Position statement summary

Cough in Children and Adults: Diagnosis, Assessment

and Management (CICADA). Summary of an updated
position statement on chronic cough in Australia
Julie M Marchant 1,2 , Anne B Chang1,2,3 , Emma Kennedy4, David King5, Jennifer L Perret6, Andre Schultz7,8, Maree R Toombs9,
Lesley Versteegh3, Shyamali C Dharmage6, Rebecca Dingle10, Naomi Fitzerlakey 10, Johnson George11, Anne Holland12,13,14,
Debbie Rigby5,15, Jennifer Mann14,16, Stuart Mazzone17, Mearon O’Brien10, Kerry-­Ann O’Grady 1, Helen L Petsky 18, Jonathan Pham19,
Sheree MS Smith20 , Danielle F Wurzel21, Anne E Vertigan22,23, Peter Wark 22,23

C
ough is a common condition leading to clinical consultation Abstract
and results in significant health care costs. Guidelines Introduction: Cough is the most common symptom leading to
seek to standardise and assist in diagnosis, investigation medical consultation. Chronic cough results in significant health
and management of cough.1,2 Cough in Children and Adults: care costs, impairs quality of life, and may indicate the presence of
Diagnosis, Assessment and Management (CICADA) is an a serious underlying condition. Here, we present a summary of an
updated Australian position statement on the clinical assessment updated position statement on cough management in the clinical
and management of chronic cough that highlights the burden consultation.
of chronic cough, including the disproportionate burden in Main recommendations: Assessment of children and adults
our First Nations population. We provide recommendations requires a focused history of chronic cough to identify any red
for initial assessment of chronic cough in clinical practice, flag cough pointers that may indicate an underlying disease.
including red flags in history and examination, and CICADA Further assessment with examination should include a chest
diagnostic management algorithms for use in paediatrics (Box 1) x-­ray and spirometry (when age > 6 years). Separate paediatric
and adults (Box 2). As there is high quality evidence that the and adult diagnostic management algorithms should be followed.
Management of the underlying condition(s) should follow specific
common aetiologies of chronic cough in children and adults
disease guidelines, as well as address adverse environmental
are not the same, we discuss the management of paediatric and exposures and patient/carer concerns. First Nations adults and
adult chronic cough separately.3 children should be considered a high risk group. The full statement
from the Thoracic Society of Australia and New Zealand and Lung
Method Foundation Australia for managing chronic cough is available at
https://lungf​ounda​tion.com.au/resou​rces/cicada-full-posit​ion-state​
CICADA was developed by a multidisciplinary expert ment.
committee that convened to undertake a systematic literature Changes in management as a result of this statement:
review and discuss updated recommendations. A total of 6395 • Algorithms for assessment and diagnosis of adult and paediatric
articles were screened and 277 new studies since 2010 (the chronic cough are recommended.
previous CICADA update)4 were included in the updated full • High quality evidence supports the use of child-­specific chronic
statement (Box 3 provides details of the guideline development cough management algorithms to improve clinical outcomes, but
process). Throughout the position statement (in the main text none exist in adults.
and in the box summarising the recommendations and their • Red flags that indicate serious underlying conditions requiring
investigation or referral should be identified.
level of evidence and strength), the GRADE of evidence6 refers
to evidence of the efficacy of treatment recommendations for • Early and effective treatment of chronic wet/productive cough in
children is critical.
cough in association with the respective conditions. The full
• Culturally specific strategies for facilitating the management of
statement can be found at https://lungf​ounda​tion.com.au/ chronic cough in First Nations populations should be adopted.
resou​rces/cicada-full-posit​ion-state​ment. We plan to update the • If the chronic cough does not resolve or is unexplained, the
statement every 2 years. patient should be referred to a respiratory specialist or cough
clinic.
Burden of chronic cough

In 2015, the prevalence of chronic cough in adults was estimated There are limited Australian studies on population prevalence
to be 9.6% (95% CI, 7.6–­11.7%) globally,7 and 8.8% in Australia.8 of chronic cough in children.11 In a recent study of Australian
MJA 220 (1) ▪ 15 January 2024

The prevalence of chronic cough gradually increases to peak in children presenting to emergency departments, 7.5% had chronic
the sixth decade9 and has been estimated to occur in 3% of never cough, and 20–­23% had persistent cough at day 28 irrespective of
smokers, 4% of former smokers and 8% of current smokers.10 duration of cough on presentation.12 The prevalence of chronic
Overall, chronic cough presents more commonly in middle-­aged wet cough in children living in Indigenous communities is
women.2 higher (around 13%).13

1
Australian Centre for Health Services Innovation, Queensland University of Technology, Brisbane, QLD. 2 Queensland Children’s Hospital, Brisbane, QLD. 3 Menzies School of Health Research,
Darwin, NT. 4 Rural and Remote Health, Flinders University, Darwin, NT. 5 University of Queensland, Brisbane, QLD. 6 Melbourne School of Population and Global Health, University of
Melbourne, Melbourne, VIC. 7 Wal-­y an Respiratory Research Centre, Perth, WA. 8 Perth Children’s Hospital, Perth, WA. 9 University of Sydney, Sydney, NSW. 10 Lung Foundation Australia,
Brisbane, QLD. 11 Centre for Medicine Use and Safety, Monash University, Melbourne, VIC. 12 Alfred Health, Melbourne, VIC. 13 Monash University, Melbourne, VIC. 14 Institute for Breathing and
Sleep, University of Melbourne, Melbourne, VIC. 15 Queensland University of Technology, Brisbane, QLD. 16 Austin Health, Melbourne, VIC. 17 University of Melbourne, Melbourne, VIC. 18 Griffith
University, Brisbane, QLD. 19 Alfred Health, Melbourne, VIC. 20 Western Sydney University, Sydney, NSW. 21 Royal Children’s Hospital, Melbourne, VIC. 22 Hunter Medical Research
Institute, University of Newcastle, Newcastle, NSW. 23 John Hunter Hospital, Newcastle, NSW. [email protected] ▪ doi: 10.5694/mja2.52157
35
[Correction added on 22 November 2023 after first online publication: one of the co-author's names has been amended.]
 Position statement summary

1 Algorithm for diagnosis and assessment of a child with chronic cough

PBB = protracted bacterial bronchitis ◆

2 Algorithm for diagnosis and assessment of an adult with chronic cough

MJA 220 (1) ▪ 15 January 2024

ACE = angiotensin-­converting enzyme; COPD = chronic obstructive pulmonary disease; CT = computed tomography; ENT = ear, nose and throat; ICS = inhaled corticosteroids;
◆
FeNO = fractional exhaled nitric oxide; GORD = gastro-­oesophageal reflux disease; ppb = parts per billion; RAST = radioallergosorbent test; SPT = skin prick test.

