Chest
SupplementDiagnosis and Management of Cough: ACCP Evidence-Based Clinical Practice GuidelinesChronic Cough Due to Asthma: ACCP Evidence-Based Clinical Practice Guidelines
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
REFERENCES (22)
- et al.
Effects of inhaled corticosteroids on cough threshold in patients with bronchial asthma
Pulm Pharmacol Ther
(2001) - et al.
Managing cough as a defense mechanism and as a symptom: a consensus panel report of the American College of Chest Physicians
Chest
(1998) - et al.
Airway remodeling in cough-variant asthma
Lancet
(2000) - et al.
Non-eosinophilic, corticosteroid unresponsive asthma
Lancet
(1999) - et al.
Chronic cough: the spectrum and frequency of causes, key components of the diagnostic evaluation, and outline of specific therapy
Am Rev Respir Dis
(1990) - et al.
An algorithmic approach to chronic cough
Ann Intern Med
(1993) - et al.
Evaluation and outcome of patients with chronic non-productive cough using a comprehensive diagnostic protocol
Thorax
(1998) Exertional dyspnea and cough as preludes to acute attacks of bronchial asthma
N Engl J Med
(1975)- et al.
Chronic cough as the sole presenting manifestation of bronchial asthma
N Engl J Med
(1979) - et al.
Antitussive effect of the leukotriene receptor antagonist zafirlukast in subjects with cough-variant asthma
J Asthma
(2002)
Cough receptor sensitivity and bronchial responsiveness in normal and asthmatic subjects
Eur Respir J
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