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Chronic Cough in Adults - Approach to the Patient


General Information

General InformationGeneral Information


  • cough lasting for > 8 weeks1,2,3

Also called

  • unexplained cough (preferred term)
  • idiopathic cough


  • "upper airway cough syndrome" preferred term for previously used "postnasal drip syndrome"3


General references used

  1. Gibson P, Wang G, McGarvey L, Vertigan AE, Altman KW, Birring SS, ACCP. Treatment of Unexplained Chronic Cough: CHEST Guideline and Expert Panel Report. Chest. 2016 Jan;149(1):27-44OpenInNew
  2. Smith JA, Woodcock A. Chronic Cough. N Engl J Med. 2016 Oct 20;375(16):1544-1551OpenInNew
  3. Michaudet C, Malaty J. Chronic Cough: Evaluation and Management. Am Fam Physician. 2017 Nov 1;96(9):575-580OpenInNew
  4. Achilleos A. Evidence-based Evaluation and Management of Chronic Cough. Med Clin North Am. 2016 Sep;100(5):1033-45OpenInNew
  5. Terasaki G, Paauw DS. Evaluation and treatment of chronic cough. Med Clin North Am. 2014 May;98(3):391-403OpenInNew

Recommendation grading systems used

  • American College of Chest Physicians (ACCP) 2016 grading system
    • strength of recommendations
      • Grade 1 - strong recommendation based on clear risk/benefit balance
      • Grade 2 - weak recommendation based on unclear or close risk/benefit balance
      • Grade Consensus-Based (CB) - uncertainty due to lack of evidence but expert opinion that benefits outweigh risk and burdens or vice versa
      • Grade E/B - moderate recommendation based on expert opinion only
    • quality of evidence
      • Grade A - high-quality evidence based on consistent evidence from randomized trials without important limitations or exceptionally strong evidence from observational studies
      • Grade B - moderate-quality evidence based on randomized trials with important limitations (inconsistent results, methodologic flaws, indirect or imprecise results) or very strong evidence from observational studies
      • Grade C - low- or very low-quality evidence based on observational studies, case series, or randomized trials with serious flaws or indirect evidence
  • American College of Chest Physicians (ACCP) grades of recommendations
    • Grade A - Strong
    • Grade B - Moderate
    • Grade C - Weak
    • Grade D - Negative
    • Grade I - Inconclusive (no recommendation possible)
    • Grade E/A - Strong recommendation based on expert opinion only
    • Grade E/B - Moderate recommendation based on expert opinion only
    • Grade E/C - Weak recommendation based on expert opinion only
    • Grade E/D - Negative recommendation based on expert opinion only
    • Reference - ACCP evidence-based clinical practice guideline on diagnosis and management of cough (16428686Chest 2006 Jan;129(1 Suppl):1SOpenInNewfull-textOpenInNew, 16428689Chest 2006 Jan;129(1 Suppl):28SOpenInNew)

