Classification of Cough as a Symptom in Adults and Management Algorithms: CHEST Guideline and Expert Panel Report

Abstract

Background: We performed systematic reviews using the population, intervention, comparison, outcome (PICO) format to answer the following key clinical question: Are the CHEST 2006 classifications of acute, subacute and chronic cough and associated management algorithms in adults that were based on durations of cough useful?

Methods: We used the CHEST Expert Cough Panel's protocol for the systematic reviews and the American College of Chest Physicians (CHEST) methodological guidelines and Grading of Recommendations Assessment, Development, and Evaluation framework. Data from the systematic reviews in conjunction with patient values and preferences and the clinical context were used to form recommendations or suggestions. Delphi methodology was used to obtain the final grading.

Results: With respect to acute cough (< 3 weeks), only three studies met our criteria for quality assessment, and all had a high risk of bias. As predicted by the 2006 CHEST Cough Guidelines, the most common causes were respiratory infections, most likely of viral cause, followed by exacerbations of underlying diseases such as asthma and COPD and pneumonia. The subjects resided on three continents: North America, Europe, and Asia. With respect to subacute cough (duration, 3-8 weeks), only two studies met our criteria for quality assessment, and both had a high risk of bias. As predicted by the 2006 guidelines, the most common causes were postinfectious cough and exacerbation of underlying diseases such as asthma, COPD, and upper airway cough syndrome (UACS). The subjects resided in countries in Asia. With respect to chronic cough (> 8 weeks), 11 studies met our criteria for quality assessment, and all had a high risk of bias. As predicted by the 2006 guidelines, the most common causes were UACS from rhinosinus conditions, asthma, gastroesophageal reflux disease, nonasthmatic eosinophilic bronchitis, combinations of these four conditions, and, less commonly, a variety of miscellaneous conditions and atopic cough in Asian countries. The subjects resided on four continents: North America, South America, Europe, and Asia.

Conclusions: Although the quality of evidence was low, the published literature since 2006 suggests that CHEST's 2006 Cough Guidelines and management algorithms for acute, subacute, and chronic cough in adults appeared useful in diagnosing and treating patients with cough around the globe. These same algorithms have been updated to reflect the advances in cough management as of 2017.

Keywords: cough; evidence-based medicine; guidelines; management algorithms for acute, subacute, and chronic cough in adults.

Figure 1

Selection of studies that addressed the key clinical question for acute and subacute cough: Are the CHEST 2006 classifications of acute and subacute cough and associated management algorithms in adults that were based on durations of cough useful?

Figure 2

Selection of studies that addressed the key clinical question for chronic cough: Are the CHEST 2006 classifications of chronic cough and associated management algorithms in adults that were based on durations of cough useful?

Figure 3

Acute cough algorithm for the management of patients ≥ 15 years of age with cough lasting < 3 weeks. Always screen for the presence of red flags as a clue to a potentially life-threatening condition. Always consider the presence of TB in endemic areas or high-risk populations even if chest radiographs are normal. Remember to routinely assess cough severity or quality of life before and after treatment and routinely follow patients 4-6 weeks after initial visit. LRTI = lower respiratory tract infection; PE = pulmonary embolism; UACS = upper airway cough syndrome; URI = upper respiratory tract infection.

Figure 4

Representative Punum ladders to assess (A) cough severity or (B) overall quality of life.

Figure 5

Subacute cough algorithm for the management of patients ≥ 15 years of age with cough lasting 3 to 8 weeks. Always screen for the presence of red flags as a clue to a potentially life-threatening condition as well as historical clues for environmental and occupational factors that might be contributing to the cough. Always consider the presence of TB in endemic areas or high-risk populations even if chest radiographs are normal. Remember to routinely assess cough severity or quality of life before and after treatment and routinely follow patients 4 to 6 weeks after initial visit. AECB = acute exacerbation of chronic bronchitis; GERD = gastroesophageal reflux disease; NAEB = nonasthmatic eosinophilic bronchitis. See Figure 1 and 3 legends for expansion of other abbreviations.

Figure 6

Chronic cough algorithm for the management of patients ≥ 15 years of age with cough lasting > 8 weeks. Always screen for red flags as a clue to a potentially life-threatening condition, as well as historical clues for environmental and occupational factors that might be contributing to the cough. Always evaluate whether sitagliptin as well as angiotensin-converting enzyme inhibitors are contributing to the patient’s cough. Always consider the presence of TB in endemic areas or high-risk populations even if chest radiographs are normal. Be aware that treatment of cough due to GERD should not be limited to acid suppression. Remember to routinely assess cough severity or quality of life before and after treatment and routinely follow patients 4 to 6 weeks after the initial visit. Consider referral to a recognized cough clinic for patients with refractory unexplained chronic cough. ACEI = angiotensin-converting enzyme inhibitor; A/D = antihistamine/decongestant; BD = bronchodilator; HRCT = high-resolution CT; ICS = inhaled corticosteroid; LTRA = leukotriene antagonist; PPI = proton pump inhibitor. See Figure 3 and 4 legends for expansion of other abbreviations.