Note from the National Guideline Clearinghouse (NGC): For full context of the major recommendations stated below, please see the National Guideline Clearinghouse (NGC) summary of the American College of Chest Physician's guideline An Empiric Integrative Approach to the Management of Cough: ACCP Evidence-based Clinical Practice Guidelines, which utilizes a comprehensive approach, including algorithms for the clinician to follow in evaluating and treating the patient with acute, subacute, and chronic cough.
Definitions for the level of evidence, strength of recommendation, and net benefit follow the "Major Recommendations."
1a. In adult patients with chronic cough, the diagnoses of habit cough or psychogenic cough can only be made after an extensive evaluation has been performed that includes ruling out tic disorders and uncommon causes (as described in another section), and cough improves with specific therapy such as behavior modification or psychiatric therapy. Level of evidence, expert opinion; benefit, substantial; grade of recommendation, E/A
1b. In adult patients with chronic cough that remains persistently troublesome despite an extensive and thorough evidence-based evaluation, and after behavior modification and/or psychiatric therapy have failed, unexplained cough should be diagnosed rather than a habit cough or psychogenic cough. Level of evidence, expert opinion; benefit, substantial; grade of recommendation, E/A
1c. In children with chronic cough, the diagnoses of habit cough or psychogenic cough can only be made after tic disorders and Tourette syndrome have been evaluated and cough improves with specific therapy such as behavior modification or psychiatric therapy. Level of evidence, expert opinion; benefit, substantial; grade of recommendation, E/A
2. In adult patients with cough, the diagnosis of habit cough should not be made unless biological and genetic tic disorders associated with coughing such as Tourette syndrome have been ruled out. Level of evidence, expert opinion; benefit, substantial; grade of recommendation, E/A
3. In adults with chronic cough, the presence or absence of nighttime cough or cough with a barking or honking character should not be used to diagnose or exclude a diagnosis of psychogenic cough. Level of evidence, low; benefit, substantial; grade of recommendation, B
4. In children with chronic cough, the characteristics 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 exclude psychogenic cough. Level of evidence, expert opinion; benefit, substantial; grade of recommendation, E/A
5. In adult and pediatric patients with chronic unexplained cough, common psychosocial problems such as anxiety, depression, domestic violence, and child abuse/neglect that are often associated with somatization disorders should be evaluated. Level of evidence, expert opinion; benefit, substantial; grade of recommendation, E/A
6. In adult and pediatric patients with chronic cough associated with troublesome psychological manifestations, psychological counseling or psychiatric intervention should be encouraged, after other causes have been ruled out. Level of evidence, expert opinion; benefit, small/weak; grade of recommendation, E/C
Definitions:
Quality of the Evidence
Good = evidence is based on good randomized controlled trials (RCTs) or meta-analyses
Fair = evidence is based on other controlled trials or RCTs with minor flaws
Low = evidence is based on nonrandomized, case-control, or other observational studies
Expert opinion = evidence is based on the consensus of the carefully selected panel of experts in the topic field. There are no studies that meet the criteria for inclusion in the literature review.
Strength of Recommendations
A = strong recommendation
B = moderate recommendation
C = weak recommendation
D = negative recommendation
I = no recommendation possible (inconclusive)
E/A = strong recommendation based on expert opinion only
E/B = moderate recommendation based on expert opinion only
E/C = weak recommendation based on expert opinion only
E/D = negative recommendation based on expert opinion only
Net Benefit
Substantial = There is evidence of benefit that clearly exceeds the minimum clinically significant benefit and evidence of little harm
Intermediate = Clear evidence of benefit but with some evidence of harms, with a net benefit between that defined for "substantial" and "small/weak"
Small/weak = There is evidence of a benefit that may not clearly exceed the minimum clinically significant benefit, or there is evidence of harms that substantially reduce (but do not eliminate) the benefit such that it may not clearly exceed the minimum clinically significant benefit
None = Evidence shows that either there is no benefit or the benefits equal the harms
Conflicting = Evidence is inconsistent with regard to benefits and/or harms such that the net benefit is uncertain
Negative = Expected harms exceed the expected benefits to the population
Table: Relationship of Strength of the Recommendations Scale to Quality of Evidence and Net Benefits
|
Net Benefit |
Quality of Evidence |
Substantial |
Intermediate |
Small/Weak |
None |
Conflicting |
Negative |
Good |
A |
A |
B |
D |
I |
D |
Fair |
A |
B |
C |
D |
I |
D |
Low |
B |
B |
C |
I |
I |
D |
Expert Opinion |
E/A |
E/B |
E/C |
I |
I |
E/D |