Postinfectious Cough: ACCP Evidence-Based Clinical Practice Guidelines

doi:10.1378/chest.129.1_suppl.138S

Chest

Volume 129, Issue 1, Supplement, January 2006, Pages 138S-146S

https://doi.org/10.1378/chest.129.1_suppl.138S Get rights and content

Background:

Patients who complain of a persistent cough lasting > 3 weeks after experiencing the acute symptoms of an upper respiratory tract infection may have a postinfectious cough. Such patients are considered to have a subacute cough because the condition lasts for no > 8 weeks. The chest radiograph findings are normal, thus ruling out pneumonia, and the cough eventually resolves, usually on its own. The purpose of this review is to present the evidence for the diagnosis and treatment of postinfectious cough, including the most virulent form caused by Bordetella pertussis infection, and make recommendations that will be useful for clinical practice.

Methods:

Recommendations for this section of the guideline were obtained from data using a National Library of Medicine (PubMed) search dating back to 1950, which was performed in August 2004, of the literature published in the English language. The search was limited to human studies, using the search terms “cough,” “postinfectious cough,” “postviral cough,” “Bordetella pertussis,” “pertussis infection,” and “whooping cough.”

Results:

The pathogenesis of the postinfectious cough is not known, but it is thought to be due to the extensive inflammation and disruption of upper and/or lower airway epithelial integrity. When postinfectious cough emanates from the lower airway, this is often associated with the accumulation of an excessive amount of mucus hypersecretion and/or transient airway and cough receptor hyperresponsiveness; all may contribute to the subacute cough. In these patients, the optimal treatment is not known. Except for bacterial sinusitis or early on in a B pertussis infection, therapy with antibiotics has no role, as the cause is not bacterial infection. The use of inhaled ipratropium may be helpful. Other causes of postinfectious cough are persistent inflammation of the nose and paranasal sinuses, which leads to an upper airway cough syndrome (previously referred to as postnasal drip syndrome), and gastroesophageal reflux disease, which may be a complication of the vigorous coughing. One type of postinfectious cough that is particularly virulent is that caused by B pertussis infection. When the cough is accompanied by paroxysms of coughing, posttussive vomiting, and/or an inspiratory whooping sound, the diagnosis of a B pertussis infection should be made unless another diagnosis is proven. This infection is highly contagious but responds to antibiotic coverage with an oral macrolide when administered early in the course of the disease. A safe and effective vaccine to prevent B pertussis is now available for adults as well as children. It is recommended according to CDC guidelines.

Conclusions:

In patients who have a cough lasting from 3 to 8 weeks with normal chest radiograph findings, consider the diagnosis of postinfectious cough. In most patients, a specific etiologic agent will not be identified, and empiric therapy may be helpful. A high degree of suspicion for cough due to B pertussis infection will lead to earlier diagnosis, patient isolation, and antibiotic treatment.

Section snippets

Pathogenesis

While the pathogenesis of the postinfectious cough is not known, it has been thought to be due to the extensive disruption of epithelial integrity and widespread airway inflammation of the upper and/or lower airways with or without transient airway hyperresponsiveness.5, 6, 7, 8 Bronchoscopy and biopsy performed on patients with uncomplicated influenza A infection, for example, reveals extensive desquamation of epithelial cells to the level of the basement membrane.⁹ The percentage of

RECOMMENDATIONS

1. When a patient complains of cough that has been present following symptoms of an acute respiratory infection for at least 3 weeks, but not more than 8 weeks, consider a diagnosis of postinfectious cough. Quality of evidence, expert opinion; net benefit, intermediate; strength of recommendation, E/B

2. In patients with subacute postinfectious cough, because there are multiple pathogenetic factors that may contribute to the cause of cough (including postviral airway inflammation with its

RECOMMENDATION

3. In children and adult patients with cough following an acute respiratory tract infection, if cough has persisted for > 8 weeks, consider diagnoses other than postinfectious cough. Quality of evidence, low; net benefit, intermediate; strength of recommendation, C

RECOMMENDATIONS

4. For adult patients with postinfectious cough, not due to bacterial sinusitis or early on in a Bordetella pertussis infection, while the optimal treatment is not known:

4a. Therapy with antibiotics has no role, as the cause is not bacterial infection. Level of evidence, expert opinion; net benefit, none; grade of evidence, I

4b. Consider a trial of inhaled ipratropium as it may attenuate the cough. Level of evidence, fair; net benefit, intermediate; grade of evidence, B