36
 Position statement summary
Box 4 lists potential strategies in combatting chronic wet cough
3 Guideline development process in First Nations patients.
• From Jan 2021 to December 2022, members of the CICADA committee
regularly convened (email, face-­to-­f ace, virtual meetings) to undertake an Chronic cough: initial assessment of both children and
extensive literature review and discuss recommendations.
• The committee included several working groups (children, adult,
adults
epidemiology and prevention, overall approach) who undertook systematic
searches for relevant literature published since 2010 (the previous CICADA In both adults and children, estimating duration of cough is
update),4 including but not limited to “all RCTs, systematic reviews, critical in assessment.3,22 A chronic cough is defined as a daily
guidelines, position statements in any setting”. cough for > 4 weeks in children,3 and > 8 weeks in adults (Box 5).22
• Databases searched included OVID MEDLINE, PubMed, the Cochrane
Library, and Embase. Search results were then screened (total 6395
The initial assessment for chronic cough relies on history and
abstracts); a total of 277 new studies were included in this statement. examination to identify any red flags —­indicators that may
The search strategies, PRISMA diagrams, full reference list of included signal an underlying disease or systemic exposure (Box 6).
evidence, and complete guideline document are available on the Australian Probability-­based algorithms are an important clinical decision
Lung Foundation website at https://lungf​ounda​tion.com.au/resou​rces/
tool and are presented for both children (Box 1) and adults
cicada-full-posit​ion-state​ment/.
• The recommendations use the principles of evidence-­based medicine5 and (Box 2) separately. Initial assessment should always include
the GRADE approach to guide recommendations to inform the strength of a chest x-­ ray and spirometry (age, > 6 years).2,3,22 Although a
the evidence: strong, weak, or no specific recommendation.6 primary diagnosis may be made, it should be remembered that
• The implications of strong recommendation are: many common conditions co-­exist.
‣ for patients —­most people in your situation would want the
recommended course of action and only a small proportion would not; An assessment of risk factors and modification of such exposures
suggest request discussion if the intervention is not offered is essential to the optimal management of chronic cough (Box 7).
‣ for clinicians —­most patients should receive this recommended course These risk factors are mostly common to both children and
of action
‣ for policy makers —­the recommendation can be adopted as a policy in adults.
most situations.
• The implications of a weak recommendation are:
Diagnosis and management in children
‣ for patients —­some people in your situation would want the
recommended course of action, but many would not
‣ for clinicians —­you should recognise that different choices will be In children, “specific cough” refers to a cough that occurs with a
appropriate for different patients and that you must help each patient condition known to be associated with or cause a chronic cough.
to arrive at a management decision consistent with their values and Identification of the conditions associated with chronic cough
preferences
forms the basis of specific treatment and investigation. These
‣ for policy makers —­policy making will require substantial debate. conditions can usually be identified by cough characteristics
and reviewing red flags (Box 6), a probability-­based diagnostic
approach (Box 8), and consideration of important conditions not to
First Nations Australians are disproportionately affected by be missed (Box 9). This approach has been validated in children.3
conditions that present with chronic wet cough, such as protracted
There is high quality evidence that using children-­specific cough
bacterial bronchitis and bronchiectasis. The mortality difference
management algorithms improves clinical outcomes, as shown
between First Nations and non-­First Nations Australians with
in a systematic review that focused on chronic cough managed
bronchiectasis is about 22 years.14 In 180 First Nations children
by specialists.26 This approach was supported by a randomised
aged < 5 years presenting to primary care in urban Queensland
controlled trial (RCT) applying the cough management algorithm
for any reason, 24% had a history of chronic cough in the previous
in community-­ based children.12 Box 1 shows the paediatric
12 months, and at 12-­month follow-­up 26% had a further episode
algorithm, adapted from international ones.3,27,28
of chronic wet cough.15 Owing to multiple factors, chronic wet
cough in First Nations children is often incorrectly considered
Causes of paediatric specific cough
a normal feature by both families and doctors.16,17 First Nations
Australians who have been symptomatic since childhood are Protracted bacterial bronchitis. This condition is considered in
more likely to have considerably poorer clinical outcomes in children with a chronic wet cough in the absence of other specific
adulthood than those who had onset symptoms in adulthood.18 cough diagnoses or red flags.24 Chest x-­ ray and spirometry

4 Specific recommendations for addressing chronic cough in First Nations people

Recommendations Level of evidence* Strength of recommendation†

Address environmental factors: air quality (airborne particulate matter), cigarette smoke Good Strong
exposure (patient, parental, household) 19
MJA 220 (1) ▪ 15 January 2024

Provide culturally secure health information to facilitate detection of chronic wet cough: Satisfactory Strong
accurate history taking in First Nations settings, provision of appropriate health information
in a culturally secure way, community engagement at a local level20

Implement strategies in health systems that include targeted training of clinicians; Satisfactory Strong
implementation programs that include targeted training of clinicians, health system changes
and the provision of culturally secure health information tools have been shown to improve
physician assessment of chronic cough and appropriate antibiotic prescription20

Utilise chronic cough management algorithms; randomised controlled trials including First Excellent Strong
Nations children have shown the effectiveness of management algorithms for chronic
cough, usual care12,21
* NHMRC additional levels of evidence and grades for recommendations for developers of guidelines. 5 † The GRADE (Grading of Recommendations Assessment, Development and
37
◆
Evaluation) system was used to grade the strength of recommendations.6
 Position statement summary

5 Definitions of cough3,22 8 Probability-based diagnosis of chronic cough in children

• Cough: protective respiratory behaviour of forced expulsion of air against If the examination, chest x-­ray and spirometry are normal, the most common
a closed glottis diagnoses and exposures associated with chronic cough in children are:
• Acute cough: cough lasting up to 2 weeks • Diagnoses:
• Protracted acute cough:
‣ Protracted bacterial bronchitis (if wet/productive cough and no other
‣ in children —­cough lasting 2 to 4 weeks systemic symptoms or signs)24
‣ in adults —­cough lasting 2 to 8 weeks ‣ Asthma21(if other respiratory symptoms are present)25
• Chronic cough: • Exposures:
‣ in children —­cough lasting more than 4 weeks ‣ Respiratory infection (post-­infectious cough, including pertussis)
‣ in adults —­cough lasting more than 8 weeks ‣ Tobacco smoke or e-­cigarettes/vaping and other pollutants (active,
environmental) can exacerbate chronic cough but are rarely the cause

