WAO-ARIA consensus on chronic cough - Part III: Management strategies in primary and cough-specialty care. Updates in COVID-19

Abstract

Background: Chronic cough management necessitates a clear integrated care pathway approach. Primary care physicians initially encounter the majority of chronic cough patients, yet their role in proper management can prove challenging due to limited access to advanced diagnostic testing. A multidisciplinary approach involving otolaryngologists and chest physicians, allergists, and gastroenterologists, among others, is central to the optimal diagnosis and treatment of conditions which underly or worsen cough. These include infectious and inflammatory, upper and lower airway pathologies, or gastro-esophageal reflux. Despite the wide armamentarium of ancillary testing conducted in cough multidisciplinary care, such management can improve cough but seldom resolves it completely. This can be due partly to the limited data on the role of tests (eg, spirometry, exhaled nitric oxide), as well as classical pharmacotherapy conducted in multidisciplinary specialties for chronic cough. Other important factors include presence of multiple concomitant cough trigger mechanisms and the central neuronal complexity of chronic cough. Subsequent management conducted by cough specialists aims at control of cough refractory to prior interventions and includes cough-specific behavioral counseling and pharmacotherapy with neuromodulators, among others. Preliminary data on the role of neuromodulators in a proof-of-concept manner are encouraging but lack strong evidence on efficacy and safety.

Objectives: The World Allergy Organization (WAO)/Allergic Rhinitis and its Impact on Asthma (ARIA) Joint Committee on Chronic Cough reviewed the recent literature on management of chronic cough in primary, multidisciplinary, and cough-specialty care. Knowledge gaps in diagnostic testing, classical and neuromodulator pharmacotherapy, in addition to behavioral therapy of chronic cough were also analyzed.

Outcomes: This third part of the WAO/ARIA consensus on chronic cough suggests a management algorithm of chronic cough in an integrated care pathway approach. Insights into the inherent limitations of multidisciplinary cough diagnostic testing, efficacy and safety of currently available antitussive pharmacotherapy, or the recently recognized behavioral therapy, can significantly improve the standards of care in patients with chronic cough.

Keywords: Chronic cough management; Cough primary care; Cough specialty care; Lower airway disease; Neuromodulators; Reflux cough; Speech therapy; Upper airway cough syndrome.

Fig. 1

Suggested algorithm for management of cough phenotypic traits in primary (A) and cough-specialty (B) care. ACO (asthma COPD overlap; AR, allergic rhinitis; BCTs, bronchial challenge tests; CA, classic asthma; COPD, chronic obstructive pulmonary disease; CPAP, continuous positive airway pressure; CQLQ, Cough Quality-of-Life Questionnaire; CRSsNP, chronic rhinosinusitis without nasal polyps; CRSwNP, chronic rhinosinusitis with nasal polyps; CSI, cough symptom index; CT, computerized tomography; CVA, cough variant asthma; EGD, esophagogastroduodenoscopy; FeNO, fractional exhaled nitric oxide; GERD, gastroesophageal reflux disease; GI, Gastrointestinal; HARQ, Hull Airway Reflux Questionnaire; LCQ, Leicester Cough Questionnaire; LHR, laryngeal hyperresponsiveness; MII-pH, multichannel intraluminal impedance monitoring combined with pH-metry; NAEB, non-asthmatic eosinophilic bronchitis; OSA, obstructive sleep apnea; PPI, proton-pump inhibitors; RSI, reflux symptom index; SABA, short-acting beta agonist; SAP, symptom association probability)