EvidenceAlerts

Morice AH, Millqvist E, Bieksiene K, et al. ERS guidelines on the diagnosis and treatment of chronic cough in adults and children. Eur Respir J. 2020 Jan 2;55(1). pii: 13993003.01136-2019. doi: 10.1183/13993003.01136-2019. Print 2020 Jan. (Evidence-based guideline)
Abstract

These guidelines incorporate the recent advances in chronic cough pathophysiology, diagnosis and treatment. The concept of cough hypersensitivity has allowed an umbrella term that explains the exquisite sensitivity of patients to external stimuli such a cold air, perfumes, smoke and bleach. Thus, adults with chronic cough now have a firm physical explanation for their symptoms based on vagal afferent hypersensitivity. Different treatable traits exist with cough variant asthma (CVA)/eosinophilic bronchitis responding to anti-inflammatory treatment and non-acid reflux being treated with promotility agents rather the anti-acid drugs. An alternative antitussive strategy is to reduce hypersensitivity by neuromodulation. Low-dose morphine is highly effective in a subset of patients with cough resistant to other treatments. Gabapentin and pregabalin are also advocated, but in clinical experience they are limited by adverse events. Perhaps the most promising future developments in pharmacotherapy are drugs which tackle neuronal hypersensitivity by blocking excitability of afferent nerves by inhibiting targets such as the ATP receptor (P2X3). Finally, cough suppression therapy when performed by competent practitioners can be highly effective. Children are not small adults and a pursuit of an underlying cause for cough is advocated. Thus, in toddlers, inhalation of a foreign body is common. Persistent bacterial bronchitis is a common and previously unrecognised cause of wet cough in children. Antibiotics (drug, dose and duration need to be determined) can be curative. A paediatric-specific algorithm should be used.

Ratings
Discipline Area Score
Pediatrics (General) 6 / 7
Respirology/Pulmonology 6 / 7
Family Medicine (FM)/General Practice (GP) 6 / 7
General Internal Medicine-Primary Care(US) 6 / 7
Internal Medicine 5 / 7
Comments from MORE raters

Pediatrics (General) rater

I wonder what chronic environmental smoke after bush fires is going to do with these recommendations.

Respirology/Pulmonology rater

This is a clear, organized review of the topic with a diagnostic algorithm and evidence-based treatment recommendations. This should be a good clinical resource for primary care physicians and pediatricians.

Respirology/Pulmonology rater

This guideline presents consensus recommendation for diagnosis and treatment of chronic cough. The most influential guidelines currently used are those from the ACCP that were updated in the past 2-4 years and still reflect current evidence needed to guide practice. The ACCP guidelines are more rigourous, evidence-based, and more detailed than these guidelines that used a blend of GRADE methodology and subjective expert opinion. Some key differences between the 2 guidelines stand out: 1. the recommendation for morphine (based on a single RCT done by the guideline's first author), which ACCP recommends against; 2. the relative lack of attention given to upper airway cough syndrome, which the ACCP guidelines emphasize as the single most common cause of chronic cough; and 3. the recommendation for empiric trials of inhaled medications without attempting first to establish a definitive diagnosis of asthma or COPD. Overall, these guidelines lack credibility due to their weaker methodology and do not add anything new and useful.

Respirology/Pulmonology rater

Chronic cough is one of the most common complaints fielded by pulmonologists. While we are well-versed in finding and treating the more common causes of chronic cough, the more nuanced causes can be challenging. This update represents state-of-the art management of chronic cough. The way the information is presented and the useful algorithms should improve our success in treating chronic cough.
Comments from EvidenceAlerts subscribers

No subscriber has commented on this article yet.