Cough Guidelines ACCP CHEST 2006

DOI: 10.1378/chest.129.1_suppl.1S 2006;129;1-23 Chest

Smith Hammond and Susan M. Tarlo Melvin R. Pratter, Mark J. Rosen, Edward Schulman, John Jay Shannon, Carol Zelman Lewis, F. Dennis McCool, Douglas C. McCrory, Udaya B.S. Prakash,Goldstein, LeRoy M. Graham, Frederick E. Hargreave, Paul A. Kvale, Sandra

Anne B. Chang, Peter V. Dicpinigaitis, Ron Eccles, W. Brendle Glomb, Larry B.Sidney S. Braman, Christopher E. Brightling, Kevin K. Brown, Brendan J. Canning, Richard S. Irwin, Michael H. Baumann, Donald C. Bolser, Louis-Philippe Boulet,

Evidence-Based Clinical Practice GuidelinesDiagnosis and Management of Cough Executive Summary: ACCP

This information is current as of January 23, 2006

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Diagnosis and Management of CoughExecutive SummaryACCP 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 ThoracicSociety; DPB � diffuse panbronchiolitis; dTap � acellular pertussis; FEES � fiberoptic endoscopic evaluation ofswallowing; GERD � gastroesophageal reflux disease; HRCT � high-resolution CT; HSP � Health and Science PolicyCommittee; 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 ecognition of the importance of cough in clinicalmedicine was the impetus for the original evi-

dence-based consensus panel report on “ManagingCough as a Defense Mechanism and as a Symptom,”published in 1998,1 and this updated revision. Com-pared to the original cough consensus statement, thisrevision (1) more narrowly focuses the guidelines onthe diagnosis and treatment of cough, the symptom,in adult and pediatric populations, and minimizes thediscussion of cough as a defense mechanism; (2)improves on the rigor of the evidence-based reviewand describes the methodology in a separate section;

(3) updates and expands, when appropriate, all pre-vious sections; and (4) adds new sections with topicsthat were not previously covered. These new sectionsinclude nonasthmatic eosinophilic bronchitis (NAEB);acute bronchitis; nonbronchiectatic suppurative air-way diseases; cough due to aspiration secondary tooral/pharyngeal dysphagia; environmental/occupa-tional causes of cough; tuberculosis (TB) and otherinfections; cough in the dialysis patient; uncommoncauses of cough; unexplained cough, previously re-ferred to as idiopathic cough; an empiric integrativeapproach to the management of cough; assessingcough severity and efficacy of therapy in clinicalresearch; potential future therapies; and future di-rections for research.

To mitigate future diagnostic confusion, two newdiagnostic terms have been introduced to replace two

Reproduction of this article is prohibited without written permissionfrom the American College of Chest Physicians (www.chestjournal.org/misc/reprints.shtml).Correspondence to: Richard S. Irwin, MD, FCCP, University ofMassachusetts Medical School, Room S6-842, 55 Lake Ave North,Worcester, MA 01655; e-mail address: [email protected]

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



older terms that may represent misnomers. The com-mittee unanimously recommends that the term upperairway cough syndrome (UACS) be used in preferenceto postnasal drip syndrome (PNDS) when discussingcough that is associated with upper airway conditionsbecause it is unclear whether the mechanism of coughis postnasal drip, direct irritation, or inflammation ofthe cough receptors in the upper airway. The commit-tee also recommends using the term unexplained coughrather than idiopathic cough because it is likely thatmore than one unknown cause of chronic cough will bediscovered. The term idiopathic implies that one isdealing with only one disease.

For managing adult patients with cough, the com-mittee recommends an empiric, integrative diagnos-tic approach, which is presented in the sectionentitled “An Empiric Integrative Approach to theManagement of Cough”.3 Guidelines for managingacute, subacute, and chronic cough are presented inalgorithmic form (Fig 1–3). Guidelines with algo-rithms for evaluating chronic cough in pediatricpatients � 15 years of age are presented in thesection entitled “Guidelines for Evaluating ChronicCough in Pediatrics”2,4 [Fig 4, 5]. For a full discus-sion on how to use the algorithms, please refer tothese sections.

Summary and Recommendations

Recommendations for each section of these guide-lines are listed under their respective section titles.

For an in-depth discussion or clarification of eachrecommendation, readers are encouraged to readthe specific section in question in its entirety.

Methodology and Grading of the Evidence for theDiagnosis and Management of Cough5

• The recommendations were graded, by consensusby the panel, using the American College of ChestPhysicians Health and Science Policy GradingSystem, which is based on the following two compo-nents: quality of evidence; and the net benefit of thediagnostic and therapeutic procedure.

• The quality of evidence is rated according to thestudy design and strength of other methodologiesused in the included studies.

• The net benefit of the recommendations is basedon the estimated benefit to the specific patientpopulation described in each recommendationand not for an individual patient. Usually, the netbenefit is a clinical benefit to the population ofpatients defined in the first phrase of the recom-mendation, but, in recommendations for futureresearch or other nonclinical recommendations, itmay be a societal benefit.

• Both the quality of evidence and the net benefitcomponents are listed after each recommenda-tion; their interaction defines the strength of therecommendations.

• The recommendations scale is as follows: A,strong; B, moderate; C, weak; D, negative; I,inconclusive (no recommendation possible); E/A,

Figure 1. Acute cough algorithm for the management of patients � 15 years of age with cough lasting� 3 weeks. For diagnosis and treatment recommendations refer to the section indicated in thealgorithm. PE � pulmonary embolism; Dx � diagnosis; Rx � treatment; URTI � upper respiratorytract 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



strong recommendation based on expert opiniononly; E/B, moderate recommendation based onexpert opinion only; E/C, weak recommendationbased on expert opinion only; and E/D, negativerecommendation based on expert opinion only

Anatomy and Neurophysiology of the Cough Reflex6

• There is clear evidence that vagal afferent nervesregulate involuntary coughing.

• Coughing, like swallowing, belching, urinating,and defecating, is unique because there is highercortical control of this visceral reflex.

• Cortical control can manifest as cough inhibitionor voluntary cough. The implications of this areseveral-fold: because placebos can have a pro-found effect on coughing, treatment studies mustbe placebo-controlled. Because cough can be anaffective behavior, psychological issues must beconsidered as a cause or effect of coughing.

• There is a need to study the roles of consciousnessand perception in coughing.

Global Physiology and Pathophysiology of Cough7

1. In patients with endotracheal tubes, tra-cheostomy need not be performed to improve

cough effectiveness. Level of evidence, expertopinion; net benefit, substantial; grade of recom-mendation, E/A

2. Individuals with neuromuscular weaknessand no concomitant airway obstruction maybenefit from mechanical aids to improve cough.Level of evidence, low; net benefit, intermediate;grade of recommendation, C

3. In patients with ineffective cough, the cli-nician should be aware of and monitor forpossible complications, such as pneumonia, at-electasis, and/or respiratory failure. Level ofevidence, low; net benefit, substantial; grade ofrecommendation, B

Complications of Cough8

1. In patients complaining of cough, evaluatefor a variety of complications associated withcoughing (eg, cardiovascular, constitutional, GI,genitourinary, musculoskeletal, neurologic, oph-thalmologic, psychosocial, and skin complica-tions), which can lead to a decrease in a patient’shealth-related quality of life. Level of evidence, low;benefit, substantial; grade of recommendation, B

2. Patients with cough should have a thor-

Figure 2. Subacute cough algorithm for the management of patients � 15 years of age with coughlasting 3 to 8 weeks. For diagnosis and treatment recommendations refer to the section indicated in thealgorithm. AECB � acute exacerbation of chronic bronchitis. See the legend of Figure 1 forabbreviations not used in the text. See Figure 1 for references to Sections.




ough diagnostic evaluation, according to theguidelines set forth in this document, to miti-gate or prevent these complications. Level ofevidence, low; net benefit, substantial; grade ofrecommendation, B

Overview of Common Causes of Chronic Cough9

1. In patients with chronic cough and a nor-mal chest roentgenogram finding who are non-smokers and are not receiving therapy with an

Figure 3. Chronic cough algorithm for the management of patients � 15 years of age with coughlasting � 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.




angiotensin-converting enzyme (ACE) inhibi-tor, the diagnostic approach should focus on thedetection and treatment of UACS (formerlycalled PNDS), asthma, NAEB, or GERD, aloneor in combination. This approach is most likely

to result in a high rate of success in achievingcough resolution. Level of evidence, low; benefit,substantial; grade of recommendation, B

2. In all patients with chronic cough, regard-less of clinical signs or symptoms, because

Figure 4. Approach to a child � 15 years of age with chronic cough. There are limitations of thealgorithm, which should be read with the accompanying text. Spirometry can usually be reliablyperformed in children � 6 years of age and in some children � 3 years of age if trained pediatricpersonnel are present. CXR � chest radiograph.2




UACS (formerly called PNDS), asthma, andGERD each may present only as cough with noother associated clinical findings (ie, “silentPNDS,” “cough variant asthma,” and “silentGERD”), each of these diagnoses must be con-sidered. Level of evidence, low; benefit, substantial;grade of recommendation, B

3. In patients with chronic cough, neither thepatient’s description of his or her cough interms of its character or timing, nor the pres-ence or absence of sputum production, shouldbe used to rule in or rule out a diagnosis or todetermine the clinical approach. Level of evi-dence, low; benefit, substantial; grade of recommen-dation, B

Chronic Upper Airway Cough Syndrome Secondaryto Rhinosinus Diseases (Previously Referred to asPostnasal Drip Syndrome)10