4c. In patients with

B PERTUSSIS INFECTION AND COUGH

One type of postinfectious cough that is particularly virulent is that caused by B pertussis infection. Recommendations for this section of the review relating to Bordetella infection and cough were made using data obtained from a National Library of Medicine (PubMed) search dating back to 1950, which was performed in August 2004, of the literature published in the English language. The search was limited to human studies, using the search terms “cough,” “Bordetella pertussis,” “Pertussis

RECOMMENDATIONS

5. When a patient has a cough lasting for ≥ 2 weeks without another apparent cause and it is accompanied by paroxysms of coughing, posttussive vomiting, and/or an inspiratory whooping sound, the diagnosis of a B pertussis infection should be made unless another diagnosis is proven. Level of evidence, low; net benefit, substantial; grade of evidence, B

6a. For all patients who are suspected of having whooping cough, to make a definitive diagnosis order a nasopharyngeal aspirate or polymer

RECOMMENDATIONS

9. Children and adult patients with confirmed or probable whooping cough should receive a macrolide antibiotic and should be isolated for 5 days from the start of treatment because early treatment within the first few weeks will diminish the coughing paroxysms and prevent spread of the disease; treatment beyond this period may be offered but it is unlikely the patient will respond. Level of evidence, good; net benefit, substantial; grade of evidence, A

10. Long-acting β-agonists, antihistamines,

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Cited by (126)

