Diagnosis and Management of Cough PDF

Diagnosis and Management of Cough
Executive Summary : ACCP Evidence-Based

Clinical Practice Guidelines
Richard S. Irwin, Michael H. Baumann, Donald C. Bolser, Louis-Philippe
Boulet, Sidney S. Braman, Christopher E. Brightling, Kevin K. Brown,
Brendan J. Canning, Anne B. Chang, Peter V. Dicpinigaitis, Ron Eccles,
W. Brendle Glomb, Larry B. Goldstein, LeRoy M. Graham, Frederick E.
Hargreave, Paul A. Kvale, Sandra Zelman Lewis, F. Dennis McCool,
Douglas C. McCrory, Udaya B.S. Prakash, Melvin R. Pratter, Mark J.
Rosen, Edward Schulman, John Jay Shannon, Carol Smith Hammond
and Susan M. Tarlo
Chest 2006;129;1S-23S
DOI 10.1378/chest.129.1_suppl.1S
The online version of this article, along with updated information and
services can be found online on the World Wide Web at:
http://chestjournal.chestpubs.org/content/129/1_suppl/1S.full.html
Supplemental material related to this article is available at:
http://chestjournal.chestpubs.org/content/suppl/2006/05/25/129.1_suppl.
1S.DC1.html
Chest is the official journal of the American College of Chest

Physicians. It has been published monthly since 1935.
Copyright2006by the American College of Chest Physicians, 3300
Dundee Road, Northbrook, IL 60062. All rights reserved. No part of
this article or PDF may be reproduced or distributed without the prior
written permission of the copyright holder.
(http://chestjournal.chestpubs.org/site/misc/reprints.xhtml)
ISSN:0012-3692
Downloaded from chestjournal.chestpubs.org by guest on December 20, 2011

© 2006 American College of Chest Physicians
Diagnosis and Management of Cough
Executive Summary
ACCP Evidence-Based Clinical Practice Guidelines
Richard S. Irwin, MD, FCCP, Chair;
Michael H. Baumann, MD, FCCP (HSP Liaison); Donald C. Bolser, PhD;
Louis-Philippe Boulet, MD, FCCP (CTS Representative);
Sidney S. Braman, MD, FCCP; Christopher E. Brightling, MBBS, FCCP;
Kevin K. Brown, MD, FCCP; Brendan J. Canning, PhD;
Anne B. Chang, MBBS, PhD; Peter V. Dicpinigaitis, MD, FCCP;
Ron Eccles, DSc; W. Brendle Glomb, MD, FCCP; Larry B. Goldstein, MD;
LeRoy M. Graham, MD, FCCP; Frederick E. Hargreave, MD;
Paul A. Kvale, MD, FCCP; Sandra Zelman Lewis, PhD;
F. Dennis McCool, MD, FCCP; Douglas C. McCrory, MD, MHSc;
Udaya B.S. Prakash, MD, FCCP; Melvin R. Pratter, MD, FCCP;
Mark J. Rosen, MD, FCCP;
Edward Schulman, MD, FCCP (ATS Representative);
John Jay Shannon, MD, FCCP (ACP Representative);
Carol Smith Hammond, PhD; and Susan M. Tarlo, MBBS, FCCP
(CHEST 2006; 129:1S–23S)

Abbreviations: ACE ⫽ angiotensin-converting enzyme; ACP ⫽ American College of Physicians; A/D ⫽ antihistamine/
decongestant; ATS ⫽ American Thoracic Society; BPC ⫽ bronchoprovocation challenge; CTS ⫽ Canadian Thoracic
Society; DPB ⫽ diffuse panbronchiolitis; dTap ⫽ acellular pertussis; FEES ⫽ fiberoptic endoscopic evaluation of
swallowing; GERD ⫽ gastroesophageal reflux disease; HRCT ⫽ high-resolution CT; HSP ⫽ Health and Science Policy
Committee; IBD ⫽ inflammatory bowel disease; ICS ⫽ inhaled corticosteroid; ILD ⫽ interstitial lung disease;
NAEB ⫽ nonasthmatic eosinophilic bronchitis; NSCLC ⫽ non-small cell lung cancer; SLP ⫽ speech-language pathol-
ogist; TB ⫽ tuberculosis; UACS ⫽ upper airway cough syndrome; URI ⫽ upper respiratory infection; VC ⫽ voluntary cough;
VSE ⫽ videofluoroscopic swallow evaluation
R medicine
ecognition of the importance of cough in clinical
was the impetus for the original evi-
(3) updates and expands, when appropriate, all pre-
vious sections; and (4) adds new sections with topics
dence-based consensus panel report on “Managing that were not previously covered. These new sections
Cough as a Defense Mechanism and as a Symptom,” include nonasthmatic eosinophilic bronchitis (NAEB);
published in 1998,1 and this updated revision. Com- acute bronchitis; nonbronchiectatic suppurative air-
pared to the original cough consensus statement, this way diseases; cough due to aspiration secondary to
revision (1) more narrowly focuses the guidelines on oral/pharyngeal dysphagia; environmental/occupa-
the diagnosis and treatment of cough, the symptom, tional causes of cough; tuberculosis (TB) and other
in adult and pediatric populations, and minimizes the infections; cough in the dialysis patient; uncommon
discussion of cough as a defense mechanism; (2) causes of cough; unexplained cough, previously re-
improves on the rigor of the evidence-based review ferred to as idiopathic cough; an empiric integrative
and describes the methodology in a separate section;
approach to the management of cough; assessing
Reproduction of this article is prohibited without written permission
cough severity and efficacy of therapy in clinical
from the American College of Chest Physicians (www.chestjournal. research; potential future therapies; and future di-
org/misc/reprints.shtml). rections for research.
Correspondence to: Richard S. Irwin, MD, FCCP, University of
Massachusetts Medical School, Room S6-842, 55 Lake Ave North, To mitigate future diagnostic confusion, two new
Worcester, MA 01655; e-mail address: Irwinr@ummhc.org diagnostic terms have been introduced to replace two
www.chestjournal.org CHEST / 129 / 1 / JANUARY, 2006 SUPPLEMENT 1S

older terms that may represent misnomers. The com- For an in-depth discussion or clarification of each
mittee unanimously recommends that the term upper recommendation, readers are encouraged to read
airway cough syndrome (UACS) be used in preference the specific section in question in its entirety.
to postnasal drip syndrome (PNDS) when discussing
cough that is associated with upper airway conditions Methodology and Grading of the Evidence for the
because it is unclear whether the mechanism of cough Diagnosis and Management of Cough5
is postnasal drip, direct irritation, or inflammation of
• The recommendations were graded, by consensus
the cough receptors in the upper airway. The commit-
by the panel, using the American College of Chest
tee also recommends using the term unexplained cough
Physicians Health and Science Policy Grading
rather than idiopathic cough because it is likely that
System, which is based on the following two compo-
more than one unknown cause of chronic cough will be
nents: quality of evidence; and the net benefit of the
discovered. The term idiopathic implies that one is
diagnostic and therapeutic procedure.
dealing with only one disease.
• The quality of evidence is rated according to the
For managing adult patients with cough, the com-
study design and strength of other methodologies
mittee recommends an empiric, integrative diagnos-
used in the included studies.
tic approach, which is presented in the section
• The net benefit of the recommendations is based
entitled “An Empiric Integrative Approach to the
on the estimated benefit to the specific patient
Management of Cough”.3 Guidelines for managing
population described in each recommendation
acute, subacute, and chronic cough are presented in
and not for an individual patient. Usually, the net
algorithmic form (Fig 1–3). Guidelines with algo-
benefit is a clinical benefit to the population of
rithms for evaluating chronic cough in pediatric
patients defined in the first phrase of the recom-
patients ⬍ 15 years of age are presented in the
mendation, but, in recommendations for future
section entitled “Guidelines for Evaluating Chronic
research or other nonclinical recommendations, it
Cough in Pediatrics”2,4 [Fig 4, 5]. For a full discus-
may be a societal benefit.
sion on how to use the algorithms, please refer to
• Both the quality of evidence and the net benefit
these sections.
components are listed after each recommenda-
tion; their interaction defines the strength of the
Summary and Recommendations recommendations.
• The recommendations scale is as follows: A,
Recommendations for each section of these guide- strong; B, moderate; C, weak; D, negative; I,
lines are listed under their respective section titles. inconclusive (no recommendation possible); E/A,
Figure 1. Acute cough algorithm for the management of patients ⱖ 15 years of age with cough lasting
⬍ 3 weeks. For diagnosis and treatment recommendations refer to the section indicated in the
algorithm. PE ⫽ pulmonary embolism; Dx ⫽ diagnosis; Rx ⫽ treatment; URTI ⫽ upper respiratory
tract infection; LRTI ⫽ lower respiratory tract infection. Section 7 ⫽ Irwin8; Section 8 ⫽ Pratter9;
Section 9 ⫽ Pratter10; Section 10 ⫽ Pratter11; Section 11 ⫽ Dicpinigaitis12; Section 12 ⫽ Irwin13;
Section 13 ⫽ Braman14; Section 14 ⫽ Braman15; Section 16 ⫽ Rosen17; Section 22 ⫽ Irwin et al.23
2S Diagnosis and Management of Cough: ACCP Guidelines

Figure 2. Subacute cough algorithm for the management of patients ⱖ 15 years of age with cough
lasting 3 to 8 weeks. For diagnosis and treatment recommendations refer to the section indicated in the
algorithm. AECB ⫽ acute exacerbation of chronic bronchitis. See the legend of Figure 1 for
abbreviations not used in the text. See Figure 1 for references to Sections.
strong recommendation based on expert opinion cough effectiveness. Level of evidence, expert
only; E/B, moderate recommendation based on opinion; net benefit, substantial; grade of recom-
expert opinion only; E/C, weak recommendation mendation, E/A
based on expert opinion only; and E/D, negative 2. Individuals with neuromuscular weakness
recommendation based on expert opinion only and no concomitant airway obstruction may
benefit from mechanical aids to improve cough.
Anatomy and Neurophysiology of the Cough Reflex6 Level of evidence, low; net benefit, intermediate;
• There is clear evidence that vagal afferent nerves grade of recommendation, C
regulate involuntary coughing. 3. In patients with ineffective cough, the cli-
• Coughing, like swallowing, belching, urinating, nician should be aware of and monitor for
and defecating, is unique because there is higher possible complications, such as pneumonia, at-
cortical control of this visceral reflex. electasis, and/or respiratory failure. Level of
• Cortical control can manifest as cough inhibition evidence, low; net benefit, substantial; grade of
or voluntary cough. The implications of this are recommendation, B
several-fold: because placebos can have a pro-
found effect on coughing, treatment studies must Complications of Cough8
be placebo-controlled. Because cough can be an
1. In patients complaining of cough, evaluate
affective behavior, psychological issues must be
for a variety of complications associated with
considered as a cause or effect of coughing.
coughing (eg, cardiovascular, constitutional, GI,
• There is a need to study the roles of consciousness
genitourinary, musculoskeletal, neurologic, oph-
and perception in coughing.
thalmologic, psychosocial, and skin complica-
tions), which can lead to a decrease in a patient’s
Global Physiology and Pathophysiology of Cough7
health-related quality of life. Level of evidence, low;
1. In patients with endotracheal tubes, tra- benefit, substantial; grade of recommendation, B
cheostomy need not be performed to improve 2. Patients with cough should have a thor-

Figure 3. Chronic cough algorithm for the management of patients ⱖ 15 years of age with cough
lasting ⬎ 8 weeks. ACE-I ⫽ ACE inhibitor; BD ⫽ bronchodilator; LTRA ⫽ leukotriene receptor antago-
nist; PPI ⫽ proton pump inhibitor. See the legend of Figure 1 for abbreviations not used in the text.
ough diagnostic evaluation, according to the Overview of Common Causes of Chronic Cough9
guidelines set forth in this document, to miti-
gate or prevent these complications. Level of 1. In patients with chronic cough and a nor-
evidence, low; net benefit, substantial; grade of mal chest roentgenogram finding who are non-
recommendation, B smokers and are not receiving therapy with an

Figure 4. Approach to a child ⬍ 15 years of age with chronic cough. There are limitations of the
algorithm, which should be read with the accompanying text. Spirometry can usually be reliably
performed in children ⬎ 6 years of age and in some children ⬎ 3 years of age if trained pediatric
personnel are present. CXR ⫽ chest radiograph.2
angiotensin-converting enzyme (ACE) inhibi- to result in a high rate of success in achieving

tor, the diagnostic approach should focus on the cough resolution. Level of evidence, low; benefit,
detection and treatment of UACS (formerly substantial; grade of recommendation, B
called PNDS), asthma, NAEB, or GERD, alone 2. In all patients with chronic cough, regard-
or in combination. This approach is most likely less of clinical signs or symptoms, because

