A CHEST Expert Cough Panel has released new consensus-based recommendations on the management of chronic cough related to stable chronic bronchitis as well as the management of acute cough related to acute bronchitis in immunocompetent adult outpatients.1,2 These recommendations were both published in CHEST.

Development of the Recommendations

The committee convened to develop key clinical questions in the management of adult patients with acute or chronic bronchitis in an effort to update the 2006 CHEST guidelines. The multidisciplinary expert panel consisted of academic and private practice primary care providers as well as a consumer representative whose input represented the patient perspective.1,2

Questions were developed using the PICO (Population, Intervention, Comparator, Outcome) format. An independent review of the published literature was performed to identify relevant articles that answered the key clinical questions. The strength of recommendation was also included for each statement, based on balance of benefits to harms, patient values and preferences, and resource considerations. Drafted suggestions were presented to the panel, and an anonymous voting survey was used to identify consensus on each statement.1,2


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CHEST Consensus Statements for Managing Bronchitis-Associated Cough

In an ungraded consensus statement, the CHEST Expert Cough Panel suggested that cigarette smoke and environmental exposures to inhalants and pollutants increase the risk for bronchitis-related chronic cough in adults. The panel recommended clinicians encourage smoking cessation in patients with chronic bronchitis or other chronic lung disease to reduce the risk for chronic cough.1

Based on the current literature, the CHEST Expert Cough Panel did not believe there was sufficient evidence to recommend regular use of antibiotics, bronchodilators, mucolytics, or other pharmacologic treatments to relieve cough in patients with chronic bronchitis. Recommendations can only be made once these treatments have been clinically proven as safe and effective for reducing cough severity or improving the speed at which cough is resolved.1

A total of 6 eligible studies were identified to address whether treatment of stable chronic bronchitis improves or eliminates chronic cough. The routine use of positive end expiratory pressure, among other nonpharmacologic treatments, is also not recommended for adult patients with cough associated with stable chronic bronchitis. Only once these treatments have sufficient amount of data to support their safety and efficacy for relieving cough or reducing the severity of cough should they be considered in these patients.1

In an ungraded consensus-based statement, the CHEST Expert Cough Panel also suggested that immunocompetent adult outpatients with cough because of suspected acute bronchitis should not undergo routine targeted investigations using chest radiography, peak flow measurement, respiratory tract samples for viral polymerase chain reaction, serum C-reactive protein, spirometry, sputum for microbial culture, or procalcitonin.2

Similarly, the Expert Cough Panel recommended avoiding the routine prescription of antibiotic therapy, antiviral therapy, antitussives, inhaled beta agonists, inhaled anticholinergics, inhaled corticosteroids, oral corticosteroids, oral nonsteroidal anti-inflammatory drugs, or other therapies in these patients. Prescriptions may be considered when these therapies have demonstrated sufficient data suggesting they are safe and effective for resolving cough or reducing the severity of cough.2

For immunocompetent adult outpatients with related to acute bronchitis, the Expert Cough Panel recommended that clinicians encourage patients to seek reassessment and targeted investigation(s) in an effort to establish etiology if the suspected condition persists or worsens. In these same patients, the CHEST Expert Cough Panel suggested that clinicians should consider antibiotic therapy if the acute bronchitis worsens and if a complicating bacterial infection is suspected.2

The panel also recommended clinicians consider differential diagnoses in these patients, particularly in those who may require varying treatments, such as oral corticosteroids. Differential diagnoses could include chronic obstructive pulmonary disease, asthma, bronchiectasis, or any other chronic airway diseases.2

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Areas for Future Research

In their report, the Expert Cough Panel wrote that additional randomized controlled trials with comparators and patients who accurately meet the definition of chronic bronchitis are needed to develop more robust treatment guidelines. These trials should include reliable and valid cough outcome measures. Also, they suggested that future trials should examine the role of antibiotic and nonantibiotic therapies in adult patients with suspected acute bronchitis.2

The expert committee also suggested that stronger conclusions could be drawn from studies that account for patient comorbidities, such as diabetes, which could be of clinical importance to physicians. Additionally, studies that examine the predictive value of routine investigations in the diagnosis process of cough in acute bronchitis could also prove useful in the clinical setting.2

References

1. Malesker MA, Callahan-Lyon P, Madison JM, Ireland B, Irwin RS; on behalf of the CHEST Expert Cough Panel. Chronic cough due to stable chronic bronchitis: CHEST expert panel report [published online February 24, 2020]. CHEST. doi:10.1016/j.chest.2020.02.015

2. Smith MP, Lown M, Singh S, et al; on behalf of the CHEST Expert Cough Panel. Acute cough due to acute bronchitis in immunocompetent adult outpatient: CHEST expert panel report [published online February 21, 2020]. CHEST. doi:10.1016/j.chest.2020.01.044