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."
- In patients with chronic cough that is related to upper airway abnormalities, the committee considers the term upper airway cough syndrome (UACS) to be more accurate, and it should therefore be used instead of the term postnasal drip syndrome (PNDS). Level of evidence, expert opinion; benefit, substantial; grade of recommendation, E/A
- In patients with chronic cough, the diagnosis of UACS-induced cough should be determined by considering a combination of criteria, including symptoms, physical examination findings, radiographic findings, and, ultimately, the response to specific therapy. Because it is a syndrome, no pathognomonic findings exist. Level of evidence, low; benefit, substantial; grade of recommendation, B
- In patients in whom the cause of the UACS-induced cough is apparent, specific therapy directed at this condition should be instituted. Level of evidence, low; benefit, substantial; grade of recommendation, B
- For patients with chronic cough, an empiric trial of therapy for UACS should be administered because the improvement or resolution of cough in response to specific treatment is the pivotal factor in confirming the diagnosis of UACS as a cause of cough. Level of evidence, low; benefit, substantial; grade of recommendation, B
- A patient suspected of having UACS induced cough who does not respond to empiric antihistamine/decongestant (A/D) therapy with a first-generation antihistamine should next undergo sinus imaging. Although chronic sinusitis may cause a productive cough, it may also be clinically silent, in that the cough can be relatively or even completely non-productive and none of the typical findings associated with acute sinusitis may be present. Level of evidence, low; benefit, substantial; grade of recommendation, B
- In patients for whom a specific etiology of chronic cough is not apparent, empiric therapy for UACS in the form of a first generation A/D preparation should be prescribed before beginning an extensive diagnostic workup. Level of evidence, low; benefit, intermediate; grade of recommendation, 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 |