6 Red flags and cough pointers (indicators of serious

pathology)
Children23 Asthma. Asthma may cause a cough that is episodic and
• Dyspnoea (at rest or exertional) associated with other features such as expiratory wheeze and/
• Recurrent episodes of chronic or wet or productive cough
• Recurrent pneumonia
or exertional dyspnoea. The diagnosis and management of
• Chest pain asthma should be undertaken in accordance with paediatric
• Haemoptysis asthma management guidelines. Treatment is expected to
• Systemic symptoms: fever, weight loss, growth failure reduce symptoms within 2–­ 4 weeks [GRADE: Strong]. In
• Neurodevelopmental abnormality
children, chronic cough in the absence of other symptoms/
• Feeding difficulties (including choking/vomiting)
• Stridor and other respiratory noises
signs is seldom due to asthma, and inhaled corticosteroids
• Abnormal clinical respiratory examination (eg, crackles, digital clubbing) are not indicated unless there are specific features to suggest
• Abnormal systemic examination (eg, growth failure) asthma. When used, the trial period should be of a defined
• Abnormal chest x-­ray duration (eg, one month) to confirm or refute the provisional
• Abnormal lung function
• Co-­e xisting chronic diseases (eg, immunodeficiency, syndromes)
diagnosis.27
Adults Allergic rhinitis. The evidence that postnasal drip is a
• Haemoptysis significant cause of cough in children is not fully established,
• Smoking/vaping (especially new/altered cough, cough with voice
and when present, likely reflects co-­ existing upper airway
disturbance)
• Prominent dyspnoea (especially at rest or at night) disease. Some paediatric studies reported upper airways cough
• Chronic productive cough with substantial sputum production syndrome as the aetiology of chronic cough,33 but we did not
• Hoarseness find high quality RCTs on therapies for upper airway disorders
• Recurrent pneumonia in children with cough, and in children, antihistamines have not
• Systemic symptoms: fever, weight loss
• Swallowing difficulties (including choking/vomiting)
been shown to be efficacious for the treatment of chronic cough.3
• Abnormal clinical respiratory examination (eg, crackles, wheeze, digital Allergic rhinitis can be diagnosed by symptoms of nasal itching,
clubbing) nasal blockage, or nasal discharge. Management should follow
• Abnormal chest radiograph current guidelines [GRADE: Weak].34
Chronic rhinosinusitis. Chronic cough may occur concurrently
in children with chronic rhinosinusitis.25 However, any
7 Preventive strategies for chronic cough
association between rhinosinusitis and cough does not necessarily
indicate causality. Notably, the bacterial pathogens associated
• Immunisations: pneumococcus, Haemophilus influenzae, Bordetella
pertussis, influenza
with chronic rhinosinusitis are the same as those of protracted
bacterial bronchitis, hence treatment recommendations for
• Avoidance of airway pollutants, irritants and triggers:
prolonged antibiotics (~ 2–­4 weeks of amoxicillin–­clavulanate)
‣ cigarette smoke, wood-­f ire smoke, e-­cigarettes
are similar.24,35 While there are currently insufficient data, this
‣ fumes, strong odours, subfreezing air
‣ for those susceptible, animals, pollens, and other allergens raises the question of whether the chronic wet cough in children
• Health education: with chronic rhinosinusitis is related to protracted bacterial
‣ early clinical review and adequate treatment of a chronic wet cough bronchitis [GRADE: Weak].
including post-­acute respiratory infection (> 4 weeks in children, > 8
weeks in adults) Obstructive sleep apnoea. Obstructive sleep apnoea (OSA) is
‣ workplace education about hazard minimisation for workers in high suggested by a history of snoring associated with witnessed
risk occupations apnoeas, sleep disturbance or sweating at night, excessive
MJA 220 (1) ▪ 15 January 2024

daytime sleepiness, failure to thrive (in infants), obesity, large

tonsils, or nasal blockage. The association between cough and
are usually normal. Two to four weeks of antibiotic treatment
OSA is very weak.36 Hence, in children with OSA and cough, the
(typically amoxicillin–­ clavulanate if no history of allergy)
OSA and cough should be evaluated and treated independently
should lead to complete cough resolution29,30 [GRADE: Strong].
[GRADE: Weak].
The diagnosis can only be definitive when patients become
asymptomatic with treatment.24,31 A significant proportion Gastro-­oesophageal reflux disease. In children, gastro-­
of children with protracted bacterial bronchitis have ongoing oesophageal reflux disease (GORD) is not commonly identified
symptoms at 5-­year follow-­up, including bronchiectasis in 9.6%; as a cause of chronic cough.25 There is little current convincing
these children therefore require careful follow-­up and specialist evidence that GORD is a common cause of isolated chronic cough
referral if episodes recur more than three times per year or (ie, without gastrointestinal-­ related GORD symptoms) and
38 treatment fails (Box 1).32 proving causality is difficult.37 Thus, in line with international
 Position statement summary

9 Significant conditions in children with chronic cough3,25

Condition Typical symptoms

Diagnoses with specific removable causes or usually good

treatment response

Protracted bacterial bronchitis Wet/productive cough and no other systemic symptoms or signs24

Asthma Recurrent wheeze and/or dyspnoea responsive to β 2 agonists

Tic (habit cough) and somatic cough syndrome (psychogenic Continuous, excessive dry cough with no sign of physical disease; stops when asleep or
cough) distracted

Significant conditions not to be missed

Congenital airway abnormalities Symptoms commencing in infancy/early childhood

Recurrent aspiration Cough or choking with feeds

Foreign body inhalation Symptoms commenced after choking episode

Chronic infection

Tuberculosis Focal signs, weight loss lymphadenopathy, contact history

Lung abscess Fever and local signs

Pertussis Dry cough, contact history; paroxysms in unvaccinated children

Bronchiectasis/chronic suppurative lung disease/cystic fibrosis Wet cough not responding to 4 weeks of antibiotics or recurring

Chronic atelectasis Focal signs on auscultation

Interstitial lung disease Diffuse inspiratory crepitations growth failure with or without hypoxia

guidelines,3,33,38 CICADA recommends against empirical Causes of adult chronic cough

treatment for GORD in children with chronic cough and against
Asthma/eosinophilic bronchitis/cough variant asthma.
fundoplication for the treatment of isolated cough in children
Eosinophilic airway inflammation is found in 30–­50% of adults
(Box 10). When symptoms of GORD are present, paediatric
with chronic cough47-­49 and may reflect asthma, cough variant
GORD guidelines42 should be followed.
asthma, and eosinophilic bronchitis. Asthma is diagnosed
Tic and somatic cough syndrome. Tic (habit cough) and somatic in 24–­32% of adults with chronic cough,48 and is associated
cough syndrome (psychogenic cough) are characterised by a with episodic chest tightness, wheeze and dyspnoea.41
continuous, excessive dry barking/honking cough in a child with Asthma diagnosis relies upon the presence of variable airflow
no red flags in their history or examination. The key indicator obstruction (as measured by spirometry, peak flow monitoring)
is that cough is absent in sleep. Treatment involves suggestion or bronchial hyperresponsiveness.39,41,50 Cough variant asthma,
therapy without further investigation [GRADE: Weak].43,44 a subtype of asthma, is less common and presents solely with
cough (without dyspnoea or wheeze), normal spirometry, and
Non-­specific cough in children a positive bronchial provocation challenge.51 As asthma is
Non-­specific cough is chronic dry cough without any cough commonly associated with chronic cough,19 we recommend
pointers or cough-­associated diagnoses, and normal chest x-­ray spirometry, including post bronchodilator, be considered
and spirometry. Most children with non-­specific cough undergo in the initial assessment of all patients with chronic cough.
spontaneous resolution or improvement,25 but they need to be Eosinophilic bronchitis is characterised by an increase in lower
reviewed to ensure that no new cough pointers emerge. The airway eosinophils, normal spirometry, and negative bronchial
management of non-­ specific cough adopts the approach of provocation challenge.48,49 Fractional exhaled nitric oxide
counsel, watch, wait and review [GRADE: Strong], and addresses (FeNO) has been proposed as a surrogate marker of eosinophilic
parental stress and concerns [GRADE: Strong]. At each review, airway inflammation.2,52 FeNO has good diagnostic accuracy
look out for specific pointers (Box 1). CICADA recommends in predicting cough variant asthma, but was less sensitive in
against use of narcotic cough suppressants45 in children predicting eosinophilic bronchitis.53 Treatment of asthma,
MJA 220 (1) ▪ 15 January 2024

[GRADE: Strong]. according to current management guidelines, has been shown

to improve chronic cough [GRADE: Strong].

