ReviewAdult and paediatric cough guidelines: Ready for an overhaul?
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
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