Chest
Volume 129, Issue 1, Supplement, January 2006, Pages 75S-79S
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Supplement
Diagnosis and Management of Cough: ACCP Evidence-Based Clinical Practice Guidelines
Chronic Cough Due to Asthma: ACCP Evidence-Based Clinical Practice Guidelines

https://doi.org/10.1378/chest.129.1_suppl.75SGet rights and content

Background:

Asthma is among the most common causes of chronic cough in adult nonsmokers. Although cough usually accompanies dyspnea and wheezing, it may present in isolation as a precursor of typical asthmatic symptoms, or it may remain the predominant or sole symptom of asthma. The latter condition is known as cough-variant asthma (CVA).

Methods:

Data for this review were obtained from a National Library of Medicine (PubMed) search, performed in April 2004, of the English language literature from 1975 to 2004, limited to human studies, using the search terms “cough” and “asthma.”

Results:

The diagnosis of cough not associated with typical asthmatic symptoms (ie, CVA) presents a challenge, because physical examination and spirometry findings may be entirely normal. Methacholine inhalation challenge testing can demonstrate the presence of bronchial hyperresponsiveness; however, the diagnosis of cough due to asthma is only confirmed after the resolution of cough with antiasthmatic therapy. In general, the therapeutic approach to asthmatic cough is similar to that of the typical form of asthma. Most patients will respond to inhaled bronchodilators and inhaled corticosteroids. A subgroup of patients will require the addition of leukotriene receptor antagonists and/or a short course of oral corticosteroids.

Conclusions:

Asthma should be considered as a potential etiology in any patient with chronic cough, because asthma is a common condition that is commonly associated with cough. Because the subgroup of asthmatic patients with CVA presents with no other symptoms of asthma, clinical suspicion must remain high. Cough due to asthma responds to standard antiasthmatic therapy.

Section snippets

RECOMMENDATION

1. In a patient with chronic cough, asthma should always be considered as a potential etiology because asthma is a common condition with which cough is commonly associated. Quality of evidence, fair; net benefit, substantial; grade of recommendation, A

Recent data support the concept that patients with CVA comprise a distinct subgroup of individuals with asthma, rather than simply being asthmatic patients who cough. For example, subjects with the typical form of asthma do not differ from healthy

EVALUATION

If reversible airflow obstruction is demonstrated in a patient with chronic cough, empiric therapy for asthma is appropriate. However, a patient with chronic cough due to asthma may present a diagnostic challenge, because physical examination and pulmonary function test results can be entirely normal. In this setting, bronchoprovocation testing with inhaled methacholine should be used to document the presence of bronchial hyperresponsiveness and, therefore, the diagnosis of asthma. It must be

RECOMMENDATION

2. In a patient suspected of having CVA but in whom physical examination and spirometry findings are nondiagnostic, MIC testing should be performed to confirm the presence of asthma. However, a diagnosis of CVA is established only after the resolution of cough with specific antiasthmatic therapy. If MIC testing cannot be performed, empiric therapy should be given; however, a response to steroid therapy will not exclude nonasthmatic eosinophilic bronchitis as an etiology of the patient's cough.

TREATMENT

In general, the therapeutic approach to CVA is similar to that of the typical form of asthma. Partial improvement is often achieved after 1 week of inhaled bronchodilator therapy, but the complete resolution of cough may require up to 8 weeks of treatment with inhaled corticosteroids.13, 15

RECOMMENDATION

3. Patients with cough due to asthma should initially be treated with a standard antiasthmatic regimen of inhaled bronchodilators and inhaled corticosteroids. Quality of evidence, fair; net benefit, substantial; grade of recommendation, A

A potential pitfall of inhaled steroid therapy in patients with CVA is that the treatment itself may induce or exacerbate cough, which is likely due to a constituent of the aerosol. For example, the more common occurrence of cough after the inhalation of

RECOMMENDATION

4. In patients whose cough is refractory to inhaled corticosteroids, an assessment of airway inflammation should be performed whenever available and feasible. The demonstration of persistent airway eosinophilia during such an assessment will identify those patients who may benefit from more aggressive antiinflammatory therapy. Quality of evidence, low; net benefit, substantial; grade of recommendation, B

The LTRA zafirlukast has been shown6 to improve subjective cough scores as well as to

RECOMMENDATIONS

5a. For patients with asthmatic cough that is refractory to treatment with inhaled corticosteroids and bronchodilators, in whom poor compliance or another contributing condition has been excluded, an LTRA may be added to the therapeutic regimen before the escalation of therapy to systemic corticosteroids. Quality of evidence, fair; net benefit, intermediate; grade of recommendation, B

5b. Patients with severe and/or refractory cough due to asthma should receive a short course (1 to 2 weeks) of

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