Diagnosis and management in adults Chronic bronchitis/chronic obstructive pulmonary disease/

bronchiectasis. In adults, chronic bronchitis is defined by
The assessment of chronic cough in adults includes a history2,22 recurring chronic cough with sputum production54 and has
to define the duration and characteristics of the cough (sputum been described with and without chronic obstructive pulmonary
production, cough hypersensitivity, triggers), to elicit any red disease, bronchiectasis, or a smoking history.55,56 Chronic
flags that suggest underlying disease (Box 6, Box 11)2,46 We bronchitis associated with chronic obstructive pulmonary
recommend a chest x-­ray and spirometry followed by use of a disease and asthma is linked to more frequent exacerbations and
probability-­based algorithm (Box 2) to identify whether these worse outcomes.57 It is recommended to treat these underlying
triggers are present and then to manage them to reduce chronic disorders [GRADE: Strong]. Non-­smoking adults with chronic 39
cough (Box 10, Box 12). bronchitis without airflow obstruction should be investigated
 Position statement summary

10 Strength of recommendations for the efficacy of treatment of cough in association with the conditions
Recommendations Level of evidence* Strength of recommendation†

Children

Cessation of parental smoking to reduce cough Good Strong

Cough with allergic rhinitis

Treatment according to current rhinitis management guidelines involving topical nasal Poor Weak
corticosteroid, antihistamines, and allergen management

Cough with obstructive sleep apnoea

Tonsillectomy and adenoidectomy Poor Weak

Cough with asthma

Treatment according to current asthma management guidelines involving education and self-­ Good Strong
management, inhaled bronchodilators, and inhaled corticosteroids; if empirical treatment is
used, review in 2–­4 weeks

Cough with protracted bacterial bronchitis

Medium term (2–­4 weeks) antibiotics for protracted bacterial bronchitis Excellent Strong

Cough with GORD

Treatment(s) for GORD should not be used when there are no gastro-­intestinal clinical features Good Weak
of GORD; paediatric GORD guidelines should be used to guide treatment and investigations

Treatment with laparoscopic fundoplication Poor Strong recommendation against

Non-­specific or refractory cough

Address patient/parental stress and concerns Poor Strong

Address exacerbating factors, such as tobacco smoke exposure Good Strong

Minimise use of medications other than demulcents (eg, honey) if no contraindications (young Good Strong
age) exist

Adopt counsel, watch, wait and review approach Excellent Strong

Empirical trial of inhaled corticosteroid therapy Poor No recommendation

Empirical trial of proton pump inhibitors Good Strong recommendation against

Speech pathology techniques designed to relieve glottal constriction during inspiration and to Poor No recommendation
recognise and alter response to precipitants

Antitussive therapy with narcotic Good Strong recommendation against

Adults

Cough with allergic rhinitis

Treatment according to current rhinitis management guidelines 39 involving nasal corticosteroid Good Weak
spray, nasal antihistamine spray, combination corticosteroid/antihistamine nasal spray

Cough with chronic rhinosinusitis

Treatment according to current chronic sinusitis management guidelines 39 involving nasal Poor Weak
corticosteroid spray, large volume saline irrigation, long term antibiotic therapy (macrolide, 3
months)

Cough with laryngeal hypersensitivity

Treatment with speech pathology management Good Strong

Cough with vocal cord dysfunction/intermittent laryngeal obstruction

MJA 220 (1) ▪ 15 January 2024

Treatment with speech pathology management Good Strong

Cough with GORD/dysmotility

Treatment(s) for GORD in adults with cough alone and no other symptoms of GORD with PPI Good Strong recommendation against
therapy; when other symptoms of GORD occur, use appropriate clinical guidelines 40 use of PPI for cough alone

Cough with asthma

Treatment according to current asthma management guidelines 41 involving education, inhaled Excellent Strong
bronchodilators, inhaled corticosteroids

Leukotriene receptor antagonists, alone or with inhaled corticosteroids Good Weak

40 Continues
 Position statement summary

10 Continued

Recommendations Level of evidence* Strength of recommendation†

Cough with eosinophilic bronchitis

Treatment with inhaled corticosteroids Satisfactory Strong

Leukotriene receptor antagonists, alone or with inhaled corticosteroids Satisfactory Weak

Cough with chronic bronchitis without airflow obstruction

Mucolytic therapy and/or macrolide antibiotic therapy Poor Weak

Cough with ILD

Treatment according to current ILD guidelines Poor Weak

Cough with COPD

Treatment according to current COPD management guidelines involving education and self-­ Excellent Strong
management, smoking cessation, pulmonary rehabilitation and treatment of exacerbations

Addition of combination inhaled long-­acting bronchodilators and corticosteroids may reduce Good Weak
cough severity

Cough with bronchiectasis

Treatment according to current bronchiectasis management guidelines involving treatment of Good Weak
exacerbations with 14 days antibiotics, regular airway clearance and pulmonary rehabilitation

Unexplained chronic cough

An empirical treatment trial supervised by a specialist cough clinic using validated, objective Satisfactory Weak
measures of cough severity (cough severity scales, the cough severity diary, quality-­of-­life
measures [Leicester cough questionnaire, cough specific quality of life questionnaire], objective
cough recording devices and cough reflex sensitivity challenges)

Cessation of smoking, nicotine containing cigarettes or e-­cigarettes Excellent Strong

Identify and minimise environmental/occupational exposures Satisfactory Weak

Cessation of angiotensin-­converting enzyme inhibitors Satisfactory Strong

Speech and language therapy Excellent Strong

Inhaled corticosteroids or leukotriene antagonist empirical treatment trial Poor Weak

Macrolide antibiotics Satisfactory Weak recommendation against

Acid suppressive therapy, proton pump inhibitors, or H2 antagonist empirical treatment trial Excellent Strong recommendation against

Neuromodulators (amitriptyline, gabapentin, pregabalin) treatment trial Satisfactory Weak

