This is the current release of the guideline.

Definitions for the level of evidence, strength of recommendation, and net benefit follow the "Major Recommendations."

1. In patients with cystic fibrosis (CF), chest physiotherapy is recommended as an effective technique to increase mucus clearance, but the effects of each treatment 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 weakness, manually assisted cough should be considered to reduce the incidence of respiratory complications. Level of evidence, low; benefit, small; grade of recommendation, C
3. In persons with airflow obstruction caused by disorders like chronic obstructive pulmonary disease (COPD), manually assisted cough may be detrimental and should not be used. Level of evidence, low; benefit, negative; grade of recommendation, D
4. In patients with COPD and CF, huffing should be taught as an adjunct to other methods of sputum clearance. Level of evidence, low; benefit, small; grade of recommendation, C
5. In patients with CF, autogenic drainage should be taught as an adjunct to postural drainage as a method to clear sputum because it has the advantage of being performed without assistance and in one position. Level of evidence, low; benefit, small; grade of recommendation, C
6. In patients with neuromuscular weakness and impaired cough, expiratory muscle training is recommended to improve peak expiratory pressure, which may have a beneficial effect on cough. Level of evidence, expert opinion; benefit, small; grade of recommendation, E/C
7. In patients with CF, positive expiratory pressure (PEP) is recommended over conventional chest physiotherapy because it is approximately as effective as chest physiotherapy, and is inexpensive, safe, and can be self-administered. Level of evidence, fair; benefit, intermediate; grade of recommendation, B
8. In patients with CF, devices designed to oscillate gas in the airway, either directly or by compressing the chest wall, can be considered as an alternative to chest physiotherapy. Level of evidence, low; benefit, conflicting; grade of recommendation, I
9. In patients with neuromuscular disease with impaired cough, mechanical cough assist devices are recommended to prevent respiratory complications. Level of evidence, low; benefit, intermediate; grade of recommendation, C
10. The effect of nonpharmacologic airway clearance techniques on long-term outcomes such as health-related quality of life and rates of exacerbations, hospitalizations, and mortality is not known at this time. The committee recommends that future investigations measure these outcomes in patients with CF, and in other populations with bronchiectasis, COPD, and neuromuscular diseases. Level of evidence, expert opinion; benefit, substantial; grade of recommendation, E/A

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

The following clinical algorithms are provided in the section titled "Diagnosis and Management of Cough Executive Summary" (see "Availability of Companion Documents" field)"

• Acute cough algorithm for the management of patients >15 years of age with cough lasting <3 weeks
• Subacute cough algorithm for the management of patients >15 years of age with cough lasting 3 to 8 weeks
• Chronic cough algorithm for the management of patients >15 years of age with cough lasting >8 weeks
• Approach to a child <15 years of age with chronic cough
• Approach to a child <14 years of age with chronic specific cough

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

Not applicable: The guideline was not adapted from another source.

2006 Jan

American College of Chest Physicians - Medical Specialty Society

American College of Chest Physicians

American College of Chest Physicians (ACCP) Expert Panel on the Diagnosis and Management of Cough

Primary Author: F. Dennis McCool, MD, FCCP; Mark J. Rosen, MD, FCCP

Panel Members: 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

American Thoracic Society - Medical Specialty Society
Canadian Thoracic Society - Medical Specialty Society

This is the current release of the guideline.

None available

This NGC summary was completed by ECRI on May 4, 2006. The information was verified by the guideline developer on June 5, 2006.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.