Briefly describe a specific question, or set of related questions, about a health care test or treatment that this program should consider.

The American College of Chest Physicians (ACCP) proposes to update the following 4 guideline topics from the 2006 publication on the Diagnosis and Management of Cough: ACCP Evidence-Based Clinical Practice Guidelines.1

1. Assessing Cough Severity and Efficacy of Therapy in adults and children
2. Unexplained (Idiopathic, Unresponsive, Refractory, Intractable) Chronic Cough
3. Evaluating Chronic Cough in Pediatrics
4. Pharmacologic treatment of cough: suppressant, antitussive, protussive agents
5. Diagnosis and management of cough: ACCP evidence-based clinical practice guidelines. Chest 2006; 129(suppl): 1S-292S http://www.chestjournal.org/content/vol129/1_suppl/

Does your question include a comparison of different health care approaches? (If no, your topic will still be considered.)

yes

If yes, explain the specific technologies, devices, drugs, or interventions you would like to see compared:

• In the case of assessing cough severity and efficacy of therapy, health-related quality of life versus visual analogue scale or versus objective cough counting or versus exhaled nitric oxide versus tussigenic challenge
• In the case of unresponsive cough, opiates versus usual care or speech therapy versus usual care
• In the case of evaluating chronic cough in pediatrics, what is the best protocol to use in before and after intervention trials
• In the case of pharmacologic treatment, are there effective antitussive and/or protussive agents shown in placebo controlled or comparator controlled prospective, randomized controlled clinical trials.

What patients or group(s) of patients does your question apply to? (Please include specific details such as age range, gender, coexisting diagnoses, and indications for therapy.)

Adults with unexplained cough of more than 8 weeks in duration Pediatric (age 14 or younger) patients with cough of more than 3 and more than 8 weeks in duration

Patients with co-morbidities should be included, especially the following:

• Upper airway cough syndrome (previously called postnasal drip syndrome)
• Asthma
• GERD
• Bronchitis
• Acute Bronchitis
• Chronic Bronchitis
• Acute Exacerbation of Chronic Bronchitis
• Bronchiectasis
• Postinfectious cough
• Bronchogenic carcinoma
• Angiotensin converting enzyme inhibitorCEI-induced cough
• Psychogenic and habit cough
• Chronic interstitial pulmonary disease
• Environmental/occupational causes of cough
• Tuberculosis and other infections

Are there subgroups of patients that your question might apply to? (For example, an ethnic group, stage or severity of a disease.)

Adults and children

Describe the health-related benefits you are interested in. (For example, improvements in patient symptoms or problems from treatment or diagnosis.)

Improvement in cough symptoms, cough severity, cough counts, cough related quality of life

Describe any health-related risks, side effects, or harms that you are concerned about.

Complications caused by coughing as well as adverse drugs reactions due to cough suppressants or protussive agents; and, harmful effects of over the counter cough medications particularly in children that have been shown to be harmful for children resulting in both morbidity and mortality.

Appropriateness for EHC Program

Does your question include a health care drug, intervention, device, or technology available (or likely to be available) in the U.S.?

yes

Which priority area(s) and population(s) does this topic apply to? (check all that apply)

EHC Priority Conditions (updated in 2008)

• Cancer
• Infectious diseases, including HIV/AIDS
• Peptic ulcer disease and dyspepsia
• Pulmonary disease/asthma

AHRQ Priority Populations

• Women
• Children

Federal Health Care Program

None

Importance

Describe why this topic is important.

Cough is one of the most common symptoms for which patients seek medical advice, miss work and school, and increase healthcare spending.2 In the US and Australia, it accounts for the greatest volume of complaints presented to primary are providers.3,4 Persistent cough of more than 8 weeks duration is one of the most common reasons for new adult patient visits to pulmonologists or respirologists.5 Cough is also an important factor in the spread of infections. 2. Morice A. Epidemiology of cough. Pulm Pharmacol Ther 2002; 15:253-259 3. Woodell D. National ambulatory medical care survey:1998 summary. Hyattsville, MD: National Center for Health Statistics, 2000 4. Britt H, Miller GC, Knox S, et al. General practice activity in Australia 2001-2002. Cambers, ACT, Australia: Australian Institute of Health and Welfare, 2002 5. Curley F, Irwin RS, Pratter MR, et al. Cough and the common cold. Am Rev Respir Dis 1988; 138:305-311Irwin RS, Curley FJ, French CL. Chronic cough: the spectrum and frequency of causes, key components of the diagnostic evaluation, and outcome of specific therapy. Am Rev Respir Dis 1990; 141: 640-647.

What specifically motivated you to ask this question? (For example, you are developing a clinical guideline, working with a policy with large uncertainty about the appropriate approach, costly intervention, new research you have read, items in the media you may have seen, a clinical practice dilemma you know of, etc.)

