Key Point

Cough is the main reason for physician visits. Thus, it is important for caregivers to be well versed in the new ACCP cough guidelines.

WORCESTER, MASS—Caregivers who are not yet completely familiar with the new ACCP-based cough guidelines should keep in mind that there are nearly 30 million physician visits for cough in the United States each year and about $3.5 billion spent on over-the-counter cough medicines.¹

"Cough is the number one reason why patients seek medical attention," stated Richard S. Irwin, MD, chair of the guidelines committee and Chair of Critical Care Operations at the University of Massachusetts Memorial Medical Center in Worcester. "Although an occasional cough is normal, excessive coughing or coughing that produces blood or thick, discolored mucus is abnormal," he stressed.

While the common cold is the most frequent reason for cough, other causes should be considered—particularly for persistent cough. Gastroesophageal reflux disease, asthma, and chronic obstructive pulmonary disease are among the other possible causes. Cough is also a common side effect of angiotensin-converting enzyme inhibitors.

One of the most notable and potentially controversial implications of the guidelines is that over-the-counter expectorants and cough suppressants (ie, cough syrups and drops) are usually a waste of money. "There is no clinical evidence that over-the-counter cough expectorants or suppressants actually relieve cough," pointed out Dr. Irwin. However, there is considerable evidence that an early-generation antihistamine plus a decongestant is effective for that purpose, he related.

Brompheniramine is the only older antihistamine recommended by the ACCP for that type of combination therapy. But some experts have maintained that it is reasonable to substitute one of the others, such as diphenhydramine or chlorpheniramine. It is unclear how the early-generation antihistamines help to suppress cough; histamine blockade in the central nervous system is one mechanism that has been suggested.

Surprisingly, the new ACCP cough guidelines were the first to provide comprehensive, evidence-based recommendations for the diagnosis and management of cough in children. They included a particularly strong warning against the use of over-the-counter cough and cold medications in children 14 and younger.

The effectiveness of these remedies is unproven in that age-group and thus may place younger children unnecessarily at risk for medication side effects such as liver damage due to accidental overdose. "In most cases, a cough that is unrelated to chronic lung conditions, environmental influences, or other specific factors will resolve on its own," asserted Dr. Irwin.

The new guidelines strongly advise that individuals ages 19 to 64 receive the tetanus, diphtheria, pertussis booster vaccine recently approved for use in adults. "Because the older vaccine caused serious side effects when given to older children and adults, it was only given to children," Dr. Irwin said. Furthermore, he added, that vaccine provides protection for less than 10 years.

—Timothy Begany

Reference
1. Irwin RS, Baumann MH, Bolser DC, et al. Diagnosis and management of cough: ACCP evidence-based clinical practice guidelines. Chest. 2006;129(suppl):1S-23S.

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