1. In patients with chronic cough that is re-lated to upper airway abnormalities, the com-mittee considers the term UACS to be more

accurate, and it should therefore be used in-stead of the term PNDS. Level of evidence, expertopinion; benefit, substantial; grade of recommenda-tion, E/A

2. In patients with chronic cough, the diag-nosis of UACS-induced cough should be deter-mined by considering a combination of criteria,including symptoms, physical examination find-ings, radiographic findings, and, ultimately, theresponse to specific therapy. Because it is asyndrome, no pathognomonic findings exist.Level of evidence, low; benefit, substantial; grade ofrecommendation, B

3. In patients in whom the cause of theUACS-induced cough is apparent, specific ther-apy directed at this condition should be insti-tuted. Level of evidence, low; benefit, substantial;grade of recommendation, B

4. For patients with chronic cough, an em-piric trial of therapy for UACS should be admin-istered because the improvement or resolutionof cough in response to specific treatment is the

Figure 5. Approach to a child � 14 years of age with chronic specific cough (ie, cough associated withother features suggestive of an underlying pulmonary and/or systemic abnormality). Children � 14years of age should be managed as outlined in adult guidelines but there is no good evidence where theage cutoff should be. TEF � tracheal esophageal fistula. See the legend of Figure 4 for abbreviationnot used in the text.




pivotal factor in confirming the diagnosis ofUACS as a cause of cough. Level of evidence, low;benefit, substantial; grade of recommendation, B

5. A patient suspected of having UACS-in-duced cough who does not respond to empiricantihistamine/decongestant (A/D) therapy witha first-generation antihistamine should next un-dergo sinus imaging. Although chronic sinusitismay cause a productive cough, it may also beclinically silent, in that the cough can be rela-tively or even completely nonproductive andnone of the typical findings associated withacute sinusitis may be present. Level of evidence,low; benefit, substantial; grade of recommendation, B

6. In patients for whom a specific etiology ofchronic cough is not apparent, empiric therapyfor UACS in the form of a first-generation A/Dpreparation should be prescribed before begin-ning an extensive diagnostic workup. Level ofevidence, low; benefit, intermediate; grade of rec-ommendation, C

Cough and the Common Cold11

1. Patients with acute cough (as well as PNDand throat clearing) associated with the com-mon cold can be treated with a first-genera-tion A/D preparation (brompheniramine andsustained-release pseudoephedrine). Naproxencan also be administered to help decreasecough in this setting. Level of evidence, fair;benefit, substantial; grade of recommendation, A

2. In patients with the common cold, newergeneration nonsedating antihistamines are inef-fective for reducing cough and should not beused. Level of evidence, fair; benefit, none; grade ofrecommendation, D

3. In patients with cough and acute URTI,because symptoms, signs, and even sinus-imag-ing abnormalities may be indistinguishablefrom acute bacterial sinusitis, the diagnosis ofbacterial sinusitis should not be made duringthe first week of symptoms. (Clinical judgmentis required to decide whether to institute anti-biotic therapy.) Level of evidence, fair; benefit,none; grade of recommendation, D

Chronic Cough Due to Asthma12

1. In a patient with chronic cough, asthmashould always be considered as a potential eti-ology because asthma is a common conditionwith which cough is commonly associated. Qual-ity of evidence, fair; net benefit, substantial; grade ofrecommendation, A

2. In a patient suspected of having CVA butin whom physical examination and spirometry

findings are nondiagnostic, MIC testing shouldbe performed to confirm the presence ofasthma. However, a diagnosis of CVA as thecause of cough is established only after theresolution of cough with specific antiasthmatictherapy. If MIC testing cannot be performed,empiric therapy should be administered; how-ever, a response to steroid therapy will notexclude NAEB as an etiology of the patient’scough. Quality of evidence, good; net benefit, sub-stantial; grade of recommendation, A

3. Patients with cough due to asthma shouldinitially be treated with a standard antiasth-matic regimen of inhaled bronchodilators andinhaled corticosteroids (ICSs). Quality of evi-dence, fair; net benefit, substantial; grade of recom-mendation, A

4. In patients whose cough is refractory totreatment with ICSs, an assessment of airwayinflammation should be performed wheneveravailable and feasible. The demonstration ofpersistent airway eosinophilia during such anassessment will identify those patients who maybenefit from more aggressive antiinflammatorytherapy. Quality of evidence, low; net benefit,substantial; grade of recommendation, B

5a. For patients with asthmatic cough that isrefractory to treatment with ICSs and broncho-dilators, in whom poor compliance or anothercontributing condition has been excluded, aleukotriene receptor antagonist may be addedto the therapeutic regimen before the escala-tion of therapy to systemic corticosteroids. Qual-ity of evidence, fair; net benefit, intermediate; gradeof recommendation, B

5b. Patients with severe and/or refractorycough due to asthma should receive a shortcourse (1 to 2 weeks) of systemic (oral) cortico-steroids followed by ICSs. Quality of evidence,low; net benefit,: substantial; grade of recommenda-tion, B

Chronic Cough Due to Gastroesophageal RefluxDisease13

1. In patients with chronic cough due togastroesophageal reflux disease (GERD), theterm acid reflux disease, unless it can be defin-itively shown to apply, should be replaced bythe more general term reflux disease so as not tomislead the clinicians into thinking that allpatients with cough due to GERD should im-prove with acid-suppression therapy. Level ofevidence, expert opinion; benefit, substantial; gradeof recommendation, E/A

2. In patients with chronic cough who also




complain of typical and frequent GI complaintssuch as daily heartburn and regurgitation, es-pecially when the findings of chest-imagingstudies and/or clinical syndrome are consistentwith an aspiration syndrome, the diagnosticevaluation should always include GERD as apossible cause. Level of evidence, low; benefit,substantial; grade of recommendation, B

3. Patients with chronic cough who have GIsymptoms that are consistent with GERD orwho fit the clinical profile described in Table 1in Irwin13, should be considered to have a highlikelihood of having GERD and should be pre-scribed antireflux treatment even when theyhave no GI symptoms. Level of evidence, low;benefit, substantial; grade of recommendation, B

4. In patients with chronic cough, it shouldnot be assumed that GERD has been defini-tively ruled out as a cause of cough simplybecause there is a history of antireflux surgery.Level of evidence, low; benefit, substantial; grade ofrecommendation, B

5. In patients with chronic cough, while teststhat link GERD with cough suggest a potentialcause-effect relationship, a definitive diagnosisof cough due to GERD requires that coughnearly or completely disappear with antirefluxtreatment. Level of evidence, low; benefit, substan-tial; grade of recommendation, B

6. In patients with chronic cough being eval-uated for GERD, the 24-h esophageal pH-mon-itoring test is the most sensitive and specifictest; however, it is recommended that the testresults be interpreted as normal only whenconventional indices for acid reflux are withinthe normal range and no reflux-induced coughsappear during the monitoring study. Level ofevidence, low; benefit, substantial; grade of recom-mendation, B

7. In patients with cough who are undergoing24-h monitoring, a low percentage of coughsassociated with (or induced by) reflux does notexclude a diagnosis of cough due to GERD. Levelof evidence, low; benefit, substantial; grade of recom-mendation, B

8. In patients with cough due to GERD, thedegree of abnormality noted in the esophagealpH-monitoring variables, such as the frequencyand duration of reflux events, does not directlycorrelate with the severity of the patients’cough. Level of evidence, low; benefit, substantial;grade of recommendation, B

9. In diagnosing nonacid GERD as the causeof cough, barium esophagography may be theonly available test to reveal GER of potentialpathologic significance in this setting (see the

“Discussion” section regarding esophageal im-pedance monitoring). When this is the case,barium esophagography is the test of choice toreveal GER of potential pathologic significance.Level of evidence, low; benefit, substantial; grade ofrecommendation, B

10. In patients with cough due to GERD, anormal esophagoscopy finding does not rule outGERD as the cause of cough. Level of evidence,low; benefit, substantial; grade of recommendation, B

11. For patients fitting the clinical profile forcough due to GERD, it is recommended thattreatment be initially started in lieu of testing.Level of evidence, low; benefit, substantial; grade ofrecommendation, B

12. For patients fitting the clinical profile forcough due to GERD, the performance of 24-hesophageal pH monitoring is recommended ontherapy when cough does not improve or re-solve to assist in determining whether the ther-apy needs to be intensified or if medical therapyhas failed. Level of evidence, low; benefit, substan-tial; grade of recommendation, B

13. For patients with chronic cough, the fol-lowing tests are not routinely recommended tolink cough with GERD: (a) assessing for lipid-laden macrophages in BAL fluid and inducedsputum, because this test has not been studiedin patients with chronic cough and because apositive test result is not specific for aspiration;(b) exhaled nitric oxide measurements, becausethey do not appear to be helpful in diagnosingcough due to GERD; (c) a Bernstein test, be-cause a negative Bernstein test result cannot beused to exclude the diagnosis of cough due toGERD; and (d) inhaled tussigenic challengeswith capsaicin, because they are not specific forcoughs due to GERD and because the testresult can be positive in patients with GERDwithout cough. Level of evidence, low; benefit,conflicting; grade of recommendation, I

14. In patients who meet the clinical profilepredicting that silent GERD is the likely causeof chronic cough or in patients with chroniccough who also have prominent upper GI symp-toms consistent with GERD, an empiric trial ofmedical antireflux therapy is recommended.Level of evidence, low; benefit, substantial; grade ofrecommendation, B

15. For treating the majority of patients withchronic cough due to GERD, the followingmedical therapies are recommended: (a) di-etary and lifestyle modifications; (b) acid sup-pression therapy; and (c) the addition of proki-netic therapy either initially or if there is noresponse to the first two therapies. The re-




sponse to these therapies should be assessedwithin 1 to 3 months. Level of evidence, expertopinion; benefit, substantial; grade of recommenda-tion, E/A

