German Respiratory Society guidelines for diagnosis and treatment of adults suffering from acute, subacute and chronic cough

Key points

• This S2k consensus guideline for pneumologists contains 48 recommendations and 16 statements; cough is classified as acute (up to 3 weeks), subacute (3-8 weeks) or chronic (longer than 8 weeks), and the character of the cough (dry or productive) is not helpful for diagnosis.
• In acute cough without alarm signals such as shortness of breath, haemoptysis, severe chest pain, high fever or signs of pneumonia, technical examinations should not be performed and antibiotics should not be started primarily in otherwise healthy people; alarm signals need prompt diagnostics.
• In chronic cough, diagnosis should start immediately, usually with a chest X-ray and lung function test; an ACE inhibitor should be stopped before further assessment.
• A PPI trial should not be carried out for suspected reflux with only extraoesophageal symptoms; with heartburn or regurgitation, lifestyle measures plus acid-inhibiting drugs for three months are advised.
• Chronic idiopathic or refractory cough is a diagnosis of exclusion and can be treated as a neuropathy of the cough reflex with gabapentin or pregabalin, with respiratory physiotherapy or speech therapy where available.

Overview

The 2019 guideline of the German Respiratory Society covers epidemiology, physiology, classification, acute, subacute and chronic cough, diagnostics, therapy and chronic idiopathic or refractory cough, with three simplified diagnostic algorithms. Viral infection of the respiratory tract is the most common cause of acute and subacute cough and the most common reason for a medical consultation worldwide. This overview is based on the abstract and the recommendation table; the therapy recommendations R39-R46 were not reviewed.

Acute and subacute cough

For severe acute dry irritable cough, dextromethorphan should be prescribed for about 7 days; other opiates should not be used for cough in a common cold, as they are no better than placebo. Patients with acute cough should be reassessed after 4 weeks. Subacute post-infectious cough due to temporary bronchial hyperreactivity should be treated with inhaled corticosteroids or inhaled beta2-agonists for about two weeks, and viral or post-viral rhinosinusitis may be treated with a nasal corticosteroid (off label); patients should be reassessed 4-8 weeks after the first consultation.

Chronic cough causes

If chest X-ray and lung function do not explain chronic cough, upper airway disease, cough-variant asthma and gastro-oesophageal reflux should be considered. Chronic rhinosinusitis is treated with nasal corticosteroids, chronic pharyngitis or laryngitis with inhaled corticosteroids, and cough-variant asthma is diagnosed with a methacholine provocation test when lung function is normal. In bronchiectasis, antibiotic courses should usually last at least 14 days, and long-term antibiotics may be considered for 3 or more exacerbations a year. CT and bronchoscopy should only follow exclusion of the most frequent triggers.

FAQ

When does acute cough need tests?

Only when alarm signals are present, such as shortness of breath, haemoptysis, severe chest pain, high fever or signs of pneumonia.

What should be done first in chronic cough?

Start diagnostics immediately with a chest X-ray and lung function test, and stop any ACE inhibitor before further assessment.

How is refractory chronic cough treated?

As a neuropathy of the cough reflex with gabapentin or pregabalin, plus respiratory physiotherapy or speech therapy where an experienced therapist is available.

Source

Kardos P, Dinh QT, Fuchs KH, et al. German Respiratory Society guidelines for diagnosis and treatment of adults suffering from acute, subacute and chronic cough. Respir Med 2020;170:105939. DOI: 10.1016/j.rmed.2020.105939. © 2020 Elsevier Ltd, made available under the Elsevier license. Summary prepared by Medpresso from the original publication; it is not a substitute for the full text or for medical advice.