Patient Safety / Quality

Diagnosing and managing cough

Colds may seem to hang on forever, but actually the average cold interferes with a person’s daily activities for 7 days and disturbs sleep for 4 days.

These and other findings appear in “Diagnosis and Management of Cough” recently published by the American College of Chest Physicians. This evidence-based work, which updates a 1998 report, focuses on guidelines for diagnosing and treating cough in both adults and children. New topics include nonasthmatic eosino­philic bronchitis, acute bronchitis, nonbronchiectatic suppurative airway diseases, cough caused by aspiration secondary to oropharyngeal dysphagia, and environmental and occupational causes of cough.

Here are some highlights of the report:
• The vagal afferent nerves regulate involuntary cough, but a higher cortical control can inhibit cough and can cause voluntary cough. Because of this control, placebos can profoundly affect coughing. Thus, all cough treatment studies should be placebo-controlled.
• The diagnostic term postnasal drip syndrome has been replaced by upper airway cough syndrome (UACS) to indicate cough associated with upper airway conditions. This change is based on several issues, including the continuing speculation about whether this type of cough results from postnasal drip, direct irritation, or inflammation of the cough receptors in the upper airway.
• The diagnostic term idiopathic cough has been replaced by unexplained cough. The word idiopathic implies a single underlying disease, but chronic cough likely has more than one unknown cause.
• In children with chronic cough, diagnoses of habit cough or psychogenic cough can be made only after an evaluation rules out tic disorders and Tourette syndrome and after the cough improves with specific therapy, such as behavior modification or psychiatric therapy.
• In adults with troublesome chronic cough that persists despite a thorough evidence-based evaluation and behavior modification or psychiatric therapy, unexplained cough should be diagnosed, not habit cough or psychogenic cough.
• During the first phases of acute bacterial sinusitis and upper respiratory tract infection, their signs, symptoms, and sinus-imaging abnormalities are usually indistinguishable. Thus, a diagnosis of bacterial sinusitis should not be made during the first week.
• A diagnosis of postinfectious cough should be considered when a patient complains of cough lasting 3 to 8 weeks after symptoms of an acute respiratory infection. Inhaled ipratropium bromide (Atrovent) can reduce the severity of postinfectious cough. If the cough persists despite inhaled ipratropium and the cough adversely affects the patient’s quality of life, consider inhaled corticosteroids. These drugs take about 1 week before providing significant relief.
• For severe paroxysms of postinfectious cough, consider 30 to 40 mg of prednisone per day for a short period after other common causes, including UACS from  rhinosinusitis, asthma, and gastroesophageal reflux disease, have been ruled out. Central-acting antitussives, such as codeine and dextromethorphan, should be considered when other measures fail. In children and adults with cough persisting more than 8 weeks after an acute respiratory tract infection, consider other diagnoses.
• Patients with an acute cough associated with a common cold can be treated with a first-generation antihistamine–decongestant, such as brompheniramine and sustained-release pseudoephedrine (Bromfed). Another treatment option is naproxen. The newer generation of nonsedating antihistamines such as loratadine (Claritin) plays no role in treating such a cough.
• In adults, the median duration of a cold is 91⁄2 to 11 days.
To go beyond the highlights for more information, including practice-based algorithms, go to www.chestjournal.org/cgi/content/full/129/1_suppl/1S.

Selected reference
Irwin RS, et al. ACCP Evidence-Based Clinical Practice Guidelines Executive Summary: diagnosis and management of cough. Chest. 2006;129:1S-23S.

Margaret Fitzgerald, DNP, APRN, BC, NP-C, FAANP, CSP, is President of Fitzgerald Health Education Associates, Inc. in North Andover, Massachusetts and a Family Nurse Practitioner and Adjunct Faculty in the Family Practice Residency Program at the Greater Lawrence Family Health Center in Lawrence, Massachusetts.


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