Chest
Volume 129, Issue 1, Supplement, January 2006, Pages 147S-153S
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Supplement
Diagnosis and Management of Cough: ACCP Evidence-Based Clinical Practice Guidelines
Chronic Cough Due to Lung Tumors: ACCP Evidence-Based Clinical Practice Guidelines

https://doi.org/10.1378/chest.129.1_suppl.147SGet rights and content

Goals/objectives:

To review the scientific evidence on cough associated with tumors in the lungs.

Methods:

MEDLINE literature review (through March 2004) for all studies published in the English language, including case series and case reports, since 1966 using the medical subject heading terms “cough” and “lung neoplasms.”

Results:

Primary bronchogenic carcinoma is the most common lethal neoplasm in the United States. Malignancies that arise in other organs will often metastasize to the lungs. Any form of cancer involving the lungs may be associated with cough. However, cough is far more likely to indicate involvement of the airways than the lung parenchyma because of the location of cough receptors. Cough is present in > 65% of patients at the time lung cancer is diagnosed, and productive cough is present in > 25% of patients. While cough as a presenting symptom of lung cancer is common, many studies have shown that lung cancer is the cause of chronic cough in ≤ 2% of all patients who present with a chronic cough.

Conclusions:

Bronchoscopy is usually indicated when there is suspicion of airway involvement by a malignancy. Conversely, bronchoscopy usually should not be performed to assess a cough for the possibility of lung cancer when there is little risk for lung cancer (nonsmokers) and when there are normal findings on a plain chest radiograph. If the lung cancer can be removed surgically, cough will usually abate. Radiation therapy, chemotherapy (especially with gemcitabine), and endobronchial treatment methods likely will improve cough caused by lung cancer. Centrally acting narcotic antitussive agents are usually administered for the control of cough caused by lung cancer when other treatment methods fail.

Section snippets

CLINICAL FEATURES OF CANCER AS A CAUSE OF COUGH

Smoking tobacco causes 90% of primary lung cancers.9 Thus, heavy cigarette smokers who have a new onset of cough, a change in the characteristics of a preexisting cough, and the presence of hemoptysis (usually a small volume, often only streaks) should promote consideration of cancer as the cause of cough.10 Among other important points in a person's medical history that lead to a higher index of suspicion for primary lung cancer are passive cigarette smoke exposure; exposure to asbestos,

DIAGNOSIS OF LUNG CANCER

A chest radiograph should be obtained when a patient with cough has risk factors for lung cancer or a known or suspected cancer in another site that may metastasize to the lungs. A CT scan of the chest is often needed to further characterize abnormalities that are seen on the plain chest radiograph. Occasionally, a central airway cancer will be not visible on a plain chest radiograph, yet will be quite evident on assessment of the airways via CT imaging or at the time of bronchoscopy.19 Precise

RECOMMENDATIONS

1. In a patient with cough who has risk factors for lung cancer or a known or suspected cancer in another site that may metastasize to the lungs, a chest radiograph should be obtained. Level of evidence, expert opinion; benefit, substantial; grade of recommendation, E/A

2. In patients with a suspicion of airway involvement by a malignancy (eg, smokers with hemoptysis), even when the chest radiograph findings are normal, bronchoscopy is indicated. Level of evidence, low; benefit, substantial;

Surgery

Surgery to remove non-small cell lung cancer (NSCLC) is the treatment of choice for patients with stage I and II NSCLC, assuming that comorbid diseases (eg, COPD and heart disease) do not create a prohibitive risk. If cough was caused by a NSCLC that can be surgically removed, clinical experience suggests that the cough will typically cease. However, there are no studies that have systematically addressed the incidence of cough cessation after surgical resection of lung cancer. Palliative,

RECOMMENDATIONS

3. For patients with stage I and II NSCLC, surgery to remove the NSCLC is the treatment of choice. If cough was caused by a NSCLC that can be surgically removed, the cough will typically cease. Level of evidence, low; benefit, substantial; grade of recommendation, B

4. For patients with more advanced NSCLC (stages III and IV), external beam radiation and/or chemotherapy should usually be offered. Level of evidence, good; benefit, intermediate; grade of recommendation, A

5. For patients with

PHARMACOTHERAPY OF COUGH

Cough may persist in the setting of lung cancer, despite all other treatments that are directed at the cancer and the associated symptom of cough. When cough persists, most patients will be offered pharmacologic therapy that is designed to control cough. The use of various protussive and antitussive pharmacologic agents is evaluated extensively elsewhere in these guidelines.

When a comorbid disease that causes cough is present together with lung cancer, pharmacologic treatment of the comorbid

RECOMMENDATION

6. For patients with cough and lung cancer, the use of centrally acting cough suppressants such as dihydrocodeine and hydrocodone is recommended. Level of evidence, low; benefit, intermediate; grade of recommendation, C

SUMMARY OF RECOMMENDATIONS

  • 1.

    In a patient with cough who has risk factors for lung cancer or a known or suspected cancer in another site that may metastasize to the lungs, a chest radiograph should be obtained. Level of evidence, expert opinion; benefit, substantial; grade of

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