Zhisou powder suppresses airway inflammation in LPS and CS-induced post-infectious cough model mice via TRPA1/TRPV1 channels
2024, Journal of Ethnopharmacology
Zhisou Powder (ZSP), a traditional Chinese medicine (TCM) prescription, has been widely used in the clinic for the treatment of post-infectious cough (PIC). However, the exact mechanism is not clear.
The aim of this study was to investigate the ameliorative effect of ZSP on PIC in mice. The possible mechanisms of action were screened based on network pharmacology, and the potential mechanisms were explored through molecular docking and in vivo experimental validation.
Lipopolysaccharide (LPS) (80μg/50 μL) was used to induce PIC in mice, followed by daily exposure to cigarette smoke (CS) for 30 min for 30 d to establish PIC model. The effects of ZSP on PIC mice were observed by detecting the number of coughs and cough latency, peripheral blood and bronchoalveolar lavage fluid (BALF) inflammatory cell counts, enzyme-linked immunosorbent assay (ELISA), and histological analysis. The core targets and key pathways of ZSP on PIC were analyzed using network pharmacology, and TRPA1 and TRPV1 were validated using RT-qPCR and western blotting assays.
ZSP effectively reduced the number of coughs and prolonged the cough latency in PIC mice. Airway inflammation was alleviated by reducing the expression levels of the inflammatory mediators TNF-α and IL-1β. ZSP modulated the expression of Substance P, Calcitonin gene-related peptide (CGRP), and nerve growth factor (NGF) in BALF. Based on the results of network pharmacology, the mechanism of action of ZSP may exert anti-neurogenic airway-derived inflammation by regulating the expression of TRPA1 and TRPV1 through the natural active ingredients α-spinastero, shionone and didehydrotuberostemonine.
ZSP exerts anti-airway inflammatory effects through inhibition of TRPA1/TRPV1 channels regulating neuropeptides to alleviate cough hypersensitivity and has a favorable therapeutic effect on PIC model mice. It provides theoretical evidence for the clinical application of ZSP.
Xingbei antitussive granules ameliorate cough hypersensitivity in post-infectious cough guinea pigs by regulating tryptase/PAR2/TRPV1 pathway
2024, Journal of Ethnopharmacology
Xingbei antitussive granules (XB) is a classic Chinese Medicine prescription for treating post-infectious cough(PIC), based on the Sanao Decoction from Formularies of the Bureau of People’s Welfare Pharmacies in the Song Dynasty and Jiegeng decoction from Essentials of the Golden Chamber in the Han Dynasty. However, the therapeutic effects and pharmacological mechanisms are still ambiguous. In the present study, we endeavored to elucidate these underlying mechanisms.
This study aimed to explore the potential impact and mechanism of XB on PIC, and provide a scientific basis for its clinical application.
Cigarette smoking (CS) combined with lipopolysaccharide (LPS) nasal drops were administered to induce the PIC guinea pig with cough hypersensitivity status. Subsequently, the model guinea pigs were treated with XB and the cough frequency was observed by the capsaicin cough provocation test. The pathological changes of lung tissue were assessed by HE staining, and the levels of inflammatory mediators, mast cell degranulating substances, and neuropeptides were detected. The protein and mRNA expression of transient receptor potential vanilloid type 1(TRPV1), proteinase-activated receptor2(PAR2), and protein kinase C (PKC) were measured by Immunohistochemical staining, Western blot, and RT-qPCR. Changes in the abundance and composition of respiratory bacterial microbiota were determined by 16S rRNA sequencing.
After XB treatment, the model guinea pigs showed a dose-dependent decrease in cough frequency, along with a significant alleviation in inflammatory infiltration of lung tissue and a reduction in inflammatory mediators. In addition, XB high-dose treatment significantly decreased the levels of mast cell Tryptase as well as β-hexosaminidase (β-Hex) and downregulated the expression of TRPV1, PAR2, and p-PKC. Simultaneously, levels of neuropeptides like substance P (SP), calcitonin gene-related peptide (CGRP), neurokinin A (NKA), and nerve growth factor (NGF) were improved. Besides, XB also can modulate the structure of respiratory bacterial microbiota and restore homeostasis.
XB treatment alleviates cough hypersensitivity and inflammatory responses, inhibits the degranulation of mast cells, and ameliorates neurogenic inflammation in PIC guinea pigs whose mechanism may be associated with the inhibition of Tryptase/PAR2/PKC/TRPV1 and the recovery of respiratory bacterial microbiota.
Effectiveness and safety of Xingbei Zhike granules in patients with postinfectious cough: A multicenter, randomized, double-blinded, placebo-controlled trial
2023, Phytomedicine
Postinfectious cough (PIC) is a common symptom following a respiratory tract infection. Xingbei Zhike (XBZK) granules, a Chinese patent medicine, has been widely used for PIC in clinics. However, there is a lack of evidence on the effectiveness.
To investigate whether treatment with XBZK granules is effective for PIC.
A multicenter, randomized, double-blinded, placebo-controlled trial.
Eligible participants from fourteen hospitals were randomly assigned in 3:1 ratio to receive either XBZK granules or placebo for 14 days. The primary outcome was the area under the curve (AUC) of a visual analogue scale (VAS) for cough symptoms. Secondary outcomes included cough symptom score (CSS), time and probability of recovery from cough, traditional Chinese medicine (TCM) syndrome score, relief rates of individual symptoms, Leicester Cough Questionnaire (LCQ) score, and the use of reliever drug.
A total of 235 patients (176 in XBZK and 59 in placebo groups) were included in the analysis. The AUC for cough VAS scores was lower in the XBZK than placebo group (−8.10, 95 % CI -14.12 to −2.07, p = 0.009), indicating superiority. XBZK decreased CSS (−0.68 points, 95 % CI −1.13 to −0.22, p = 0.01), shortened time to cough recovery (−2 days, hazard ratio [HR] 1.48, 95 % CI 1.03 to 2.13, p = 0.02), enhanced the probability of cough recovery (risk ratio [RR] 1.66, 95 % CI 1.07 to 2.58, p = 0.03), lowered TCM syndrome score (−0.99 points, 95 % CI −1.58 to −0.40, p = 0.004), increased the rate of daytime (RR 1.84, 95 % CI 1.07 to 3.15, p = 0.02) and nighttime (RR 2.07, 95 % CI 1.29 to 3.35, p = 0.004) cough recovery, and reduced the viscosity of sputum (RR 2.92, 95 % CI 1.66 to 5.13, p < 0.001) compared to placebo. There were no significant differences in LCQ scores and taking reliever drugs between groups. No severe adverse events were reported in either group.