Synthesized Recommendation Grading System for DynaMed

  • DynaMed systematically monitors clinical evidence to continuously provide a synthesis of the most valid relevant evidence to support clinical decision-making (see 7-Step Evidence-Based MethodologyOpenInNew).
  • Guideline recommendations summarized in the body of a DynaMed topic are provided with the recommendation grading system used in the original guideline(s), and allow DynaMed users to quickly see where guidelines agree and where guidelines differ from each other and from the current evidence.
  • In DynaMed (DM), we synthesize the current evidence, current guidelines from leading authorities, and clinical expertise to provide recommendations to support clinical decision-making in the Overview & Recommendations section.
  • We use the Grading of Recommendations Assessment, Development and Evaluation (GRADE)OpenInNew to classify synthesized recommendations as Strong or Weak.
    • Strong recommendations are used when, based on the available evidence, clinicians (without conflicts of interest) consistently have a high degree of confidence that the desirable consequences (health benefits, decreased costs and burdens) outweigh the undesirable consequences (harms, costs, burdens).
    • Weak recommendations are used when, based on the available evidence, clinicians believe that desirable and undesirable consequences are finely balanced, or appreciable uncertainty exists about the magnitude of expected consequences (benefits and harms). Weak recommendations are used when clinicians disagree in judgments of relative benefit and harm, or have limited confidence in their judgments. Weak recommendations are also used when the range of patient values and preferences suggests that informed patients are likely to make different choices.
  • DynaMed (DM) synthesized recommendations (in the Overview & Recommendations section) are determined with a systematic methodology:
    • Recommendations are initially drafted by clinical editors (including ≥ 1 with methodological expertise and ≥ 1 with content domain expertise) aware of the best current evidence for benefits and harms, and the recommendations from guidelines.
    • Recommendations are phrased to match the strength of recommendation. Strong recommendations use "should do" phrasing, or phrasing implying an expectation to perform the recommended action for most patients. Weak recommendations use "consider" or "suggested" phrasing.
    • Recommendations are explicitly labeled as Strong recommendations or Weak recommendations when a qualified group has explicitly deliberated on making such a recommendation. Group deliberation may occur during guideline development. When group deliberation occurs through DynaMed-initiated groups:
      • Clinical questions will be formulated using the PICO (Population, Intervention, Comparison, Outcome) framework for all outcomes of interest specific to the recommendation to be developed.
      • Systematic searches will be conducted for any clinical questions where systematic searches were not already completed through DynaMed content development.
      • Evidence will be summarized for recommendation panel review including for each outcome, the relative importance of the outcome, the estimated effects comparing intervention and comparison, the sample size, and the overall quality rating for the body of evidence.
      • Recommendation panel members will be selected to include at least 3 members that together have sufficient clinical expertise for the subject(s) pertinent to the recommendation, methodological expertise for the evidence being considered, and experience with guideline development.
      • All recommendation panel members must disclose any potential conflicts of interest (professional, intellectual, and financial), and will not be included for the specific panel if a significant conflict exists for the recommendation in question.
      • Panel members will make Strong recommendations if and only if there is consistent agreement in a high confidence in the likelihood that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. Panel members will make Weak recommendations if there is limited confidence (or inconsistent assessment or dissenting opinions) that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. No recommendation will be made if there is insufficient confidence to make a recommendation.
      • All steps in this process (including evidence summaries which were shared with the panel, and identification of panel members) will be transparent and accessible in support of the recommendation.
    • Recommendations are verified by ≥ 1 editor with methodological expertise, not involved in recommendation drafting or development, with explicit confirmation that Strong recommendations are adequately supported.
    • Recommendations are published only after consensus is established with agreement in phrasing and strength of recommendation by all editors.
    • If consensus cannot be reached then the recommendation can be published with a notation of "dissenting commentary" and the dissenting commentary is included in the topic details.
    • If recommendations are questioned during peer review or post publication by a qualified individual, or reevaluation is warranted based on new information detected through systematic literature surveillance, the recommendation is subject to additional internal review.

DynaMed Editorial Process

Special acknowledgements

  • DynaMed topics are written and edited through the collaborative efforts of the above individuals. Deputy Editors, Section Editors, and Topic Editors are active in clinical or academic medical practice. Recommendations Editors are actively involved in development and/or evaluation of guidelines.
  • Editorial Team role definitions
    Topic Editors define the scope and focus of each topic by formulating a set of clinical questions and suggesting important guidelines, clinical trials, and other data to be addressed within each topic. Topic Editors also serve as consultants for the internal DynaMed Editorial Team during the writing and editing process, and review the final topic drafts prior to publication.
    Section Editors have similar responsibilities to Topic Editors but have a broader role that includes the review of multiple topics, oversight of Topic Editors, and systematic surveillance of the medical literature.
    Recommendations Editors provide explicit review of DynaMed Overview and Recommendations sections to ensure that all recommendations are sound, supported, and evidence-based. This process is described in "Synthesized Recommendation Grading."
    Deputy Editors are employees of DynaMed and oversee DynaMed internal publishing groups. Each is responsible for all content published within that group, including supervising topic development at all stages of the writing and editing process, final review of all topics prior to publication, and direction of an internal team.