Figure 5. Approach to a child ⱕ 14 years of age with chronic specific cough (ie, cough associated with
other features suggestive of an underlying pulmonary and/or systemic abnormality). Children ⬎ 14
years of age should be managed as outlined in adult guidelines but there is no good evidence where the
age cutoff should be. TEF ⫽ tracheal esophageal fistula. See the legend of Figure 4 for abbreviation
not used in the text.
UACS (formerly called PNDS), asthma, and accurate, and it should therefore be used in-
GERD each may present only as cough with no stead of the term PNDS. Level of evidence, expert
other associated clinical findings (ie, “silent opinion; benefit, substantial; grade of recommenda-
PNDS,” “cough variant asthma,” and “silent tion, E/A
GERD”), each of these diagnoses must be con- 2. In patients with chronic cough, the diag-
sidered. Level of evidence, low; benefit, substantial; nosis of UACS-induced cough should be deter-
grade of recommendation, B mined by considering a combination of criteria,
3. In patients with chronic cough, neither the including symptoms, physical examination find-
patient’s description of his or her cough in ings, radiographic findings, and, ultimately, the
terms of its character or timing, nor the pres- response to specific therapy. Because it is a
ence or absence of sputum production, should syndrome, no pathognomonic findings exist.
be used to rule in or rule out a diagnosis or to
Level of evidence, low; benefit, substantial; grade of
determine the clinical approach. Level of evi-
recommendation, B
dence, low; benefit, substantial; grade of recommen-
3. In patients in whom the cause of the
dation, B
UACS-induced cough is apparent, specific ther-
apy directed at this condition should be insti-
Chronic Upper Airway Cough Syndrome Secondary
tuted. Level of evidence, low; benefit, substantial;
to Rhinosinus Diseases (Previously Referred to as
grade of recommendation, B
Postnasal Drip Syndrome)10
4. For patients with chronic cough, an em-
1. In patients with chronic cough that is re- piric trial of therapy for UACS should be admin-
lated to upper airway abnormalities, the com- istered because the improvement or resolution
mittee considers the term UACS to be more of cough in response to specific treatment is the

pivotal factor in confirming the diagnosis of findings are nondiagnostic, MIC testing should
UACS as a cause of cough. Level of evidence, low; be performed to confirm the presence of
benefit, substantial; grade of recommendation, B asthma. However, a diagnosis of CVA as the
5. A patient suspected of having UACS-in- cause of cough is established only after the
duced cough who does not respond to empiric resolution of cough with specific antiasthmatic
antihistamine/decongestant (A/D) therapy with therapy. If MIC testing cannot be performed,
a first-generation antihistamine should next un- empiric therapy should be administered; how-
dergo sinus imaging. Although chronic sinusitis ever, a response to steroid therapy will not
may cause a productive cough, it may also be exclude NAEB as an etiology of the patient’s
clinically silent, in that the cough can be rela- cough. Quality of evidence, good; net benefit, sub-
tively or even completely nonproductive and stantial; grade of recommendation, A
none of the typical findings associated with 3. Patients with cough due to asthma should
acute sinusitis may be present. Level of evidence, initially be treated with a standard antiasth-
low; benefit, substantial; grade of recommendation, B matic regimen of inhaled bronchodilators and
6. In patients for whom a specific etiology of inhaled corticosteroids (ICSs). Quality of evi-
chronic cough is not apparent, empiric therapy dence, fair; net benefit, substantial; grade of recom-
for UACS in the form of a first-generation A/D mendation, A
preparation should be prescribed before begin- 4. In patients whose cough is refractory to
ning an extensive diagnostic workup. Level of treatment with ICSs, an assessment of airway
evidence, low; benefit, intermediate; grade of rec- inflammation should be performed whenever
ommendation, C available and feasible. The demonstration of
persistent airway eosinophilia during such an
Cough and the Common Cold11 assessment will identify those patients who may
1. Patients with acute cough (as well as PND benefit from more aggressive antiinflammatory
and throat clearing) associated with the com- therapy. Quality of evidence, low; net benefit,
mon cold can be treated with a first-genera- substantial; grade of recommendation, B
tion A/D preparation (brompheniramine and 5a. For patients with asthmatic cough that is
sustained-release pseudoephedrine). Naproxen refractory to treatment with ICSs and broncho-
can also be administered to help decrease dilators, in whom poor compliance or another
cough in this setting. Level of evidence, fair; contributing condition has been excluded, a
benefit, substantial; grade of recommendation, A leukotriene receptor antagonist may be added
2. In patients with the common cold, newer to the therapeutic regimen before the escala-
generation nonsedating antihistamines are inef- tion of therapy to systemic corticosteroids. Qual-
fective for reducing cough and should not be ity of evidence, fair; net benefit, intermediate; grade
used. Level of evidence, fair; benefit, none; grade of of recommendation, B
recommendation, D 5b. Patients with severe and/or refractory
3. In patients with cough and acute URTI, cough due to asthma should receive a short
because symptoms, signs, and even sinus-imag- course (1 to 2 weeks) of systemic (oral) cortico-
ing abnormalities may be indistinguishable steroids followed by ICSs. Quality of evidence,
from acute bacterial sinusitis, the diagnosis of low; net benefit,: substantial; grade of recommenda-
bacterial sinusitis should not be made during tion, B
the first week of symptoms. (Clinical judgment
is required to decide whether to institute anti- Chronic Cough Due to Gastroesophageal Reflux
biotic therapy.) Level of evidence, fair; benefit, Disease13
none; grade of recommendation, D
1. In patients with chronic cough due to
gastroesophageal reflux disease (GERD), the
Chronic Cough Due to Asthma 12
term acid reflux disease, unless it can be defin-
1. In a patient with chronic cough, asthma itively shown to apply, should be replaced by
should always be considered as a potential eti- the more general term reflux disease so as not to
ology because asthma is a common condition mislead the clinicians into thinking that all
with which cough is commonly associated. Qual- patients with cough due to GERD should im-
ity of evidence, fair; net benefit, substantial; grade of prove with acid-suppression therapy. Level of
recommendation, A evidence, expert opinion; benefit, substantial; grade
2. In a patient suspected of having CVA but of recommendation, E/A
in whom physical examination and spirometry 2. In patients with chronic cough who also

complain of typical and frequent GI complaints “Discussion” section regarding esophageal im-
such as daily heartburn and regurgitation, es- pedance monitoring). When this is the case,
pecially when the findings of chest-imaging barium esophagography is the test of choice to
studies and/or clinical syndrome are consistent reveal GER of potential pathologic significance.
with an aspiration syndrome, the diagnostic Level of evidence, low; benefit, substantial; grade of
evaluation should always include GERD as a recommendation, B
possible cause. Level of evidence, low; benefit, 10. In patients with cough due to GERD, a
substantial; grade of recommendation, B normal esophagoscopy finding does not rule out
3. Patients with chronic cough who have GI GERD as the cause of cough. Level of evidence,
symptoms that are consistent with GERD or low; benefit, substantial; grade of recommendation, B
who fit the clinical profile described in Table 1 11. For patients fitting the clinical profile for
in Irwin13, should be considered to have a high cough due to GERD, it is recommended that
likelihood of having GERD and should be pre- treatment be initially started in lieu of testing.
scribed antireflux treatment even when they Level of evidence, low; benefit, substantial; grade of
have no GI symptoms. Level of evidence, low; recommendation, B
benefit, substantial; grade of recommendation, B 12. For patients fitting the clinical profile for
4. In patients with chronic cough, it should cough due to GERD, the performance of 24-h
not be assumed that GERD has been defini- esophageal pH monitoring is recommended on
tively ruled out as a cause of cough simply therapy when cough does not improve or re-
because there is a history of antireflux surgery. solve to assist in determining whether the ther-
Level of evidence, low; benefit, substantial; grade of apy needs to be intensified or if medical therapy
recommendation, B has failed. Level of evidence, low; benefit, substan-
5. In patients with chronic cough, while tests tial; grade of recommendation, B
that link GERD with cough suggest a potential 13. For patients with chronic cough, the fol-
cause-effect relationship, a definitive diagnosis lowing tests are not routinely recommended to
of cough due to GERD requires that cough link cough with GERD: (a) assessing for lipid-
nearly or completely disappear with antireflux laden macrophages in BAL fluid and induced
treatment. Level of evidence, low; benefit, substan- sputum, because this test has not been studied
tial; grade of recommendation, B in patients with chronic cough and because a
6. In patients with chronic cough being eval- positive test result is not specific for aspiration;
uated for GERD, the 24-h esophageal pH-mon- (b) exhaled nitric oxide measurements, because
itoring test is the most sensitive and specific they do not appear to be helpful in diagnosing
test; however, it is recommended that the test cough due to GERD; (c) a Bernstein test, be-
results be interpreted as normal only when cause a negative Bernstein test result cannot be
conventional indices for acid reflux are within used to exclude the diagnosis of cough due to
the normal range and no reflux-induced coughs GERD; and (d) inhaled tussigenic challenges
appear during the monitoring study. Level of with capsaicin, because they are not specific for
evidence, low; benefit, substantial; grade of recom- coughs due to GERD and because the test
mendation, B result can be positive in patients with GERD
7. In patients with cough who are undergoing without cough. Level of evidence, low; benefit,
24-h monitoring, a low percentage of coughs conflicting; grade of recommendation, I
associated with (or induced by) reflux does not 14. In patients who meet the clinical profile
exclude a diagnosis of cough due to GERD. Level predicting that silent GERD is the likely cause
of evidence, low; benefit, substantial; grade of recom- of chronic cough or in patients with chronic
mendation, B cough who also have prominent upper GI symp-
8. In patients with cough due to GERD, the toms consistent with GERD, an empiric trial of
degree of abnormality noted in the esophageal medical antireflux therapy is recommended.
pH-monitoring variables, such as the frequency Level of evidence, low; benefit, substantial; grade of
and duration of reflux events, does not directly recommendation, B
correlate with the severity of the patients’ 15. For treating the majority of patients with
cough. Level of evidence, low; benefit, substantial; chronic cough due to GERD, the following
grade of recommendation, B medical therapies are recommended: (a) di-
9. In diagnosing nonacid GERD as the cause etary and lifestyle modifications; (b) acid sup-
of cough, barium esophagography may be the pression therapy; and (c) the addition of proki-
only available test to reveal GER of potential netic therapy either initially or if there is no
pathologic significance in this setting (see the response to the first two therapies. The re-

sponse to these therapies should be assessed months of intensive therapy (Table 3 in Irwin13),
within 1 to 3 months. Level of evidence, expert and serial esophageal pH-monitoring studies or
opinion; benefit, substantial; grade of recommenda- other objective studies (eg, barium esophagog-
tion, E/A raphy, esophagoscopy, and gastric-emptying
16. In patients in which this empiric treat- study with solids) performed while the patient
ment fails, it cannot be assumed that GERD has receives therapy show that intensive medical
been ruled out as a cause of chronic cough; therapy has failed to control the reflux disease
rather, the objective investigation for GERD is and that GERD is still the likely cause of cough;
then recommended because the empiric ther- and (d) patients express the opinion that their
apy may not have been intensive enough or persisting cough does not allow them a satisfac-
medical therapy may have failed. Level of evi- tory quality of life. Level of evidence, expert
dence, expert opinion; benefit, substantial; grade of opinion; benefit, substantial; grade of recommenda-
recommendation, E/A tion, E/A
17. In some patients, cough due to GERD
will favorably respond to acid suppression ther-
Chronic Cough Due to Acute Bronchitis14
apy alone; proton pump inhibition may be ef-
fective when H2-antagonism has been ineffec- 1. In a patient with an acute respiratory infec-
tive; prokinetic therapy and diet, when added to tion manifested predominantly by cough, with or
proton pump inhibition, may be effective when without sputum production, lasting no more than
proton pump inhibition alone has been ineffec- 3 weeks, a diagnosis of acute bronchitis should not
tive. Level of evidence, low; benefit, substantial; be made unless there is no clinical or radio-
grade of recommendation, B graphic evidence of pneumonia, and the common
18. Patients requiring an intensive medical cold, acute asthma, or an exacerbation of COPD
treatment regimen should be treated with the have been ruled out as the cause of cough. Quality
following: (a) antireflux diet that includes no of evidence, expert opinion; benefit, substantial; grade
> 45 g of fat in 24 h and no coffee, tea, soda, of recommendation, E/A
chocolate, mints, citrus products, including to- 2. In patients with the presumed diagnosis of
matoes, or alcohol, no smoking, and limiting acute bronchitis, viral cultures, serologic assays,
vigorous exercise that will increase intraab- and sputum analyses should not be routinely
dominal pressure; (b) acid suppression with a performed because the responsible organism is
proton pump inhibitor; (c) prokinetic therapy; rarely identified in clinical practice. Quality of
and (d) efforts to mitigate the influences of evidence, low; benefit, intermediate; grade of rec-
comorbid diseases such as obstructive sleep ommendation, C
apnea or therapy for comorbid conditions (eg, 3. In patients with acute cough and sputum
nitrates, progesterone, and calcium channel production suggestive of acute bronchitis, the
blockers) whenever possible. Level of evidence, absence of the following findings reduces the
expert opinion; benefit, substantial; grade of recom- likelihood of pneumonia sufficiently to elimi-
mendation, E/A nate the need for a chest radiograph: (1) heart
19. In patients with chronic cough due to rate > 100 beats/min; (2) respiratory rate > 24
GERD that has failed to improve with the most breaths/min; (3) oral body temperature of
maximal medical therapy, which includes an > 38°C; and (4) chest examination findings of
intensive antireflux diet and lifestyle modifica- focal consolidation, egophony, or fremitus.
tion, maximum acid suppression, and prokinetic Quality of evidence, low; benefit, substantial; grade
therapy, and the rest of the spectrum of treat- of recommendation, B
ment options in Table 3 in Irwin,13 cough may 4a. For patients with the putative diagnosis
only improve or be eliminated with antireflux of acute bronchitis, routine treatment with an-
surgery. Level of evidence, low; benefit, substantial; tibiotics is not justified and should not be of-
grade of recommendation, B fered. Quality of evidence, good; benefit, none;
20. In patients who meet the following crite- grade of recommendation, D
ria, antireflux surgery is the recommended 4b. For these patients, the decision not to use
treatment: (a) findings of a 24-h esophageal an antibiotic should be addressed individually
pH-monitoring study before treatment is posi- and explanations should be offered because
tive, as defined above; (b) patients fit the clini- many patients expect to receive an antibiotic
cal profile suggesting that GERD is the likely based on previous experiences and public ex-
cause of their cough (Table 1 in Irwin13); (c) pectation. Quality of evidence, expert opinion; ben-
cough has not improved after a minimum of 3 efit, intermediate; grade of recommendation, E/B