16. In patients in which this empiric treat-ment fails, it cannot be assumed that GERD hasbeen ruled out as a cause of chronic cough;rather, the objective investigation for GERD isthen recommended because the empiric ther-apy may not have been intensive enough ormedical therapy may have failed. Level of evi-dence, expert opinion; benefit, substantial; grade ofrecommendation, E/A

17. In some patients, cough due to GERDwill favorably respond to acid suppression ther-apy alone; proton pump inhibition may be ef-fective when H2-antagonism has been ineffec-tive; prokinetic therapy and diet, when added toproton pump inhibition, may be effective whenproton pump inhibition alone has been ineffec-tive. Level of evidence, low; benefit, substantial;grade of recommendation, B

18. Patients requiring an intensive medicaltreatment regimen should be treated with thefollowing: (a) antireflux diet that includes no> 45 g of fat in 24 h and no coffee, tea, soda,chocolate, mints, citrus products, including to-matoes, or alcohol, no smoking, and limitingvigorous exercise that will increase intraab-dominal pressure; (b) acid suppression with aproton pump inhibitor; (c) prokinetic therapy;and (d) efforts to mitigate the influences ofcomorbid diseases such as obstructive sleepapnea or therapy for comorbid conditions (eg,nitrates, progesterone, and calcium channelblockers) whenever possible. Level of evidence,expert opinion; benefit, substantial; grade of recom-mendation, E/A

19. In patients with chronic cough due toGERD that has failed to improve with the mostmaximal medical therapy, which includes anintensive antireflux diet and lifestyle modifica-tion, maximum acid suppression, and prokinetictherapy, and the rest of the spectrum of treat-ment options in Table 3 in Irwin,13 cough mayonly improve or be eliminated with antirefluxsurgery. Level of evidence, low; benefit, substantial;grade of recommendation, B

20. In patients who meet the following crite-ria, antireflux surgery is the recommendedtreatment: (a) findings of a 24-h esophagealpH-monitoring study before treatment is posi-tive, as defined above; (b) patients fit the clini-cal profile suggesting that GERD is the likelycause of their cough (Table 1 in Irwin13); (c)cough has not improved after a minimum of 3

months of intensive therapy (Table 3 in Irwin13),and serial esophageal pH-monitoring studies orother objective studies (eg, barium esophagog-raphy, esophagoscopy, and gastric-emptyingstudy with solids) performed while the patientreceives therapy show that intensive medicaltherapy has failed to control the reflux diseaseand that GERD is still the likely cause of cough;and (d) patients express the opinion that theirpersisting cough does not allow them a satisfac-tory quality of life. Level of evidence, expertopinion; benefit, substantial; grade of recommenda-tion, E/A

Chronic Cough Due to Acute Bronchitis14

1. In a patient with an acute respiratory infec-tion manifested predominantly by cough, with orwithout sputum production, lasting no more than3 weeks, a diagnosis of acute bronchitis should notbe made unless there is no clinical or radio-graphic evidence of pneumonia, and the commoncold, acute asthma, or an exacerbation of COPDhave been ruled out as the cause of cough. Qualityof evidence, expert opinion; benefit, substantial; gradeof recommendation, E/A

2. In patients with the presumed diagnosis ofacute bronchitis, viral cultures, serologic assays,and sputum analyses should not be routinelyperformed because the responsible organism israrely identified in clinical practice. Quality ofevidence, low; benefit, intermediate; grade of rec-ommendation, C

3. In patients with acute cough and sputumproduction suggestive of acute bronchitis, theabsence of the following findings reduces thelikelihood of pneumonia sufficiently to elimi-nate the need for a chest radiograph: (1) heartrate > 100 beats/min; (2) respiratory rate > 24breaths/min; (3) oral body temperature of> 38°C; and (4) chest examination findings offocal consolidation, egophony, or fremitus.Quality of evidence, low; benefit, substantial; gradeof recommendation, B

4a. For patients with the putative diagnosisof acute bronchitis, routine treatment with an-tibiotics is not justified and should not be of-fered. Quality of evidence, good; benefit, none;grade of recommendation, D

4b. For these patients, the decision not to usean antibiotic should be addressed individuallyand explanations should be offered becausemany patients expect to receive an antibioticbased on previous experiences and public ex-pectation. Quality of evidence, expert opinion; ben-efit, intermediate; grade of recommendation, E/B




5. Children and adult patients with con-firmed and probable whooping cough shouldreceive a macrolide antibiotic and should beisolated for 5 days from the start of treatment;early treatment within the first few weeks willdiminish the coughing paroxysms and preventspread of the disease; the patient is unlikely torespond to treatment beyond this period. Levelof evidence, good; net benefit, substantial; grade ofevidence, A

6a. In most patients with a diagnosis of acutebronchitis, �2-agonist bronchodilators shouldnot be routinely used to alleviate cough. Qualityof evidence, fair; benefit, none; grade of recommen-dation, D

6b. In select adult patients with a diagnosis ofacute bronchitis and wheezing accompanyingthe cough, treatment with �2-agonist broncho-dilators may be useful. Quality of evidence, fair;benefit, small/weak; grade of recommendation, C

7. In patients with a diagnosis of acute bron-chitis, antitussive agents are occasionally usefuland can be offered for short-term symptomaticrelief of coughing. Quality of evidence, fair; bene-fit, small/weak; grade of recommendation, C

8. In patients with a diagnosis of acute bron-chitis, because there is no consistent favorableeffect of mucokinetic agents on cough, they arenot recommended. Quality of evidence, fair; ben-efit, conflicting; grade of recommendation, I

Chronic Cough Due to Chronic Bronchitis15

1. Adults who have a history of chroniccough and sputum expectoration occurring onmost days for at least 3 months and for at least2 consecutive years should be given a diagnosisof chronic bronchitis when other respiratory orcardiac causes of chronic productive cough areruled out. Level of evidence, low; net benefit,substantial; grade of recommendation, B

2. The evaluation of patients with chroniccough should include a complete history re-garding exposures to respiratory irritants in-cluding cigarette, cigar, and pipe smoke; passivesmoke exposures; and hazardous environmentsin the home and workplace. All are predispos-ing factors of chronic bronchitis. Level of evi-dence, low; net benefit, substantial; grade of recom-mendation, B

3. Smoke-free workplace and public placelaws should be enacted in all communities.Level of evidence, expert opinion; net benefit, sub-stantial; grade of recommendation, E/A

4. Stable patients with chronic bronchitiswho have a sudden deterioration of symptoms

with increased cough, sputum production, spu-tum purulence, and/or shortness of breath,which are often preceded by symptoms of anupper respiratory tract infection, should beconsidered to have an acute exacerbation ofchronic bronchitis, as long as conditions otherthan acute tracheobronchitis are ruled out orare considered unlikely. Level of evidence, expertopinion; net benefit, substantial; grade of recom-mendation, E/A

5. In patients with chronic cough who havechronic exposure to respiratory irritants, suchas personal tobacco use, passive smoke expo-sure, and workplace hazards, avoidanceshould always be recommended. It is the mosteffective means to improve or eliminate thecough of chronic bronchitis. Ninety percent ofpatients will have resolution of their coughafter smoking cessation. Level of evidence,good; net benefit, substantial; grade of recommen-dation, A

6. In stable patients with chronic bronchi-tis, there is no role for long-term prophylactictherapy with antibiotics. Level of evidence, low;benefit, none; grade of recommendation, I

7. In patients with acute exacerbations ofchronic bronchitis, the use of antibiotics is rec-ommended; patients with severe exacerbationsand those with more severe airflow obstructionat baseline are the most likely to benefit. Levelof evidence, fair; net benefit, substantial; grade ofrecommendation, A

8. In stable patients with chronic bronchitis,the clinical benefits of postural drainage andchest percussion have not been proven, andthey are not recommended. Level of evidence,fair; net benefit, conflicting; grade of recommenda-tion, I

9. In patients with an acute exacerbation ofchronic bronchitis, the clinical benefits of pos-tural drainage and chest percussion have notbeen proven, and they are not recommended.Level of evidence, fair; net benefit, conflicting; grade ofrecommendation, I

10a. In stable patients with chronic bronchi-tis, therapy with short-acting �-agonists shouldbe used to control bronchospasm and relievedyspnea; in some patients, it may also reducechronic cough. Level of evidence, good; net bene-fit, substantial; grade of recommendation, A

10b. In stable patients with chronic bronchi-tis, therapy with ipratropium bromide shouldbe offered to improve cough. Level of evidence,fair; net benefit, substantial; grade of recommenda-tion, A

10c. In stable patients with chronic bronchi-




tis, treatment with theophylline should be con-sidered to control chronic cough; careful mon-itoring for complications is necessary. Level ofevidence, fair; net benefit, substantial; grade ofrecommendation, A

11. For patients with an acute exacerbationof chronic bronchitis, therapy with short-acting�-agonists or anticholinergic bronchodilatorsshould be administered during the acute exac-erbation. If the patient does not show a promptresponse, the other agent should be added afterthe first is administered at the maximal dose.Level of evidence, good; net benefit, substantial;grade of recommendation, A

12. For patients with an acute exacerbationof chronic bronchitis, theophylline should notbe used for treatment. Level of evidence, good;net benefit, none; grade of recommendation, D

13. For stable patients with chronic bronchi-tis, there is no evidence that the currentlyavailable expectorants are effective and there-fore they should not be used. Level of evidence,low; net benefit, none; grade of recommendation, I

