Clinical Edge

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Treatment of Unexplained Chronic Cough

Guideline offers diagnosis & treatment options

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The American College of Chest Physicians (CHEST) has developed recommendations and suggestions for the diagnosis and treatment of patients with unexplained chronic cough (UCC). These recommendations are based on a systematic review of 11 randomized controlled trials of 570 participants with chronic cough of > 8 weeks. Among the updated recommendations are:

• In adult patients with chronic cough, unexplained chronic cough is defined as a cough that persists longer than 8 weeks, and remains unexplained after investigation, and supervised therapeutic trials.

• In adult patients with chronic cough, patients with chronic cough should undergo a guideline/protocol based assessment process that includes objective testing for bronchial hyperresponsiveness and eosinophilic bronchitis, or a therapeutic corticosteroid trial.

• In adult patients with unexplained chronic cough, a therapeutic trial of multimodality speech pathology therapy is recommended (Grade 2C).

• In adult patients with unexplained chronic cough and negative tests for bronchial hyperresponsiveness and eosinophilia (sputum eosinophils, exhaled nitric oxide), inhaled corticosteroids should not be prescribed (Grade 2B).

• In adult patients with unexplained chronic cough, a therapeutic trial of gabapentin and a reassessment of the risk-benefit profile at 6 months before continuing the drug are suggested. (Grade 2C).

◊ Remarks: With respect to dosing, patients without contraindications to gabapentin can be prescribed a dose escalation schedule beginning at 300 mg once a day with additional doses being added each day as tolerated up to a maximum tolerable daily dose of 1,800 mg a day in 2 divided doses.

• In adult patients with unexplained chronic cough and a negative workup for acid gastroesophageal reflux disease, a proton pump inhibitor (PPI) therapy should not be prescribed (Grade 2C).

Citation: Gibson P, Wang G, McGarvey L, Vertigan AE, Altman KW, Birring SS. Treatment of unexplained chronic cough: CHEST guideline and expert panel report. Chest. 2016;149(1):27-44. doi:10.1378/chest.15-1496.

Commentary: UCC is only diagnosed after an appropriate diagnostic work-up and empiric treatments of likely causes. The diagnostic work-up should include addressing the most common causes of chronic cough including asthma and COPD, GERD, allergic rhinitis, sinusitis, post-nasal drip (now called upper airway cough syndrome),1 smoking, and nonasthmatic eosinophilic bronchitis.2 What stands out in this guideline are the options for a therapeutic corticosteroid trial, speech pathology referral, and gabapentin use to address neurogenic causes of cough. The recommendation of not using a PPI for chronic cough is surprising and is based on 1 trial where a PPI was shown not to be effective, though it is not clear whether people who entered the trial had already had a work-up and empiric treatment trial for GERD. If no work-up or empiric trial had been done, then in my opinion it might make sense to trial a PPI before abandoning GERD as a potential cause. This guideline offers helpful evidence-based advice for this frustrating problem. —Neil Skolnik, MD

1. Pratter M. Chronic upper airway cough syndrome secondary to rhinosinus diseases (previously referred to as postnasal drip syndrome) - ACCP evidence-based clinical practice guidelines. Chest. 2006 Jan;129(1 Suppl):63S-71S. doi:10.1378/chest.129.1_suppl.63S.

2. Brightling CE. Chronic cough due to nonasthmatic eosinophilic bronchitis: ACCP evidence-based clinical practice guidelines. Chest. 2006;129(1_suppl):116S-121S. doi:10.1378/chest.129.1_suppl.116S.

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