XBZK granules are a promising therapy against PIC, effective in lowering the overall severity of cough, shortening the time to cough recovery, and reducing the viscosity of sputum.
Experimental research on the cross-infection control performance of different ventilation strategies
2023, Building and Environment
Sustained pandemics have awakened the growing need to select appropriate indoor ventilation strategies to create a healthy environment. Hence, this study experimentally evaluated the cross-infection control performance of different ventilation strategies, namely mixing ventilation with outlets installed in the bottom of the side wall (MV-BR) and at ceilings (MV-CR), stratum ventilation with outlets installed in the side wall (SV-SR) and at ceilings (SV-CR), interactive cascade ventilation with outlets installed in the side wall (ICV-SR) and at ceilings (ICV-CR). The supply air flow rate of the studied ventilation strategies remains the same (6.51 h⁻¹) for fair comparison. The infection risk and maximum cumulative exposure are introduced as the evaluation indicators. The research results show that the mean infection risk in the respiratory zone of susceptible individuals who are standing in the sidewind directions of the infected people under ICV-SR has the lowest potential infection risk (P_i) value of 0.012, which is consistently lower than ICV-CR by 8.3%, MV-CR by 42%, MV-BR by 45%, SV-CR by 50%, and SV-SR by 55%, respectively. And the average max long-term exposure of MV-BR is 15.2% lower than MV-CR. Compared with SV-CR and ICV-CR, SV-SR and ICV-SR can also realize to reduce the max long-term exposure by 21.3% and 25%, respectively. The integrated scenario index calculation results demonstrate that ICV presents excellent cross-infection control performance than SV and MV, obtaining 53.5% and 61.2% lower cross-infection risk. The conclusions got from this study can provide guide for the design of indoor airflow organization with the epidemic normalizing.
Post-infectious cough of different syndromes treated by traditional Chinese medicines: A review
2022, Chinese Herbal Medicines
Citation Excerpt :
In addition, the patients' chests radiographs findings are negative (Braman, 2006; Hu, Zhao, & Cui, 2016). According to studies of unselected adult patients with a history of upper respiratory tract infection, the proportion of PIC symptoms increased from 11% to 25%, while the incidence of Mycoplasma pneumoniae and Bordetella pertussis outbreaks can increase from 25% to 50% (Braman, 2006). Compared with adults, the incidence of PIC is higher, accounting for 39.4% of children with long-term cough, which is a common cause of chronic cough in children and preschool children (Xiong, Wan, Huang, Lin & Wu, 2019).
The application of traditional Chinese medicines (TCMs) has a history of more than 2000 years, which have the characteristics of multi-component, multi-target, and high safety. Post-infectious cough (PIC) is a respiratory disease with high incidence. It belongs to subacute cough and accounts for as much as 40%–50%. Cough is the main clinical manifestation of PIC. PIC seriously affects people's life quality because of complex etiology, long-term course of disease, treatment difficulties and other characteristics. Western medicines are based on the principle of symptomatic treatment, so they are often difficult to control PIC fundamentally. These factors could due to that PIC is prolonged and unable to heal repeatedly. TCMs have obvious advantages in treating PIC, with accurate curative effects, less side effects and adverse reactions and are effective in improving PIC-related symptoms and indicators, enhancing patients' life quality and reducing pain. TCMs, guided by holistic concept and syndrome differentiation, advocate determine treatment on the basis of pattern types, and have remarkable clinical treatment effects. As for TCMs etiology, pathogenesis and syndrome types of PIC, TCM scholars have not yet reached a unified standard. However, most of them think that wind pathogen can cause PIC alone, or it can be combined with other evils, which might be the main mechanism of PIC. This paper discusses the advantages and limitations of TCMs in PIC treatment from etiology, pathogenesis, distribution of syndrome types and treatment of TCMs. This article focuses on the treatment methods and pharmacodynamic material basis of wind pathogen, providing ideas in treating PIC of TCMs clinically and innovative drug development.
WAO-ARIA consensus on chronic cough - Part II: Phenotypes and mechanisms of abnormal cough presentation — Updates in COVID-19
2021, World Allergy Organization Journal
Chronic cough can be triggered by respiratory and non-respiratory tract illnesses originating mainly from the upper and lower airways, and the GI tract (ie, reflux). Recent findings suggest it can also be a prominent feature in obstructive sleep apnea (OSA), laryngeal hyperresponsiveness, and COVID-19. The classification of chronic cough is constantly updated but lacks clear definition. Epidemiological data on the prevalence of chronic cough are informative but highly variable. The underlying mechanism of chronic cough is a neurogenic inflammation of the cough reflex which becomes hypersensitive, thus the term hypersensitive cough reflex (HCR). A current challenge is to decipher how various infectious and inflammatory airway diseases and esophageal reflux, among others, modulate HCR.
The World Allergy Organization/Allergic Rhinitis and its Impact on Asthma (WAO/ARIA) Joint Committee on Chronic Cough reviewed the current literature on classification, epidemiology, presenting features, and mechanistic pathways of chronic cough in airway- and reflux-related cough phenotypes, OSA, and COVID-19. The interplay of cough reflex sensitivity with other pathogenic mechanisms inherent to airway and reflux-related inflammatory conditions was also analyzed.
Currently, it is difficult to clearly ascertain true prevalence rates in epidemiological studies of chronic cough phenotypes. This is likely due to lack of standardized objective measures needed for cough classification and frequent coexistence of multi-organ cough origins. Notwithstanding, we emphasize the important role of HCR as a mechanistic trigger in airway- and reflux-related cough phenotypes. Other concomitant mechanisms can also modulate HCR, including type2/Th1/Th2 inflammation, presence or absence of deep inspiration-bronchoprotective reflex (lower airways), tissue remodeling, and likely cough plasticity, among others.