5. Children and adult patients with con- with increased cough, sputum production, spu-
firmed and probable whooping cough should tum purulence, and/or shortness of breath,
receive a macrolide antibiotic and should be which are often preceded by symptoms of an
isolated for 5 days from the start of treatment; upper respiratory tract infection, should be
early treatment within the first few weeks will considered to have an acute exacerbation of
diminish the coughing paroxysms and prevent chronic bronchitis, as long as conditions other
spread of the disease; the patient is unlikely to than acute tracheobronchitis are ruled out or
respond to treatment beyond this period. Level are considered unlikely. Level of evidence, expert
of evidence, good; net benefit, substantial; grade of opinion; net benefit, substantial; grade of recom-
evidence, A mendation, E/A
6a. In most patients with a diagnosis of acute 5. In patients with chronic cough who have
bronchitis, ␤2-agonist bronchodilators should chronic exposure to respiratory irritants, such
not be routinely used to alleviate cough. Quality as personal tobacco use, passive smoke expo-
of evidence, fair; benefit, none; grade of recommen- sure, and workplace hazards, avoidance
dation, D should always be recommended. It is the most
6b. In select adult patients with a diagnosis of effective means to improve or eliminate the
acute bronchitis and wheezing accompanying cough of chronic bronchitis. Ninety percent of
the cough, treatment with ␤2-agonist broncho- patients will have resolution of their cough
dilators may be useful. Quality of evidence, fair; after smoking cessation. Level of evidence,
benefit, small/weak; grade of recommendation, C good; net benefit, substantial; grade of recommen-
7. In patients with a diagnosis of acute bron- dation, A
chitis, antitussive agents are occasionally useful 6. In stable patients with chronic bronchi-
and can be offered for short-term symptomatic tis, there is no role for long-term prophylactic
relief of coughing. Quality of evidence, fair; bene- therapy with antibiotics. Level of evidence, low;
fit, small/weak; grade of recommendation, C benefit, none; grade of recommendation, I
8. In patients with a diagnosis of acute bron- 7. In patients with acute exacerbations of
chitis, because there is no consistent favorable chronic bronchitis, the use of antibiotics is rec-
effect of mucokinetic agents on cough, they are ommended; patients with severe exacerbations
not recommended. Quality of evidence, fair; ben- and those with more severe airflow obstruction
efit, conflicting; grade of recommendation, I at baseline are the most likely to benefit. Level
of evidence, fair; net benefit, substantial; grade of
recommendation, A
Chronic Cough Due to Chronic Bronchitis15
8. In stable patients with chronic bronchitis,
1. Adults who have a history of chronic the clinical benefits of postural drainage and
cough and sputum expectoration occurring on chest percussion have not been proven, and
most days for at least 3 months and for at least they are not recommended. Level of evidence,
2 consecutive years should be given a diagnosis fair; net benefit, conflicting; grade of recommenda-
of chronic bronchitis when other respiratory or tion, I
cardiac causes of chronic productive cough are 9. In patients with an acute exacerbation of
ruled out. Level of evidence, low; net benefit, chronic bronchitis, the clinical benefits of pos-
substantial; grade of recommendation, B tural drainage and chest percussion have not
2. The evaluation of patients with chronic been proven, and they are not recommended.
cough should include a complete history re- Level of evidence, fair; net benefit, conflicting; grade of
garding exposures to respiratory irritants in- recommendation, I
cluding cigarette, cigar, and pipe smoke; passive 10a. In stable patients with chronic bronchi-
smoke exposures; and hazardous environments tis, therapy with short-acting ␤-agonists should
in the home and workplace. All are predispos- be used to control bronchospasm and relieve
ing factors of chronic bronchitis. Level of evi- dyspnea; in some patients, it may also reduce
dence, low; net benefit, substantial; grade of recom- chronic cough. Level of evidence, good; net bene-
mendation, B fit, substantial; grade of recommendation, A
3. Smoke-free workplace and public place 10b. In stable patients with chronic bronchi-
laws should be enacted in all communities. tis, therapy with ipratropium bromide should
Level of evidence, expert opinion; net benefit, sub- be offered to improve cough. Level of evidence,
stantial; grade of recommendation, E/A fair; net benefit, substantial; grade of recommenda-
4. Stable patients with chronic bronchitis tion, A
who have a sudden deterioration of symptoms 10c. In stable patients with chronic bronchi-

tis, treatment with theophylline should be con- 19. In patients with chronic bronchitis, cen-
sidered to control chronic cough; careful mon- tral cough suppressants such as codeine and
itoring for complications is necessary. Level of dextromethorphan are recommended for short-
evidence, fair; net benefit, substantial; grade of term symptomatic relief of coughing. Level of
recommendation, A evidence, fair; benefit, intermediate; grade of evi-
11. For patients with an acute exacerbation dence, B
of chronic bronchitis, therapy with short-acting
␤-agonists or anticholinergic bronchodilators Chronic Cough Due to Nonasthmatic Eosinophilic
should be administered during the acute exac- Bronchitis16
erbation. If the patient does not show a prompt
1. In patients with chronic cough who have
response, the other agent should be added after
normal chest radiograph findings, normal spi-
the first is administered at the maximal dose.
rometry findings, and no evidence of variable
Level of evidence, good; net benefit, substantial;
airflow obstruction or airway hyperresponsive-
grade of recommendation, A
ness, the diagnosis of NAEB should be consid-
12. For patients with an acute exacerbation
ered. Level of evidence, expert opinion; benefit,
of chronic bronchitis, theophylline should not
substantial; grade of recommendation, E/A
be used for treatment. Level of evidence, good;
2. In patients with chronic cough with nor-
net benefit, none; grade of recommendation, D
mal chest radiograph findings, normal spirom-
13. For stable patients with chronic bronchi-
etry findings, and no evidence of variable
tis, there is no evidence that the currently
airflow obstruction or airway hyperresponsive-
available expectorants are effective and there-
ness, the diagnosis of NAEB as the cause of the
fore they should not be used. Level of evidence,
chronic cough is confirmed by the presence of
low; net benefit, none; grade of recommendation, I
airway eosinophilia, either by sputum induction
14. In stable patients with chronic bronchitis,
or bronchial wash fluid obtained by bronchos-
treatment with a long-acting ␤-agonist when
copy, and an improvement in the cough follow-
coupled with an ICS should be offered to con-
ing corticosteroid therapy. Level of evidence,
trol chronic cough. Level of evidence, good; net
expert opinion; benefit, substantial; grade of recom-
benefit, substantial; grade of recommendation, A
mendation, E/A
3. In patients with chronic cough due to
tis and an FEV1 of < 50% predicted or for those
NAEB, the possibility of an occupation-related
patients with frequent exacerbations of chronic
cause needs to be considered. Level of evidence,
bronchitis, ICS therapy should be offered. Level
of evidence, good; net benefit, substantial; grade of
mendation, E/A
recommendation, A
4. For patients with chronic cough due to
NAEB, the first-line treatment is ICSs (except
tis, long-term maintenance therapy with oral
when a causal allergen or sensitizer is identified
corticosteroids such as prednisone should not
[see recommendation 5]). Level of evidence, low;
be used; there is no evidence that it improves
benefit, substantial; grade of recommendation, B
cough and sputum production, and the risks of
serious side effects are high. Level of evidence,
NAEB, when a causal allergen or occupational
expert opinion; net benefit, negative; grade of rec-
sensitizer is identified, avoidance is the best
ommendation, E/D
treatment. Level of evidence, expert opinion; ben-
17. For patients with an acute exacerbation of
efit, substantial; grade of recommendation, E/A
chronic bronchitis, there is no evidence that the
currently available expectorants are effective,
NAEB, if symptoms are persistently trouble-
and therefore they should not be used. Level of
some and/or the natural history of eosinophilic
evidence, low; net benefit, none; grade of recommen-
airway inflammation progresses despite treat-
dation, I
ment with high-dose ICSs, oral corticosteroids
18. For patients with an acute exacerbation
should be given. Level of evidence, expert opinion;
of chronic bronchitis, a short course (10 to 15
benefit, substantial; grade of recommendation, E/A
days) of systemic corticosteroid therapy should
be given; IV therapy in hospitalized patients
Chronic Cough Due to Bronchiectasis17
and oral therapy for ambulatory patients have
both proven to be effective. Level of evidence, 1. In patients with suspected bronchiectasis
good; net benefit, substantial; grade of recommen- without a characteristic chest radiograph find-
dation, A ing, an high-resolution CT (HRCT) scan of the

chest should be ordered because it is the diag- selection of agents depending on the likely
nostic procedure of choice to confirm the diag- pathogens. Level of evidence, low; benefit, substan-
nosis. Level of evidence, low; benefit, substantial; tial; grade of recommendation, B
grade of recommendation, B
2. In patients for whom there is no obvious
Chronic Cough Due to Nonbronchiectatic
cause, a diagnostic evaluation for an underlying
Suppurative Airway Disease (Bronchiolitis)18
disorder causing bronchiectasis should be per-
formed, because the results may lead to treat- 1. In patients with cough and incomplete or
ment that may slow or halt the progression of irreversible airflow limitation, direct or indirect
disease. Level of evidence, low; benefit, substantial; signs of small airways disease seen on HRCT
grade of recommendation, B scan, or purulent secretions seen on bronchos-
3. In patients with bronchiectasis with air- copy, nonbronchiectatic suppurative airways
flow obstruction and/or bronchial hyperreactiv- disease (bronchiolitis) should be suspected as
ity, therapy with bronchodilators may be of the primary cause. Level of evidence, expert opin-
benefit. Level of evidence, expert opinion; benefit, ion; benefit, substantial; grade of recommendation,
small; grade of recommendation, E/C E/A
4. In patients with bronchiectasis caused by 2. In patients with cough in whom more
cystic fibrosis (CF), rhDNase should be used to common causes have been excluded, because
improve spirometry. Level of evidence, low; ben- bacterial suppurative airways disease may be
efit, small; grade of recommendation, C present and clinically unsuspected, bronchos-
5. In patients with CF, prolonged treatment copy is required before excluding it as a cause.
with systemic corticosteroids should not be of- Level of evidence, low; benefit, substantial; grade of
fered to most patients because of significant recommendation, B
side effects. Level of evidence, low; benefit, con- 3. In patients in whom bronchiolitis is sus-
flicting; grade of recommendation, I pected, a surgical lung biopsy should be per-
6. In patients with CF, prolonged courses of formed when the combination of the clinical
ibuprofen should not be used. Level of evidence, syndrome, physiology, and HRCT findings do
low; benefit, conflicting; grade of recommendation, I not provide a confident diagnosis. Level of evi-
7. In patients with idiopathic bronchiectasis, dence, expert opinion; benefit, substantial; grade of
the prolonged systemic administration of anti- recommendation, E/A
biotics may produce small benefits in reducing 4. In patients with bacterial bronchiolitis,
sputum volume and purulence, but may also be prolonged antibiotic therapy improves cough
associated with intolerable side effects. Level of and is recommended. Level of evidence, low;
evidence, low; benefit, conflicting, grade of recom- benefit, substantial; grade of recommendation, B
mendation, I 5. In patients with toxic/antigenic exposure
8. In patients with CF, therapy with aerosol- or drug-related bronchiolitis, cessation of the
ized antipseudomonal antibiotics are recom- exposure or medication plus corticosteroid
mended. Level of evidence, low; benefit, interme- therapy for those with physiologic impairment
diate; grade of recommendation, C is appropriate. Level of evidence, expert opinion;
9. In patients with idiopathic bronchiectasis, benefit, substantial; grade of recommendation, E/A
aerosolized antibiotics should not be used. Level 6. In the inflammatory bowel disease (IBD)
of evidence, low; benefit, negative; recommendation, D patient with cough, bronchiolitis should be sus-
10. In patients with conditions associated pected as a potential cause. Level of evidence,
with the hypersecretion of mucus and the in- low; benefit, substantial; grade of recommendation, B
ability to expectorate effectively, chest physio- 7. In patients in whom IBD-related bronchi-
therapy should be used and patients should be olitis is suspected, both adverse drug reaction
monitored for symptom improvement. Level of and infection should be specifically considered.
evidence, expert opinion; benefit, small/weak; grade Level of evidence, expert opinion; benefit, substan-
of recommendation, E/C tial; grade of recommendation, E/A
11. In selected patients with localized bron- 8. In patients with IBD, therapy with both
chiectasis that causes intolerable symptoms de- oral corticosteroids and ICSs may improve
spite maximal medical therapy, surgery should cough, and a trial of therapy is suggested. Level
be offered. Level of evidence, low; benefit, substan- of evidence, low; benefit, substantial; grade of rec-
tial; grade of recommendation, B ommendation, B
12. In patients with exacerbations of bronchi- 9. In patients with chronic cough who have
ectasis, antibiotics should be used, with the recently lived in Japan, Korea, or China, diffuse

