Guideline sources The following summarized guidelines for the evaluation and management of chronic cough are prepared by our editorial team based on guidelines from the American College of Chest Physicians (ACCP 2020; 2018; 2016; 2015) and the British Thoracic Society (BTS 2020). 1 2 3 4 5 6 7 7 7 7 Definition Chronic cough is defined as a cough symptom that persists for longer than 8 weeks. 7 Epidemiology Common causes of cough include upper airway cough syndrome, GERD/laryngopharyngeal reflux disease, asthma, and nonasthmatic eosinophilic bronchitis. 7 Disease course Cough persistence may lead to vomiting, muscle pain, urinary incontinence, tiredness, syncope, and depression. 7 Prognosis and risk of recurrence https://web.pathway.md/diseases/rec1z99sLmYRqgv2Y 1/5 6/29/23, 3:52 AM Chronic cough Pathway Prognosis and risk of recurrence Chronic cough is not associated with an increase in mortality in the absence of a serious underlying disease. 7 Guidelines 1. Screening and diagnosis Diagnosis of unexplained chronic cough: define an unexplained chronic cough as a cough that persists > 8 weeks, remains unexplained after investigation, and persists despite supervised therapeutic trial(s) conducted according to published best-practice guidelines in adult patients with chronic cough. E 2. Classification and risk stratification Risk factors: recognize that smoking and dusty environmental exposures, such as irritating inhalants and environmental pollutants, are risk factors for chronic cough due to chronic bronchitis in adult patients. Visual analogue scale: consider using visual analog scales or NRSs to evaluate cough on a standard basis. E 3. Diagnostic investigations Cough questionnaire assessment: Use validated and reliable health-related quality of life questionnaires in adult and adolescent patients 14 years of age with complaints of chronic cough. B Use the Cough-Specific Quality-of-Life Questionnaire and Leicester Cough Questionnaire in adult and adolescent patients with chronic cough, as they are the most extensively studied and commonly used questionnaires to assess the impact of cough. B Acoustic cough counting: use acoustic cough counting to assess cough frequency in patients of all ages. B Tussigenic challenges: consider tussigenic challenges in research settings to understand mechanisms of cough in adult and adolescent patients with cough of any duration. E Evaluation for bronchial hyperresponsiveness: consider a guideline/protocol based assessment process that includes objective testing for bronchial hyperresponsiveness and eosinophilic bronchitis, or a therapeutic corticosteroid trial in adult patients with chronic cough. E 4. Respiratory support https://web.pathway.md/diseases/rec1z99sLmYRqgv2Y 2/5 6/29/23, 3:52 AM Chronic cough Pathway Positive end-expiratory pressure: avoid offering PEEP to relieve cough in adult patients with cough due to stable chronic bronchitis. 5. Medical management Inhaled corticosteroids: consider avoiding ICSs in adult patients with unexplained chronic cough and negative tests for bronchial hyperresponsiveness and eosinophilia (sputum eosinophils, exhaled nitric oxide). D Gabapentin: consider a therapeutic trial of gabapentin in adult patients with unexplained chronic cough after an appropriate discussion of risks and benefits. Reassess the risk benefit profile at 6 months before continuing the drug. C Proton pump inhibitors: consider avoiding PPI therapy in adult patients with unexplained chronic cough and a negative workup for acid GERD. D Antibiotics: As per ACCP 2020 guidelines, insufficient evidence to support the routine use of antibiotics to relieve cough in adult patients with chronic cough due to stable chronic bronchitis. I As per BTS 2020 guidelines, do not use long-term macrolide antibiotics for the management of patients with unexplained chronic cough. D Bronchodilators: insufficient evidence to support the routine use of bronchodilators to relieve cough in adult patients with chronic cough