Opioids empirical treatment trial Satisfactory Weak recommendation against

COPD = chronic obstructive pulmonary disease; GORD = gastro-­oesophageal reflux disease; H2 = histamine type 2; ILD = interstitial lung disease; PPI = proton pump inhibitor. * NHMRC
additional levels of evidence and grades for recommendations for developers of guidelines. 5 † GRADE (Grading of Recommendations Assessment, Development and Evaluation) system.6 ◆

for underlying lung disease such as bronchiectasis. Treatments Gastro-­ oesophageal reflux disease/airway reflux. The
trialled have included mucolytics and/or macrolide antibiotics, prevalence of chronic cough associated with GORD in adults
but the evidence for their use is scarce [GRADE: Weak]. varies depending on the definition. When this requires the
demonstration of acid reflux the prevalence is low;62 however,
Interstitial lung disease. Chronic cough that has been reported
definitions based on symptoms or oesophageal dysmotility are
in up to 80% of people with interstitial lung disease58 is often
more frequently associated with chronic cough. A systematic
severe, leads to a significantly impaired quality of life, and is
review identified nine RCTs that treated patients with acid
associated with worse clinical outcomes.59
suppression and no symptomatic GORD. Only two trials
MJA 220 (1) ▪ 15 January 2024

Laryngeal hypersensitivity/intermittent laryngeal obstruction/ reported a reduction in cough frequency or severity, limited
vocal cord dysfunction. Several well defined clinical syndromes to those with abnormal 24-­ hour pH monitoring.63 CICADA
comprise laryngeal dysfunction and often have overlapping recommends against acid suppressive therapy without a history
symptoms.60 They can also be associated with intermittent of reflux, or evidence of reflux on objective testing [GRADE:
laryngeal obstruction, which describes an inappropriate, Strong].40
transient, reversible narrowing of the larynx in response to
external triggers. Intermittent laryngeal obstruction is an Chronic rhinosinusitis. Chronic rhinosinusitis (allergic or non-­
important cause of chronic cough and dyspnoea and can mimic allergic) is found in 12% of people from the United Kingdom
asthma.61 Speech pathology management including education, presenting with chronic cough,64,65 and treatment follows current
vocal hygiene training, breathing techniques, and psycho-­ evidence-­based guidelines.39 Intranasal corticosteroids are the
educational counselling are effective in reducing symptoms first line therapy, although evidence they improve chronic cough 41
[GRADE: Strong]. is weak [GRADE: Weak]. A systematic review of antihistamines66
 Position statement summary

11 Conditions associated with chronic cough in adults

ACE = angiotensin-converting enzyme; COPD = chronic obstructive pulmonary disease; GORD = gastro-oesophageal reflux disease; ILD = interstitial lung disease; ILO = intermittent
laryngeal obstruction. Reproduced with permission from Lung Foundation Australia. ◆

(ten placebo-­controlled trials in chronic rhinitis, asthma or cough should be seen within 4 weeks, and if not evident, ICSs should
associated with allergy) found treatment led to improved cough be ceased. Every effort should be made to diagnose asthma
symptom scores, although the effect appeared greatest in those and demonstrate variable airflow obstruction, as this predicts
with allergy [GRADE: Weak]. response to ICSs.2 In RCC/UCC, the evidence for empirical ICS
use is weak, and there are greater odds of cough improvement
Cough hypersensitivity syndrome. Cough hypersensitivity
with an elevated FeNO (> 50 ppB) [GRADE: Weak].71
syndrome describes excessive coughing triggered by low levels
of thermal, mechanical or chemical stimuli, and can be the result The use of leukotriene receptor antagonists is limited to small
of multiple triggers (Box 11).2,46 Where cough persists beyond open label trials.72 The evidence for their use is weak and may
management of triggers, it is called unexplained chronic cough. be independent of FeNO [GRADE: Weak].
Antibiotics. A small trial of azithromycin in RCC/UCC
Adult unexplained chronic cough
found no improvement in cough scores, except for a subgroup
Where cough persists despite optimal treatment of diagnosed with asthma where a significant improvement was seen.73
conditions, it is termed refractory chronic cough (RCC). If There is no evidence for other antibiotic regimens. We
no identifiable cause for the cough can be determined, it is recommend against the use of empirical antibiotic trials
termed unexplained chronic cough (UCC), estimated to occur [GRADE: Weak].
in 10% of adult chronic cough,2,67 and is clinically important.64
Neuromodulators. Two systematic reviews investigating
We recommend referral for all adults with RCC or UCC to a
neuromodulators including amitriptyline, gabapentin,
specialist respiratory clinic.
pregabalin and baclofen consistently found improvements in
Therapies for RCC/UCC in adults. Specialists use several cough symptoms and quality of life in RCC/UCC.74,75 A trial of
MJA 220 (1) ▪ 15 January 2024

options to treat RCC and UCC, including speech therapy and/ neuromodulators could be considered in RCC/UCC [GRADE:
or antitussive therapies. Two RCTs of speech therapy in adults Weak].
with RCC or UCC found benefits.68,69 We recommend speech
Opioids. There are short term trials76 showing that low dose
pathology for RCC and UCC [GRADE: Strong], following
morphine reduces RCC/UCC; however, CICADA recommends
assessment by respiratory/otolaryngology clinics.
against its use in chronic cough given concerns and limitations
The evidence-­base for antitussive therapies in RCC/UCC is not regarding long term use of opioids [GRADE: Weak].
strong, and a trial of treatment under the supervision of specialist
Specific antitussive therapies. Although the detailed
is recommended. The trial should be of sufficient duration to
neurophysiology of cough is beyond the scope of this statement,
establish efficacy using objective measures of cough severity.70
changes in the activity and sensitivity of peripheral and central
42 Inhaled corticosteroids. Inhaled corticosteroids (ICSs) are cough neural circuits are critical to chronic cough pathology and
often trialled in RCC/UCC empirically. A response to treatment a targetable mechanism. There is emerging evidence for the use
 Position statement summary

12 Conditions associated with chronic cough in adults

Condition Key features Investigations

Chronic rhinitis Nasal obstruction (variable or persistent), loss of smell, RAST/SPT

nasal discharge Anterior rhinoscopy

Chronic sinusitis Nasal obstruction, and at least one other of nasal RAST/SPT
discharge, postnasal drip, reduction/loss of sense of CT sinuses
smell, facial pain

Laryngeal Hypersensitive cough reflex, allotussia Laryngeal Hypersensitivity Questionnaire

hypersensitivity

Vocal cord Inspiratory dyspnoea Functional laryngoscopy

dysfunction/ Throat tightness, dysphonia, sensation of choking/ Laryngeal CT
inspiratory suffocation Flattened inspiratory loop of flow volume curve
laryngeal
obstruction

GORD/ Heartburn, reflux symptoms Oesophageal manometry

dysmotility Cough associated with meals pH-­metry (resistant cases)

Post infectious Post acute respiratory illness Bordetella pertussis serology

CT chest

Asthma/cough Wheeze, dyspnoea Spirometry (bronchodilator reversibility)

variant asthma/ Cough as the only symptom Elevated FeNO
eosinophilic Peak flow variability
bronchitis Bronchial provocation challenge
without asthma Reversible airflow limitation as for asthma, FeNO, may require bronchial
provocation challenge to rule out
No evidence of variable airflow obstruction
Elevated FeNO

