WAO - ARIA consensus on chronic cough: Executive summary

Philip W Rouadi¹, Samar A Idriss¹, Jean Bousquet^{2

3

4}, Mario Morais-Almeida⁵, Cecilio R Azar^{6

7

8}, Mona Sulaiman Al-Ahmad⁹, Anahí Yáñez¹⁰, Maryam Ali Y Al-Nesf¹¹, Talal M Nsouli¹², Sami L Bahna¹³, Eliane Abou-Jaoude¹², Fares H Zaitoun^{14

15}, Usamah M Hadi¹⁶, Glenis K Scadding¹⁷, Peter K Smith¹⁸, René Maximiliano Gómez¹⁹, Sandra N González-Díaz^{20

21}, Ludger Klimek²², Georges S Juvelekian²³, Moussa A Riachy²⁴, Giorgio Walter Canonica²⁵, David Peden²⁶, Gary W K Wong²⁷, James Sublett²⁸, Jonathan A Bernstein²⁹, Lianglu Wang³⁰, Luciana Kase Tanno^{31

32

33}, Manana Chikhladze³⁴, Michael Levin³⁵, Yoon-Seok Chang³⁶, Bryan L Martin³⁷, Luis Caraballo³⁸, Adnan Custovic³⁹, José Antonio Ortega-Martell⁴⁰, Olivia J Ly Lesslar⁴¹, Pedro Giavina-Bianchi⁴², Nikolaos Papadopoulos^{43

44}, Elham Hossny⁴⁵, Motohiro Ebisawa⁴⁶, Alessandro Fiocchi⁴⁷, Ignacio J Ansotegui⁴⁸

Affiliations

¹ Department of Otolaryngology, Dar Al Shifa Hospital, Hawally, Kuwait.
² Institute of Allergology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.
³ Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Allergology and Immunology, Berlin, Germany.
⁴ MASK-air, Montpellier, France.
⁵ Allergy Center, CUF Descobertas Hospital, Lisboa, Portugal.
⁶ Department of Gastroenterology, American University of Beirut Medical Center (AUBMC), Beirut, Lebanon.
⁷ Department of Gastroenterology, Middle East Institute of Health (MEIH), Beirut, Lebanon.
⁸ Department of Gastroenterology, Clemenceau Medical Center (CMC), Beirut, Lebanon.
⁹ Department of Microbiology, College of Medicine, Kuwait University, Kuwait.
¹⁰ INAER - Investigaciones en Alergia y Enfermedades Respiratorias, Buenos Aires, Argentina.
¹¹ Allergy and Immunology Division, Department of Medicine, Hamad Medical Corporation, Doha, Qatar.
¹² International Cough Institute, Washington, DC, USA.
¹³ Allergy & Immunology Section, Louisiana State University Health Sciences Center, Shreveport, LA, USA.
¹⁴ Allergy, Asthma and Immunology Center, Beirut, Lebanon.
¹⁵ Clemenceau Medical Center Hospital, Dubai, United Arab Emirates.
¹⁶ Clinical Professor Department of Otolaryngology Head and Neck Surgery, American University of Beirut, Lebanon.
¹⁷ Department of ENT, RNENT Hospital and Division of Immunity and Infection, University College London, London, UK.
¹⁸ Clinical Medicine Griffith University, Southport, Qld, 4215, Australia.
¹⁹ Faculty of Health Sciences, Catholic University of Salta, Argentina.
²⁰ Universidad Autónoma de Nuevo León, Hospital Universitario and Facultad de Medicina, Monterrey, Nuevo León, Mexico.
²¹ Head and Professor Centro Regional de Alergia Asma e Inmunologia, Mexico.
²² Center for Rhinology and Allergology, Wiesbaden, Germany.
²³ Visiting Clinical Associate Professor of Medicine, American University of Beirut Medical Center, Beirut, Lebanon.