due to stable chronic bronchitis. I Mucolytics: insufficient evidence to support the routine use of mucolytics to relieve cough in adult patients with chronic cough due to stable chronic bronchitis. I 6. Nonpharmacologic interventions Speech therapy: consider a therapeutic trial of multimodality speech pathology therapy in adult patients with unexplained chronic cough. C 7. Specific circumstances Pediatric patients: use validated and reliable health-related quality of life questionnaires in pediatric patients with chronic cough. B Patients with asthma: consider obtaining noninvasive measurement of airway inflammation in adult and adolescent patients with chronic cough due to asthma. Recognize that the presence of eosinophilic airway inflammation is likely to be associated with a more favorable response to corticosteroids. C Show 3 more Patients with non-asthmatic eosinophilic bronchitis: https://web.pathway.md/diseases/rec1z99sLmYRqgv2Y 3/5 6/29/23, 3:52 AM Chronic cough Pathway Consider initiating ICSs as first-line therapy in adult and adolescent patients with chronic cough due to non-asthmatic eosinophilic bronchitis. C Consider stepping-up the dose of ICSs and initiating a therapeutic trial of a leukotriene inhibitor after reconsideration of alternative causes of cough in adult and adolescent patients with chronic cough due to non-asthmatic eosinophilic bronchitis, if response to ICSs is incomplete. C Patients with interstitial lung disease: consider evaluating patients with ILD presenting with a troublesome cough for progression of their underlying disease or complications from immunosuppressive treatment (such as drug side effect, pulmonary infection). Consider obtaining further investigation/treatment trials for cough according to published guidelines for acute, subacute and chronic cough. E Show 4 more Clinical findings Patient demographics Symptoms Female sex Chronic cough Coughing up blood Past medical history Drainage of mucus in the back of the throat Aspiration pneumonia Heartburn Asthma Hoarseness COPD Infection Cystic fibrosis Runny nose Gastroesophageal reflux Sore throat Lung cancer Sour taste Medications Sarcoidosis Respiratory exam Histological findings Dyspnea Wheezing Pulmonary eosinophilia Pulmonary fibrosis References 1. Boulet LP, Coeytaux RR, McCrory DC et al. Tools for assessing outcomes in studies of chronic cough: CHEST guideline and expert panel report. Chest. 2015 Mar;147 3 804 814. Open 2. Gibson P, Wang G, McGarvey L et al. Treatment of Unexplained Chronic Cough: CHEST Guideline and Expert Panel Report. Chest. 2016 Jan;149 1 27 44. Open 3. Andreanne C t , Richard J Russell, Louis-Philippe Boulet et al. Managing Chronic Cough Due to Asthma and NAEB in Adults and Adolescents: CHEST Guideline and Expert Panel Report. Chest. 2020 Jul;158 1 68 96. Open https://web.pathway.md/diseases/rec1z99sLmYRqgv2Y 4/5 6/29/23, 3:52 AM Chronic cough Pathway 4. David Smith, Ingrid Du Rand, Charlotte Louise Addy et al. British Thoracic Society guideline for the use of long-term macrolides in adults with respiratory disease. Thorax. 2020 May;75 5 370 404. Open 5. Surinder S Birring, Joanne E Kavanagh, Richard S Irwin et al. Treatment of Interstitial Lung Disease Associated Cough: CHEST Guideline and Expert Panel Report. Chest. 2018 Oct;154 4 904 917. Open 6. Mark A Malesker, Priscilla Callahan-Lyon, J Mark Madison et al. Chronic Cough Due to Stable Chronic Bronchitis: CHEST Expert Panel Report. Chest. 2020 Aug;158 2 705 718. Open 7. Charlie Michaudet, John Malaty. Chronic Cough: Evaluation and Management. Am Fam Physician. 2017 Nov 1;96 9 575 580.2017 Nov 1;96 9 575 580. Open 8. Kahrilas PJ, Altman KW, Chang AB et al. Chronic Cough Due to Gastroesophageal Reflux in Adults: CHEST Guideline and Expert Panel Report. Chest. 2016 Dec;150 6 1341 1360. Open 9. Charlie Michaudet, John Malaty. Chronic Cough: Evaluation and Management. Am Fam Physician. 2017 Nov 1;96 9 575 580. Open https://web.pathway.md/diseases/rec1z99sLmYRqgv2Y 5/5