panbronchiolitis (DPB) should be considered in 4c. In patients with postinfectious cough,
the evaluations of the cause. Level of evidence, when the cough adversely affects the patient’s
low; benefit, substantial; grade of recommendation, B quality of life and when cough persists despite
10. In patients with suspected DPB, an ap- use of inhaled ipratropinin, consider the use of
propriate clinical setting and characteristic inhaled corticosteroids. Level of evidence, expert
HRCT scan findings may obviate the need for opinion; net benefit, intermediate; grade of evi-
invasive testing and a trial of macrolide therapy dence, E/B
(erythromycin or other 14-member ring macro- 4d. For severe paroxysms of postinfectious
lides such as clarithromycin and roxithromycin) cough, consider prescribing 30 to 40 mg of
is appropriate. Level of evidence, expert opinion; prednisone per day for a short, finite period of
benefit, substantial; grade of recommendation, E/A time when other common causes of cough (eg,
11. In patients with DPB, prolonged treat- UACS due to rhinosinus diseases, asthma, or
ment (> 2 to 6 months) with erythromycin (or gastroesophageal reflux disease) have been
other 14-member ring macrolides such as clar-
ruled out. Level of evidence, low; net benefit,
ithromycin and roxithromycin) is recom-
intermediate; grade of evidence, C
mended. Level of evidence, low; benefit, substan-
4e. Central acting antitussive agents such as
tial; grade of recommendation, B
codeine and dextromethorphan should be con-
sidered when other measures fail. Level of evi-
Postinfectious Cough19 dence, expert opinion; net benefit, intermediate;
1. When a patient complains of cough that grade of evidence, E/B
has been present following symptoms of an 5. When a patient has a cough lasting for > 2
acute respiratory infection for at least 3 weeks, weeks without another apparent cause and it is
but not more than 8 weeks, consider a diagnosis accompanied by paroxysms of coughing, post-
of postinfectious cough. Quality of evidence, ex- tussive vomiting, and/or an inspiratory whoop-
pert opinion; net benefit, intermediate; strength of ing sound, the diagnosis of a B pertussis infec-
recommendation, E/B tion should be made unless another diagnosis is
2. In patients with subacute postinfectious proven. Level of evidence, low; net benefit, sub-
cough, because there are multiple pathogenetic stantial; grade of evidence, B
factors that may contribute to the cause of cough 6a. For all patients who are suspected of
(including postviral airway inflammation with its having whooping cough, to make a definitive
attendant complications such as bronchial hyper- diagnosis order a nasopharyngeal aspirate or
responsiveness, mucus hypersecretion and im- polymer (Dacron; INVISTA; Wichita, KS) swab
paired mucociliary clearance, upper airway cough of the nasopharynx for culture to confirm the
syndrome [UACS], asthma, and gastroesophageal presence of B pertussis. Isolation of the bacteria
reflux disease), judge which factors are most is the only certain way to make the diagnosis.
likely provoking cough before considering ther-
Level of evidence, low; net benefit, substantial;
apy. Quality of evidence, expert opinion; net benefit,
grade of evidence, B
intermediate; strength of recommendation, E/B
6b. PCR confirmation is available but is not
3. In children and adult patients with cough
following an acute respiratory tract infection, if recommended as there is no universally ac-
cough has persisted for > 8 weeks, consider cepted, validated technique for routine clinical
diagnoses other than postinfectious cough. testing. Level of evidence, low; net benefit, conflict-
Quality of evidence, low; net benefit, intermediate; ing; grade of evidence, I
strength of recommendation, C 7. In patients with suspected pertussis infec-
4. For adult patients with postinfectious tion, to make a presumptive diagnosis of this
cough, not due to bacterial sinusitis or early on infection, order paired acute and convalescent
in a Bordetella pertussis infection, while the sera in a reference laboratory. A fourfold in-
optimal treatment is not known: crease in IgG or IgA antibodies to PT or FHA is
4a. Therapy with antibiotics has no role, as consistent with the presence of a recent B
the cause is not bacterial infection. Level of pertussis infection. Level of evidence, low; net
evidence, expert opinion; net benefit, none; grade of benefit, intermediate; grade of evidence, C
evidence, I 8. A confirmed diagnosis of pertussis infec-
4b. Consider a trial of inhaled ipratropium as tion should be made when a patient with cough
it may attenuate the cough. Level of evidence, has B pertussis isolated from a nasopharyngeal
fair; net benefit, intermediate; grade of evidence, B culture or has a compatible clinical picture with

an epidemiologic linkage to a confirmed case. and/or chemotherapy should usually be offered.
Level of evidence, low; net benefit, substantial; Level of evidence, good; benefit, intermediate; grade
grade of evidence, B of recommendation, A
9. Children and adult patients with con- 5. For patients with dyspnea or hemoptysis
firmed or probable whooping cough should due to endobronchial tumors, cough may also
receive a macrolide antibiotic and should be be present. Endobronchial methods should be
isolated for 5 days from the start of treatment considered for the palliation of these symptoms,
because early treatment within the first few but cough alone is seldom a reason to offer such
weeks will diminish the coughing paroxysms treatment. Level of evidence, fair; benefit, small;
and prevent spread of the disease; treatment grade of recommendation, C
beyond this period may be offered but it is 6. For patients with cough and lung cancer,
unlikely the patient will respond. Level of evi- the use of centrally acting cough suppressants
dence, good; net benefit, substantial; grade of evi- such as dihydrocodeine and hydrocodone is
dence, A
recommended. Level of evidence, low; benefit,
10. Long-acting ␤-agonists, antihistamines,
intermediate; grade of recommendation, C
corticosteroids, and pertussis Ig should not be
offered to patients with whooping cough be-
cause there is no evidence that they benefit Cough and Aspiration of Food and Liquids Due to
these patients. Level of evidence, good; net benefit, Oral-Pharyngeal Dysphagia21
none; grade of evidence, D
1. In patients with cough, a medical history
11. All children should receive prevention
against pertussis infection as part of a complete particularly directed at identifying conditions
diphtheria, tetanus, acellular pertussis (DTap) increasing the likelihood of oral-pharyngeal
primary vaccination series. This should be fol- dysphagia and aspiration (as indicated in Table
lowed by a single dose DTap booster vaccina- 1 in Smith Hammond and Goldstein21) should
tion early in adolescence. Level of evidence, good; be obtained. Patients with high-risk conditions
net benefit, substantial; grade of evidence, A should be referred for an oral-pharyngeal swal-
12. For all adults up to the age of 65, vacci- lowing evaluation. Level of evidence, low; benefit,
nation with the stronger formulation of TDap substantial; grade of recommendation, B
vaccine should be administered according to 2a. Patients with cough and their caregivers
CDC guidelines. Level of evidence, expert opinion; should be questioned regarding perceived swal-
net benefit, substantial; grade of evidence, E/A lowing problems, including an association of
cough while eating or drinking and a fear of
Chronic Cough Due to Lung Tumors20 choking while eating and drinking. If a patient
with cough reports swallowing problems, further
1. In a patient with cough who has risk fac- evaluation for oral-pharyngeal dysphagia is indi-
tors for lung cancer or a known or suspected cated. Level of evidence, low; benefit, substantial;
cancer in another site that may metastasize to grade of recommendation, B
the lungs, a chest radiograph should be ob- 2b. Further evaluation, including a chest ra-
tained. Level of evidence, expert opinion; benefit, diograph and a nutritional assessment, should
substantial; grade of recommendation, E/A
be considered in patients with cough or condi-
2. In patients with a suspicion of airway in-
tions associated with aspiration. Level of evi-
volvement by a malignancy (eg, smokers with
dence, low; benefit, substantial; grade of recommen-
hemoptysis), even when the chest radiograph
findings are normal, bronchoscopy is indicated. dation, B
Level of evidence, low; benefit, substantial; grade of 3. Patients with oral-pharyngeal dysphagia
recommendation, B and cough should be referred, ideally to a
3. For patients with stage I and II non-small speech-language pathologist (SLP), for an oral-
cell lung cancer (NSCLC), surgery to remove the pharyngeal swallow evaluation. Level of evi-
NSCLC is the treatment of choice. If cough was dence, low; benefit, substantial; grade of recommen-
caused by a NSCLC that can be surgically re- dation, B
moved, the cough will typically cease. Level of 4. Patients with cough related to pneumonia
evidence, low; benefit, substantial; grade of recommen- and bronchitis who have received medical diag-
dation, B noses and conditions associated with aspiration
4. For patients with more advanced NSCLC (Table 1 in Smith Hammond and Goldstein21)
(stages III and IV), external beam radiation should be referred, ideally to an SLP, for an

oral-pharyngeal swallow evaluation. Level of ev- ommendations should be prescribed when indi-
idence, low; benefit, substantial; grade of recommen- cated, and can be refined by testing with foods
dation, B and liquids simulating those in a normal diet
5. Patients with a reduced level of conscious- during the VSE or FEES. Level of evidence, low;
ness are at high risk for aspiration and should benefit, substantial; grade of recommendation, B
not be fed orally until the level of consciousness 14. For patients with muscular weakness dur-
has improved. Level of evidence, low; benefit, ing swallowing, muscle strength training, with
substantial; grade of recommendation, B or without electromyographic biofeedback, and
6. Alert patients with cough who are in high- electrical stimulation treatment of the swallow-
risk groups for aspiration (Table 1 in Smith ing musculature are promising techniques but
Hammond and Goldstein21) should be observed cannot be recommended at this time until fur-
drinking small amounts of water (3 oz). If the ther work in larger populations is performed.
patient coughs or shows clinical signs that are Level of evidence, low; benefit, conflicting; grade of
associated with aspiration (Tables 2, 3 in Smith evidence, I
Hammond and Goldstein21), the patient should 15. Patients with intractable aspiration may
be referred for a detailed swallowing evalua- be considered for surgical intervention. Level of
tion, preferably to an SLP. Level of evidence, low; evidence, low; benefit, substantial; grade of recom-
benefit, substantial; grade of recommendation, B mendation, B
7. In patients with cough, the value of the
subjective assessment of voluntary cough (VC)
Angiotensin-Converting Enzyme Inhibitor-Induced
as the sole predictor of aspiration is uncertain
Cough22
because of poor reliability and an unclear asso-
ciation with evaluation. Level of evidence, low; 1. In patients presenting with chronic cough,
benefit, conflicting; grade of evidence, I in order to determine that the angiotensin-
8. The assessment of the reflexive cough re- converting enzyme (ACE) inhibitor is the cause
sponse to inhaled irritants as a predictor of of the cough, therapy with ACE inhibitors
aspiration risk and subsequent pneumonia is should be discontinued regardless of the tem-
not recommended due to a lack of adequate poral relation between the onset of cough and
supportive studies. Level of evidence, low; benefit, the initiation of ACE inhibitor therapy. The
conflicting; grade of evidence, I diagnosis is confirmed by the resolution of
9. In acute stroke patients, the expulsive cough, usually within 1 to 4 weeks of the cessa-
phase rise time of VC may predict aspiration. tion of the offending agent; however, the reso-
The use of this test has not been validated in lution of cough may be delayed in a subgroup of
other patient groups, and further studies com- patients for up to 3 months. Quality of evidence,
paring the accuracy of objective measures of low; net benefit, substantial; grade of recommenda-
VC to the clinical swallow evaluation to identify tion, B
aspiration risk are needed. Level of evidence, low; 2. In patients presenting with chronic ACE
benefit, small; grade of recommendation, C inhibitor-induced cough, discontinue therapy
10. Patients with dysphagia should undergo with the drug because it is the only uniformly
videofluoroscopic swallow evaluation (VSE) or effective treatment. Quality of evidence, low; net
fiberoptic endoscopic evaluation of swallowing benefit, substantial; grade of recommendation, B
(FEES) to identify appropriate treatment. Level 3. In patients whose cough resolves after the
of evidence, low; benefit, substantial; grade of rec- cessation of therapy with ACE inhibitors, and
ommendation, B for whom there is a compelling reason to treat
11. Patients with dysphagia should be man- with these agents, a repeat trial of ACE inhibi-
aged by organized multidisciplinary teams that tor therapy may be attempted. Quality of evi-
may include a physician, a nurse, an SLP, a dence, fair; net benefit, substantial; grade of recom-
dietitian, and physical and occupational thera- mendation, A
pists. Level of evidence, low; benefit, substantial; 4. In patients for whom the cessation of ACE
grade of recommendation, B inhibitor therapy is not an option, pharmacologic
12. In patients with dysphagia, VSE or FEES therapy, including that with sodium cromogly-
can be useful for determining compensatory cate, theophylline, sulindac, indomethacin, amlo-
strategies enabling patients with dysphagia to dipine, nifedipine, ferrous sulfate, and picota-
safely swallow. Level of evidence, low; benefit, mide that is aimed at suppressing cough should
substantial; grade of recommendation, B be attempted. Quality of evidence, fair; net benefit,
13. In patients with dysphagia, dietary rec- intermediate; grade of recommendation, B

5. In patients in whom persistent or intoler- should not be used to diagnose or exclude
able ACE inhibitor-induced cough occurs, ther- psychogenic cough. Level of evidence, expert
apy should be switched, when indicated, to an opinion; benefit, substantial; grade of recommenda-
angiotensin receptor blocker, with which the tion, E/A
incidence of associated cough appears to be 5. In adult and pediatric patients with chronic
similar to that for the control drug, or to an unexplained cough, common psychosocial prob-
appropriate agent of another drug class. Quality lems such as anxiety, depression, domestic vio-
of evidence, good; net benefit, substantial; grade of lence, and child abuse/neglect that are often as-
recommendation, A sociated with somatization disorders should be
evaluated. Level of evidence, expert opinion; benefit,
Habit Cough, Tic Cough, and Psychogenic Cough substantial; grade of recommendation, E/A
in Adult and Pediatric Populations23 6. In adult and pediatric patients with
chronic cough associated with troublesome psy-
1a. In adult patients with chronic cough, the chological manifestations, psychological coun-
diagnoses of habit cough or psychogenic cough seling or psychiatric intervention should be
can only be made after an extensive evaluation encouraged, after other causes have been ruled
has been performed that includes ruling out tic out. Level of evidence, expert opinion; benefit,
disorders and uncommon causes (as described small/weak; grade of recommendation, E/C
in the section “Uncommon Causes of Cough”),
and cough improves with specific therapy such
Chronic Cough Due to Chronic Interstitial
as behavior modification or psychiatric therapy.
Pulmonary Diseases24
Level of evidence, expert opinion; benefit, substan-
tial; grade of recommendation, E/A 1. In patients with chronic cough, before
1b. In adult patients with chronic cough that diagnosing interstitial lung disease (ILD) as the
remains persistently troublesome despite an sole cause, common etiologies such as UACS,
extensive and thorough evidence-based evalua- which was previously referred to as PNDS,
tion, and after behavior modification and/or asthma, and GERD should be considered. As
psychiatric therapy have failed, unexplained these common causes may also share clinical
cough should be diagnosed rather than a habit features with specific ILDs, a diagnosis of ILD
cough or psychogenic cough. Level of evidence, as the cause of cough should be considered a
expert opinion; benefit, substantial; grade of recom- diagnosis of exclusion. Level of evidence, expert
mendation, E/A opinion; benefit, substantial; grade of recommenda-
1c. In children with chronic cough, the diag- tion, E/A
noses of habit cough or psychogenic cough can 2. In patients with cough secondary to an
only be made after tic disorders and Tourette ILD, because of the prognostic implications,
syndrome have been evaluated and cough im- primary treatment should be dictated by the
proves with specific therapy such as behavior specific disorder. Level of evidence, low; benefit,
modification or psychiatric therapy. Level of substantial; grade of recommendation, B
evidence, expert opinion; benefit, substantial; grade 3. In patients with cough secondary to idio-
of recommendation, E/A pathic pulmonary fibrosis, corticosteroids may
2. In adult patients with cough, the diagnosis lead to symptomatic improvement; however, as
of habit cough should not be made unless bio- they have been shown to neither prolong survival
logical and genetic tic disorders associated with nor improve quality of life and may be associated
coughing such as Tourette syndrome have been with significant side effects, their use requires an
ruled out. Level of evidence, expert opinion; bene- individualized analysis of the overall benefits and
fit, substantial; grade of recommendation, E/A risks. Level of evidence, expert opinion; benefit, inter-
3. In adults with chronic cough, the presence mediate; grade of recommendation, E/B
or absence of nighttime cough or cough with a 4. In patients with cough and characteristic
barking or honking character should not be clinical and radiographic features, sarcoidosis
used to diagnose or exclude a diagnosis of should be considered as a cause. Level of evi-
psychogenic cough. Level of evidence, low; bene- dence, expert opinion; benefit, substantial; grade of
fit, substantial; grade of recommendation, B recommendation, E/A
4. In children with chronic cough, the char- 5. In patients with cough secondary to sarcoid-
acteristics of the cough may be suggestive of, osis, although therapy with oral corticosteroids
but are not diagnostic of, psychogenic cough. may lead to symptomatic improvement, as they
The presence or absence of nighttime cough have not been proven to have a durable benefit