²⁴ Department of Pulmonary and Critical Care, Hôtel-Dieu de France University Hospital, Beirut, Lebanon.
²⁵ Humanitas University & Personalized Medicine Asthma & Allergy Clinic-Humanitas Research Hospital-IRCCS-Milano, Italy.
²⁶ UNC Center for Environmental Medicine, Asthma, and Lung Biology, Division of Allergy, Immunology and Rheumatology, Department of Pediatrics UNC School of Medicine, USA.
²⁷ Department of Pediatrics, Chinese University of Hong Kong, Hong Kong, China.
²⁸ Department of Pediatrics, Section of Allergy and Immunology, University of Louisville School of Medicine, 9800 Shelbyville Rd, Louisville, KY, USA.
²⁹ University of Cincinnati College of Medicine, Department of Internal Medicine, Division of Rheumatology, Allergy and Immunology, Cincinnati, OH, USA.
³⁰ Department of Allergy, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing Key Laboratory of Precision Medicine for Diagnosis and Treatment of Allergic Disease, State Key Laboratory of Complex Severe and Rare Diseases, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Beijing, 100730, China.
³¹ Université Montpellier, Montpellier, France.
³² Desbrest Institute of Epidemiology and Public Health, UMR UA-11, INSERM University of Montpellier, Montpellier, France.
³³ WHO Collaborating Centre on Scientific Classification Support, Montpellier, France.
³⁴ Medical Faculty at Akaki Tsereteli State University, National Institute of Allergy, Asthma & Clinical Immunology, KuTaisi, Tskaltubo, Georgia.
³⁵ Division of Paediatric Allergology, Department of Paediatrics, University of Cape Town, South Africa.
³⁶ Division of Allergy and Clinical Immunology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea.
³⁷ Department of Otolaryngology, Division of Allergy & Immunology, The Ohio State University, Columbus, OH, USA.
³⁸ Institute for Immunological Research, University of Cartagena, Cartagena de Indias, Colombia.
³⁹ National Heart and Lund Institute, Imperial College London, UK.
⁴⁰ Health Science Institute, Autonomous University of Hidalgo, Mexico.
⁴¹ The National Centre for Neuroimmunology and Emerging Disease, Griffith University, Southport, Qld, 4215, Australia.
⁴² Clinical Immunology and Allergy Division, University of Sao Paulo, Brazil.
⁴³ Allergy Department, 2nd Pediatric Clinic, National and Kapodistrian, University of Athens, Athens, Greece.
⁴⁴ Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, UK.
⁴⁵ Ain Shams University, Ain Shams University Children's Hospital, Cairo, Egypt.
⁴⁶ Clinical Research Center for Allergy and Rheumatology, NHO Sagamihara National Hospital, Sagamihara, Japan.
⁴⁷ Translational Pediatric Research Area, Allergic Diseases Research Unit, Bambino Gesù Children's Hospital IRCCS, Rome, Holy See.
⁴⁸ Department of Allergy and Immunology, Hospital Quironsalud Bizkaia, Bilbao, Spain.

