Review
Adult and paediatric cough guidelines: Ready for an overhaul?

https://doi.org/10.1016/j.pupt.2015.01.007Get rights and content

Abstract

Cough is one of the most common reasons that patients seek medical attention. Cough guidelines from numerous countries and societies are available to assist the clinician to investigate and manage patients with cough. We review some of the recent progress in the field of cough that may lead to revision of these guidelines. In adults with chronic cough, new causes such as obstructive sleep apnoea have been identified. A new terminology, cough hypersensitivity syndrome (CHS), has been proposed for patients with chronic cough, which emphasises cough reflex hypersensitivity as a key feature. New therapeutic options are now available, particularly for patients with refractory or idiopathic chronic cough, which include gabapentin, speech pathology management and morphine. There has been great progress in the assessment of cough with the development of validated quality of life questionnaires and cough frequency monitoring tools. In children, common aetiologies differ from adults and those managed according to guidelines have better outcomes compared to usual care. New diagnostic entities such as protracted bacterial bronchitis have been described. Paediatric-specific cough assessment tools such as the Parent/Child Quality of Life Questionnaire will help improve the assessment of patients. Further research is necessary to improve the evidence base for future clinical guideline recommendations. Guidelines in future should also aim to reach a wider audience that includes primary care physicians, non-specialists and patients.

Introduction

Cough is a prevalent worldwide health problem. A recent survey of >10,000 subjects from specialist clinics evaluating adult patients with chronic cough from America, Europe and Asia highlighted that patients experiencing chronic cough have a strikingly similar clinical phenotype regardless of the country of origin. Patients present most commonly in middle or late age and women are twice as likely as men to suffer from chronic cough [1]. The prevalence of cough in the community has been estimated to be as high as 12% [2] and cough is one of the most common reasons for patients to consult their doctor [3], [4]. Cough has been traditionally divided into acute, sub-acute and chronic categories according to its duration [5]. Acute cough and sub-acute cough typically present to primary care physicians and are usually caused by viral upper respiratory tract infections, whereas chronic cough is often referred to secondary care physicians and can be caused by a wide range of conditions. Patients often have to visit their doctor on multiple occasions before referral to an appropriate specialist and misdiagnosis is common [6]. [7] Regardless of the cause and category, cough can be very disruptive to the individual and those around them, such as parents [8], and it is often associated with an impaired health-related quality of life [6], [9]. It can be associated with absence from work, social embarrassment and severe adverse effects, for example, urinary incontinence [10].

The assessment and management of cough can vary widely between clinicians [11] and there is variation in treatment success outcomes between clinics, ranging from 60% to 95% [12]. This variation may reflect the paucity of effective tools to investigate patients, and also of treatment options. The American College of Chest Physicians (ACCP) cough guidelines were one of the first to be published by an international society in 1998 [13] and many others have been published subsequently in an attempt to standardise practice and improve outcomes. The focus of most guidelines has been the secondary case setting, with some attention to patients with acute cough in primary care. The algorithm for most adult cough guidelines is based on investigating patients according to the anatomic diagnostic protocol [14], which evaluates patients for asthma, gastro-oesophageal reflux disease (GORD) and rhinitis before rarer causes. In paediatrics, aetiology-based management is emphasised with avoidance of an empiric approach.

There has been little focus on developing protocols for specialist cough clinics in tertiary care, although this is the setting where most clinical research is conducted that will ultimately influence future clinical guidelines. A limitation for developers of cough guidelines is the lack of a strong evidence base to make recommendations, and a key issue in the field has been the lack of investment in basic science relative to other pulmonary conditions, to understand the mechanisms of cough. Nevertheless, there have been some significant developments that may warrant revision of current guidelines. A good example is the progress in therapeutic options for adult patients with refractory or idiopathic chronic cough. In children there has been the recognition of protracted bacterial bronchitis, an important cause of persistent cough. A number of validated outcome tools are now available that have improved the assessment of cough. This review will focus on guidelines published in English and some examples of recent progress in the field of cough that may lead to revision of both adult and paediatric cough guidelines.

Section snippets

An overview of international cough guidelines

The ACCP Guideline published in 1998 was the first published cough guideline [13] and it was subsequently revised in 2006 [5]. It is a comprehensive review of both adult and paediatric patients and covers all categories of cough and cough due to a range of chronic lung diseases. The ACCP Guidelines were written by a large panel of international experts in the field. It is an authoritative review, and some of its many achievements include embedding the anatomic diagnostic protocol into clinical

An overview of international cough guidelines

“Children are not little adults”. Almost all aspects of children's health including clinical trials and drug development are poor cousins of adult health. Over the years, paediatricians worldwide have cautioned against the blind extrapolation of adult data to children as it may result in considerable harm [32], [62], [63]. Also, it is increasingly recognised that the root of many chronic diseases in adulthood stem from childhood, and tackling health issues in children may lead to improved

Adults

There are many areas of cough in adults that deserve further study. The authors have listed some suggestions below, but this should not be considered exhaustive. In acute cough associated with upper respiratory tract infection, there is a clear need to develop effective anti-tussive medications. The efficacy of Dextromethorphan, the active ingredient of most over-the-counter cough syrups, also deserves a thorough re-evaluation in a randomised control trial. In cough-variant asthma, the clinical

Improving the awareness of cough guidelines

It is difficult to assess the effectiveness of previous cough guidelines. In paediatrics there is evidence that early management of patients according to a standardised algorithm improves outcomes [6] and other studies have supported the view that guidelines are helpful, although have not compared the use of guidelines with normal practice or their delayed use [85], [86], [87]. The management of cough in both primary and secondary care does remain varied, and therefore there is scope for

Conclusion

There has been significant progress in the field of cough to warrant the revision of cough guidelines. In adults, the assessment of cough with validated quality of life questionnaires and objective cough frequency monitors is one such area where progress has been made recently. Numerous therapies for unexplained chronic cough have been evaluated, most significantly gabapentin. The authors are aware of only one guideline, the ACCP, which is currently under revision. This guideline is going to

References (88)

  • H. Ogawa et al.

