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."
- Patients with acute cough (as well as postnasal drip [PND] and throat clearing) associated with the common cold can be treated with a first-generation antihistamine/decongestant (A/D) preparation (brompheniramine and sustained-release pseudoephedrine). Naproxen can also be administered to help decrease cough in this setting. Level of evidence, fair; benefit, substantial; grade of recommendation, A
- In patients with the common cold, newer generation nonsedating antihistamines are ineffective for reducing cough and should not be used. Level of evidence, fair; benefit, none; grade of recommendation, D
- In patients with cough and acute upper respiratory tract infection (URTI), because symptoms, signs, and even sinus imaging abnormalities may be indistinguishable from acute bacterial sinusitis, the diagnosis of bacterial sinusitis should not be made during the first week of symptoms. (Clinical judgment is required to decide whether to institute antibiotic therapy.) Level of evidence, fair; benefit, none; grade of recommendation, D
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 |