How to cite

National Library of Medicine, or "Vancouver style" (International Committee of Medical Journal Editors):

  • DynaMed [Internet]. Ipswich (MA): EBSCO Information Services. 1995 - . Record No. T146529, Chronic Cough in Adults - Approach to the Patient; [updated 2018 Nov 30, cited place cited date here]. Available from Registration and login required.
  • KeyboardArrowRight

    Overview and Recommendations

    • Background

    • Evaluation

    • Management

  • Related Summaries

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    General Information

    • Description

    • Also called

    • Definitions

  • Risk Factors

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    Differential Diagnosis

    • Common causes

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      Less common causes

      • Obstructive lung diseases

      • Restrictive lung diseases

      • Infections

      • Miscellaneous causes

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    History and Physical

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      • Onset, pattern, and characteristics

      • Triggers and aggravating factors

      • Exposures

      • Past medical history (PMH)

      • Family history (FH)

      • Additional considerations

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      • General physical

      • HEENT

      • Cardiac

      • Lungs

      • Extremities

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    Diagnostic Testing

    • Initial testing

    • Pulmonary function testing

    • Imaging studies

    • Sputum analysis

    • Testing for gastroesophageal reflux disease (GERD)

    • Bronchoscopy

    • Fractional exhaled nitric oxide (FENO)

    • Additional testing considerations

    • Diagnosis of somatic cough disorder and tic cough

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    • Management algorithms in adults

    • Consultation and referral

    • Asthma therapies

    • Gastroesophageal reflux disease (GERD) therapies

    • Symptomatic treatment of cough in adults with lung cancer

    • Symptomatic treatment of cough in adults with interstitial lung disease

    • Antitussive medications

    • Expectorants

    • Speech therapy

    • Neuromodulators

    • Surgery and procedures

    • Other treatments

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    Complications and Prognosis

    • Complications

    • Prognosis

    • Screening

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    Guidelines and Resources

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      • United States guidelines

      • United Kingdom guidelines

      • European guidelines

      • Asian guidelines

      • Central and South American guidelines

      • Australian and New Zealand guidelines

    • Review articles

    • MEDLINE search

  • Patient Information

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    ICD Codes

    • ICD-10 codes

  • KeyboardArrowRight


    • General references used

    • Recommendation grading systems used

    • Synthesized Recommendation Grading System for DynaMed

    • DynaMed Editorial Process

    • Special acknowledgements

    • How to cite

Topic Editor
Mark Metersky MD

Professor of Medicine, Associate Chief of Service, Department of Medicine, Chief, Division of Pulmonary and Critical Care, and Director, Center for Bronchiectasis Care, University of Connecticut Health; Connecticut, United States

Conflicts of Interest

Dr. Metersky declares a relevant financial relationship with Insmed (Consultant).

Recommendations Editor
Zbys Fedorowicz MSc, DPH, BDS, LDSRCS

Director of Bahrain Branch of the United Kingdom Cochrane Center, The Cochrane Collaboration; Awali, Bahrain

Conflicts of Interest

Dr. Fedorowicz declares no relevant financial conflicts of interest.

Deputy Editor
Terence K. Trow MD, FACP, FCCP

Deputy Editor of Pulmonary, Critical Care, and Sleep Medicine; Connecticut, United States; Ex-Director of the Yale Pulmonary Vascular Disease Program, Associate Clinical Professor of Medicine, Yale University School of Medicine; Connecticut, United States

Conflicts of Interest

Dr. Trow declares no relevant financial conflicts of interest.

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