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Chest

SupplementDiagnosis and Management of Cough: ACCP Evidence-Based Clinical Practice GuidelinesPostinfectious Cough: ACCP Evidence-Based Clinical Practice Guidelines

Background:

Methods:

Results:

Conclusions:

Section snippets

Pathogenesis

RECOMMENDATIONS

RECOMMENDATION

RECOMMENDATIONS

B PERTUSSIS INFECTION AND COUGH

RECOMMENDATIONS

RECOMMENDATIONS

Chest

J Allergy Clin Immunol

Respir Med

Chest

Clin Microbiol Infect

Pediatr Clin North Am

Aust N Z J Public Health

Chest

Respir Med

Lancet

Chest

J Pediatr

J Pediatr

Chronic cough: bronchoscopy or pulmonary function testing?

Am Rev Respir Dis

Persistent cough in nonsmokers

Can Respir J

The diagnosis and treatment of cough

N Engl J Med

Mechanisms of bronchial hyperreactivity in normal subjects after upper respiratory tract infection

Am Rev Respir Dis

Airway hyperreactivity and peripheral airway dysfunction in influenza A infection

Am Rev Respir Dis

Bronchial hyperresponsiveness in normal subjects during attenuated influenza virus infection

Am Rev Respir Dis

Mechanisms of virus induced exacerbations of asthma

Thorax

Bronchotracheal response in human influenza: type A, Asian strain, as studied by light and electron microscopic examination of bronchoscopic biopsies

Arch Intern Med

Airway cough sensitivity to inhaled capsaicin and bronchial responsiveness to methacholine in asthmatic and bronchitic subjects

Respirology

Cough and the common cold

Am Rev Respir Dis

Predictive values of the character, timing, and complications of chronic cough in diagnosing its cause

Arch Intern Med

An algorithmic approach to chronic cough

Ann Intern Med

Bordetella pertussisinfection: a cause of persistent cough in adults

Med J Aust

Concurrent outbreaks of pertussis andMycoplasma pneumoniaeinfection: clinical and epidemiological characteristics of illnesses manifested by cough

Clin Infect Dis

Chronic persistent cough in the adult: the spectrum and frequency of causes and successful outcome of specific therapy

Am Rev Respir Dis

Chronic cough: the spectrum and frequency of causes, key components of the diagnostic evaluation, and outcome of specific therapy

Am Rev Respir Dis

Infant pneumonitis associated with cytomegalovirus, Chlamydia, Pneumocystis, and Ureaplasma: a prospective study

Pediatrics

Moraxella catarrhalis: clinical significance, antimicrobial susceptibility and BRO β-lactamases

Eur J Clin Microbiol Infect Dis

Prolonged afebrile nonproductive cough illnesses in American soldiers in Korea: a serological search for causation

Clin Infect Dis

A serologic study of organisms possibly associated with pertussis-like coughing

Pediatr Infect Dis J

Chlamydia pneumoniaeinfection in adult patients with persistent cough

J Med Microbiol

Bordetella pertussis Bordetella parapertussis Mycoplasma pneumoniae Chlamydia pneumoniae and persistent cough in children

Scand J Infect Dis

Chlamydia pneumoniae(TWAR) infections in children

Pediatr Infect Dis J

Infection and activation of airway epithelial cells byChlamydia pneumoniae

J Infect Dis

Markers of inflammation in induced sputum in acute bronchitis caused byChlamydia pneumoniae

Thorax

Supplement
Diagnosis and Management of Cough: ACCP Evidence-Based Clinical Practice Guidelines
Postinfectious Cough: ACCP Evidence-Based Clinical Practice Guidelines