14. In stable patients with chronic bronchitis,treatment with a long-acting �-agonist whencoupled with an ICS should be offered to con-trol chronic cough. Level of evidence, good; netbenefit, substantial; grade of recommendation, A

15. For stable patients with chronic bronchi-tis and an FEV1 of < 50% predicted or for thosepatients with frequent exacerbations of chronicbronchitis, ICS therapy should be offered. Levelof evidence, good; net benefit, substantial; grade ofrecommendation, A

16. For stable patients with chronic bronchi-tis, long-term maintenance therapy with oralcorticosteroids such as prednisone should notbe used; there is no evidence that it improvescough and sputum production, and the risks ofserious side effects are high. Level of evidence,expert opinion; net benefit, negative; grade of rec-ommendation, E/D

17. For patients with an acute exacerbation ofchronic bronchitis, there is no evidence that thecurrently available expectorants are effective,and therefore they should not be used. Level ofevidence, low; net benefit, none; grade of recommen-dation, I

18. For patients with an acute exacerbationof chronic bronchitis, a short course (10 to 15days) of systemic corticosteroid therapy shouldbe given; IV therapy in hospitalized patientsand oral therapy for ambulatory patients haveboth proven to be effective. Level of evidence,good; net benefit, substantial; grade of recommen-dation, A

19. In patients with chronic bronchitis, cen-tral cough suppressants such as codeine anddextromethorphan are recommended for short-term symptomatic relief of coughing. Level ofevidence, fair; benefit, intermediate; grade of evi-dence, B

Chronic Cough Due to Nonasthmatic EosinophilicBronchitis16

1. In patients with chronic cough who havenormal chest radiograph findings, normal spi-rometry findings, and no evidence of variableairflow obstruction or airway hyperresponsive-ness, the diagnosis of NAEB should be consid-ered. Level of evidence, expert opinion; benefit,substantial; grade of recommendation, E/A

2. In patients with chronic cough with nor-mal chest radiograph findings, normal spirom-etry findings, and no evidence of variableairflow obstruction or airway hyperresponsive-ness, the diagnosis of NAEB as the cause of thechronic cough is confirmed by the presence ofairway eosinophilia, either by sputum inductionor bronchial wash fluid obtained by bronchos-copy, and an improvement in the cough follow-ing corticosteroid therapy. Level of evidence,expert opinion; benefit, substantial; grade of recom-mendation, E/A

3. In patients with chronic cough due toNAEB, the possibility of an occupation-relatedcause needs to be considered. Level of evidence,expert opinion; benefit, substantial; grade of recom-mendation, E/A

4. For patients with chronic cough due toNAEB, the first-line treatment is ICSs (exceptwhen a causal allergen or sensitizer is identified[see recommendation 5]). Level of evidence, low;benefit, substantial; grade of recommendation, B

5. For patients with chronic cough due toNAEB, when a causal allergen or occupationalsensitizer is identified, avoidance is the besttreatment. Level of evidence, expert opinion; ben-efit, substantial; grade of recommendation, E/A

6. For patients with chronic cough due toNAEB, if symptoms are persistently trouble-some and/or the natural history of eosinophilicairway inflammation progresses despite treat-ment with high-dose ICSs, oral corticosteroidsshould be given. Level of evidence, expert opinion;benefit, substantial; grade of recommendation, E/A

Chronic Cough Due to Bronchiectasis17

1. In patients with suspected bronchiectasiswithout a characteristic chest radiograph find-ing, an high-resolution CT (HRCT) scan of the




chest should be ordered because it is the diag-nostic procedure of choice to confirm the diag-nosis. Level of evidence, low; benefit, substantial;grade of recommendation, B

2. In patients for whom there is no obviouscause, a diagnostic evaluation for an underlyingdisorder causing bronchiectasis should be per-formed, because the results may lead to treat-ment that may slow or halt the progression ofdisease. Level of evidence, low; benefit, substantial;grade of recommendation, B

3. In patients with bronchiectasis with air-flow obstruction and/or bronchial hyperreactiv-ity, therapy with bronchodilators may be ofbenefit. Level of evidence, expert opinion; benefit,small; grade of recommendation, E/C

4. In patients with bronchiectasis caused bycystic fibrosis (CF), rhDNase should be used toimprove spirometry. Level of evidence, low; ben-efit, small; grade of recommendation, C

5. In patients with CF, prolonged treatmentwith systemic corticosteroids should not be of-fered to most patients because of significantside effects. Level of evidence, low; benefit, con-flicting; grade of recommendation, I

6. In patients with CF, prolonged courses ofibuprofen should not be used. Level of evidence,low; benefit, conflicting; grade of recommendation, I

7. In patients with idiopathic bronchiectasis,the prolonged systemic administration of anti-biotics may produce small benefits in reducingsputum volume and purulence, but may also beassociated with intolerable side effects. Level ofevidence, low; benefit, conflicting, grade of recom-mendation, I

8. In patients with CF, therapy with aerosol-ized antipseudomonal antibiotics are recom-mended. Level of evidence, low; benefit, interme-diate; grade of recommendation, C

9. In patients with idiopathic bronchiectasis,aerosolized antibiotics should not be used. Levelof evidence, low; benefit, negative; recommendation, D

10. In patients with conditions associatedwith the hypersecretion of mucus and the in-ability to expectorate effectively, chest physio-therapy should be used and patients should bemonitored for symptom improvement. Level ofevidence, expert opinion; benefit, small/weak; gradeof recommendation, E/C

11. In selected patients with localized bron-chiectasis that causes intolerable symptoms de-spite maximal medical therapy, surgery shouldbe offered. Level of evidence, low; benefit, substan-tial; grade of recommendation, B

12. In patients with exacerbations of bronchi-ectasis, antibiotics should be used, with the

selection of agents depending on the likelypathogens. Level of evidence, low; benefit, substan-tial; grade of recommendation, B

Chronic Cough Due to NonbronchiectaticSuppurative Airway Disease (Bronchiolitis)18

1. In patients with cough and incomplete orirreversible airflow limitation, direct or indirectsigns of small airways disease seen on HRCTscan, or purulent secretions seen on bronchos-copy, nonbronchiectatic suppurative airwaysdisease (bronchiolitis) should be suspected asthe primary cause. Level of evidence, expert opin-ion; benefit, substantial; grade of recommendation,E/A

2. In patients with cough in whom morecommon causes have been excluded, becausebacterial suppurative airways disease may bepresent and clinically unsuspected, bronchos-copy is required before excluding it as a cause.Level of evidence, low; benefit, substantial; grade ofrecommendation, B

3. In patients in whom bronchiolitis is sus-pected, a surgical lung biopsy should be per-formed when the combination of the clinicalsyndrome, physiology, and HRCT findings donot provide a confident diagnosis. Level of evi-dence, expert opinion; benefit, substantial; grade ofrecommendation, E/A

4. In patients with bacterial bronchiolitis,prolonged antibiotic therapy improves coughand is recommended. Level of evidence, low;benefit, substantial; grade of recommendation, B

5. In patients with toxic/antigenic exposureor drug-related bronchiolitis, cessation of theexposure or medication plus corticosteroidtherapy for those with physiologic impairmentis appropriate. Level of evidence, expert opinion;benefit, substantial; grade of recommendation, E/A

6. In the inflammatory bowel disease (IBD)patient with cough, bronchiolitis should be sus-pected as a potential cause. Level of evidence,low; benefit, substantial; grade of recommendation, B

7. In patients in whom IBD-related bronchi-olitis is suspected, both adverse drug reactionand infection should be specifically considered.Level of evidence, expert opinion; benefit, substan-tial; grade of recommendation, E/A

8. In patients with IBD, therapy with bothoral corticosteroids and ICSs may improvecough, and a trial of therapy is suggested. Levelof evidence, low; benefit, substantial; grade of rec-ommendation, B

9. In patients with chronic cough who haverecently lived in Japan, Korea, or China, diffuse




panbronchiolitis (DPB) should be considered inthe evaluations of the cause. Level of evidence,low; benefit, substantial; grade of recommendation, B

10. In patients with suspected DPB, an ap-propriate clinical setting and characteristicHRCT scan findings may obviate the need forinvasive testing and a trial of macrolide therapy(erythromycin or other 14-member ring macro-lides such as clarithromycin and roxithromycin)is appropriate. Level of evidence, expert opinion;benefit, substantial; grade of recommendation, E/A

11. In patients with DPB, prolonged treat-ment (> 2 to 6 months) with erythromycin (orother 14-member ring macrolides such as clar-ithromycin and roxithromycin) is recom-mended. Level of evidence, low; benefit, substan-tial; grade of recommendation, B

Postinfectious Cough19

1. When a patient complains of cough thathas been present following symptoms of anacute respiratory infection for at least 3 weeks,but not more than 8 weeks, consider a diagnosisof postinfectious cough. Quality of evidence, ex-pert opinion; net benefit, intermediate; strength ofrecommendation, E/B

2. In patients with subacute postinfectiouscough, because there are multiple pathogeneticfactors that may contribute to the cause of cough(including postviral airway inflammation with itsattendant complications such as bronchial hyper-responsiveness, mucus hypersecretion and im-paired mucociliary clearance, upper airway coughsyndrome [UACS], asthma, and gastroesophagealreflux disease), judge which factors are mostlikely provoking cough before considering ther-apy. Quality of evidence, expert opinion; net benefit,intermediate; strength of recommendation, E/B

3. In children and adult patients with coughfollowing an acute respiratory tract infection, ifcough has persisted for > 8 weeks, considerdiagnoses other than postinfectious cough.Quality of evidence, low; net benefit, intermediate;strength of recommendation, C