Chronic non-­ Sputum production without airflow obstruction Spirometry: pre/post bronchodilator to exclude asthma and COPD
eosinophilic Consider bronchiectasis and need for HRCT chest
bronchitis

Interstitial lung Presence of dyspnoea HRCT chest, history (exposures, serology)

disease

COPD Exertional dyspnoea, sputum production, history of Spirometry (post bronchodilator FEV 1/FVC < 0.7)
smoking/exposure to noxious agents

Bronchiectasis Sputum production, chronic bronchial infection HRCT chest

Congestive Dyspnoea, peripheral oedema, crackles +/-­wheeze on ECG, CXR, BNP or

cardiac failure auscultation NT-­BNP Echocardiography

Lung cancer Haemoptysis, dyspnoea, chest pain, history of smoking, CT scan of the chest, bronchoscopy, PET scan
constitutional symptoms
BNP = B-­t ype natriuretic peptide; COPD = chronic obstructive pulmonary disease; CT = computed tomography; CXR = chest x-­r ay; ECG = electrocardiogram; FeNO = fractional exhaled nitric
oxide; FEV 1 = forced expiratory volume; FVC = forced vital capacity; GORD = gastro-oesophageal reflux disease; HRCT = high resolution computed tomography; NT-­B NP = N-­terminal pro
hormone BNP; PET = positron emission tomography; RAST = radioallergosorbent test; SPT = skin prick test. ◆

of specific antitussive agents for RCC/UCC, but none are yet • Management of the underlying condition(s) should follow
approved for use in Australia. specific disease guidelines, as well as address adverse
environmental exposures and patient/carer concerns.
Conclusion • Aboriginal and Torres Strait Islander adults and children
should be considered high risk groups.
Cough is the most common symptom leading to medical
consultation. Chronic cough results in significant health care
Full details of the position statement update, complete reference
costs, impairs quality of life, and may indicate the presence of
list, and chronic cough health professional and consumer
MJA 220 (1) ▪ 15 January 2024

a serious underlying condition. We have presented an updated

resources developed in conjunction are available from Lung
Australian position statement on cough management in the
Foundation Australia at https://lungf​ounda​tion.com.au/resou​
clinical consultation.
rces/cicada-full-posit​ion-state​ment.
The main recommendations are:
Acknowledgements: We thank Lung Foundation Australia and the Thoracic
Society of Australia and New Zealand for their support in the preparation of these
• Assessment of children and adults requires a focused history guidelines.
of the chronic cough to elicit any red flag cough pointers that
Open access: Open access publishing facilitated by Queensland University of
may indicate an underlying disease. Technology, as part of the Wiley - Queensland University of Technology agreement via
the Council of Australian University Librarians.
• Further assessment with examination should include a chest
x-­ray and spirometry (age, > 6 years). Competing interests: The authors received no specific funding for this work.
• Separate paediatric and adult diagnostic management
Julie Marchant is supported by the Lung Foundation Australia Hope Research Fund 43
Andrew Harrison Fellowship in Bronchiectasis Research 2021 and receives personal
algorithms should be followed. fees from being an author of two UpToDate chapters, outside of the submitted
 Position statement summary
work. Anne Chang reports multiple grants from the National Health and Medical grants from AstraZeneca and GSK for unrelated research. Jennifer Perret is supported
Research Council (NHMRC) during the conduct of this work; is an independent data by an NHMRC Early Career Fellowship (APP1159090). Johnson George has received
monitoring committee member for an unlicensed vaccine (GSK) and an unlicensed honoraria through consultations for AstraZeneca, GSK and Pfizer which have been
monoclonal antibody (AstraZeneca); is an advisory member on the study design for paid to his employer, and has held research grants from Boehringer Ingelheim, GSK
an unlicensed molecule for chronic cough (Merck); and has received personal fees and Pfizer through investigator-­initiated research schemes. All other authors have no
from being an author of two UpToDate chapters, outside the submitted work. Andre conflicts of interest to declare in relation to this work.
Schultz receives salary support from a Medical Research Future Fund Investigator
Grant (APP1193796). Danielle Wurzel has received research grants from the NHMRC
and GSK, and honoraria from Merck and MSD. Stuart Mazzone has received honoraria
Provenance: Not commissioned; externally peer reviewed. ■
from Merck, NeRRe Therapeutics, Reckitt Benckiser and Bellus Health for consultancy
on their antitussive programs, and antitussive-­related grant support from Merck, © 2023 The Authors. Medical Journal of Australia published by John Wiley & Sons Australia, Ltd
Bellus Health and Reckitt Benckiser, as well as multiple grants from the NHMRC on behalf of AMPCo Pty Ltd.
and the Australian Research Council. Shyamali Dharmage has received multiple
grants from the NHMRC and the Australian Research Council, including the NHMRC This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-
Investigator Grant (APP1193993) that currently supports her. Additionally, Shyamali NoDerivs License, which permits use and distribution in any medium, provided the original work is
Dharmage and Jennifer Perret have received independent investigator-­initiated properly cited, the use is non-commercial and no modifications or adaptations are made.