PMID: 40093560
PMCID: PMC11903822
DOI: 10.1016/j.waojou.2025.101034

Review

WAO - ARIA consensus on chronic cough: Executive summary

Philip W Rouadi et al. World Allergy Organ J. 2025.

. 2025 Feb 24;18(3):101034.

doi: 10.1016/j.waojou.2025.101034. eCollection 2025 Mar.

Authors

Affiliations

¹ Department of Otolaryngology, Dar Al Shifa Hospital, Hawally, Kuwait.
² Institute of Allergology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.
³ Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Allergology and Immunology, Berlin, Germany.
⁴ MASK-air, Montpellier, France.
⁵ Allergy Center, CUF Descobertas Hospital, Lisboa, Portugal.
⁶ Department of Gastroenterology, American University of Beirut Medical Center (AUBMC), Beirut, Lebanon.
⁷ Department of Gastroenterology, Middle East Institute of Health (MEIH), Beirut, Lebanon.
⁸ Department of Gastroenterology, Clemenceau Medical Center (CMC), Beirut, Lebanon.
⁹ Department of Microbiology, College of Medicine, Kuwait University, Kuwait.
¹⁰ INAER - Investigaciones en Alergia y Enfermedades Respiratorias, Buenos Aires, Argentina.
¹¹ Allergy and Immunology Division, Department of Medicine, Hamad Medical Corporation, Doha, Qatar.
¹² International Cough Institute, Washington, DC, USA.
¹³ Allergy & Immunology Section, Louisiana State University Health Sciences Center, Shreveport, LA, USA.
¹⁴ Allergy, Asthma and Immunology Center, Beirut, Lebanon.
¹⁵ Clemenceau Medical Center Hospital, Dubai, United Arab Emirates.
¹⁶ Clinical Professor Department of Otolaryngology Head and Neck Surgery, American University of Beirut, Lebanon.
¹⁷ Department of ENT, RNENT Hospital and Division of Immunity and Infection, University College London, London, UK.
¹⁸ Clinical Medicine Griffith University, Southport, Qld, 4215, Australia.
¹⁹ Faculty of Health Sciences, Catholic University of Salta, Argentina.
²⁰ Universidad Autónoma de Nuevo León, Hospital Universitario and Facultad de Medicina, Monterrey, Nuevo León, Mexico.
²¹ Head and Professor Centro Regional de Alergia Asma e Inmunologia, Mexico.
²² Center for Rhinology and Allergology, Wiesbaden, Germany.
²³ Visiting Clinical Associate Professor of Medicine, American University of Beirut Medical Center, Beirut, Lebanon.
²⁴ Department of Pulmonary and Critical Care, Hôtel-Dieu de France University Hospital, Beirut, Lebanon.
²⁵ Humanitas University & Personalized Medicine Asthma & Allergy Clinic-Humanitas Research Hospital-IRCCS-Milano, Italy.
²⁶ UNC Center for Environmental Medicine, Asthma, and Lung Biology, Division of Allergy, Immunology and Rheumatology, Department of Pediatrics UNC School of Medicine, USA.
²⁷ Department of Pediatrics, Chinese University of Hong Kong, Hong Kong, China.
²⁸ Department of Pediatrics, Section of Allergy and Immunology, University of Louisville School of Medicine, 9800 Shelbyville Rd, Louisville, KY, USA.
²⁹ University of Cincinnati College of Medicine, Department of Internal Medicine, Division of Rheumatology, Allergy and Immunology, Cincinnati, OH, USA.
³⁰ Department of Allergy, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing Key Laboratory of Precision Medicine for Diagnosis and Treatment of Allergic Disease, State Key Laboratory of Complex Severe and Rare Diseases, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Beijing, 100730, China.
³¹ Université Montpellier, Montpellier, France.
³² Desbrest Institute of Epidemiology and Public Health, UMR UA-11, INSERM University of Montpellier, Montpellier, France.
³³ WHO Collaborating Centre on Scientific Classification Support, Montpellier, France.
³⁴ Medical Faculty at Akaki Tsereteli State University, National Institute of Allergy, Asthma & Clinical Immunology, KuTaisi, Tskaltubo, Georgia.
³⁵ Division of Paediatric Allergology, Department of Paediatrics, University of Cape Town, South Africa.
³⁶ Division of Allergy and Clinical Immunology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea.
³⁷ Department of Otolaryngology, Division of Allergy & Immunology, The Ohio State University, Columbus, OH, USA.
³⁸ Institute for Immunological Research, University of Cartagena, Cartagena de Indias, Colombia.
³⁹ National Heart and Lund Institute, Imperial College London, UK.
⁴⁰ Health Science Institute, Autonomous University of Hidalgo, Mexico.
⁴¹ The National Centre for Neuroimmunology and Emerging Disease, Griffith University, Southport, Qld, 4215, Australia.
⁴² Clinical Immunology and Allergy Division, University of Sao Paulo, Brazil.
⁴³ Allergy Department, 2nd Pediatric Clinic, National and Kapodistrian, University of Athens, Athens, Greece.
⁴⁴ Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, UK.
⁴⁵ Ain Shams University, Ain Shams University Children's Hospital, Cairo, Egypt.
⁴⁶ Clinical Research Center for Allergy and Rheumatology, NHO Sagamihara National Hospital, Sagamihara, Japan.
⁴⁷ Translational Pediatric Research Area, Allergic Diseases Research Unit, Bambino Gesù Children's Hospital IRCCS, Rome, Holy See.
⁴⁸ Department of Allergy and Immunology, Hospital Quironsalud Bizkaia, Bilbao, Spain.