4. For adult patients with postinfectiouscough, not due to bacterial sinusitis or early onin a Bordetella pertussis infection, while theoptimal treatment is not known:

4a. Therapy with antibiotics has no role, asthe cause is not bacterial infection. Level ofevidence, expert opinion; net benefit, none; grade ofevidence, I

4b. Consider a trial of inhaled ipratropium asit may attenuate the cough. Level of evidence,fair; net benefit, intermediate; grade of evidence, B

4c. In patients with postinfectious cough,when the cough adversely affects the patient’squality of life and when cough persists despiteuse of inhaled ipratropinin, consider the use ofinhaled corticosteroids. Level of evidence, expertopinion; net benefit, intermediate; grade of evi-dence, E/B

4d. For severe paroxysms of postinfectiouscough, consider prescribing 30 to 40 mg ofprednisone per day for a short, finite period oftime when other common causes of cough (eg,UACS due to rhinosinus diseases, asthma, orgastroesophageal reflux disease) have beenruled out. Level of evidence, low; net benefit,intermediate; grade of evidence, C

4e. Central acting antitussive agents such ascodeine and dextromethorphan should be con-sidered when other measures fail. Level of evi-dence, expert opinion; net benefit, intermediate;grade of evidence, E/B

5. When a patient has a cough lasting for > 2weeks without another apparent cause and it isaccompanied by paroxysms of coughing, post-tussive vomiting, and/or an inspiratory whoop-ing sound, the diagnosis of a B pertussis infec-tion should be made unless another diagnosis isproven. Level of evidence, low; net benefit, sub-stantial; grade of evidence, B

6a. For all patients who are suspected ofhaving whooping cough, to make a definitivediagnosis order a nasopharyngeal aspirate orpolymer (Dacron; INVISTA; Wichita, KS) swabof the nasopharynx for culture to confirm thepresence of B pertussis. Isolation of the bacteriais the only certain way to make the diagnosis.Level of evidence, low; net benefit, substantial;grade of evidence, B

6b. PCR confirmation is available but is notrecommended as there is no universally ac-cepted, validated technique for routine clinicaltesting. Level of evidence, low; net benefit, conflict-ing; grade of evidence, I

7. In patients with suspected pertussis infec-tion, to make a presumptive diagnosis of thisinfection, order paired acute and convalescentsera in a reference laboratory. A fourfold in-crease in IgG or IgA antibodies to PT or FHA isconsistent with the presence of a recent Bpertussis infection. Level of evidence, low; netbenefit, intermediate; grade of evidence, C

8. A confirmed diagnosis of pertussis infec-tion should be made when a patient with coughhas B pertussis isolated from a nasopharyngealculture or has a compatible clinical picture with




an epidemiologic linkage to a confirmed case.Level of evidence, low; net benefit, substantial;grade of evidence, B

9. Children and adult patients with con-firmed or probable whooping cough shouldreceive a macrolide antibiotic and should beisolated for 5 days from the start of treatmentbecause early treatment within the first fewweeks will diminish the coughing paroxysmsand prevent spread of the disease; treatmentbeyond this period may be offered but it isunlikely the patient will respond. Level of evi-dence, good; net benefit, substantial; grade of evi-dence, A

10. Long-acting �-agonists, antihistamines,corticosteroids, and pertussis Ig should not beoffered to patients with whooping cough be-cause there is no evidence that they benefitthese patients. Level of evidence, good; net benefit,none; grade of evidence, D

11. All children should receive preventionagainst pertussis infection as part of a completediphtheria, tetanus, acellular pertussis (DTap)primary vaccination series. This should be fol-lowed by a single dose DTap booster vaccina-tion early in adolescence. Level of evidence, good;net benefit, substantial; grade of evidence, A

12. For all adults up to the age of 65, vacci-nation with the stronger formulation of TDapvaccine should be administered according toCDC guidelines. Level of evidence, expert opinion;net benefit, substantial; grade of evidence, E/A

Chronic Cough Due to Lung Tumors20

1. In a patient with cough who has risk fac-tors for lung cancer or a known or suspectedcancer in another site that may metastasize tothe lungs, a chest radiograph should be ob-tained. Level of evidence, expert opinion; benefit,substantial; grade of recommendation, E/A

2. In patients with a suspicion of airway in-volvement by a malignancy (eg, smokers withhemoptysis), even when the chest radiographfindings are normal, bronchoscopy is indicated.Level of evidence, low; benefit, substantial; grade ofrecommendation, B

3. For patients with stage I and II non-smallcell lung cancer (NSCLC), surgery to remove theNSCLC is the treatment of choice. If cough wascaused by a NSCLC that can be surgically re-moved, the cough will typically cease. Level ofevidence, low; benefit, substantial; grade of recommen-dation, B

4. For patients with more advanced NSCLC(stages III and IV), external beam radiation

and/or chemotherapy should usually be offered.Level of evidence, good; benefit, intermediate; gradeof recommendation, A

5. For patients with dyspnea or hemoptysisdue to endobronchial tumors, cough may alsobe present. Endobronchial methods should beconsidered for the palliation of these symptoms,but cough alone is seldom a reason to offer suchtreatment. Level of evidence, fair; benefit, small;grade of recommendation, C

6. For patients with cough and lung cancer,the use of centrally acting cough suppressantssuch as dihydrocodeine and hydrocodone isrecommended. Level of evidence, low; benefit,intermediate; grade of recommendation, C

Cough and Aspiration of Food and Liquids Due toOral-Pharyngeal Dysphagia21

1. In patients with cough, a medical historyparticularly directed at identifying conditionsincreasing the likelihood of oral-pharyngealdysphagia and aspiration (as indicated in Table1 in Smith Hammond and Goldstein21) shouldbe obtained. Patients with high-risk conditionsshould be referred for an oral-pharyngeal swal-lowing evaluation. Level of evidence, low; benefit,substantial; grade of recommendation, B

2a. Patients with cough and their caregiversshould be questioned regarding perceived swal-lowing problems, including an association ofcough while eating or drinking and a fear ofchoking while eating and drinking. If a patientwith cough reports swallowing problems, furtherevaluation for oral-pharyngeal dysphagia is indi-cated. Level of evidence, low; benefit, substantial;grade of recommendation, B

2b. Further evaluation, including a chest ra-diograph and a nutritional assessment, shouldbe considered in patients with cough or condi-tions associated with aspiration. Level of evi-dence, low; benefit, substantial; grade of recommen-dation, B

3. Patients with oral-pharyngeal dysphagiaand cough should be referred, ideally to aspeech-language pathologist (SLP), for an oral-pharyngeal swallow evaluation. Level of evi-dence, low; benefit, substantial; grade of recommen-dation, B

4. Patients with cough related to pneumoniaand bronchitis who have received medical diag-noses and conditions associated with aspiration(Table 1 in Smith Hammond and Goldstein21)should be referred, ideally to an SLP, for an




oral-pharyngeal swallow evaluation. Level of ev-idence, low; benefit, substantial; grade of recommen-dation, B

5. Patients with a reduced level of conscious-ness are at high risk for aspiration and shouldnot be fed orally until the level of consciousnesshas improved. Level of evidence, low; benefit,substantial; grade of recommendation, B

6. Alert patients with cough who are in high-risk groups for aspiration (Table 1 in SmithHammond and Goldstein21) should be observeddrinking small amounts of water (3 oz). If thepatient coughs or shows clinical signs that areassociated with aspiration (Tables 2, 3 in SmithHammond and Goldstein21), the patient shouldbe referred for a detailed swallowing evalua-tion, preferably to an SLP. Level of evidence, low;benefit, substantial; grade of recommendation, B

7. In patients with cough, the value of thesubjective assessment of voluntary cough (VC)as the sole predictor of aspiration is uncertainbecause of poor reliability and an unclear asso-ciation with evaluation. Level of evidence, low;benefit, conflicting; grade of evidence, I

8. The assessment of the reflexive cough re-sponse to inhaled irritants as a predictor ofaspiration risk and subsequent pneumonia isnot recommended due to a lack of adequatesupportive studies. Level of evidence, low; benefit,conflicting; grade of evidence, I

9. In acute stroke patients, the expulsivephase rise time of VC may predict aspiration.The use of this test has not been validated inother patient groups, and further studies com-paring the accuracy of objective measures ofVC to the clinical swallow evaluation to identifyaspiration risk are needed. Level of evidence, low;benefit, small; grade of recommendation, C

10. Patients with dysphagia should undergovideofluoroscopic swallow evaluation (VSE) orfiberoptic endoscopic evaluation of swallowing(FEES) to identify appropriate treatment. Levelof evidence, low; benefit, substantial; grade of rec-ommendation, B

11. Patients with dysphagia should be man-aged by organized multidisciplinary teams thatmay include a physician, a nurse, an SLP, adietitian, and physical and occupational thera-pists. Level of evidence, low; benefit, substantial;grade of recommendation, B

12. In patients with dysphagia, VSE or FEEScan be useful for determining compensatorystrategies enabling patients with dysphagia tosafely swallow. Level of evidence, low; benefit,substantial; grade of recommendation, B

13. In patients with dysphagia, dietary rec-

ommendations should be prescribed when indi-cated, and can be refined by testing with foodsand liquids simulating those in a normal dietduring the VSE or FEES. Level of evidence, low;benefit, substantial; grade of recommendation, B

14. For patients with muscular weakness dur-ing swallowing, muscle strength training, withor without electromyographic biofeedback, andelectrical stimulation treatment of the swallow-ing musculature are promising techniques butcannot be recommended at this time until fur-ther work in larger populations is performed.Level of evidence, low; benefit, conflicting; grade ofevidence, I