1 Gibson P, Wang G, McGarvey L, et al. Treatment bronchitis in Aboriginal children. ERJ Open Res children with chronic cough: systematic reviews.
of unexplained chronic cough: CHEST guideline 2019; 5: 00248-2019. Chest 2016; 149: 106-119.
and expert panel report. Chest 2016; 149: 27-44. 14 McCallum GB, Chang AB. ‘Good enough’ is ‘not 27 Chang AB, Oppenheimer JJ, Weinberger
2 Morice AH, Millqvist E, Bieksiene K, et al. ERS enough’ when managing indigenous adults with MM, et al. Use of management pathways or
guidelines on the diagnosis and treatment of bronchiectasis in Australia and New Zealand. algorithms in children with chronic cough:
chronic cough in adults and children. Eur Respir J Respirology 2018; 23: 725-726. CHEST guideline and expert panel report. Chest
2020; 55: 1901136. 15 Hall KK, Chang AB, Anderson J, et al. 2017; 151: 875-883.
3 Chang AB, Oppenheimer JJ, Irwin RS. Managing Characteristics and respiratory risk profile of 28 Alsubaie H, Al-­Shamrani A, Alharbi AS, Alhaider
chronic cough as a symptom in children and children aged less than 5 years presenting to S. Clinical practice guidelines: approach to cough
management algorithms: CHEST guideline and an urban, Aboriginal-­f riendly, comprehensive in children: the official statement endorsed by
expert panel report. Chest 2020; 158: 303-329. primary health practice in Australia. J Paediatr the Saudi Pediatric Pulmonology Association
4 Gibson PG, Chang AB, Glasgow NJ, et al. CICADA: Child Health 2017; 53: 636-643. (SPPA). Int J Pediatr Adolesc Med 2015; 2: 38-43.
Cough in Children and Adults: Diagnosis and 16 Laird P, Walker R, Lane M, et al. We won’t find 29 Marchant JM, Petsky HL, Morris PS, Chang
Assessment. Australian cough guidelines what we don’t look for: Identifying barriers AB. Antibiotics for prolonged wet cough in
summary statement. Med J Aust 2010; 192: and enablers of chronic wet cough in Aboriginal children. Cochrane Database Syst Rev 2018; (7):
265-271. https://www.mja.com.au/journ​ children. Respirology 2020; 25: 383-392. CD004822.
al/2010/192/5/cicada-cough-child​ren-and- 17 D’Sylva P, Walker R, Lane M, et al. Chronic 30 Ruffles TJC, Goyal V, Marchant JM, et al. Duration
adults-diagn​osis-and-asses​sment-austr​ wet cough in Aboriginal children: it’s not just a of amoxicillin-­clavulanate for protracted
alian-cough cough. J Paediatr Child Health 2019; 55: 833-843. bacterial bronchitis in children (DACS): a multi-­
5 National Health and Medical Research Council. 18 King PT, Holdsworth SR, Farmer M, et al. centre, double blind, randomised controlled trial.
NHMRC levels of evidence and grades for Phenotypes of adult bronchiectasis: onset of Lancet Respir Med 2021; 9: 1121-1129.
recommendations for developers of guidelines. productive cough in childhood and adulthood. 31 Kantar A, Chang AB, Shields MD, et al. ERS
2009. https://www.mja.com.au/sites/​defau​lt/ COPD 2009; 6: 130-136. statement on protracted bacterial bronchitis in
files/​NHMRC.levels.of.evide​nce.2008-09.pdf children. Eur Respir J 2017; 50: 1602139.
19 Zhang J, Perret JL, Chang AB, et al. Risk factors
(viewed Oct 2023).
for chronic cough in adults: a systematic 32 Ruffles TJC, Marchant JM, Masters IB, et al.
6 Andrews J, Guyatt G, Oxman AD, et al. review and meta-­analysis. Respirology 2022; Outcomes of protracted bacterial bronchitis
GRADE guidelines: 14. Going from evidence 27: 36-47. in children: a 5-­year prospective cohort study.
to recommendations: the significance and Respirology 2021; 26: 241-248.
20 Laird P, Walker R, Lane M, et al. Recognition and
presentation of recommendations. J Clin
management of protracted bacterial bronchitis 33 Marseglia GL, Manti S, Chiappini E, et al. Chronic
Epidemiol 2013; 66: 719-725.
in Australian Aboriginal children: a knowledge cough in childhood: a systematic review for
7 Song WJ, Chang YS, Faruqi S, et al. The global translation approach. Chest 2021; 159: 249-258. practical guidance by the Italian Society of
epidemiology of chronic cough in adults: a Pediatric Allergy and Immunology. Allergol
21 Chang AB, Robertson CF, Van Asperen PP, et al.
systematic review and meta-­analysis. Eur Respir Immunopathol (Madr) 2021; 49: 133-154.
A multicenter study on chronic cough in children:
J 2015; 45: 1479-1481.
burden and etiologies based on a standardized 34 Dykewicz MS, Wallace DV, Baroody F,
8 Alif SM, Dharmage SC, Benke G, management pathway. Chest 2012; 142: et al. Treatment of seasonal allergic rhinitis: an
et al. Occupational exposure to pesticides are 943-950. evidence-­based focused 2017 guideline update.
associated with fixed airflow obstruction in Ann Allergy Asthma Immunol 2017; 119: 489-511.
22 Irwin RS, French CL, Chang AB, Altman KW.
middle-­age. Thorax 2017; 72: 990-997. e41.
Classification of cough as a symptom in adults
9 Morice AH, Jakes AD, Faruqi S, et al. A worldwide and management algorithms: CHEST guideline 35 Brietzke SE, Shin JJ, Choi S, et al. Clinical
survey of chronic cough: a manifestation of and expert panel report. Chest 2018; 153: consensus statement: pediatric chronic
enhanced somatosensory response. Eur Respir J 196-209. rhinosinusitis. Otolaryngol Head Neck Surg 2014;
2014; 44: 1149-1155. 151: 542-553.
23 Chang AB, Van Asperen PP, et al. Children
10 Colak Y, Nordestgaard BG, Laursen LC, et al. with chronic cough: when is watchful waiting 36 Teoh L, Hurwitz M, Acworth JP, et al. Treatment
MJA 220 (1) ▪ 15 January 2024

