCP (CHEST 2006; 129:1S–23S) Abbreviations: ACE ϭ angiotensin-converting enzyme; ACP ϭ American College of Physicians; A/D ϭ antihistamine/ decongestant; ATS ϭ American Thoracic Society; BPC ϭ bronchoprovocation challenge; CTS ϭ Canadian Thoracic Society; DPB ϭ diffuse panbronchiolitis; dTap ϭ acellular pertussis; FEES ϭ fiberoptic endoscopic evaluation of swallowing; GERD ϭ gastroesophageal reflux disease; HRCT ϭ high-resolution CT; HSP ϭ Health & Psychosocial Instruments; IBD ϭ inflammatory bowel disease; ICS ϭ inhaled corticosteroid; ILD ϭ interstitial lung disease; NAEB ϭ nonasthmatic eosinophilic bronchitis; NSCLC ϭ non-small cell lung cancer; SLP ϭ speech-language pathol- ogist; TB ϭ tuberculosis; UACS ϭ upper airway cough syndrome; URI ϭ upper respiratory infection; VC ϭ voluntary cough; VSE ϭ videofluoroscopic swallow evaluation ecognition of the importance of cough in clinical (3) updates and expands, when appropriate, all pre- R medicine was the impetus for the original evi- vious sections; and (4) adds new sections with topics dence-based consensus panel report on “Managing that were not previously covered. These new sections Cough as a Defense Mechanism and as a Symptom,” include nonasthmatic eosinophilic bronchitis (NAEB); published in 1998,1 and this updated revision. Com- acute bronchitis; nonbronchiectatic suppurative air- pared to the original cough consensus statement, this way diseases; cough due to aspiration secondary to revision (1) more narrowly focuses the guidelines on oral/pharyngeal dysphagia; environmental/occupa- the diagnosis and treatment of cough, the symptom, tional causes of cough; tuberculosis (TB) and other in adult and pediatric populations, and minimizes the infections; cough in the dialysis patient; uncommon discussion of cough as a defense mechanism; (2) causes of cough; unexplained cough, previously re- improves on the rigor of the evidence-based review ferred to as idiopathic cough; an empiric integrative and describes the methodology in a separate section; approach to the management of cough; assessing Reproduction of this article is prohibited without written permission cough severity and efficacy of therapy in clinical from the American College of Chest Physicians (www.chestjournal. research; potential future therapies; and future di- org/misc/reprints.shtml). rections for research. Correspondence to: Richard S. Irwin, MD, FCCP, University of Massachusetts Medical School, Room S6-842, 55 Lake Ave North, To mitigate future diagnostic confusion, two new Worcester, MA 01655; e-mail address: [email protected] diagnostic terms have been introduced to replace two www.chestjournal.org CHEST / 129/1/JANUARY, 2006 SUPPLEMENT 1S older terms that may represent misnomers. The com- For an in-depth discussion or clarification of each mittee unanimously recommends that the term upper recommendation, readers are encouraged to read airway cough syndrome (UACS) be used in preference the specific section in question in its entirety. to postnasal drip syndrome (PNDS) when discussing cough that is associated with upper airway conditions Methodology and Grading of the Evidence for the because it is unclear whether the mechanism of cough Diagnosis and Management of Cough5 is postnasal drip, direct irritation, or inflammation of • The recommendations were graded, by consensus the cough receptors in the upper airway. The commit- by the panel, using the American College of Chest tee also recommends using the term unexplained cough Physicians Health and Science Policy Grading rather than idiopathic cough because it is likely that System, which is based on the following two compo- more than one unknown cause of chronic cough will be nents: quality of evidence; and the net benefit of the discovered. The term idiopathic implies that one is diagnostic and therapeutic procedure. dealing with only one disease. • The quality of evidence is rated according to the For managing adult patients with cough, the com- study design and strength of other methodologies mittee recommends an empiric, integrative diagnos- used in the included studies. tic approach, which is presented in the section • The net benefit of the recommendations is based entitled “An Empiric Integrative Approach to the on the estimated benefit to the specific patient Management of Cough”.3 Guidelines