15. Patients with intractable aspiration maybe considered for surgical intervention. Level ofevidence, low; benefit, substantial; grade of recom-mendation, B

Angiotensin-Converting Enzyme Inhibitor-InducedCough22

1. In patients presenting with chronic cough,in order to determine that the angiotensin-converting enzyme (ACE) inhibitor is the causeof the cough, therapy with ACE inhibitorsshould be discontinued regardless of the tem-poral relation between the onset of cough andthe initiation of ACE inhibitor therapy. Thediagnosis is confirmed by the resolution ofcough, usually within 1 to 4 weeks of the cessa-tion of the offending agent; however, the reso-lution of cough may be delayed in a subgroup ofpatients for up to 3 months. Quality of evidence,low; net benefit, substantial; grade of recommenda-tion, B

2. In patients presenting with chronic ACEinhibitor-induced cough, discontinue therapywith the drug because it is the only uniformlyeffective treatment. Quality of evidence, low; netbenefit, substantial; grade of recommendation, B

3. In patients whose cough resolves after thecessation of therapy with ACE inhibitors, andfor whom there is a compelling reason to treatwith these agents, a repeat trial of ACE inhibi-tor therapy may be attempted. Quality of evi-dence, fair; net benefit, substantial; grade of recom-mendation, A

4. In patients for whom the cessation of ACEinhibitor therapy is not an option, pharmacologictherapy, including that with sodium cromogly-cate, theophylline, sulindac, indomethacin, amlo-dipine, nifedipine, ferrous sulfate, and picota-mide that is aimed at suppressing cough shouldbe attempted. Quality of evidence, fair; net benefit,intermediate; grade of recommendation, B




5. In patients in whom persistent or intoler-able ACE inhibitor-induced cough occurs, ther-apy should be switched, when indicated, to anangiotensin receptor blocker, with which theincidence of associated cough appears to besimilar to that for the control drug, or to anappropriate agent of another drug class. Qualityof evidence, good; net benefit, substantial; grade ofrecommendation, A

Habit Cough, Tic Cough, and Psychogenic Coughin Adult and Pediatric Populations23

1a. In adult patients with chronic cough, thediagnoses of habit cough or psychogenic coughcan only be made after an extensive evaluationhas been performed that includes ruling out ticdisorders and uncommon causes (as describedin the section “Uncommon Causes of Cough”),and cough improves with specific therapy suchas behavior modification or psychiatric therapy.Level of evidence, expert opinion; benefit, substan-tial; grade of recommendation, E/A

1b. In adult patients with chronic cough thatremains persistently troublesome despite anextensive and thorough evidence-based evalua-tion, and after behavior modification and/orpsychiatric therapy have failed, unexplainedcough should be diagnosed rather than a habitcough or psychogenic cough. Level of evidence,expert opinion; benefit, substantial; grade of recom-mendation, E/A

1c. In children with chronic cough, the diag-noses of habit cough or psychogenic cough canonly be made after tic disorders and Tourettesyndrome have been evaluated and cough im-proves with specific therapy such as behaviormodification or psychiatric therapy. Level ofevidence, expert opinion; benefit, substantial; gradeof recommendation, E/A

2. In adult patients with cough, the diagnosisof habit cough should not be made unless bio-logical and genetic tic disorders associated withcoughing such as Tourette syndrome have beenruled out. Level of evidence, expert opinion; bene-fit, substantial; grade of recommendation, E/A

3. In adults with chronic cough, the presenceor absence of nighttime cough or cough with abarking or honking character should not beused to diagnose or exclude a diagnosis ofpsychogenic cough. Level of evidence, low; bene-fit, substantial; grade of recommendation, B

4. In children with chronic cough, the char-acteristics of the cough may be suggestive of,but are not diagnostic of, psychogenic cough.The presence or absence of nighttime cough

should not be used to diagnose or excludepsychogenic cough. Level of evidence, expertopinion; benefit, substantial; grade of recommenda-tion, E/A

5. In adult and pediatric patients with chronicunexplained cough, common psychosocial prob-lems such as anxiety, depression, domestic vio-lence, and child abuse/neglect that are often as-sociated with somatization disorders should beevaluated. Level of evidence, expert opinion; benefit,substantial; grade of recommendation, E/A

6. In adult and pediatric patients withchronic cough associated with troublesome psy-chological manifestations, psychological coun-seling or psychiatric intervention should beencouraged, after other causes have been ruledout. Level of evidence, expert opinion; benefit,small/weak; grade of recommendation, E/C

Chronic Cough Due to Chronic InterstitialPulmonary Diseases24

1. In patients with chronic cough, beforediagnosing interstitial lung disease (ILD) as thesole cause, common etiologies such as UACS,which was previously referred to as PNDS,asthma, and GERD should be considered. Asthese common causes may also share clinicalfeatures with specific ILDs, a diagnosis of ILDas the cause of cough should be considered adiagnosis of exclusion. Level of evidence, expertopinion; benefit, substantial; grade of recommenda-tion, E/A

2. In patients with cough secondary to anILD, because of the prognostic implications,primary treatment should be dictated by thespecific disorder. Level of evidence, low; benefit,substantial; grade of recommendation, B

3. In patients with cough secondary to idio-pathic pulmonary fibrosis, corticosteroids maylead to symptomatic improvement; however, asthey have been shown to neither prolong survivalnor improve quality of life and may be associatedwith significant side effects, their use requires anindividualized analysis of the overall benefits andrisks. Level of evidence, expert opinion; benefit, inter-mediate; grade of recommendation, E/B

4. In patients with cough and characteristicclinical and radiographic features, sarcoidosisshould be considered as a cause. Level of evi-dence, expert opinion; benefit, substantial; grade ofrecommendation, E/A

5. In patients with cough secondary to sarcoid-osis, although therapy with oral corticosteroidsmay lead to symptomatic improvement, as theyhave not been proven to have a durable benefit




and are associated with significant side effects, anindividualized analysis of the overall benefit andrisk is necessary. Level of evidence, fair; benefit,intermediate; grade of recommendation, B

6. In patients with cough secondary to sar-coidosis, therapy with oral corticosteroids fol-lowed by ICSs may improve symptoms. Level ofevidence, fair; benefit, conflicting; grade of recom-mendation, I

7. In patients with cough, ILD, and a con-cerning environmental, occupational, or avoca-tional exposure, hypersensitivity pneumonitisshould be considered as a potential cause. Levelof evidence, expert opinion; benefit, substantial;grade of recommendation, E/A

8. In patients with cough due to hypersensi-tivity pneumonitis, treatment should includethe removal of the offending exposure andsystemic corticosteroid therapy in those withevidence of physiologic impairment. Level ofevidence, low; benefit, substantial; grade of recom-mendation, B

Cough: Occupational and EnvironmentalConsiderations25

1. In every patient with cough, when taking amedical history, ask about occupational andenvironmental causes. Level of evidence, expertopinion; benefit, substantial; grade of recommenda-tions, E/A

2. In every patient with cough who has po-tentially significant exposures to suspicious en-vironmental or occupational causes, determinethe relationship of these occupational and envi-ronmental factors to confirm or refute theirrole in cough and to modify or eliminate expo-sure to the relevant agents. Level of evidence,expert opinion; benefit, substantial; grade of recom-mendations, E/A

3. Because outdoor environmental pollutionand occupational exposures can be importantfactors in causing cough, physicians should playa role in developing and supporting enforce-able standards for safe workplace and outdoorair pollution exposure limits. Level of evidence,expert opinion; benefit, substantial; grade of recom-mendations, E/A

4. In patients with a high suspicion of coughdue to environmental or occupational expo-sures, consider referring the patient to aspecialist in this area or consult evidence-based guidelines. Level of evidence, expert opin-ion; net benefit, substantial; grade of recommen-dation, E/A

Chronic Cough Due to Tuberculosis and OtherInfections26

1. In areas where there is a high prevalenceof TB, chronic cough should be defined as it isin the World Health Organization Practical Ap-proach to Lung Health program as being 2 to 3weeks in duration. Level of evidence, low; benefit,substantial; grade of recommendation, B

2. In patients with chronic cough who live inareas with a high prevalence of TB, this diagnosisshould be considered, but not to the exclusion ofthe more common etiologies. Sputum smears andcultures for acid-fast bacilli and a chest radio-graph should be obtained whenever possible.Level of evidence, low; benefit, substantial; grade ofrecommendation, B

3. In patients with suspected TB, future in-vestigations are needed to refine the criteria forsuspecting TB and initiating a diagnostic evalu-ation, to utilize resources in a cost-effectivemanner and to improve patient and caregiveradherence to diagnostic recommendations.Level of evidence, expert opinion; benefit, substan-tial; grade of recommendation, E/A

4. In populations at increased risk of becom-ing infected with TB and transmitting it toothers by cough (eg, those persons in prisonsand nursing homes), special measures to pre-vent outbreaks must be made by public healthagencies to screen for new cases, maintain sur-veillance of existing populations, and establisheffective diagnostic and treatment programsearly in the evaluation. Level of evidence, good;benefit, substantial; grade of recommendation, A

5. In patients with unexplained chronic coughwho have resided in areas of endemic infectionwith fungi or parasites, a diagnostic evaluation forthese pathogens should be undertaken whenmore common causes of cough have been ruledout. Level of evidence, low; benefit, substantial; gradeof recommendation, B

Peritoneal Dialysis and Cough27

1. In patients receiving long-term peritonealdialysis with cough, evaluate the patient for thepotential causes with increased prevalence inthis population such as GERD, ACE inhibitors,pulmonary edema, asthma that may be exacer-bated by �-adrenergic-blocking medications,and infection. Level of evidence, expert opinion;benefit, substantial; grade of recommendation, E/A