and are associated with significant side effects, an Chronic Cough Due to Tuberculosis and Other
individualized analysis of the overall benefit and Infections26
risk is necessary. Level of evidence, fair; benefit,
1. In areas where there is a high prevalence
intermediate; grade of recommendation, B
of TB, chronic cough should be defined as it is
6. In patients with cough secondary to sar- in the World Health Organization Practical Ap-
coidosis, therapy with oral corticosteroids fol- proach to Lung Health program as being 2 to 3
lowed by ICSs may improve symptoms. Level of weeks in duration. Level of evidence, low; benefit,
evidence, fair; benefit, conflicting; grade of recom- substantial; grade of recommendation, B
mendation, I 2. In patients with chronic cough who live in
7. In patients with cough, ILD, and a con- areas with a high prevalence of TB, this diagnosis
cerning environmental, occupational, or avoca- should be considered, but not to the exclusion of
tional exposure, hypersensitivity pneumonitis the more common etiologies. Sputum smears and
should be considered as a potential cause. Level cultures for acid-fast bacilli and a chest radio-
of evidence, expert opinion; benefit, substantial; graph should be obtained whenever possible.
grade of recommendation, E/A Level of evidence, low; benefit, substantial; grade of
8. In patients with cough due to hypersensi- recommendation, B
tivity pneumonitis, treatment should include 3. In patients with suspected TB, future in-
the removal of the offending exposure and vestigations are needed to refine the criteria for
systemic corticosteroid therapy in those with suspecting TB and initiating a diagnostic evalu-
evidence of physiologic impairment. Level of ation, to utilize resources in a cost-effective
evidence, low; benefit, substantial; grade of recom- manner and to improve patient and caregiver
mendation, B adherence to diagnostic recommendations.
Level of evidence, expert opinion; benefit, substan-
tial; grade of recommendation, E/A
Cough: Occupational and Environmental 4. In populations at increased risk of becom-
Considerations25 ing infected with TB and transmitting it to
1. In every patient with cough, when taking a others by cough (eg, those persons in prisons
medical history, ask about occupational and and nursing homes), special measures to pre-
environmental causes. Level of evidence, expert vent outbreaks must be made by public health
opinion; benefit, substantial; grade of recommenda- agencies to screen for new cases, maintain sur-
tions, E/A veillance of existing populations, and establish
2. In every patient with cough who has po- effective diagnostic and treatment programs
tentially significant exposures to suspicious en- early in the evaluation. Level of evidence, good;
vironmental or occupational causes, determine benefit, substantial; grade of recommendation, A
the relationship of these occupational and envi- 5. In patients with unexplained chronic cough
ronmental factors to confirm or refute their who have resided in areas of endemic infection
role in cough and to modify or eliminate expo- with fungi or parasites, a diagnostic evaluation for
sure to the relevant agents. Level of evidence, these pathogens should be undertaken when
expert opinion; benefit, substantial; grade of recom- more common causes of cough have been ruled
mendations, E/A out. Level of evidence, low; benefit, substantial; grade
3. Because outdoor environmental pollution of recommendation, B
and occupational exposures can be important Peritoneal Dialysis and Cough27
factors in causing cough, physicians should play
a role in developing and supporting enforce- 1. In patients receiving long-term peritoneal
able standards for safe workplace and outdoor dialysis with cough, evaluate the patient for the
air pollution exposure limits. Level of evidence, potential causes with increased prevalence in
expert opinion; benefit, substantial; grade of recom- this population such as GERD, ACE inhibitors,
mendations, E/A pulmonary edema, asthma that may be exacer-
4. In patients with a high suspicion of cough bated by ␤-adrenergic-blocking medications,
due to environmental or occupational expo- and infection. Level of evidence, expert opinion;
sures, consider referring the patient to a benefit, substantial; grade of recommendation, E/A
specialist in this area or consult evidence-
Cough in the Immunocompromised Host28
based guidelines. Level of evidence, expert opin-
ion; net benefit, substantial; grade of recommen- 1. In patients with immune deficiency, the
dation, E/A initial diagnostic algorithm for patients with

acute, subacute, and chronic cough is the same Unexplained (Idiopathic) Cough30
as that for immunocompetent persons, taking
1. The diagnosis of unexplained (idiopathic)
into account an expanded list of differential
cough is a diagnosis of exclusion. It should not
diagnoses that considers the type and severity
be made until a thorough diagnostic evaluation
of immune defect and geographic factors. Level
is performed, specific and appropriate treat-
of evidence, expert opinion; benefit, substantial;
ment (according to the management protocols
grade of recommendation, E/A
that have performed the best in the literature)
2. In HIV-infected patients, CD4ⴙ lympho-
has been tried and has failed, and uncommon
cyte counts should be used in constructing the
causes have been ruled out. Level of evidence,
list of differential diagnostic possibilities poten-
tially causing cough. Level of evidence, low; ben-
mendation, E/A
efit, substantial; grade of recommendation, B
3. HIV-infected patients with CD4ⴙ lympho- An Empiric Integrative Approach to the
cyte counts of < 200 cells/␮L or those patients Management of Cough3
with counts of > 200 cells/␮L with unexplained
fever, weight loss, or thrush who have unex- 1. In patients with cough, the starting point
plained cough should be suspected of having is the medical history and physical examination.
Pneumocystis pneumonia, tuberculosis, and Although the timing and characteristics of the
other opportunistic infections, and should be cough are of little diagnostic value, the medical
evaluated accordingly. Level of evidence, low; history is important to determine whether the
benefit, substantial; grade of recommendation, B patient is receiving an ACE inhibitor, is a
smoker, or has evidence of a serious life-threat-
ening or systemic disease. Level of evidence,
Uncommon Causes of Cough29
1. In patients with chronic cough, uncommon mendation, E/A
causes should be considered when cough per- 2. In patients with an acute cough, first de-
sists after evaluation for common causes and termine whether the acute cough is a reflection
when the diagnostic evaluation suggests that an of a serious illness such as pneumonia or pul-
uncommon cause, pulmonary as well as ex- monary embolism, or, as is usually the case, a
trapulmonary (see Table 1 in section 28), may manifestation of a non-life-threatening disease
be contributing. Level of evidence, low; benefit, such as a respiratory tract infection (eg, com-
substantial; grade of recommendation, B mon cold or lower respiratory tract infection),
2. In patients with chronic cough, until un- an exacerbation of a preexisting condition (eg,
common causes that potentially may be contrib- COPD, UACS, asthma, or bronchiectasis), or an
uting to the patient’s cough have been ruled environmental or occupational exposure to
out, the diagnosis of unexplained cough should some noxious or irritating agent (eg, allergic or
not be made. Level of evidence, low; benefit, irritant-induced rhinitis). Level of evidence, ex-
substantial; grade of recommendation, B pert opinion; benefit, substantial; grade of recom-
3. If cough persists after consideration of the mendation, E/A
most common causes, perform a chest CT scan 3. In patients with a subacute cough, first
and, if necessary, a bronchoscopic evaluation. determine whether it is a postinfectious cough
Level of evidence, low; benefit, substantial; grade of or not. If it is postinfectious, determine whether
recommendation, B it is a result of UACS, transient bronchial hy-
4. In patients who present with abrupt onset of perresponsiveness, asthma, pertussis, or an
cough, consider the possibility of an airway for- acute exacerbation of chronic bronchitis. If it is
eign body. Level of evidence, low; benefit, substantial; noninfectious, manage the cough the same way
grade of recommendation, B as chronic cough. Level of evidence, expert opin-
5. In patients with unexplained cough, eval- ion; benefit, substantial; grade of recommendation,
uate the possibility of drug-induced cough. E/A
Level of evidence, low; benefit, substantial; grade of 4a. In patients with chronic cough, systemat-
recommendation, B ically direct empiric treatment at the most com-
6. In patients with unexplained cough, con- mon causes of cough (ie, UACS, asthma, NAEB,
sider a therapeutic trial of withdrawing the and GERD). Level of evidence, low; benefit, sub-
drug that is suspected to cause the cough. Level stantial; grade of recommendation, B
of evidence, low; benefit, substantial; grade of rec- 4b. In patients with chronic cough, therapy
ommendation, B should be given in sequential and additive steps

because more than one cause of cough may be and asthma or NAEB, treatment for GERD
present. Level of evidence, low; benefit, substantial; should be instituted next. Level of evidence, low;
grade of recommendation, B benefit, substantial; grade of recommendation, B
5. Patients with a chronic cough who smoke 11. In patients with cough whose condition
should be counseled and assisted with smoking remains undiagnosed after all of the above has
cessation. Level of evidence, low; benefit, substan- been done, referral to a cough specialist is indi-
tial; grade of recommendation, B cated. Level of evidence, expert opinion; benefit,
6. In a patient with cough who is receiving an substantial; grade of recommendation, E/A
ACE inhibitor, therapy with the drug should be
stopped and the drug should be replaced. Level
Assessing Cough Severity and Efficacy of Therapy
of evidence, low; benefit, substantial; grade of rec-
in Clinical Research31
ommendation, B
7. In patients with chronic cough, initial em- 1. In patients with chronic cough, to opti-
piric treatment should begin with an oral first- mally evaluate the efficacy of cough-modifying
generation A/D. Level of evidence, low; benefit, agents, investigators should use both subjective
substantial; grade of recommendation, B and objective methods because they have the
8a. In patients whose chronic cough persists potential to measure different things. A pa-
after treatment for UACS, the possibility that tient’s subjective response is likely to be the
asthma is the cause of cough should be worked only one that measures the impact of the inten-
up next. The medical history is sometimes sug- sity of cough. Level of evidence, expert opinion;
gestive, but is not reliable in either ruling in or benefit, substantial; grade of recommendation, E/A
ruling out asthma. Therefore, ideally, broncho- 2. In patients with chronic cough, with re-
provocation challenge (BPC), if spirometry does spect to subjective methods, it is recommended
not indicate reversible airflow obstruction, that a valid and reliable cough-specific health-
should be performed in the evaluation for related quality-of-life instrument be utilized.
asthma as a cause of cough. In the absence of Level of evidence, fair; benefit, substantial; grade of
the availability of BPC, an empiric trial of recommendation, A
antiasthma therapy should be administered (see 3. When assessing patients with chronic
section on the treatment of asthma in this cough, even though visual analog scales have
guideline). Level of evidence, low; benefit, substan- not been psychometrically tested, they are rec-
tial; grade of recommendation, B ommended because they are commonly used
8b. In patients with chronic cough, in whom and valid, and they are likely to yield different
the diagnoses of UACS and asthma have been but complementary results to cough-specific
eliminated or treated without the elimination of health-related quality-of-life instruments. Level
cough, NAEB should be considered next with a of evidence, low; benefit, intermediate; grade of
properly performed induced sputum test for recommendation, C
eosinophils. If a properly performed induced 4. When assessing patients with chronic cough,
sputum test to determine whether eosinophilic because health-related quality-of-life instruments
bronchitis is present cannot be performed, an have been psychometrically tested and visual an-
empiric trial of corticosteroids should be the alog scales have not, the cough-specific health-
next step. Level of evidence, low; benefit, substan- related quality-of-life instruments are recom-
tial; grade of recommendation, B mended as the primary subjective outcome
9. In the majority of patients with suspected measure. Level of evidence, fair; benefit, intermedi-
cough due to asthma, ideally, before starting an ate; grade of recommendation, B
oral corticosteroid regimen, a BPC should be 5. In patients with chronic cough, with re-
performed and, if the result is positive, some spect to objective methods, tussigenic chal-
combination therapy of ICSs, inhaled ␤-ago- lenges should be used before and after the
nists, or oral leukotriene inhibitors should be intervention to assess the effect of therapy on
administered. A limited trial of oral corticoste- cough sensitivity only in disease states in which
roids, however, should be administered in some cough reflex sensitivity is known to be height-
patients who are suspected of having asthma- ened. Level of evidence, low; benefit, small/weak;
induced cough before eliminating the diagnosis grade of recommendation, C
from further consideration. Level of evidence, 6. In patients with chronic cough, because
low; benefit, substantial; grade of recommendation, B the act of coughing has the potential to trauma-
10. In patients whose cough responds only tize the upper airway (eg, the vocal cords),
partially or not at all to interventions for UACS assessing the presence of upper airway edema

