Chest

Chest

Volume 129, Issue 1, Supplement, January 2006, Pages 222S-231S
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Supplement
Diagnosis and Management of Cough: ACCP Evidence-Based Clinical Practice Guidelines
An Empiric Integrative Approach to the Management of Cough: ACCP Evidence-Based Clinical Practice Guidelines

https://doi.org/10.1378/chest.129.1_suppl.222SGet rights and content

Objective:

Review the literature to provide a comprehensive approach, including algorithms for the clinician to follow in evaluating and treating the patient with acute, subacute, and chronic cough.

Methods:

We searched MEDLINE (through May 2004) for studies published in the English language since 1980 on human subjects using the medical subject heading terms “cough,” “treatment of cough,” and “empiric treatment of cough.” We selected case series and prospective descriptive clinical trials. We also obtained any references from these studies that were pertinent to the topic.

Results:

The relative frequency of the disorders (alone and in combination) that can cause cough as well as the sensitivity and specificity of many but not all diagnostic tests in predicting the cause of cough are known. An effective approach to successfully manage chronic cough is to sequentially evaluate and treat for the common causes of cough using a combination of selected diagnostic tests and empiric therapy. Sequential and additive therapy is often crucial because more than one cause of cough is frequently present.

Conclusion:

Algorithms that provide a “road map” that the clinician can follow are useful and are presented for acute, subacute, and chronic cough.

Section snippets

ACUTE COUGH

Although there are no, large, prospective studies that have assessed the spectrum and frequency of causes of acute cough, acute cough is most commonly transient, as in the common cold, but it can occasionally be associated with life-threatening conditions such as pulmonary embolism, congestive heart failure, and pneumonia. The recommended approach to treating a patient with an acute cough is depicted in Figure 1. Clinically (ie, based on the findings of the medical history and physical

SUBACUTE COUGH (PRESENT FOR 3 TO 8 WEEKS)

While there are no studies that have assessed the spectrum and frequency of causes of subacute cough, Figure 2offers a conceptual approach based on “expert opinion” given the paucity of data on this topic. The committee recommends that in managing patients with subacute cough, the first step is to determine whether or not the cough has followed an obvious preceding respiratory infection. If the subacute cough does not appear to be postinfectious in nature, it should be evaluated and managed as

CHRONIC COUGH

Chronic cough is a more complex problem because the differential diagnosis is broader than that for acute or subacute cough. It often is due to more than one condition being simultaneously present, the medical history often offers few clues as to the initiating event, and the characteristics of the cough have been shown to lack both diagnostic sensitivity and specificity.14 Nevertheless, when approached in a systematic fashion, an accurate diagnosis and therapeutic success can usually be

UACS

Whereas UACS is the most common cause of chronic cough and its role in causing cough cannot be prospectively predicted, the approach to chronic cough should typically begin with a diagnostic/therapeutic trial of a first-generation antihistamine-decongestant (A/D), as noted in the section on UACS in this guideline.3 If a patient has resolution or partial resolution of cough in response to A/D therapy, then UACS is considered to have been a cause of cough and A/D therapy is continued. The typical

ASTHMA-INDUCED CHRONIC COUGH

The possibility that asthma is a causative factor in cough should be formally considered after the evaluation for UACS. The medical history is sometimes suggestive, but is not reliable in either ruling in or ruling out asthma.11, 21 Several studies1, 3, 22, 23 have documented the utility of bronchoprovocation challenge (BPC) in the evaluation for asthma as a cause of cough. The negative predictive value for a negative challenge is close to 100%. The positive predictive value of a positive

NAEB

If the diagnostic/therapeutic evaluations listed above for UACS and asthma have failed to yield either a diagnosis or a resolution of the cough, then NAEB should be considered next. Although in most series GERD is a more common cause of cough than NAEB, because the diagnosis of NAEB diagnosis is relatively straightforward to make when there is access to laboratories set up to perform the rigorous analysis and the response to treatment is very predictable, it makes sense to consider this

GERD-INDUCED CHRONIC COUGH

Patients whose cough responds only partially or not at all to the above interventions should next be evaluated for GERD. Because patients with the following clinical profile have been prospectively shown to have cough due to GERD in approximately 92% of cases, empiric therapy is recommended rather than testing: cough for > 2 months; normal chest roentgenogram findings; nonsmoking; not receiving ACE inhibitors; failed to get better with treatment for UACS; and asthma and NAEB with the use of

SUMMARY

In summary, an effective approach to cough, whether acute, subacute, or chronic, is to sequentially evaluate and treat for the common causes of cough using a combination of selected diagnostic tests and empiric therapy. It is important to realize that cough may be the only clinical manifestation of the common causes of cough, emphasizing the need for selective testing and adequate treatment (both in terms of the agents used and the duration of treatment) to see whether the cough responds.

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    Copyright © 2006 The American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.