Diagnosis and Management of Cough Executive Summary: ACCP Evidence-Based Clinical Practice Guidelines

Abstract

Recognition of the importance of cough in clinical medicine was the impetus for the original evidence-based consensus panel report on “Managing Cough as a Defense Mechanism and as a Symptom,” published in 1998,1 and this updated revision. Compared to the original cough consensus statement, this revision (1) more narrowly focuses the guidelines on the diagnosis and treatment of cough, the symptom, in adult and pediatric populations, and minimizes the discussion of cough as a defense mechanism; (2) improves on the rigor of the evidence-based review and describes the methodology in a separate section; (3) updates and expands, when appropriate, all previous sections; and (4) adds new sections with topics that were not previously covered. These new sections include nonasthmatic eosinophilic bronchitis (NAEB); acute bronchitis; nonbronchiectatic suppurative airway diseases; cough due to aspiration secondary to oral/pharyngeal dysphagia; environmental/occupational causes of cough; tuberculosis (TB) and other infections; cough in the dialysis patient; uncommon causes of cough; unexplained cough, previously referred to as idiopathic cough; an empiric integrative approach to the management of cough; assessing cough severity and efficacy of therapy in clinical research; potential future therapies; and future directions for research. To mitigate future diagnostic confusion, two new diagnostic terms have been introduced to replace two older terms that may represent misnomers. The committee unanimously recommends that the term upper airway cough syndrome (UACS) be used in preference to postnasal drip syndrome (PNDS) when discussing cough that is associated with upper airway conditions because it is unclear whether the mechanism of cough is postnasal drip, direct irritation, or inflammation of the cough receptors in the upper airway. The committee also recommends using the term unexplained cough rather than idiopathic cough because it is likely that more than one unknown cause of chronic cough will be discovered. The term idiopathic implies that one is dealing with only one disease. For managing adult patients with cough, the committee recommends an empiric, integrative diagnostic approach, which is presented in the section entitled “An Empiric Integrative Approach to the Management of Cough”.3 Guidelines for managing acute, subacute, and chronic cough are presented in algorithmic form (Fig 1–3). Guidelines with algorithms for evaluating chronic cough in pediatric patients < 15 years of age are presented in the section entitled “Guidelines for Evaluating Chronic Cough in Pediatrics”2,4 [Fig 4, ​,5].5]. For a full discussion on how to use the algorithms, please refer to these sections. Figure 1 Acute cough algorithm for the management of patients ≥ 15 years of age with cough lasting < 3 weeks. For diagnosis and treatment recommendations refer to the section indicated in the algorithm. PE = pulmonary embolism; Dx = diagnosis; ... Figure 3 Chronic cough algorithm for the management of patients ≥ 15 years of age with cough lasting > 8 weeks. ACE-I = ACE inhibitor; BD = bronchodilator; LTRA = leukotriene receptor antagonist; PPI = proton pump inhibitor. See the legend of ... Figure 4 Approach to a child 6 years of age and in some children ... Figure 5 Approach to a child ≤ 14 years of age with chronic specific cough (ie, cough associated with other features suggestive of an underlying pulmonary and/or systemic abnormality). Children > 14 years of age should be managed as outlined in ...