PMID: 40093560
PMCID: PMC11903822
DOI: 10.1016/j.waojou.2025.101034

Abstract

Acute cough is a highly prevalent symptom in clinical practice. Chronic cough is a complex disease with significant impact on quality of life. The mechanistic pathways of chronic cough in cough-comorbid clinical phenotypes are elusive. Mounting evidence suggests presence of a hypersensitive cough reflex and implication of transient receptor potential channels and P2X receptors in cough neuronal pathways. Previously, the World Allergy Organization (WAO)/Allergic Rhinitis and its Impact on Asthma (ARIA) Joint Committee on Chronic Cough published updated experimental and clinical data on chronic cough, in addition to a multidisciplinary care pathway approach to its management. The goal of this manuscript is to provide clinicians with a succinct summary of chronic cough pathophysiology, clinical phenotypes, and management strategies in both primary and cough specialty care. This executive summary is a primer for clinicians on chronic cough. Increasing awareness on the topic among primary care physicians will improve the outcome of management of patients with chronic cough.

Keywords: Chronic cough; Gastroesophageal reflux disease; Hypersensitive cough reflex; Lower airway disease; Multifactorial chronic cough; Neuromodulators; Primary care physician; Refractory chronic cough; Unexplained chronic cough; Upper airway disease.

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Conflict of interest statement

Talal Nsouli: speaker for AstraZeneca. Jonathan A Bernstein: Merck and GSK related to chronic cough. Georges S Juvelekian: speaker for AstraZeneca, Abbott, Boehringer Ingelheim, Sanofi Aventis, Organon, Novartis, and Pfizer. Member of the Advisory board of AstraZeneca, Novartis, and Pfizer. Pete Smith: PI/Consultant GSK, Sanofi Regeneron, Viatris. Glenis Scadding: Honoraria for articles and speaker for GSK, advisory boards for GSK, ALK, Bayer, Chiesi, GlaxoSmithKline, Haleon, Noucor, Sanofi- Regeneron, and Viatris. Chair of BSACI rhinitis guidelines, Scientific Chief Editor, Rhinology Section of Frontiers in Allergy, Vice President, and AR lead for EUFOREA, and Chair/member Data Monitoring Committees on SLIT for ALK. Scientific Chief Editor, Rhinology Section, Frontiers in Allergy. L Klimek (LK) has received research grants from Allergy Therapeutics/Bencard, Great Britain/Germany; ALK-Abelló, Denmark; Allergopharma, Germany; Aimmune, USA; ASIT Biotech, Belgium; AstraZeneca, Sweden, Bionorica, Germany; BioNTech, Germany, Biomay, Austria, Boehringer Ingelheim, Germany, Circassia, USA; Chiesi, Italy; Cytos, Switzerland; Curalogic, Denmark; HAL, Netherlands; Lofarma, Italy; Menarini, Italy; MSD, USA, Viatris/Mylan, USA; Novartis, Switzerland, Leti, Spain; ROXALL, Germany; GlaxoSmithKline (GSK), Great Britain; Sanofi, France; Stallergenes, France; Thermofisher, USA and/or has served on the speaker's bureau or was consulting for the above mentioned pharmaceutical companies. Alessandro Fiocchi: Member of an advisory board: Abbott S.A., Danone, Ferrero SpA, Sponsored research: Ferrero SpA, Novartis S.A., Astrazeneca S.A, Vertex S.A., GSK S.A., Sanofi S.A., DVB S.A. Pedro Giavina-Bianchi: speaker and member for advisory board for: AstraZeneca, Abbvie, CSL Behring, GSK, Novartis, Sanofi, Takeda/Shire.

Figures

**Fig. 1**
Cough definition according to chronology of symptom, diagnostic workup, and response to management.

**Fig. 2**
“Propeller” model for management of chronic cough in primary (central circle) and cough specialty (propeller “blades”) care. ACO (asthma COPD overlap), AR (allergic rhinitis), CA (classic asthma), CB (chronic bronchitis), COPD (chronic obstructive pulmonary disease), CRS (chronic rhinosinusitis), CVA (cough variant asthma), GERD (gastroesophageal reflux disease), LHR (laryngeal hyperresponsiveness), NAEB (non-asthmatic eosinophilic bronchitis), NP (nasal polyp), OSA (obstructive sleep apnea), PCPs (primary care physicians), RCC (refractory chronic cough), UCC (unexplained chronic cough).

See this image and copyright information in PMC

References

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WAO - ARIA consensus on chronic cough: Executive summary

Affiliations

WAO - ARIA consensus on chronic cough: Executive summary

Authors

Affiliations

Abstract

Conflict of interest statement

Figures

References

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