ERS guidelines on the diagnosis and treatment of chronic cough in adults and children

Key points

• The European Respiratory Society (ERS) guideline answers 8 key questions (2 diagnostic, 6 therapeutic) using GRADE, complemented by narrative expert consensus.
• Initial evaluation includes spirometry and a recent chest X-ray; routine chest CT is not suggested when the chest X-ray and physical examination are normal.
• Treatable traits such as asthmatic cough and reflux are addressed first, using sequential therapeutic trials that are stopped if there is no response.
• A trial of low-dose slow-release morphine 5-10 mg twice daily is recommended for adults with chronic refractory cough (strong recommendation, moderate-quality evidence).
• Children are not small adults: an underlying cause should be sought, and a trial of antibiotics is suggested for chronic wet cough without warning signs.

Overview

This ERS guideline covers the diagnosis and treatment of chronic cough in adults and children. In adults, most chronic cough is framed as cough hypersensitivity syndrome based on vagal afferent hypersensitivity. In children, chronic cough is regarded as a symptom of an underlying disease that should be identified.

Definition and epidemiology

Recent guidelines define chronic cough as lasting more than 8 weeks in adults and 4 weeks in children, but the authors stress that the diagnosis rests on a global clinical assessment. A meta-analysis estimated adult prevalence at about 10%. In an international survey of patients attending specialist cough clinics, two thirds were women and the most common age at presentation was the sixth decade. Chronic cough occurs in about 15% of patients taking ACE inhibitors, and no patient with a cough should be given one.

Assessment

History and examination aim to exclude malignancy, infection, foreign body inhalation and ACE inhibitor use, and to identify treatable traits such as asthmatic cough/eosinophilic bronchitis and reflux. Impact can be measured with a simple score out of 10 or validated questionnaires (LCQ, CQLQ). The panel did not support using FeNO or blood eosinophils to predict response to anti-inflammatory treatment; this was left as a research recommendation.

Treatment in adults

Conditional suggestions based on low-quality evidence include a 2-4 week trial of inhaled corticosteroids and a 2-4 week anti-leukotriene trial, particularly in asthmatic cough. With fixed airflow obstruction, a 2-4 week trial of an inhaled corticosteroid plus a long-acting bronchodilator is suggested (moderate quality). Anti-acid drugs (proton pump inhibitors, H2 antagonists) should not be used routinely. Evidence is insufficient for routine macrolide therapy, but a one-month trial may be considered for the cough of chronic bronchitis refractory to other therapy, following local antimicrobial stewardship guidance. For chronic refractory cough, morphine is recommended. About half of patients respond, usually within a week, and treatment should be stopped if there is no response in 1-2 weeks. Gabapentin or pregabalin and cough control therapy (physiotherapy/speech and language therapy by experienced practitioners) are also suggested.

Chronic cough in children

Paediatric-specific protocols should be used. Common causes are post-infectious cough, asthma and protracted bacterial bronchitis (PBB). PBB is defined by chronic wet cough lasting more than 4 weeks, no pointers to another cause, and resolution after a 2-4 week course of an appropriate oral antibiotic. A short (2-4 week) trial of inhaled corticosteroids is suggested for chronic dry cough. Neuromodulators such as opioids, gabapentin or pregabalin are not used in children.

Frequently asked questions

Should every patient with chronic cough have a chest CT?

No. The guideline suggests not routinely performing chest CT when the chest X-ray and physical examination are normal (conditional recommendation, very low-quality evidence).

Are proton pump inhibitors useful for chronic cough?

Routine anti-acid treatment is not suggested in adults; benefit is unlikely unless there are peptic symptoms or evidence of acid reflux.

Which antibiotic should be used for chronic wet cough in children?

The guideline states that the preferred antibiotic, dose and duration are unknown, and that signs suggesting a specific disease should always be investigated.

Source

Morice AH, Millqvist E, Bieksiene K, Birring SS, Dicpinigaitis P, Domingo Ribas C, et al. ERS guidelines on the diagnosis and treatment of chronic cough in adults and children. Eur Respir J 2020;55(1):1901136. doi:10.1183/13993003.01136-2019. This summary was prepared by Medpresso from the original publication and is not a substitute for the full text or for medical advice.