before and after therapy with flow-volume coughing. Level of evidence, good; benefit, sub-
loops is useful. Level of evidence, low; benefit, stantial; grade of recommendation, A
intermediate; grade of recommendation, C 9. In patients with acute cough due to the
7. In patients undergoing treatment for common cold, preparations containing zinc are
chronic cough, cough counting over 24 h is not recommended. Level of evidence, good; ben-
recommended with a computerized methodol- efit, none; grade of recommendation, D
ogy that is reliable and accurate, noninvasive 10. In patients with acute cough due to the
and portable, and easy to use in unattended, common cold, over the counter combination
ambulatory, real-life settings within a patient’s cold medications, with the exception of an older
home environment. Level of evidence, low; bene- antihistamine-decongestant, are not recom-
fit, intermediate; grade of recommendation, C mended until randomized controlled trials
prove they are effective cough suppressants.
Cough Suppressant and Pharmacologic Protussive Level of evidence, fair; benefit, none; grade of
Therapy32 recommendation, D
11. In patients with acute or chronic cough
1. In patients with chronic bronchitis, not due to asthma, albuterol is not recom-
agents that have been shown to alter mucus mended. Level of evidence, good; benefit, none;
characteristics are not recommended for cough grade of recommendation, D
suppression. Level of evidence, good; benefit, 12. In patients with neuromuscular impair-
none; grade of recommendation, D ment, protussive pharmacologic agents are in-
2. In patients with cough due to upper respi- effective and should not be prescribed. Level of
ratory infection (URI) or chronic bronchitis, the evidence, good; benefit, none; grade of recommen-
only inhaled anticholinergic agent that is rec- dation, D
ommended for cough suppression is ipratro- 13. In patients with bronchitis, hypertonic
pium bromide. Level of evidence, fair; benefit, saline solution and erdosteine are recom-
substantial; grade of recommendation, A mended on a short-term basis to increase cough
3. In patients with chronic or acute bronchi- clearance. Level of evidence, good; benefit, sub-
tis, peripheral cough suppressants, such as levo- stantial; grade of recommendation, A
dropropizine and moguisteine, are recom- 14. In adult patients with CF, amiloride is
mended for the short-term symptomatic relief recommended to increase cough clearance.
of coughing. Level of evidence, good; benefit, Level of evidence, good; benefit, substantial; grade
substantial; grade of recommendation, A of recommendation, A
4. In patients with cough due to URI, periph- 15. In adult patients with CF, while recombi-
eral cough suppressants have limited efficacy nant DNase does improve spirometry it is not
and are not recommended for this use. Level of recommended to increase cough clearance.
evidence, good; benefit, none; grade of recommen- Level of evidence, good; benefit, none; grade of
dation, D recommendation, D
5. In patients with chronic bronchitis, central
cough suppressants, such as codeine and dex-
Nonpharmacologic Airway Clearance Therapies33
tromethorphan, are recommended for the
short-term symptomatic relief of coughing. 1. In patients with CF, chest physiotherapy is
Level of evidence, fair; benefit, intermediate; grade recommended as an effective technique to in-
of recommendation, B crease mucus clearance, but the effects of each
6. In patients with cough due to URI, central treatment are relatively modest and the long-
cough suppressants have limited efficacy for term benefits unproven. Level of evidence, fair;
symptomatic relief and are not recommended benefit, small; grade of recommendation, C
for this use. Level of evidence, good; benefit, none; 2. In patients with expiratory muscle weak-
grade of recommendation, D ness, manually assisted cough should be consid-
7. In patients with chronic or acute cough ered to reduce the incidence of respiratory
requiring symptomatic relief, drugs that affect complications. Level of evidence, low; benefit,
the efferent limb of the cough reflex are not small; grade of recommendation, C
recommended. Level of evidence, low; benefit, 3. In persons with airflow obstruction caused
none; grade of recommendation, D by disorders like COPD, manually assisted cough
8. In patients requiring intubation during may be detrimental and should not be used. Level
general anesthesia, the use of neuromuscular of evidence, low; benefit, negative; grade of recommen-
blocking agents is recommended to suppress dation, D

4. In patients with COPD and CF, huffing spirometry (if age appropriate). Level of evi-
should be taught as an adjunct to other methods dence, expert opinion; benefit, intermediate; grade
of sputum clearance. Level of evidence, low; ben- of recommendation, E/B
efit, small; grade of recommendation, C 3. In children with specific cough, further
5. In patients with CF, autogenic drainage investigations may be warranted, except when
should be taught as an adjunct to postural asthma is the etiologic factor. Level of evidence,
drainage as a method to clear sputum because it expert opinion; benefit, intermediate; grade of rec-
has the advantage of being performed without ommendation, E/B
assistance and in one position. Level of evidence, 4. Children with chronic productive purulent
low; benefit, small; grade of recommendation, C cough should always be investigated to docu-
6. In patients with neuromuscular weakness ment the presence or absence of bronchiectasis
and impaired cough, expiratory muscle training and to identify underlying and treatable causes
is recommended to improve peak expiratory such as cystic fibrosis and immune deficiency.
pressure, which may have a beneficial effect on Level of evidence, low; benefit, substantial; grade of
cough. Level of evidence, expert opinion; benefit, recommendation, B
small; grade of recommendation, E/C 5. In children with chronic cough, the etiol-
7. In patients with CF, positive expiratory ogy should be defined and treatment should be
pressure is recommended over conventional etiologically based. Level of evidence, expert opin-
chest physiotherapy because it is approximately ion; benefit, substantial; grade of recommendation,
as effective as chest physiotherapy, and is inex- E/A
pensive, safe, and can be self-administered. 6. In children with nonspecific cough, cough
Level of evidence, fair; benefit, intermediate; grade may spontaneously resolve, but children should
of recommendation, B be reevaluated for the emergence of specific
8. In patients with CF, devices designed to etiologic pointers (see Table 1 in Chang and
oscillate gas in the airway, either directly or by Glomb4). Level of evidence, low; benefit, substan-
compressing the chest wall, can be considered tial; grade of recommendation, B
as an alternative to chest physiotherapy. Level of 7. In children with nonspecific cough and risk
evidence, low; benefit, conflicting; grade of recom- factors for asthma, a short trial (ie, 2 to 4 weeks) of
mendation, I beclomethasone, 400 ␮g/d, or the equivalent dos-
9. In patients with neuromuscular disease age with budesonide may be warranted. How-
with impaired cough, mechanical cough assist ever, most children with nonspecific cough do not
devices are recommended to prevent respira- have asthma. In any case, these children should
tory complications. Level of evidence, low; benefit, always be reevaluated in 2 to 4 weeks. Level of
intermediate; grade of recommendation, C evidence, fair; benefit, intermediate; grade of recom-
10. The effect of nonpharmacologic airway mendation, B
clearance techniques on long-term outcomes 8. In children who have started therapy with a
such as health-related quality of life and rates of medication, if the cough does not resolve during
exacerbations, hospitalizations, and mortality is the medication trial within the expected response
not known at this time. The committee recom- time, the medication should be withdrawn and
mends that future investigations measure these other diagnoses considered. Level of evidence, low;
outcomes in patients with CF, and in other benefit, intermediate; grade of recommendation, C
populations with bronchiectasis, COPD, and 9. In children with cough, cough suppressants
neuromuscular diseases. Level of evidence, expert and other over-the-counter cough medicines
opinion; benefit, substantial; grade of recommenda- should not be used as patients, especially young
tion, E/A children, may experience significant morbidity
and mortality. Level of evidence, good; benefit, none;
grade of recommendation, D
Guidelines for Evaluating Cough in Pediatrics4
10. In children with nonspecific cough, parental
1. Children with chronic cough require expectations should be determined, and the specific
careful and systematic evaluation for the pres- concerns of the parents should be sought and ad-
ence of specific diagnostic indicators. Level of dressed. Level of evidence, low; benefit, intermediate;
evidence, expert opinion; benefit, substantial; grade grade of recommendation, E/B
of recommendation, E/A 11. In all children with cough, exacerbating fac-
2. Children with chronic cough should un- tors such as exposure to tobacco smoke should be
dergo, as a minimum, a chest radiograph and determined and interventional options for the ces-

sation of exposure advised or initiated. Level of evidence-based clinical practice guidelines. Chest 2006;
evidence, low; benefit, substantial; grade of recommenda- 129(suppl):222S–231S
4 Chang AB, Glomb WB. Guidelines for evaluating cough in
tion, B
pediatrics: ACCP evidence-based clinical practice guidelines.
12. Children should be managed according to Chest 2006; 129(suppl):260S–283S
the studies and guidelines for children (when 5 McCrory DC, Zelman Lewis S. Methodology and grading of
available), because etiologic factors and treat- the evidence for the diagnosis and management of cough:
ments in children are sometimes different from ACCP evidence-based clinical practice guidelines. Chest
those in adults. Level of evidence, low; benefit, 2006; 129(suppl):28S–32S
substantial; grade of recommendation, B 6 Canning BJ. Anatomy and neurophysiology of the cough
reflex: ACCP evidence-based clinical practice guidelines.
13. In children < 14 years of age with
Chest 2006; 129(suppl):33S– 47S
chronic cough, when pediatric-specific cough 7 McCool FD. Global physiology and pathophysiology of
recommendations are unavailable, adult recom- cough: ACCP evidence-based clinical practice guidelines.
mendations should be used with caution. Level Chest 2006; 129(suppl):48S–53S
of evidence, expert opinion; benefit, intermediate; 8 Irwin RS. Complications of cough: ACCP evidence-based
grade of recommendation, E/B clinical practice guidelines. Chest 2006; 129(suppl):54S–58S
9 Pratter MR. Overview of common causes of chronic cough:
ACCP evidence-based clinical practice guidelines. Chest
Potential Future Therapies for the Management of 2006; 129(suppl):59S– 62S
Cough34 10 Pratter MR. Chronic upper airway cough syndrome second-
• Currently available cough-suppressant therapy is se- ary to rhinosinus diseases (previously referred to as postnasal
drip syndrome): ACCP evidence-based clinical practice
verely limited by a dearth of effective agents and their
guidelines. Chest 2006; 129(suppl):63S–71S
unacceptable side affects. Several classes of pharmaco- 11 Pratter MR. Cough and the common cold: ACCP evidence-
logic agents are currently under investigation in an based clinical practice guidelines. Chest 2006; 129(suppl):
attempt to develop clinically useful cough suppression. 72S–74S
12 Dicpinigaitis PV. Chronic cough due to asthma: ACCP
evidence-based clinical practice guidelines. Chest 2006;
Future Directions in the Clinical Management of 129(suppl):75S–79S
Cough35 13 Irwin RS. Chronic cough due to gastroesophageal reflux
disease: ACCP evidence-based clinical practice guidelines.
1. As suggested in the various sections of this Chest 2006; 129(suppl):80S–94S
guideline, further research should be con- 14 Braman SS. Chronic cough due to acute bronchitis: ACCP
ducted to elucidate the mechanisms of the pro- evidence-based clinical practice guidelines. Chest 2006;
duction of cough in various diseases and condi- 129(suppl):95S–103S
tions, the optimal methods of assessment, and 15 Braman SS. Chronic cough due to chronic bronchitis: ACCP
treatment, specific to the suspected cause. Level 129(suppl):104S–115S
of evidence, expert opinion; benefit, substantial; 16 Brightling CE. Chronic cough due to nonasthmatic eosino-
strength of recommendation, E/A philic bronchitis: ACCP evidence-based clinical practice
2. Research is particularly needed in areas guidelines. Chest 2006; 129(suppl):116S–121S
such as the treatment of postinfectious cough, 17 Rosen MJ. Chronic cough due to bronchiectasis: ACCP
the characterization of psychogenic cough, the 129(suppl):122S–131S
methods of assessment of cough, and pharma- 18 Brown KK. Chronic cough due to nonbronchiectatic suppu-
cotherapy. Level of evidence, expert opinion; ben- rative airway disease (bronchiolitis): ACCP evidence-based
efit, substantial; strength of recommendation, E/A clinical practice guidelines. Chest 2006; 129(suppl):132S–
137S
ACKNOWLEDGMENT: This clinical practice guideline re- 19 Braman SS. Postinfectious cough: ACCP evidence-based
ceived the endorsements of the ATS and the CTS. clinical practice guidelines. Chest 2006; 129(suppl):138S–
146S
20 Kvale PA. Chronic cough due to lung tumors: ACCP evi-
dence-based clinical practice guidelines. Chest 2006;
References 129(suppl):147S–153S
1 Irwin RS, Boulet LP, Cloutier MM, et al. Managing cough as 21 Smith Hammond CA, Goldstein LB. Cough and aspiration of
a defense mechanism and as a symptom: a consensus panel food and liquids due to oral-pharyngeal dysphagia: ACCP
report of the American College of Chest Physicians. Chest evidence-based clinical practice guidelines. Chest 2006;
1998; 114(suppl):133S–181S 129(suppl):154S–168S
2 Rudolph C, Mazur L, Liptak G, et al. Guidelines for evalua- 22 Dicpinigaitis PV. Angiotensin-converting enzyme inhibitor-
tion and treatment of gastroesophageal reflux in infants and induced cough: ACCP evidence-based clinical practice guide-
children: recommendations of the North American Society lines. Chest 2006; 129(suppl):169S–173S
for Pediatric Gastroenterology and Nutrition. J Pediatr Gas- 23 Irwin RS, Glomb WB, Chang AB. Habit cough, tic cough, and
troenterol Nutr 2001; 32(suppl):S1–S31 psychogenic cough in adult and pediatric populations: ACCP
3 Pratter MR, Brightling CE, Boulet LP, et al. An empiric evidence-based clinical practice guidelines. Chest 2006;
integrative approach to the management of cough: ACCP 129(suppl):174S–179S