Risk factors for chronic cough among 14,669 appropriate? Development of likelihood ratios of obstructive sleep apnoea for chronic cough in
individuals from the general population. Chest for assessing children with chronic cough. Chest children. Cochrane Database Syst Rev 2011; (4):
2017; 152: 563-573. 2015; 147: 745-753. CD008182.
11 Chung KF, McGarvey L, Song WJ, et al. Cough 24 Chang AB, Oppenheimer JJ, Weinberger MM, 37 de Benedictis FM, Bush A. Respiratory
hypersensitivity and chronic cough. Nat Rev Dis et al. Management of children with chronic manifestations of gastro-­oesophageal reflux in
Primers 2022; 8: 45. wet cough and protracted bacterial bronchitis: children. Arch Dis Child 2018; 103: 292-296.
12 O’Grady KF, Grimwood K, Torzillo PJ, et al. CHEST guideline and expert panel report. Chest 38 Chang AB, Oppenheimer JJ, Kahrilas PJ, et al.
Effectiveness of a chronic cough management 2017; 151: 884-890. Chronic cough and gastroesophageal reflux
algorithm at the transitional stage from acute to 25 Chang AB, Oppenheimer JJ, Weinberger M, et al. in children: CHEST guideline and expert panel
chronic cough in children: a multicenter, nested, Etiologies of chronic cough in pediatric cohorts: report. Chest 2019; 156: 131-40.
single-­blind, randomised controlled trial. Lancet CHEST guideline and expert panel report. Chest 39 Australasian Society of Clinical Immunology
Child Adolesc Health 2019; 3: 889-898. 2017; 152: 607-617. and Allergy. ASCIA Information for Health
13 Laird P, Totterdell J, Walker R, et al. Prevalence 26 Chang AB, Oppenheimer JJ, Weinberger M, et al. Professionals: Chronic rhinosinusitis with nasal
44 of chronic wet cough and protracted bacterial Use of management pathways or algorithms in polyps (CRSwNP) position paper. 2021.
 Position statement summary
https://www.aller​gy.org.au/image​s/stori​ or without allergic rhinitis. J Asthma 2021; 58: 65 Dietz de Loos DA, Hopkins C, Fokkens WJ.
es/pospa​pers/ASCIA_HP_Posit​ion_Paper_ 326-333. Symptoms in chronic rhinosinusitis with and
CRSwNP_2021.pdf (viewed Oct 2023). 53 Song WJ, Kim HJ, Shim JS, et al. Diagnostic without nasal polyps. Laryngoscope 2013; 123:
40 Kahrilas PJ, Altman KW, Chang AB, et al. Chronic accuracy of fractional exhaled nitric oxide 57-63.
cough due to gastroesophageal reflux in adults: measurement in predicting cough-­variant 66 Lee JH, Lee JW, An J, et al. Efficacy of non-­
CHEST guideline and expert panel report. Chest asthma and eosinophilic bronchitis in adults sedating H1-­receptor antihistamines in
2016; 150: 1341-1360. with chronic cough: a systematic review and adults and adolescents with chronic cough: a
41 National Asthma Council. Australian Asthma meta-­analysis. J Allergy Clin Immunol 2017; 140: systematic review. World Allergy Organ J 2021;
Handbook: Making a diagnosis of asthma in 701-709. 14: 100568.
adults. https://www.asthm​ahand​book.org.au/ 54 Kim V, Crapo J, Zhao H, et al. Comparison 67 Usta Guc B, Asilsoy S, Durmaz C. The assessment
diagn​osis/adult​s/making-a-diagn​osis (viewed between an alternative and the classic definition and management of chronic cough in children
Oct 2023). of chronic bronchitis in COPDGene. Ann Am according to the British Thoracic Society
42 National Institute for Health and Care Thorac Soc 2015; 12: 332-339. guidelines: descriptive, prospective, clinical trial.
Excellence. Gastro-­oesophageal reflux disease in 55 Balte PP, Chaves PHM, Couper DJ, et al. Clin Respir J 2014; 8: 330-337.
children and young people. NICE Guideline [NG1]. Association of nonobstructive chronic bronchitis 68 Vertigan AE, Theodoros DG, Gibson PG,
Published 14 Jan 2015; last updated 9 Oct 2019. with respiratory health outcomes in adults. Winkworth AL. Efficacy of speech pathology
https://www.nice.org.uk/guida​nce/ng1 (viewed JAMA Intern Med 2020; 180: 676-686. management for chronic cough: a randomised
Oct 2023). 56 Çolak Y, Nordestgaard BG, Vestbo J, et al. placebo controlled trial of treatment efficacy.
43 Weinberger M. The habit cough: diagnosis Prognostic significance of chronic respiratory Thorax 2006; 61: 1065-1069.
and treatment. Pediatr Pulmonol 2018; 53: symptoms in individuals with normal spirometry. 69 Chamberlain Mitchell SA, Garrod R, Clark
535-537. Eur Respir J 2019; 54: 1900734. L, et al. Physiotherapy, and speech and
44 Vertigan AE, Murad MH, Pringsheim T, et al. 57 Hughes R, Rapsomaniki E, Janson C, et al. language therapy intervention for patients
Somatic cough syndrome (previously referred Frequent productive cough: symptom burden with refractory chronic cough: a multicentre
to as psychogenic cough) and tic cough and future exacerbation risk among patients randomised control trial. Thorax 2017; 72:
(previously referred to as habit cough) in adults with asthma and/or COPD in the NOVELTY 129-136.
and children: CHEST guideline and expert panel study. Respir Med 2022; 200: 106921. 70 Birring SS, Spinou A. How best to measure
report. Chest 2015; 148: 24-31. 58 Ryerson CJ, Abbritti M, Ley B, et al. Cough cough clinically. Curr Opin Pharmacol 2015; 22:
45 Gardiner SJ, Chang AB, Marchant JM, Petsky predicts prognosis in idiopathic pulmonary 37-40.
HL. Codeine versus placebo for chronic cough in fibrosis. Respirology 2011; 16: 969-975. 71 Price DB, Buhl R, Chan A, et al. Fractional
children. Cochrane Database Syst Rev 2016; (7): 59 Lee J, White E, Freiheit E, et al. Cough-­specific exhaled nitric oxide as a predictor of response
CD011914. quality of life predicts disease progression to inhaled corticosteroids in patients with non-­
46 McGarvey L, Gibson PG. What is chronic cough? among patients with interstitial lung disease: specific respiratory symptoms and insignificant
terminology. J Allergy Clin Immunol Pract 2019; 7: data from the Pulmonary Fibrosis Foundation bronchodilator reversibility: a randomised
1711-1714. Patient Registry. Chest 2022; 162: 603-613. controlled trial. Lancet Respir Med 2018; 6:
47 Gibson PG, Dolovich J, Denburg J, et al. Chronic 60 Vertigan AE, Bone SL, Gibson PG. 29-39.
cough: eosinophilic bronchitis without asthma. Laryngeal sensory dysfunction in laryngeal 72 Sadeghi MH, Wright CE, Hart S, et al.
Lancet 1989; 1: 1346-1348. hypersensitivity syndrome. Respirology 2013; Phenotyping patients with chronic cough:
48 Carney IK, Gibson PG, Murree-­Allen K, et al. A 18: 948-956. evaluating the ability to predict the response to
systematic evaluation of mechanisms in chronic 61 Halvorsen T, Walsted ES, Bucca C, et al. anti-­inflammatory therapy. Ann Allergy Asthma
cough. Am J Respir Crit Care Med 1997; 156: Inducible laryngeal obstruction: an official joint Immunol 2018; 120: 285-291.
211-216. European Respiratory Society and European 73 Hodgson D, Anderson J, Reynolds C, et al. The
49 Brightling CE. Chronic cough due to Laryngological Society statement. Eur Respir J effects of azithromycin in treatment-­resistant
nonasthmatic eosinophilic bronchitis: ACCP 2017; 50: 1602221. cough: a randomized, double-­blind, placebo-­
evidence-­based clinical practice guidelines. 62 Irwin RS, French CL, Curley FJ, et al. Chronic controlled trial. Chest 2016; 149: 1052-1060.
Chest 2006; 129 (1 Suppl): 116S-121S. cough due to gastroesophageal reflux. Clinical, 74 Cohen SM, Misono S. Use of specific
50 Australian Medicines Handbook. Last modified: diagnostic, and pathogenetic aspects. Chest neuromodulators in the treatment of chronic,
July 2023. https://amhon​line.amh.net.au/ 1993; 104: 1511-1517. idiopathic cough: a systematic review.
(viewed Oct 2023). 63 Kahrilas PJ, Howden CW, Hughes N, Molloy-­ Otolaryngol Head Neck Surg 2013; 148: 374-382.
51 Corrao WM, Braman SS, Irwin RS. Chronic Bland M. Response of chronic cough to 75 Wei W, Liu R, ZhangTong Y, Qiu Z. The efficacy of
cough as the sole presenting manifestation acid-­suppressive therapy in patients with specific neuromodulators on human refractory
of bronchial asthma. N Engl J Med 1979; 300: gastroesophageal reflux disease. Chest 2013; chronic cough: a systematic review and meta-­
633-637. 143: 605-612. analysis. J Thorac Dis 2016; 8: 2942-2951.
52 Chen LC, Zeng GS, Wu LL, et al. Diagnostic 64 Hull JH, Langerman H, Ul-­Haq Z, et al. Burden 76 Morice AH, Menon MS, Mulrennan SA, et al.
value of FeNO and MMEF for predicting cough and impact of chronic cough in UK primary care: Opiate therapy in chronic cough. Am J Respir Crit
variant asthma in chronic cough patients with a dataset analysis. BMJ Open 2021; 11: e054832. Care Med 2007; 175: 312-315. ■ MJA 220 (1) ▪ 15 January 2024

45