for managing population described in each recommendation acute, subacute, and chronic cough are presented in and not for an individual patient. Usually, the net algorithmic form (Fig 1–3). Guidelines with algo- benefit is a clinical benefit to the population of rithms for evaluating chronic cough in pediatric patients defined in the first phrase of the recom- patients Ͻ 15 years of age are presented in the mendation, but, in recommendations for future section entitled “Guidelines for Evaluating Chronic research or other nonclinical recommendations, it Cough in Pediatrics”2,4 [Fig 4, 5]. For a full discus- may be a societal benefit. sion on how to use the algorithms, please refer to • Both the quality of evidence and the net benefit these sections. components are listed after each recommenda- tion; their interaction defines the strength of the Summary and Recommendations recommendations. • The recommendations scale is as follows: A, Recommendations for each section of these guide- strong; B, moderate; C, weak; D, negative; I, lines are listed under their respective section titles. inconclusive (no recommendation possible); E/A, Figure 1. Acute cough algorithm for the management of patients Ն 15 years of age with cough lasting Ͻ 3 weeks. For diagnosis and treatment recommendations refer to the section indicated in the algorithm. PE ϭ pulmonary embolism; Dx ϭ diagnosis; Rx ϭ treatment; URTI ϭ upper respiratory tract infection; LRTI ϭ lower respiratory tract infection. Section 7 ϭ Irwin8; Section 8 ϭ Pratter9; Section 9 ϭ Pratter10; Section 10 ϭ Pratter11; Section 11 ϭ Dicpinigaitis12; Section 12 ϭ Irwin13; Section 13 ϭ Braman14; Section 14 ϭ Braman15; Section 16 ϭ Rosen17; Section 22 ϭ Irwin et al.23 2S Diagnosis and Management of Cough: ACCP Guidelines Figure 2. Subacute cough algorithm for the management of patients Ն 15 years of age with cough lasting 3 to 8 weeks. For diagnosis and treatment recommendations refer to the section indicated in the algorithm. AECB ϭ acute exacerbation of chronic bronchitis. See the legend of Figure 1 for abbreviations not used in the text. See Figure 1 for references to Sections. strong recommendation based on expert opinion cough effectiveness. Level of evidence, expert only; E/B, moderate recommendation based on opinion; net benefit, substantial; grade of recom- expert opinion only; E/C, weak recommendation mendation, E/A based on expert opinion only; and E/D, negative 2. Individuals with neuromuscular weakness recommendation based on expert opinion only and no concomitant airway obstruction may benefit from mechanical aids to improve cough. Anatomy and Neurophysiology of the Cough Reflex6 Level of evidence, low; net benefit, intermediate; • There is clear evidence that vagal afferent nerves grade of recommendation, C regulate involuntary coughing. 3. In patients with ineffective cough, the cli- • Coughing, like swallowing, belching, urinating, nician should be aware of and monitor for and defecating, is unique because there is higher possible complications, such as pneumonia, at- cortical control of this visceral reflex. electasis, and/or respiratory failure. Level of • Cortical control can manifest as cough inhibition evidence, low; net benefit, substantial; grade of or voluntary cough. The implications of this are recommendation, B several-fold: because placebos can have a pro- found effect on coughing, treatment studies must Complications of Cough8 be placebo-controlled. Because cough can be an 1. In patients complaining of cough, evaluate affective behavior, psychological issues must be for a variety of complications associated with considered as a cause or effect of coughing. coughing (eg, cardiovascular, constitutional, GI, • There is a need to study the roles of consciousness genitourinary, musculoskeletal, neurologic, oph- and perception in coughing. thalmologic, psychosocial, and skin complica- tions), which can lead to a decrease in a patient’s Global Physiology and Pathophysiology of Cough7 health-related quality of life. Level of evidence, low; 1. In patients with endotracheal tubes, tra- benefit, substantial; grade of recommendation, B cheostomy need not be performed to improve 2. Patients with cough should have a thor- www.chestjournal.org CHEST / 129/1/JANUARY, 2006 SUPPLEMENT 3S Figure 3. Chronic cough algorithm for