The ACCP published the Diagnosis and management of cough: ACCP evidence-based clinical practice guidelines in 2006. Since that time, a number of new studies (see below for selected representative examples) have been published that impact on the four areas that are being proposed for updating. A complete and systematic evidence review would inform the development of these updated evidence-based recommendations.

A. Assessing Cough Severity and Efficacy of Therapy in Clinical Research 1.Marchant JM, et al. What is the burden of chronic cough for families? CHEST 2008; 134: 303-309. 2.Polley L, et al. Impact of cough across different chronic respiratory diseases: comparison of two cough-specific health-related quality of life questionnaires. CHEST 2008; 124: 295-302. 3.Kalpaklioglu AF, et al. Evaluation and impact of chronic cough: comparison of specific vs generic quality-of-life questionnaires. Ann Allergy Asthma Immunol 2005; 94: 581-585. 4.Dicpinigaitis PV, et al. Prevalence of depressive symptoms among patients with chronic cough. CHEST 2006; 130: 1839-1843. 5.Smith J, et al. Cough in COPD: correlation of objective monitoring with cough challenge and subjective assessments. CHEST 2006; 130: 379-385. 6. Hunt J, et al. Identification of acid reflux cough using serial assays of exhaled breath condensate pH. Cough 2006; 2:3 doi:10.1186/1745-9974-2-3 7.Baiardini I, et al. A new tool to assess and monitor the burden of chronic cough on quality of life: chronic cough impact questionnaire.Allergy 2005; 60: 482-488. 8.Matos S, et al. An automated system for 24-h monitoring of cough frequency: the Leicester Cough Monitor. IBEEE Transactions on Biomedical Engineering 2007; 54: 1472-1479. 9.Birring SS, et al. The Leicester Cough monitor: preliminary validation of an automated cough detection system in chronic cough. Eur Respir J 2008; 31: 1013-1018. 10.Newcombe PA, et al. Development of a parent-proxy quality-of-life chronic cough -specific questionnaire: clinical

Does your question represent uncertainty for clinicians and/or policy-makers? (For example, variations in clinical care, controversy in what constitutes appropriate clinical care, or a policy decision.)

yes

If yes, please explain:

Since the last publication of the ACCP Cough guidelines in 2006, there have been advances in the field of managing cough in the 4 areas that we are targeting for this evidence based review. By doing this review and updating the ACCP Cough guidelines, there will be much less uncertainty on the part of clinicians on how 1) to assess cough severity and efficacy/effectiveness of cough medications, 2) to manage cough in children, 3) how to manage the unexplained, refractory chronic cough in adults, and 4) to know which cough antisuppressant drugs to prescribe. Several RCTs have shown no effect or harmful effects of OTC medications in children but few have shown positive results for treatment alternatives. Duration of treatment, especially in asthmatic children, is not clearly specified in existing guidelines. The benefits of antihistamines in young (primarily under 12) children with chronic cough is also not clearly understood. Physicians, including many pulmonologists, need education in how to assess the severity of the patient's cough. Unexplained coughs are a challenge to even the most experienced experts.

Potential Impact

How will an answer to your research question be used or help inform decisions for you or your group?

The ACCP intends to update its evidence-based clinical practice guidelines on this topic that will be submitted to the journal CHEST for consideration for publication. Additional dissemination efforts will facilitate implementation of these recommendations in various media and venues.

Describe the timeframe in which an answer to your question is needed.

The ACCP can be more flexible with this topic than with certain others, but we hope to have the final evidence tables or profiles by November 1, 2012.

Describe any health disparities, inequities, or impact on vulnerable populations your question applies to.

Because coughing is a global problem and past research has shown that the management of cough is similar throughout the world, updating the ACCP cough guidelines will potentially benefit all patients, no matter where they live. Therefore, the answers to our questions have the potential to benefit everyone. Patients with coughs who are not able to obtain care from experienced clinicians, (whether due to geographic location, mobility restrictions, costs, or access) may not receive the latest evidence-based treatments resulting in disparities and inequities.

Nominator Information

Other Information About You: (optional)

Please choose a description that best describes your role or perspective: (you may select more than one category if appropriate)

The ACCP intends to update its evidence-based clinical practice guidelines on this topic that will be submitted to the journal CHEST for consideration for publication. Additional dissemination efforts will facilitate implementation of these recommendations in various media and venues.

Are you making a suggestion as an individual or on behalf of an organization?

Organization

Please tell us how you heard about the Effective Health Care Program

ACCP has partnered with the AHRQ Effective Health Care Program many times previously. This particular topic was discussed with the Duke Evidence-Based Practice Center that has been selected by AHRQ to complete pulmonary and cardiovascular CERs.