24 Brown KK. Chronic cough due to chronic interstitial pulmo- 30 Pratter MR. Unexplained (idiopathic) cough: ACCP evi-
nary diseases: ACCP evidence-based clinical practice guide- dence-based clinical practice guidelines. Chest 2006;
lines. Chest 2006; 129(suppl):180S–185S 129(suppl):220S–221S
25 Tarlo SM. Cough: occupational and environmental consider- 31 Irwin RS. Assessing cough severity and efficacy of therapy in
ations: ACCP evidence-based clinical practice guidelines. clinical research: ACCP evidence-based clinical practice
Chest 2006; 129(suppl):186S–196S guidelines. Chest 2006; 129(suppl):232S–237S
26 Rosen MJ. Chronic cough due to tuberculosis and other 32 Bolser DC. Cough suppressant and pharmacologic protussive
infections: ACCP evidence-based clinical practice guidelines. therapy: ACCP evidence-based clinical practice guidelines.
Chest 2006; 129(suppl):197S–201S Chest 2006; 129(suppl):238S–249S
27 Tarlo SM. Peritoneal dialysis and cough: ACCP evidence- 33 McCool FD, Rosen MJ. Nonpharmacologic airway clearance
based clinical practice guidelines. Chest 2006; 129(suppl): therapies: ACCP evidence-based clinical practice guidelines.
202S–203S Chest 2006; 129(suppl):250S–259S
28 Rosen MJ. Cough in the immunocompromised host: ACCP 34 Dicpinigaitis PV. Potential future therapies for the manage-
evidence-based clinical practice guidelines. Chest 2006; ment of cough: ACCP evidence-based clinical practice guide-
129(suppl):204S–205S lines. Chest 2006; 129(suppl):284S–286S
29 Prakash UBS. Uncommon causes of cough: ACCP evidence- 35 Boulet LP. Future directions in the clinical management of
based clinical practice guidelines. Chest 2006; 129(suppl): cough: ACCP evidence-based clinical practice guidelines.
206S–219S Chest 2006; 129(suppl):287S–292S

Disclosure of Faculty Conflict of Interest
Diagnosis and Management of Cough: ACCP Evidence-Based Clinical Practice Guidelines
The ACCP remains strongly committed to providing Dr. Shannon reveals no real or potential conflicts of
the best available evidence-based clinical practice interest or commitment.
guidelines with an open disclosure of any potential
conflict of interest identified by our panelists. It is The following panelists have disclosed to the ACCP
not the intent of the ACCP to eliminate all situations that a relationship does exist with the identified
of potential conflict of interest, but rather to enable companies/organizations, although these may not
those who are working with the ACCP to recognize necessarily involve the topic of this guideline:
situations that may be subject to question by others. Dr. Baumann discloses that he is a shareholder of
All disclosed conflicts of interest are reviewed by the stock in Pfizer and Merck. He receives a consultant
guideline chair, the Health and Science Policy (HSP) fee and serves on both speaker bureaus and advisory
Committee, or the Conflict of Interest Review Com- committees for Pfizer, Merck, Glaxo, and Boehr-
mittee to ensure that such situations are properly inger.
evaluated and, if necessary, resolved. The ACCP
standards pertaining to conflict of interest are in- Dr. Boulet discloses university grant monies from
tended to maintain the professional autonomy of the Altana Pharma research program in collaboration
clinical experts inherent in promoting a balanced with the University Laval for $225,000 over 2 years.
presentation of science. Through our review process, Other grant monies have been received from the
all ACCP guideline development activities are en- Canadian Institute of Health research (CIHR), In-
sured of independent, objective, scientifically bal- stitut de Recherche en Santé du Québec (IRSST),
anced presentations of information. Fonds de Recherche en Santé du Québec (FRSQ),
Réseau en Santé Respiratoire (RSR-FRSQ), and
The following panelists have indicated to the ACCP Canadian Network of Centers of Excellence Aller-
that no potential conflict of interest exists with Gen. Industry grants were received from 3M, Astra-
any respective company/organization, and this is to Zeneca, Altana Pharma, Aventis, GlaxoSmithKline,
be communicated to the readers of this guideline: Merck Frosst, Novartis, Schering, Genetech, Dy-
navax, and Roche. Dr. Boulet received consultant
Dr. Irwin reveals no real or potential conflicts of fees from AstraZeneca, Altana Pharma, Aventis,
interest or commitment. Boehringer-Ingelheim, GlaxoSmithKline, Merck
Dr. Bolser reveals no real or potential conflicts of Frosst, Novartis, Schering, Lung Associations, Cana-
interest or commitment. dian Provincial and Federal Governments and has
Dr. Canning reveals no real or potential conflicts of served on advisory committees to AstraZeneca, Altana
interest or commitment. Pharma, GlaxoSmithKline, Merck Frosst, and Novartis.
Professor Eccles reveals no real or potential con-
Dr. Braman discloses that he has received grant
flicts of interest or commitment.
monies from AstraZeneca for clinical trials. He has
Dr. Glomb reveals no real or potential conflicts of
received consultant fees and serves on both speaker
interest or commitment.
bureaus and advisory committees for GlaxoSmith-
Dr. Hargreave reveals no real or potential conflicts
Kline and Pfizer/Altana
of interest or commitment.
Dr. Hammond reveals no real or potential conflicts Dr. Brightling discloses grant income from MRC,
of interest or commitment. Asthma UK, GSK, Schering-Plough, and CAT. He
Dr. Kvale reveals no real or potential conflicts of serves on a speaker bureau for AstraZeneca and GSK
interest or commitment. and has received consulting fees from AstraZeneca.
Dr. Lewis reveals no real or potential conflicts of
Dr. Brown discloses grant monies from NIH, NIEHS,
NHLBI, Wyeth, Fibrogen, Genzyme, and Actelion and
Dr. McCool reveals no real or potential conflicts of
he has served on advisory committees for Wyeth,
Fibrogen, Actelion, Encysive, Intermune, Genzyme,
Dr. McCrory reveals no real or potential conflicts of
and Arizeke.
Dr. Prakash reveals no real or potential conflicts of Dr. Chang discloses $2000 for an educational grant
interest or commitment. from Glaxo SKB.
www.chestjournal.org CHEST / 129 / 1 / JANUARY, 2006 SUPPLEMENT I

Dr. Dicpinigaitis discloses consultant fees from Elan GlaxoSmithKline, AstraZeneca, and Sepracor and on
and Adams Respiratory Therapeutics, speaker bureau advisory committees for Merck and GlaxoSmith-
participation for Boehringer-Ingelheim and Pfizer, and Kline.
membership in an advisory committee for Schering-
Plough. Dr. Pratter received an unrestricted educational grant
from Genentech and served on the speaker bureau for
Dr. Goldstein has received research grants from NIH, Boeringer-Ingelheim.
Veterans Administration, CDC and UNC – Chapel
Hill. He has served as the PI or on steering committees Dr. Rosen served on the speaker bureaus for Glaxo,
for clinical trials funded by Boehringer-Ingelheim, Boehringer, Pfizer, and Schering.
AGA Corp and Pfizer-Parke-Davis. Speaker honoraria
Dr. Schulman has received grant monies from Boehr-
were received from Bayer and Pfizer-Parke-Davis. Dr.
inger-Ingelheim, Pfizer, Novartis, Genentech, CV
Goldstein has participated in consultant or advisory
boards for AstraZeneca, BMS/Sanofi, CuraGen Corp, Therapeutics, Sepracor, and GlaxoSmithKline. Consul-
DPharma, GlaxoSmithKline, Johnson & Johnson, tant fees were received from Novartis and Genentech.
Merck Research labs, Pfizer-Parke-Davis, and Proneu- Dr. Schulman serves on speaker bureaus for Merck,
ron Biotechnologies. Novartis, and Genentech.
Dr. Graham has received grant monies from Glaxo- Dr. Tarlo has received consulting fees from Dow
SmithKline, AstraZeneca, and Sepracor. Consultant Chemical and Health Canada. She serves on an advi-
fees were paid to him by Merck and GlaxoSmith- sory committee for the Alberta University EPC for the
Kline. He served on speaker bureaus for Merck, AHRQ-funded review on occupational asthma.
J Disclosure of Faculty Conflict of Interest

Panel List
Richard S. Irwin, MD, FCCP, Chair LeRoy M. Graham, MD, FCCP

University of Massachusetts Medical School Georgia Pediatric Pulmonary Associates, PC
Worcester, MA Atlanta, GA
Michael H. Baumann, MD, FCCP (HSP Liaison)
Frederick E. Hargreave, MD
University of Mississippi Medical Center
Firestone Institute for Respiratory Health
Jackson, MS
Hamilton, Ontario, Canada
Donald Clementz Bolser, PhD
University of Florida College of Veterinary Medicine Paul A. Kvale, MD, FCCP
Gainesville, FL Henry Ford Hospital
Detroit, MI
Louis Philippe Boulet, MD, FCCP
(CTS Representative)
Sandra Zelman Lewis, PhD
Laval Hospital
American College of Chest Physicians
Sainte Foy, Canada
Northbrook, IL
Sidney S. Braman, MD, FCCP
Brown Medical School F. Dennis McCool, MD, FCCP
Providence, RI Brown Medical School
Providence, RI
Christopher E. Brightling, MBBS, FCCP
Institute of Lung Health, Glenfield Hospital Douglas McCrory, MD, MHSc
Leicester, United Kingdom
Center For Clinical Health Policy Research
Kevin K. Brown, MD, FCCP Duke University Medical Center
National Jewish Medical & Research Center Durham, NC
University of Colorado Health Sciences Center
Denver, CO Udaya B. S. Prakash, MD, FCCP
Mayo Clinic
Brendan J. Canning, PhD Rochester, MN
Johns Hopkins Asthma and Allergy Center
Baltimore, MD Melvin R. Pratter, MD, FCCP
Anne B. Chang, MBBS, PhD Cooper University Hospital
Royal Children’s Hospital Robert Wood Johnson School of Medicine at
Brisbane, Australia Camden, NJ
Peter V. Dicpinigaitis, MD, FCCP Mark J. Rosen, MD, FCCP
Einstein Division/Montefiore Medical Center Beth Israel Medical Center
Bronx, NY
New York, NY
Ron Eccles, DSc
Cardiff School of Biosciences, Cardiff University Edward Schulman, MD, FCCP
Wales, United Kingdom (ATS Representative)
Hahnemann University Hospital
Wm Brendle Glomb, MD, FCCP Philadelphia, PA
Austin Children’s Chest Associates, P.A.
Austin, Texas John Jay Shannon, MD, FCCP
Larry B. Goldstein, MD (ACP Representative)
Duke University Medical Center Cook County Hospital
Durham, NC Chicago, IL
F Panel List

Carol Smith Hammond, PhD Susan M. Tarlo, MBBS, FCCP
Duke University Toronto Western Hospital
Durham Veterans Administration Medical Center Ontario, Canada
Durham, NC 27705
www.chestjournal.org CHEST / 129 / 1 / JANUARY, 2006 SUPPLEMENT G

List of Reviewers
ACCP Board of Regents Rana B. Hejal, MD, FCCP

COL Daniel R. Ouellette, MC, USA, FCCP Ayman O. Soubani, MBBS, FCCP
LTC Lisa K. Moores, MC, USA, FCCP
Occupational and Environmental Health Network
Health and Science Policy Feroza M. Daroowalla, MD, FCCP
Michael H. Baumann, MD, FCCP, Chair Clayton T. Cowl, MD, FCCP
David D. Gutterman, MD, FCCP, Vice Chair Dorsett Smith, DO, FCCP
Doreen J. Addrizzo-Harris, MD, FCCP Pediatric Chest Medicine NetWork
Brian W. Carlin, MD, FCCP C. Michael Bowman, MD, FCCP
George L. Delclos, MD, FCCP COL Edward R. Carter, MC, USA, FCCP
Susan M. Harding, MD, FCCP COL Harlan S. Patterson, MC, USA, FCCP
Janet R. Maurer, MD, FCCP
Atul C. Mehta, MBBS, FCCP Respiratory Care NetWork
COL John P. Mitchell, MC, USAF, FCCP Russell A. Acevedo, MD, FCCP
Ian T. Nathanson, MD, FCCP Michael G Ankin MD, FCCP
Barbara A. Phillips, MD, FCCP Carl A. Kaplan, MD, FCCP
Walter J. Scott, MD, FCCP Robert S. Pikarsky, RRT
Charlie Strange, MD, FCCP Prior to submission for publication, the guideline
Pascal O. Udekwu, MBBS, FCCP review process of the ACCP is thorough and lengthy
Airways Disorders NetWork with multiple bodies charged with assessment in-
Paula J. Anderson, MD, FCCP cluding the Executive Committee of the panel, full
Claudia G. Cote, MD, FCCP guideline panel, Health and Science Policy Commit-
Lourdes R. Laraya Cuasay, MD, FCCP tee, appropriate NetWork(s) steering committee(s)
Alan M. Fein, MD, FCCP members or designated reviewers, and the Executive
Jill P. Karpel, MD, FCCP Committee Board of Regents. This list of bodies
Frank T. Leone, MD, FCCP included 39 individual reviewers whose exhaustive
COL John P. Mitchell, MC, USAF, FCCP efforts helped to improve the resulting product.
Jill A. Ohar, MD, FCCP Although Dr. Irwin is the current Editor in Chief of
Jay I. Peters, MD, FCCP CHEST as well as the chair of this guideline panel,
E. Rand Sutherland, MD, FCCP the final manuscript, after review by the 39 individ-
uals listed above, was submitted to CHEST in May
Clinical Pulmonary NetWork 2005 and approved for publication by then Editor in
Nicola A. Hanania, MBBS, FCCP Chief, Jay Block, MD, Master FCCP.
H List of Reviewers

CHEST Contents
CHEST | Volume 129 | Number 1 | January 2006 Supplement
DIAGNOSIS AND MANAGEMENT OF COUGH: ACCP EVIDENCE-BASED CLINICAL PRACTICE GUIDELINES
Diagnosis and Management of Cough Executive Summary: ACCP Evidence-Based Clinical Practice Guidelines 1S
Richard S. Irwin; Michael H. Baumann; Donald C. Bolser; Louis-Philippe Boulet; Sidney S. Braman; Christopher E. Brightling;
Kevin K. Brown; Brendan J. Canning; Anne B. Chang; Peter V. Dicpinigaitis; Ron Eccles; W. Brendle Glomb; Larry B. Goldstein;
LeRoy M. Graham; Frederick E. Hargreave; Paul A. Kvale; Sandra Zelman Lewis; F. Dennis McCool; Douglas C. McCrory;
Udaya B.S. Prakash; Melvin R. Pratter; Mark J. Rosen; Edward Schulman; John Jay Shannon; Carol Smith Hammond;
Susan M. Tarlo
Diagnosis and Management of Cough: ACCP Evidence-Based Clinical Practice Guidelines 24S
Richard S. Irwin
Introduction to the Diagnosis and Management of Cough: ACCP Evidence-Based Clinical Practice Guidelines 25S
Richard S. Irwin
Methodology and Grading of the Evidence for the Diagnosis and Management of Cough: ACCP Evidence-Based 28S
Clinical Practice Guidelines
Douglas C. McCrory; Sandra Zelman Lewis
Anatomy and Neurophysiology of the Cough Reflex: ACCP Evidence-Based Clinical Practice Guidelines 33S
Brendan J. Canning
Global Physiology and Pathophysiology of Cough: ACCP Evidence-Based Clinical Practice Guidelines 48S
F. Dennis McCool
Complications of Cough: ACCP Evidence-Based Clinical Practice Guidelines 54S

