Treatment of Unexplained Chronic Cough CHEST Guideline and Expert Panel Report

Peter Gibson, Gang Wang, Lorcan McGarvey, Anne E. Vertigan, Kenneth W. Altman, Surinder S. Birring, CHEST Expert Cough Panel, Todd M. Adams, Kenneth W. Altman, Alan F. Barker, Surinder S. Birring, Fiona Blackhall, Donald C. Bolser, Louis-Philippe Boulet, Sidney S. Braman, Christopher Brightling, Priscilla Callahan-Lyon, Brendan J. Canning, Anne B. Chang, Remy Coeytaux, Terrie Cowley, Paul Davenport, Rebecca L. Diekemper, Satoru Ebihara, Ali A. El Solh, Patricio Escalante, Anthony Feinstein, Stephen K. Field, Dina Fisher, Cynthia T. French, Peter Gibson, Philip Gold, Michael K. Gould, Cameron Grant, Susan M. Harding, Anthony Harnden, Adam T. Hill, Richard S. Irwin, Peter J. Kahrilas, Karina A. Keogh, Andrew P. Lane, Kaiser Lim, Mark A. Malesker, Peter Mazzone, Stuart Mazzone, Douglas C. McCrory, Lorcan McGarvey, Alex Molasiotis, M. Hassan Murad, Peter Newcombe, Huong Q. Nguyen, John Oppenheimer, David Prezant, Tamara Pringsheim, Marcos I. Restrepo, Mark Rosen, Bruce Rubin, Jay H. Ryu, Jaclyn Smith, Susan M. Tarlo, Anne E. Vertigan, Gang Wang, Miles Weinberger, Kelly Weir, Renda Soylemez Wiener

Unexplained chronic cough (UCC) causes significant quality of life impairment. There is a need to identify effective assessment and treatment approaches for UCC. This systematic review of randomized controlled clinical trials asked: What is the efficacy of treatment compared to usual care on cough severity, cough frequency, and cough-related quality of life in patients with unexplained chronic cough (UCC)? Studies of adults and adolescents >12 years with a chronic cough of >8 weeks duration that was unexplained after systematic investigation and treatment were included and assessed for relevance and quality. Based upon the systematic review, guideline suggestions were developed and voted upon using CHEST organization methodology. 11 RCTs and 5 systematic reviews were included. The 11 RCTs reported data on 570 participants with chronic cough who received a variety of interventions. Study quality was high in 10 RCTs. The studies used a variety of descriptors and assessments to identify unexplained chronic cough. While gabapentin and morphine showed positive effects on cough-related quality of life, only gabapentin was supported as a treatment recommendation. Studies of inhaled corticosteroids (ICS) suffered from intervention fidelity bias, and when this was addressed, ICS were not found to be effective for UCC. Esomeprazole was not effective for UCC without features of gastroesophageal acid reflux. Studies addressing non-acid gastroesophageal reflux were not identified. A multimodality speech pathology intervention improved cough severity. The evidence supporting the diagnosis and management of UCC is limited. UCC requires further study to establish agreed terminology and the optimal methods of investigation using established criteria for intervention fidelity. Speech pathology based cough suppression is suggested as a treatment option for UCC. This guideline presents suggestions for diagnosis and treatment based on the best available evidence and identifies gaps in our knowledge and areas for future research.