Cough in the Immunocompromised Host28

1. In patients with immune deficiency, theinitial diagnostic algorithm for patients with




acute, subacute, and chronic cough is the sameas that for immunocompetent persons, takinginto account an expanded list of differentialdiagnoses that considers the type and severityof immune defect and geographic factors. Levelof evidence, expert opinion; benefit, substantial;grade of recommendation, E/A

2. In HIV-infected patients, CD4� lympho-cyte counts should be used in constructing thelist of differential diagnostic possibilities poten-tially causing cough. Level of evidence, low; ben-efit, substantial; grade of recommendation, B

3. HIV-infected patients with CD4� lympho-cyte counts of < 200 cells/�L or those patientswith counts of > 200 cells/�L with unexplainedfever, weight loss, or thrush who have unex-plained cough should be suspected of havingPneumocystis pneumonia, tuberculosis, andother opportunistic infections, and should beevaluated accordingly. Level of evidence, low;benefit, substantial; grade of recommendation, B

Uncommon Causes of Cough29

1. In patients with chronic cough, uncommoncauses should be considered when cough per-sists after evaluation for common causes andwhen the diagnostic evaluation suggests that anuncommon cause, pulmonary as well as ex-trapulmonary (see Table 1 in section 28), maybe contributing. Level of evidence, low; benefit,substantial; grade of recommendation, B

2. In patients with chronic cough, until un-common causes that potentially may be contrib-uting to the patient’s cough have been ruledout, the diagnosis of unexplained cough shouldnot be made. Level of evidence, low; benefit,substantial; grade of recommendation, B

3. If cough persists after consideration of themost common causes, perform a chest CT scanand, if necessary, a bronchoscopic evaluation.Level of evidence, low; benefit, substantial; grade ofrecommendation, B

4. In patients who present with abrupt onset ofcough, consider the possibility of an airway for-eign body. Level of evidence, low; benefit, substantial;grade of recommendation, B

5. In patients with unexplained cough, eval-uate the possibility of drug-induced cough.Level of evidence, low; benefit, substantial; grade ofrecommendation, B

6. In patients with unexplained cough, con-sider a therapeutic trial of withdrawing thedrug that is suspected to cause the cough. Levelof evidence, low; benefit, substantial; grade of rec-ommendation, B

Unexplained (Idiopathic) Cough30

1. The diagnosis of unexplained (idiopathic)cough is a diagnosis of exclusion. It should notbe made until a thorough diagnostic evaluationis performed, specific and appropriate treat-ment (according to the management protocolsthat have performed the best in the literature)has been tried and has failed, and uncommoncauses have been ruled out. Level of evidence,expert opinion; benefit, substantial; grade of recom-mendation, E/A

An Empiric Integrative Approach to theManagement of Cough3

1. In patients with cough, the starting pointis the medical history and physical examination.Although the timing and characteristics of thecough are of little diagnostic value, the medicalhistory is important to determine whether thepatient is receiving an ACE inhibitor, is asmoker, or has evidence of a serious life-threat-ening or systemic disease. Level of evidence,expert opinion; benefit, substantial; grade of recom-mendation, E/A

2. In patients with an acute cough, first de-termine whether the acute cough is a reflectionof a serious illness such as pneumonia or pul-monary embolism, or, as is usually the case, amanifestation of a non-life-threatening diseasesuch as a respiratory tract infection (eg, com-mon cold or lower respiratory tract infection),an exacerbation of a preexisting condition (eg,COPD, UACS, asthma, or bronchiectasis), or anenvironmental or occupational exposure tosome noxious or irritating agent (eg, allergic orirritant-induced rhinitis). Level of evidence, ex-pert opinion; benefit, substantial; grade of recom-mendation, E/A

3. In patients with a subacute cough, firstdetermine whether it is a postinfectious coughor not. If it is postinfectious, determine whetherit is a result of UACS, transient bronchial hy-perresponsiveness, asthma, pertussis, or anacute exacerbation of chronic bronchitis. If it isnoninfectious, manage the cough the same wayas chronic cough. Level of evidence, expert opin-ion; benefit, substantial; grade of recommendation,E/A

4a. In patients with chronic cough, systemat-ically direct empiric treatment at the most com-mon causes of cough (ie, UACS, asthma, NAEB,and GERD). Level of evidence, low; benefit, sub-stantial; grade of recommendation, B

4b. In patients with chronic cough, therapyshould be given in sequential and additive steps




because more than one cause of cough may bepresent. Level of evidence, low; benefit, substantial;grade of recommendation, B

5. Patients with a chronic cough who smokeshould be counseled and assisted with smokingcessation. Level of evidence, low; benefit, substan-tial; grade of recommendation, B

6. In a patient with cough who is receiving anACE inhibitor, therapy with the drug should bestopped and the drug should be replaced. Levelof evidence, low; benefit, substantial; grade of rec-ommendation, B

7. In patients with chronic cough, initial em-piric treatment should begin with an oral first-generation A/D. Level of evidence, low; benefit,substantial; grade of recommendation, B

8a. In patients whose chronic cough persistsafter treatment for UACS, the possibility thatasthma is the cause of cough should be workedup next. The medical history is sometimes sug-gestive, but is not reliable in either ruling in orruling out asthma. Therefore, ideally, broncho-provocation challenge (BPC), if spirometry doesnot indicate reversible airflow obstruction,should be performed in the evaluation forasthma as a cause of cough. In the absence ofthe availability of BPC, an empiric trial ofantiasthma therapy should be administered (seesection on the treatment of asthma in thisguideline). Level of evidence, low; benefit, substan-tial; grade of recommendation, B

8b. In patients with chronic cough, in whomthe diagnoses of UACS and asthma have beeneliminated or treated without the elimination ofcough, NAEB should be considered next with aproperly performed induced sputum test foreosinophils. If a properly performed inducedsputum test to determine whether eosinophilicbronchitis is present cannot be performed, anempiric trial of corticosteroids should be thenext step. Level of evidence, low; benefit, substan-tial; grade of recommendation, B

9. In the majority of patients with suspectedcough due to asthma, ideally, before starting anoral corticosteroid regimen, a BPC should beperformed and, if the result is positive, somecombination therapy of ICSs, inhaled �-ago-nists, or oral leukotriene inhibitors should beadministered. A limited trial of oral corticoste-roids, however, should be administered in somepatients who are suspected of having asthma-induced cough before eliminating the diagnosisfrom further consideration. Level of evidence,low; benefit, substantial; grade of recommendation, B

10. In patients whose cough responds onlypartially or not at all to interventions for UACS

and asthma or NAEB, treatment for GERDshould be instituted next. Level of evidence, low;benefit, substantial; grade of recommendation, B

11. In patients with cough whose conditionremains undiagnosed after all of the above hasbeen done, referral to a cough specialist is indi-cated. Level of evidence, expert opinion; benefit,substantial; grade of recommendation, E/A

Assessing Cough Severity and Efficacy of Therapyin Clinical Research31

1. In patients with chronic cough, to opti-mally evaluate the efficacy of cough-modifyingagents, investigators should use both subjectiveand objective methods because they have thepotential to measure different things. A pa-tient’s subjective response is likely to be theonly one that measures the impact of the inten-sity of cough. Level of evidence, expert opinion;benefit, substantial; grade of recommendation, E/A

2. In patients with chronic cough, with re-spect to subjective methods, it is recommendedthat a valid and reliable cough-specific health-related quality-of-life instrument be utilized.Level of evidence, fair; benefit, substantial; grade ofrecommendation, A

3. When assessing patients with chroniccough, even though visual analog scales havenot been psychometrically tested, they are rec-ommended because they are commonly usedand valid, and they are likely to yield differentbut complementary results to cough-specifichealth-related quality-of-life instruments. Levelof evidence, low; benefit, intermediate; grade ofrecommendation, C

4. When assessing patients with chronic cough,because health-related quality-of-life instrumentshave been psychometrically tested and visual an-alog scales have not, the cough-specific health-related quality-of-life instruments are recom-mended as the primary subjective outcomemeasure. Level of evidence, fair; benefit, intermedi-ate; grade of recommendation, B

5. In patients with chronic cough, with re-spect to objective methods, tussigenic chal-lenges should be used before and after theintervention to assess the effect of therapy oncough sensitivity only in disease states in whichcough reflex sensitivity is known to be height-ened. Level of evidence, low; benefit, small/weak;grade of recommendation, C

6. In patients with chronic cough, becausethe act of coughing has the potential to trauma-tize the upper airway (eg, the vocal cords),assessing the presence of upper airway edema




before and after therapy with flow-volumeloops is useful. Level of evidence, low; benefit,intermediate; grade of recommendation, C

7. In patients undergoing treatment forchronic cough, cough counting over 24 h isrecommended with a computerized methodol-ogy that is reliable and accurate, noninvasiveand portable, and easy to use in unattended,ambulatory, real-life settings within a patient’shome environment. Level of evidence, low; bene-fit, intermediate; grade of recommendation, C

Cough Suppressant and Pharmacologic ProtussiveTherapy32

1. In patients with chronic bronchitis,agents that have been shown to alter mucuscharacteristics are not recommended for coughsuppression. Level of evidence, good; benefit,none; grade of recommendation, D

2. In patients with cough due to upper respi-ratory infection (URI) or chronic bronchitis, theonly inhaled anticholinergic agent that is rec-ommended for cough suppression is ipratro-pium bromide. Level of evidence, fair; benefit,substantial; grade of recommendation, A