Richard S. Irwin
Overview of Common Causes of Chronic Cough: ACCP Evidence-Based Clinical Practice Guidelines 59S
Melvin R. Pratter
Chronic Upper Airway Cough Syndrome Secondary to Rhinosinus Diseases (Previously Referred to as Postnasal Drip 63S
Syndrome): ACCP Evidence-Based Clinical Practice Guidelines
Melvin R. Pratter
Cough and the Common Cold: ACCP Evidence-Based Clinical Practice Guidelines 72S
Melvin R. Pratter
Chronic Cough Due to Asthma: ACCP Evidence-Based Clinical Practice Guidelines 75S
Peter V. Dicpinigaitis
Chronic Cough Due to Gastroesophageal Reflux Disease: ACCP Evidence-Based Clinical Practice Guidelines 80S
Richard S. Irwin
Chronic Cough Due to Acute Bronchitis: ACCP Evidence-Based Clinical Practice Guidelines 95S
Sidney S. Braman
Chronic Cough Due to Chronic Bronchitis: ACCP Evidence-Based Clinical Practice Guidelines 104S
Sidney S. Braman
Chronic Cough Due to Nonasthmatic Eosinophilic Bronchitis: ACCP Evidence-Based Clinical Practice Guidelines 116S
Christopher E. Brightling
Chronic Cough Due to Bronchiectasis: ACCP Evidence-Based Clinical Practice Guidelines 122S
Mark J. Rosen

A
CHEST Contents
continued
Chronic Cough Due to Nonbronchiectatic Suppurative Airway Disease (Bronchiolitis): ACCP Evidence-Based Clinical 132S
Practice Guidelines
Kevin K. Brown
Postinfectious Cough: ACCP Evidence-Based Clinical Practice Guidelines 138S

Sidney S. Braman
Chronic Cough Due to Lung Tumors: ACCP Evidence-Based Clinical Practice Guidelines 147S
Paul A. Kvale
Cough and Aspiration of Food and Liquids Due to Oral-Pharyngeal Dysphagia: ACCP Evidence-Based Clinical 154S
Practice Guidelines
Carol A. Smith Hammond; Larry B. Goldstein
Angiotensin-Converting Enzyme Inhibitor-Induced Cough: ACCP Evidence-Based Clinical Practice Guidelines 169S
Habit Cough, Tic Cough, and Psychogenic Cough in Adult and Pediatric Populations: ACCP Evidence-Based Clinical 174S
Practice Guidelines
Richard S. Irwin; William B. Glomb; Anne B. Chang
Chronic Cough Due to Chronic Interstitial Pulmonary Diseases: ACCP Evidence-Based Clinical Practice Guidelines 180S
Kevin K. Brown
Cough: Occupational and Environmental Considerations: ACCP Evidence-Based Clinical Practice Guidelines 186S
Susan M. Tarlo
Chronic Cough Due to Tuberculosis and Other Infections: ACCP Evidence-Based Clinical Practice Guidelines 197S
Mark J. Rosen
Peritoneal Dialysis and Cough: ACCP Evidence-Based Clinical Practice Guidelines 202S
Susan M. Tarlo
Cough in the Immunocompromised Host: ACCP Evidence-Based Clinical Practice Guidelines 204S
Mark J. Rosen
Uncommon Causes of Cough: ACCP Evidence-Based Clinical Practice Guidelines 206S

Udaya B.S. Prakash
Unexplained (Idiopathic) Cough: ACCP Evidence-Based Clinical Practice Guidelines 220S

Melvin R. Pratter
An Empiric Integrative Approach to the Management of Cough: ACCP Evidence-Based Clinical Practice Guidelines 222S
Melvin R. Pratter; Christopher E. Brightling; Louis Philippe Boulet; Richard S. Irwin
Assessing Cough Severity and Efficacy of Therapy in Clinical Research: ACCP Evidence-Based Clinical Practice 232S
Guidelines
Richard S. Irwin
Cough Suppressant and Pharmacologic Protussive Therapy: ACCP Evidence-Based Clinical Practice Guidelines 238S
Donald C. Bolser
Nonpharmacologic Airway Clearance Therapies: ACCP Evidence-Based Clinical Practice Guidelines 250S
F. Dennis McCool; Mark J. Rosen
Guidelines for Evaluating Chronic Cough in Pediatrics: ACCP Evidence-Based Clinical Practice Guidelines 260S
Anne B. Chang; William B. Glomb

B
CHEST Contents
Potential Future Therapies for the Management of Cough: ACCP Evidence-Based Clinical Practice Guidelines 284S
Future Directions in the Clinical Management of Cough: ACCP Evidence-Based Clinical Practice Guidelines 287S
Louis-Philippe Boulet
Through a comprehensive literature review, the evidence-based practice guidelines of the ACCP incorporate data
from the most recent studies then available, which the ACCP views as being the best evidence available for the
guideline’s general information purposes. Guidelines are not a substitute for the health-care provider’s own judgment
for a specific medical or health condition. Patients should consult a qualified health-care professional for advice about
a specific condition. Because of the ever-evolving field of medicine, new studies that may have become available late
in the process of guideline development may not be incorporated into a particular guideline before it is disseminated.
This prevents the ACCP from assuring the accuracy or completeness of a guideline. Therefore, the ACCP disclaims any
liability to any party for the accuracy or completeness of a guideline or for any damages arising out of the use or non-
use of its material and any information contained therein and all warranties, express or implied. Guideline users
always are urged to seek out newer information that might impact the diagnostic and treatment recommendations
contained within a guideline. Neither the ACCP nor third parties mentioned in a guideline are liable for any damages
whatsoever (including, without limitation, direct, indirect, incidental, punitive, or consequential damages) arising out
of the use, inability to use, or the results of use of a guideline, any references used in a guideline or the materials,
information, or procedures contained in a guideline, whether based on warranty, contract, tort, or another legal
theory and whether or not there was advice of the possibility of such damages.

C
Diagnosis and Management of Cough Executive Summary : ACCP
Evidence-Based Clinical Practice Guidelines
Richard S. Irwin, Michael H. Baumann, Donald C. Bolser, Louis-Philippe
Boulet, Sidney S. Braman, Christopher E. Brightling, Kevin K. Brown,
Brendan J. Canning, Anne B. Chang, Peter V. Dicpinigaitis, Ron Eccles, W.
Brendle Glomb, Larry B. Goldstein, LeRoy M. Graham, Frederick E.
Hargreave, Paul A. Kvale, Sandra Zelman Lewis, F. Dennis McCool,
Douglas C. McCrory, Udaya B.S. Prakash, Melvin R. Pratter, Mark J. Rosen,
Edward Schulman, John Jay Shannon, Carol Smith Hammond and Susan
M. Tarlo
Chest 2006;129; 1S-23S
DOI 10.1378/chest.129.1_suppl.1S
This information is current as of December 20, 2011
Supplementary Material
View e-supplements related to this article at:
http://chestjournal.chestpubs.org/content/suppl/2006/05/25/129.1_suppl.1S.DC1.html
Updated Information & Services
Updated Information and services can be found at:
http://chestjournal.chestpubs.org/content/129/1_suppl/1S.full.html
References
This article cites 35 articles, 34 of which can be accessed free at:
http://chestjournal.chestpubs.org/content/129/1_suppl/1S.full.html#ref-list-1
Cited Bys
This article has been cited by 29 HighWire-hosted articles:
http://chestjournal.chestpubs.org/content/129/1_suppl/1S.full.html#related-urls
Permissions & Licensing
Information about reproducing this article in parts (figures, tables) or in its entirety can be
found online at:
http://www.chestpubs.org/site/misc/reprints.xhtml
Reprints
Information about ordering reprints can be found online:
http://www.chestpubs.org/site/misc/reprints.xhtml
Citation Alerts
Receive free e-mail alerts when new articles cite this article. To sign up, select the
"Services" link to the right of the online article.
Images in PowerPoint format
Figures that appear in CHEST articles can be downloaded for teaching purposes in
PowerPoint slide format. See any online figure for directions.


Diagnosis and Management of Cough PDF

Hochgeladen von

Dokumentinformationen

Originaltitel

Copyright

Verfügbare Formate

Dieses Dokument teilen

Dokument teilen oder einbetten

Freigabeoptionen

Stufen Sie dieses Dokument als nützlich ein?

Sind diese Inhalte unangemessen?

Copyright:

Verfügbare Formate

Diagnosis and Management of Cough PDF

Hochgeladen von

Copyright:

Verfügbare Formate

Diagnosis and Management of Cough

Executive Summary : ACCP Evidence-Based

Chest is the official journal of the American College of Chest

Downloaded from chestjournal.chestpubs.org by guest on December 20, 2011

(CHEST 2006; 129:1S–23S)

www.chestjournal.org CHEST / 129 / 1 / JANUARY, 2006 SUPPLEMENT 1S

Downloaded from chestjournal.chestpubs.org by guest on December 20, 2011

2S Diagnosis and Management of Cough: ACCP Guidelines

Downloaded from chestjournal.chestpubs.org by guest on December 20, 2011

www.chestjournal.org CHEST / 129 / 1 / JANUARY, 2006 SUPPLEMENT 3S

Downloaded from chestjournal.chestpubs.org by guest on December 20, 2011

4S Diagnosis and Management of Cough: ACCP Guidelines

Downloaded from chestjournal.chestpubs.org by guest on December 20, 2011

angiotensin-converting enzyme (ACE) inhibi- to result in a high rate of success in achieving

www.chestjournal.org CHEST / 129 / 1 / JANUARY, 2006 SUPPLEMENT 5S

Downloaded from chestjournal.chestpubs.org by guest on December 20, 2011

6S Diagnosis and Management of Cough: ACCP Guidelines

Downloaded from chestjournal.chestpubs.org by guest on December 20, 2011

www.chestjournal.org CHEST / 129 / 1 / JANUARY, 2006 SUPPLEMENT 7S

Downloaded from chestjournal.chestpubs.org by guest on December 20, 2011

8S Diagnosis and Management of Cough: ACCP Guidelines

Downloaded from chestjournal.chestpubs.org by guest on December 20, 2011

www.chestjournal.org CHEST / 129 / 1 / JANUARY, 2006 SUPPLEMENT 9S

Downloaded from chestjournal.chestpubs.org by guest on December 20, 2011

10S Diagnosis and Management of Cough: ACCP Guidelines

Downloaded from chestjournal.chestpubs.org by guest on December 20, 2011

www.chestjournal.org CHEST / 129 / 1 / JANUARY, 2006 SUPPLEMENT 11S

Downloaded from chestjournal.chestpubs.org by guest on December 20, 2011

12S Diagnosis and Management of Cough: ACCP Guidelines

Downloaded from chestjournal.chestpubs.org by guest on December 20, 2011

www.chestjournal.org CHEST / 129 / 1 / JANUARY, 2006 SUPPLEMENT 13S

Downloaded from chestjournal.chestpubs.org by guest on December 20, 2011

14S Diagnosis and Management of Cough: ACCP Guidelines

Downloaded from chestjournal.chestpubs.org by guest on December 20, 2011

www.chestjournal.org CHEST / 129 / 1 / JANUARY, 2006 SUPPLEMENT 15S

Downloaded from chestjournal.chestpubs.org by guest on December 20, 2011

16S Diagnosis and Management of Cough: ACCP Guidelines

Downloaded from chestjournal.chestpubs.org by guest on December 20, 2011

www.chestjournal.org CHEST / 129 / 1 / JANUARY, 2006 SUPPLEMENT 17S

Downloaded from chestjournal.chestpubs.org by guest on December 20, 2011

18S Diagnosis and Management of Cough: ACCP Guidelines

Downloaded from chestjournal.chestpubs.org by guest on December 20, 2011

www.chestjournal.org CHEST / 129 / 1 / JANUARY, 2006 SUPPLEMENT 19S

Downloaded from chestjournal.chestpubs.org by guest on December 20, 2011

20S Diagnosis and Management of Cough: ACCP Guidelines

Downloaded from chestjournal.chestpubs.org by guest on December 20, 2011

www.chestjournal.org CHEST / 129 / 1 / JANUARY, 2006 SUPPLEMENT 21S

Downloaded from chestjournal.chestpubs.org by guest on December 20, 2011

22S Diagnosis and Management of Cough: ACCP Guidelines

Downloaded from chestjournal.chestpubs.org by guest on December 20, 2011

www.chestjournal.org CHEST / 129 / 1 / JANUARY, 2006 SUPPLEMENT 23S

Downloaded from chestjournal.chestpubs.org by guest on December 20, 2011

www.chestjournal.org CHEST / 129 / 1 / JANUARY, 2006 SUPPLEMENT I

Downloaded from chestjournal.chestpubs.org by guest on December 20, 2011

J Disclosure of Faculty Conflict of Interest

Downloaded from chestjournal.chestpubs.org by guest on December 20, 2011

Richard S. Irwin, MD, FCCP, Chair LeRoy M. Graham, MD, FCCP

Downloaded from chestjournal.chestpubs.org by guest on December 20, 2011

www.chestjournal.org CHEST / 129 / 1 / JANUARY, 2006 SUPPLEMENT G

Downloaded from chestjournal.chestpubs.org by guest on December 20, 2011

ACCP Board of Regents Rana B. Hejal, MD, FCCP

Downloaded from chestjournal.chestpubs.org by guest on December 20, 2011

DIAGNOSIS AND MANAGEMENT OF COUGH: ACCP EVIDENCE-BASED CLINICAL PRACTICE GUIDELINES