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

Philip W Rouadi 1 2, Samar A Idriss 1 3, Jean Bousquet 4 5 6 7, Tanya M Laidlaw 8, Cecilio R Azar 9 10 11, Mona S Al-Ahmad 12, Anahi Yañez 13, Maryam Ali Y Al-Nesf 14, Talal M Nsouli 15, Sami L Bahna 16, Eliane Abou-Jaoude 15, Fares H Zaitoun 17, Usamah M Hadi 18, Peter W Hellings 19 20 21 22, Glenis K Scadding 23, Peter K Smith 24, Mario Morais-Almeida 25, René Maximiliano Gómez 26, Sandra N Gonzalez Diaz 27, Ludger Klimek 28, Georges S Juvelekian 29, Moussa A Riachy 30, Giorgio Walter Canonica 31, David Peden 32, Gary W K Wong 33, James Sublett 34, Jonathan A Bernstein 35, Lianglu Wang 36, Luciana K Tanno 7 37 38, Manana Chikhladze 39, Michael Levin 40, Yoon-Seok Chang 41, Bryan L Martin 42, Luis Caraballo 43, Adnan Custovic 44, Jose Antonio Ortego-Martell 45, Olivia J Ly Lesslar 46, Erika Jensen-Jarolim 47 48, Motohiro Ebisawa 49, Alessandro Fiocchi 50, Ignacio J Ansotegui 51

Affiliations

14 May 2022

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doi: 10.1016/j.waojou.2022.100649

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.


 

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