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."
1. In a patient with an acute respiratory infection manifested predominantly by cough, with or without sputum production, lasting no more than 3 weeks, a diagnosis of acute bronchitis should not be made unless there is no clinical or radiographic evidence of pneumonia and the common cold, acute asthma, or an exacerbation of chronic obstructive pulmonary disease (COPD) have been ruled out as the cause of cough. Quality of evidence, expert opinion; benefit, substantial; grade of recommendation, E/A
2. In patients with the presumed diagnosis of acute bronchitis, viral cultures, serologic assays, and sputum analyses should not be routinely performed because the responsible organism is rarely identified in clinical practice. Quality of evidence, low; benefit, intermediate; grade of recommendation, C
3. In patients with acute cough and sputum production suggestive of acute bronchitis, the absence of the following findings reduces the likelihood of pneumonia sufficiently to eliminate the need for a chest radiograph: (1) heart rate >100 beats/min; (2) respiratory rate >24 breaths/min; (3) oral body temperature of >38 degrees C; and (4) chest examination findings of focal consolidation, egophony, or fremitus. Quality of evidence, low; benefit, substantial; grade of recommendation, B
4a. For patients with the putative diagnosis of acute bronchitis, routine treatment with antibiotics is not justified and should not be offered. Quality of evidence, good; benefit, none; grade of recommendation, D
4b. For these patients, the decision not to use an antibiotic should be addressed individually and explanations should be offered because many patients expect to receive an antibiotic based on previous experiences and public expectation. Quality of evidence, expert opinion; benefit, intermediate; grade of recommendation, E/B
5. Children and adult patients with confirmed and probable whooping cough should receive a macrolide antibiotic and should be isolated for 5 days from the start of treatment; early treatment within the first few weeks will diminish the coughing paroxysms and prevent spread of the disease; the patient is unlikely to respond to treatment beyond this period. Level of evidence, good; net benefit, substantial; grade of evidence, A
6a. In most patients with a diagnosis of acute bronchitis, beta2-agonist bronchodilators should not be routinely used to alleviate cough. Quality of evidence, fair; benefit, none; grade of recommendation, D
6b. In select adult patients with a diagnosis of acute bronchitis and wheezing accompanying the cough, treatment with beta2-agonist bronchodilators may be useful. Quality of evidence, fair; benefit, small/weak; grade of recommendation, C
7. In patients with a diagnosis of acute bronchitis, antitussive agents are occasionally useful and can be offered for short-term symptomatic relief of coughing. Quality of evidence, fair; benefit, small/weak; grade of recommendation, C
8. In patients with a diagnosis of acute bronchitis, because there is no consistent favorable effect of mucokinetic agents on cough, they are not recommended. Quality of evidence, fair; benefit, conflicting; grade of recommendation, I
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 |
