Chest
Volume 129, Issue 1, Supplement, January 2006, Pages 132S-137S
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Supplement
Diagnosis and Management of Cough: ACCP Evidence-Based Clinical Practice Guidelines
Chronic Cough Due to Nonbronchiectatic Suppurative Airway Disease (Bronchiolitis): ACCP Evidence-Based Clinical Practice Guidelines

https://doi.org/10.1378/chest.129.1_suppl.132SGet rights and content

Objectives:

To review the role of nonbronchiectatic suppurative airway disease (bronchiolitis) in the spectrum of causes of cough and its management.

Design/methodology:

A MEDLINE search (through May 2004) for studies published in the English language since 1980 on human subjects using the medical subject heading terms “cough,” “causes of cough,” “etiology of cough,” “interstitial lung disease,” “bronchiolitis,” “bronchiolitis obliterans,” “diffuse panbronchiolitis,” and “inflammatory bowel disease” was performed. Case series and prospective descriptive clinical trials were selected for review. Any references from these studies that were pertinent to the topic were also obtained.

Results/conclusions:

In patients with cough in whom other more common causes of cough have been excluded, incomplete or irreversible airflow limitation, small airways disease seen on high-resolution CT scan, or purulent secretions seen on bronchoscopy, should suggest nonbronchiectatic suppurative airways disease (bronchiolitis) as a potential primary cause. Successful management depends on the identification of the specific underlying disorder.

Section snippets

DEFINITION

Abnormalities of the small airways and bronchiolar disorders are diseases that affect airways with an internal diameter of ≤ 2 mm and do not contain cartilage in their walls.1 Like other ILDs, they may be affected by variable amounts of cellular inflammation (eg, lymphocytic, neutrophilic, eosinophilic, or granulomatous), fibrosis, and architectural distortion.

If the bronchiolar abnormalities associated with asthma, COPD/emphysema, and bronchiectasis are removed, bronchiolitides can be grouped

EPIDEMIOLOGY

While few data are available on the frequency of the occurrence of these diseases, it is clear that they are not common. Generally grouped with the ILDs, they make up only a small fraction of the patients seen by a practicing pulmonologist. The prevalence of cough at presentation is unknown.

PATHOGENESIS

The pathogenesis of cough in patients with the bronchiolitides is unknown. However, the inflammation, fibrosis, and architectural distortion3 of the small airways that occur both with and without mucous hypersecretion and bronchial hyperresponsiveness is almost assuredly part, if not the entire cause.

DIAGNOSIS

As these diseases can be difficult to identify and may result from a variety of causes, and appropriate therapy often requires a specific diagnosis to be successful, a high index of suspicion and a complete evaluation are required.2 Bronchiolitis should be considered in patients with cough and incompletely or nonreversible airflow limitation associated with a clinical syndrome suggestive of infection, an underlying systemic disorder known to be associated with small airways disease, or

SPECIFIC TREATMENT

Therapy for patients with the bronchiolitis should be tailored to the specific cause or diagnosis. Infectious bronchiolitis, while uncommon in adults and usually secondary to a viral etiology (eg, respiratory syncytial virus), can result from bacterial infection (eg, Mycoplasma pneumoniae) and if identified may require prolonged antibiotic therapy with or without the addition of corticosteroids.6 In a retrospective review7 of patients who had been referred for the evaluation of chronic cough

RECOMMENDATIONS

1. In patients with cough and incomplete or irreversible airflow limitation, direct or indirect signs of small airways disease seen on HRCT scan, or purulent secretions seen on bronchoscopy, nonbronchiectatic suppurative airways disease (bronchiolitis) should be suspected as the primary cause. Level of evidence, expert opinion; benefit, substantial; grade of recommendation, E/A

2. In patients with cough in whom more common causes have been excluded, because bacterial suppurative airways disease

Definition

The lung may be affected in the patient with an IBD (ie, ulcerative colitis [UC] or Crohn disease). Direct involvement by the underlying disease, pulmonary toxicity secondary to a medication, or infection may occur. The underlying disease may involve the entire airway, from larynx to the alveolus repeating the abnormalities found in the bowel including inflammatory (lymphocytic, neutrophilic, and granulomatous), fibrotic, and destructive changes.9

Epidemiology

The prevalence of UC and Crohn disease may each

RECOMMENDATIONS

6. In the IBD patient with cough, bronchiolitis should be suspected as a potential cause. Level of evidence, low; benefit, substantial; grade of recommendation, B

7. In patients in whom IBD-related bronchiolitis is suspected, both adverse drug reaction and infection should be specifically considered. Level of evidence, expert opinion; benefit, substantial; grade of recommendation, E/A

8. In patients with IBD, therapy with both oral and inhaled corticosteroids may improve cough, and a trial of

Definition

DPB is a distinct form of small airways disease found primarily, but not solely, in Japan, Korea, and China.14 It is associated with the presence of chronic sinus disease, cough with copious purulent sputum, wheezing, and dyspnea. Obstructive physiology, suggestive radiographic features, and characteristic histopathologic findings15 on surgical lung biopsy specimens are all seen.

Epidemiology

The disease was initially described and appears to be most common in Japan, Korea, and China, and while genetics

RECOMMENDATIONS

9. In patients with chronic cough who have recently lived in Japan, Korea, or China, DPB should be considered as a potential cause. Level of evidence, low; benefit, substantial; grade of recommendation, B

10. In patients with suspected DPB, an appropriate clinical setting and characteristic HRCT scan findings may obviate the need for invasive testing and a trial of macrolide therapy (erythromycin or other 14-member ring macrolides such as clarithromycin and roxithromycin) is appropriate. Level

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