Publications of the Week, March 30

Management of chronic cough

This guideline, developed by the European Respiratory Society, addresses the management of patients presenting with chronic cough, which was defined as a cough lasting at least 8 weeks in adults and 4 weeks in children. Most adult patients present with a dry cough, with sensitivity to inhalation of environmental irritants, such as perfumes, bleaches, or cold air, that leads to sensations of tickling or irritation in the throat and an urge to cough. Epidemiologically, two-thirds of adult patients are female, and chronic cough has a peak prevalence in the sixth and seventh decades of life.

The guideline identified 8 clinically important questions (2 diagnostic, 6 therapeutic) using the PICO (patient population, intervention, comparison, and outcome) framework. A systematic review of evidence was undertaken and the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach was used to assess the strength of evidence and develop recommendations.

The Task Force made the following clinical recommendations, of which all but one were conditional (weak) recommendations—worded as suggestions—that were based on low-quality or very low-quality evidence:

• Suggestion to not routinely perform chest computed tomography (CT) scanning in patients with chronic cough who have a normal chest radiograph and physical examination.
• Suggestion of a short-term (2-4 weeks) trial of inhaled corticosteroids in adult patients with chronic cough and of a similar short-term trial of inhaled corticosteroids in pediatric patients with chronic dry cough.
• Suggestion of a short-term (2-4 weeks) trial of antileukotriene therapy in adults with chronic cough, particularly in asthmatic cough.
• Suggestion of a short-term (2-4 weeks) trial of an inhaled corticosteroid/long-acting bronchodilator combination in adults with chronic cough and fixed airflow obstruction.
• Suggestion against the routine use of antacid drugs in adults with chronic cough.
• Suggestion of a 1-month trial of macrolides in the cough of chronic bronchitis refractory to other therapy, accounting for local antimicrobial stewardship guidelines.
• Recommendation of a trial of low-dose slow-release morphine (5-10 mg twice daily) in adults with chronic refractory cough.
• Suggestion of a trial of gabapentin or pregabalin in adults with chronic refractory cough.
• Suggestion of a trial of cough control therapy (physiotherapy/speech and language therapy interventions) in adults with chronic cough.
• Suggestion of a trial of antibiotics in children with chronic wet cough with normal chest radiographs, normal spirometry, and no warning signs.

The Task Force emphasized that chronic cough has only recently been recognized as a separate entity and identified the need to improve recognition of cough hypersensitivity in adults with chronic dry cough and protracted bacterial bronchitis in children with chronic wet cough.