    The importance of basidiomycetous fungi cultured from the sputum of chronic idiopathic cough: a study to determine the existence of recognizable clinical patterns to distinguish CIC from non-CIC

    Respir Med

    (2009)
  • M.J. Oh et al.

    Exhaled nitric oxide measurement is useful for the exclusion of nonasthmatic eosinophilic bronchitis in patients with chronic cough

    Chest

    (2008)
  • S. Decalmer et al.

    Chronic cough: relationship between microaspiration, gastroesophageal reflux, and cough frequency

    Chest

    (2012)
  • N.M. Ryan et al.

    Gabapentin for refractory chronic cough: a randomised, double-blind, placebo-controlled trial

    Lancet

    (2012)
  • A.E. Vertigan et al.

    Chronic refractory cough as a sensory neuropathy: evidence from a reinterpretation of cough triggers

    J Voice Off J Voice Found

    (2011)
  • C.T. French et al.

    Evaluation of a cough-specific quality-of-life questionnaire

    Chest

    (2002)
  • K.E. Fletcher et al.

    A prospective global measure, the Punum Ladder, provides more valid assessments of quality of life than a retrospective transition measure

    J Clin Epidemiol

    (2010)
  • S.S. Birring et al.

    Cough frequency, cough sensitivity and health status in patients with chronic cough

    Respir Med

    (2006)
  • B. Prudon et al.

    Cough and glottic-stop reflex sensitivity in health and disease

    Chest

    (2005)
  • B. Prudon et al.

    Cough and glottic-stop reflex sensitivity in health and disease

    CHEST J

    (2005)
  • A.B. Chang

    Specialty grand challenge–pediatric pulmonology

    Front Pediatr

    (2013)
  • A.B. Chang et al.

    Guidelines for evaluating chronic cough in Pediatrics ACCP evidence-based clinical practice guidelines

    CHEST J

    (2006)
  • A.B. Chang et al.

    Cough throughout life: children, adults and the senile

    Pulm Pharmacol Ther

    (2007)
  • A.B. Chang et al.

    Do sex and atopy influence cough outcome measurements in children?

    Chest

    (2011)
  • J.M. Marchant et al.

    Evaluation and outcome of young children with chronic cough

    CHEST J

    (2006)
  • M. Kompare et al.

    Protracted bacterial bronchitis in young children: association with airway malacia

    J Pediatr

    (2012)
  • D.F. Wurzel et al.

    Prospective characterization of protracted bacterial bronchitis in children

    CHEST J

    (2014)
  • P.A. Newcombe et al.

    Minimally important change in a parent-proxy quality-of-life questionnaire for pediatric chronic cough

    CHEST J

    (2011)
  • P.A. Newcombe et al.

    Parent cough-specific quality of life: development and validation of a short form

    J Allergy Clin Immunol

    (2013)
  • V. Plaza et al.

    Usefulness of the guidelines of the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR) in Identifying the Causes of Chronic Cough

    Archivos de Bronconeumología ((English Edition))

    (2006)
  • A.H. Morice et al.

    A worldwide survey of chronic cough: a manifestation of enhanced somatosensory response

    Eur Respir J

    (2014)
  • A.C. Ford et al.

    Cough in the community: a cross sectional survey and the relationship to gastrointestinal symptoms

    Thorax

    (2006)
  • K. Lai et al.

    Survey on the diagnosis and management of the patients with chronic cough

    Int J Respir

    (2011)
  • K. Brignall et al.

    Quality of life and psychosocial aspects of cough

    Lung

    (2008)
  • C. Yang et al.

    Survey of quality of life and incontinence in female patients with chronic cough

    Int J Respir

    (2010)
  • S. Faruqi et al.

    On the definition of chronic cough and current treatment pathways: an international qualitative study

    Cough

    (2014)
  • R.S. Irwin et al.

    Chronic cough. The spectrum and frequency of causes, key components of the diagnostic evaluation, and outcome of specific therapy

    Am Rev Respir Dis

    (1990)
  • S. Kohno et al.

    The Japanese Respiratory Society guidelines for management of cough

    Respirology (Carlton, Vic)

    (2006)
  • B. Wee et al.

    Management of chronic cough in patients receiving palliative care: review of evidence and recommendations by a task group of the Association for Palliative Medicine of Great Britain and Ireland

    Palliat Med

    (2012)
  • P.G. Gibson et al.

    CICADA: cough in children and adults: diagnosis and assessment. Australian cough guidelines summary statement

    Med J Aust

    (2010)
  • A.B. Chang et al.

    Cough in children: definitions and clinical evaluation

    Med J Aust

    (2006)
  • S. Leconte et al.

    Prolonged cough in children: a summary of the Belgian primary care clinical guideline

    Prim Care Respir J

    (2008)
  • M.D. Shields et al.

    Recommendations for the assessment and management of cough in children

    Thorax

    (2008)
  • A. Morice et al.

    Recommendations for the management of cough in adults

    Thorax

    (2006)
  • Cited by (0)

    View full text