3. In patients with chronic or acute bronchi-tis, peripheral cough suppressants, such as levo-dropropizine and moguisteine, are recom-mended for the short-term symptomatic reliefof coughing. Level of evidence, good; benefit,substantial; grade of recommendation, A

4. In patients with cough due to URI, periph-eral cough suppressants have limited efficacyand are not recommended for this use. Level ofevidence, good; benefit, none; grade of recommen-dation, D

5. In patients with chronic bronchitis, centralcough suppressants, such as codeine and dex-tromethorphan, are recommended for theshort-term symptomatic relief of coughing.Level of evidence, fair; benefit, intermediate; gradeof recommendation, B

6. In patients with cough due to URI, centralcough suppressants have limited efficacy forsymptomatic relief and are not recommendedfor this use. Level of evidence, good; benefit, none;grade of recommendation, D

7. In patients with chronic or acute coughrequiring symptomatic relief, drugs that affectthe efferent limb of the cough reflex are notrecommended. Level of evidence, low; benefit,none; grade of recommendation, D

8. In patients requiring intubation duringgeneral anesthesia, the use of neuromuscularblocking agents is recommended to suppress

coughing. Level of evidence, good; benefit, sub-stantial; grade of recommendation, A

9. In patients with acute cough due to thecommon cold, preparations containing zinc arenot recommended. Level of evidence, good; ben-efit, none; grade of recommendation, D

10. In patients with acute cough due to thecommon cold, over the counter combinationcold medications, with the exception of an olderantihistamine-decongestant, are not recom-mended until randomized controlled trialsprove they are effective cough suppressants.Level of evidence, fair; benefit, none; grade ofrecommendation, D

11. In patients with acute or chronic coughnot due to asthma, albuterol is not recom-mended. Level of evidence, good; benefit, none;grade of recommendation, D

12. In patients with neuromuscular impair-ment, protussive pharmacologic agents are in-effective and should not be prescribed. Level ofevidence, good; benefit, none; grade of recommen-dation, D

13. In patients with bronchitis, hypertonicsaline solution and erdosteine are recom-mended on a short-term basis to increase coughclearance. Level of evidence, good; benefit, sub-stantial; grade of recommendation, A

14. In adult patients with CF, amiloride isrecommended to increase cough clearance.Level of evidence, good; benefit, substantial; gradeof recommendation, A

15. In adult patients with CF, while recombi-nant DNase does improve spirometry it is notrecommended to increase cough clearance.Level of evidence, good; benefit, none; grade ofrecommendation, D

Nonpharmacologic Airway Clearance Therapies33

1. In patients with CF, chest physiotherapy isrecommended as an effective technique to in-crease mucus clearance, but the effects of eachtreatment are relatively modest and the long-term benefits unproven. Level of evidence, fair;benefit, small; grade of recommendation, C

2. In patients with expiratory muscle weak-ness, manually assisted cough should be consid-ered to reduce the incidence of respiratorycomplications. Level of evidence, low; benefit,small; grade of recommendation, C

3. In persons with airflow obstruction causedby disorders like COPD, manually assisted coughmay be detrimental and should not be used. Levelof evidence, low; benefit, negative; grade of recommen-dation, D




4. In patients with COPD and CF, huffingshould be taught as an adjunct to other methodsof sputum clearance. Level of evidence, low; ben-efit, small; grade of recommendation, C

5. In patients with CF, autogenic drainageshould be taught as an adjunct to posturaldrainage as a method to clear sputum because ithas the advantage of being performed withoutassistance and in one position. Level of evidence,low; benefit, small; grade of recommendation, C

6. In patients with neuromuscular weaknessand impaired cough, expiratory muscle trainingis recommended to improve peak expiratorypressure, which may have a beneficial effect oncough. Level of evidence, expert opinion; benefit,small; grade of recommendation, E/C

7. In patients with CF, positive expiratorypressure is recommended over conventionalchest physiotherapy because it is approximatelyas effective as chest physiotherapy, and is inex-pensive, safe, and can be self-administered.Level of evidence, fair; benefit, intermediate; gradeof recommendation, B

8. In patients with CF, devices designed tooscillate gas in the airway, either directly or bycompressing the chest wall, can be consideredas an alternative to chest physiotherapy. Level ofevidence, low; benefit, conflicting; grade of recom-mendation, I

9. In patients with neuromuscular diseasewith impaired cough, mechanical cough assistdevices are recommended to prevent respira-tory complications. Level of evidence, low; benefit,intermediate; grade of recommendation, C

10. The effect of nonpharmacologic airwayclearance techniques on long-term outcomessuch as health-related quality of life and rates ofexacerbations, hospitalizations, and mortality isnot known at this time. The committee recom-mends that future investigations measure theseoutcomes in patients with CF, and in otherpopulations with bronchiectasis, COPD, andneuromuscular diseases. Level of evidence, expertopinion; benefit, substantial; grade of recommenda-tion, E/A

Guidelines for Evaluating Cough in Pediatrics4

1. Children with chronic cough requirecareful and systematic evaluation for the pres-ence of specific diagnostic indicators. Level ofevidence, expert opinion; benefit, substantial; gradeof recommendation, E/A

2. Children with chronic cough should un-dergo, as a minimum, a chest radiograph and

spirometry (if age appropriate). Level of evi-dence, expert opinion; benefit, intermediate; gradeof recommendation, E/B

3. In children with specific cough, furtherinvestigations may be warranted, except whenasthma is the etiologic factor. Level of evidence,expert opinion; benefit, intermediate; grade of rec-ommendation, E/B

4. Children with chronic productive purulentcough should always be investigated to docu-ment the presence or absence of bronchiectasisand to identify underlying and treatable causessuch as cystic fibrosis and immune deficiency.Level of evidence, low; benefit, substantial; grade ofrecommendation, B

5. In children with chronic cough, the etiol-ogy should be defined and treatment should beetiologically based. Level of evidence, expert opin-ion; benefit, substantial; grade of recommendation,E/A

6. In children with nonspecific cough, coughmay spontaneously resolve, but children shouldbe reevaluated for the emergence of specificetiologic pointers (see Table 1 in Chang andGlomb4). Level of evidence, low; benefit, substan-tial; grade of recommendation, B

7. In children with nonspecific cough and riskfactors for asthma, a short trial (ie, 2 to 4 weeks) ofbeclomethasone, 400 �g/d, or the equivalent dos-age with budesonide may be warranted. How-ever, most children with nonspecific cough do nothave asthma. In any case, these children shouldalways be reevaluated in 2 to 4 weeks. Level ofevidence, fair; benefit, intermediate; grade of recom-mendation, B

8. In children who have started therapy with amedication, if the cough does not resolve duringthe medication trial within the expected responsetime, the medication should be withdrawn andother diagnoses considered. Level of evidence, low;benefit, intermediate; grade of recommendation, C

9. In children with cough, cough suppressantsand other over-the-counter cough medicinesshould not be used as patients, especially youngchildren, may experience significant morbidityand mortality. Level of evidence, good; benefit, none;grade of recommendation, D

10. In children with nonspecific cough, parentalexpectations should be determined, and the specificconcerns of the parents should be sought and ad-dressed. Level of evidence, low; benefit, intermediate;grade of recommendation, E/B

11. In all children with cough, exacerbating fac-tors such as exposure to tobacco smoke should bedetermined and interventional options for the ces-




sation of exposure advised or initiated. Level ofevidence, low; benefit, substantial; grade of recommenda-tion, B

12. Children should be managed according tothe studies and guidelines for children (whenavailable), because etiologic factors and treat-ments in children are sometimes different fromthose in adults. Level of evidence, low; benefit,substantial; grade of recommendation, B

13. In children < 14 years of age withchronic cough, when pediatric-specific coughrecommendations are unavailable, adult recom-mendations should be used with caution. Levelof evidence, expert opinion; benefit, intermediate;grade of recommendation, E/B

Potential Future Therapies for the Management ofCough34

• Currently available cough-suppressant therapy is se-verely limited by a dearth of effective agents and theirunacceptable side affects. Several classes of pharmaco-logic agents are currently under investigation in anattempt to develop clinically useful cough suppression.

Future Directions in the Clinical Management ofCough35

1. As suggested in the various sections of thisguideline, further research should be con-ducted to elucidate the mechanisms of the pro-duction of cough in various diseases and condi-tions, the optimal methods of assessment, andtreatment, specific to the suspected cause. Levelof evidence, expert opinion; benefit, substantial;strength of recommendation, E/A

2. Research is particularly needed in areassuch as the treatment of postinfectious cough,the characterization of psychogenic cough, themethods of assessment of cough, and pharma-cotherapy. Level of evidence, expert opinion; ben-efit, substantial; strength of recommendation, E/A

ACKNOWLEDGMENT: This clinical practice guideline re-ceived the endorsements of the ATS and the CTS.

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DOI: 10.1378/chest.129.1_suppl.1S 2006;129;1-23 Chest

Smith Hammond and Susan M. Tarlo Melvin R. Pratter, Mark J. Rosen, Edward Schulman, John Jay Shannon, Carol Zelman Lewis, F. Dennis McCool, Douglas C. McCrory, Udaya B.S. Prakash,Goldstein, LeRoy M. Graham, Frederick E. Hargreave, Paul A. Kvale, Sandra

Anne B. Chang, Peter V. Dicpinigaitis, Ron Eccles, W. Brendle Glomb, Larry B.Sidney S. Braman, Christopher E. Brightling, Kevin K. Brown, Brendan J. Canning, Richard S. Irwin, Michael H. Baumann, Donald C. Bolser, Louis-Philippe Boulet,

Evidence-Based Clinical Practice GuidelinesDiagnosis and Management of Cough Executive Summary: ACCP

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