Chest
SupplementDiagnosis and Management of Cough: ACCP Evidence-Based Clinical Practice GuidelinesCough Suppressant and Pharmacologic Protussive Therapy: ACCP Evidence-Based Clinical Practice Guidelines
Section snippets
DRUGS THAT AFFECT MUCOCILIARY FACTORS
This topic was not addressed separately in the previous evidence-based guideline.1 In disorders that have associated mucus hypersecretion, cough is elicited to enhance the clearance of accumulated secretions. One pharmacologic approach to treating these disorders is to alter the mucociliary factors. As described by Irwin et al,2 there are several mechanisms by which this may occur, as follows: (1) the drug could be an expectorant, increasing mucus volume; (2) the drug may suppress mucus
RECOMMENDATIONS
1. In patients with chronic bronchitis, agents that have been shown to alter mucus characteristics are not recommended for cough suppression. Level of evidence, good; benefit, none; grade of recommendation, D
2. In patients with cough due to URI or chronic bronchitis, the only inhaled anticholinergic agent that is recommended for cough suppression is ipratropium bromide. Level of evidence, fair; benefit, substantial; grade of recommendation, A
DRUGS THAT AFFECT THE AFFERENT LIMB OF THE COUGH REFLEX
The classification of antitussive drugs as peripheral or central is based largely on preclinical studies. Peripherally acting suppressants lack the sedation potential that is often associated with centrally acting drugs, such as opioids, because they do not penetrate the CNS to an appreciable extent. It should be noted, however, that one centrally acting drug, dextromethorphan, is not sedating, so a central action does not guarantee sedation potential as a side-effect of cough suppression.
RECOMMENDATIONS
3. In patients with chronic or acute bronchitis, peripheral cough suppressants, such as levodropropizine and moguisteine, are recommended for the short-term symptomatic relief of coughing. Level of evidence, good; benefit, substantial; grade of recommendation, A
4. In patients with cough due to URI, peripheral cough suppressants have limited efficacy and are not recommended for this use. Level of evidence, good; benefit, none; grade of recommendation, D
DRUGS THAT AFFECT THE CENTRAL MECHANISM FOR COUGH
This class of compounds is thought to act at one or more sites in the CNS to suppress cough. The particular CNS elements that are sensitive to these drugs are unknown. Based on preclinical experiments,37 the brainstem is thought to be the main region where antitussive agents act by a mechanism in which the motor control of cough is inhibited. However, the production of cough can be associated with sensation, termed the urge to cough, indicating that sensory information associated with cough
RECOMMENDATIONS
5. In patients with chronic bronchitis, central cough suppressants, such as codeine and dextromethorphan, are recommended for the short-term symptomatic relief of coughing. Level of evidence, fair; benefit, intermediate; grade of recommendation, B
6. In patients with cough due to URI, central cough suppressants have limited efficacy for symptomatic relief and are not recommended for this use. Level of evidence, good; benefit, none; grade of recommendation, D
DRUGS THAT AFFECT THE EFFERENT LIMB OF COUGH REFLEX
In this context, the efferent limb of the cough reflex is defined as a spinal action of the drug. While this definition appears to overlap with that of centrally acting drugs, it bears specific attention here. As defined above, our current definition of centrally acting antitussive drugs is restricted to those acting in the brainstem and/or at suprapontine sites. A drug that selectively suppressed the excitability of spinal pathways to abdominal muscle motoneurons would be expected to
RECOMMENDATION
7. In patients with chronic or acute cough requiring symptomatic relief, drugs that affect the efferent limb of the cough reflex are not recommended. Level of evidence, low; benefit, none; grade of recommendation, D
DRUGS THAT AFFECT THE SKELETAL MUSCLES
Neuromuscular blocking agents have been used in conjunction with anesthetics to suppress cough and thus to facilitate intubation. The depolarizing agent, succinylcholine, is most commonly used for this application but has a significant side effect profile.54 Newer non-depolarizing agents have fewer side effects but do not possess the rapid onset and recovery associated with succinylcholine.54, 55, 56 Erhan et al,56 in a double-blind study, showed that anesthetics, especially propofol, can
RECOMMENDATION
8. In patients requiring intubation during general anesthesia, the use of neuromuscular blocking agents is recommended to suppress coughing. Level of evidence, good; benefit, substantial; grade of recommendation, A
OTHER DRUGS
Table 4summarizes studies on the effects of zinc acetate or zinc gluconate on the common cold,58, 59, 60, 61, 62, 63, 64, 65, 66 and two studies63, 67 evaluated cough with subjective measures. Mixed results were obtained, with some studies58, 59, 61, 63, 67 indicating a positive effect of zinc preparations on the common cold and others60, 62, 64, 65, 66 suggesting no benefit. Two metaanalyses68, 69 of these studies have been performed, and both concluded that there was insufficient evidence to
RECOMMENDATIONS
9. In patients with acute cough due to the common cold, preparations containing zinc are not recommended. Level of evidence, good; benefit, none; grade of recommendation, D
10. In patients with acute cough due to the common cold, over the counter combination cold medications, with the exception of an older antihistamine-decongestant, are not recommended until randomized controlled trials prove that they are effective cough suppressants. Level of evidence, fair; benefit, none; grade of
PHARMACOLOGIC PROTUSSIVE THERAPY
Protussive therapy is intended to enhance cough effectiveness to promote the clearance of airway secretions. The most common disorders in which this type of therapy is indicated include cystic fibrosis, bronchiectasis, pneumonia, and postoperative atelectasis.2 In these disorders, mechanical methods to loosen mucus or pharmacologic tools that increase cough clearance may be useful to increase the effectiveness of coughing. Mechanical protussive procedures are covered in another section of this
RECOMMENDATION
12. In patients with neuromuscular impairment, protussive pharmacologic agents are ineffective and should not be prescribed. Level of evidence, good; benefit, none; grade of recommendation, D
PHARMACOLOGIC ENHANCEMENT OF COUGH CLEARANCE
The previous evidence-based guideline1 cited randomized, double-blind, placebo-controlled studies showing that hypertonic saline solution and erdosteine (which is not approved for use in the United States) were effective agents for increasing cough clearance in patients with bronchitis, and that amiloride was effective for this function in patients with cystic fibrosis. Ineffective agents (in bronchitic patients) included carbocysteine, mercaptoethane sulfonate, bromhexine, and guaifenesin.
RECOMMENDATIONS
13. In patients with bronchitis, hypertonic saline solution and erdosteine are recommended on a short-term basis to increase cough clearance. Level of evidence, good; benefit, substantial; grade of recommendation, A
14. In adult patients with cystic fibrosis, amiloride is recommended to increase cough clearance. Level of evidence, good; benefit, substantial; grade of recommendation, A
15. In adult patients with cystic fibrosis, while recombinant DNase does improve spirometry it is not recommended
CONCLUSIONS
Relatively few drugs are effective for the nonspecific suppression of cough. Our current recommendations largely confirm and extend the findings of the previous panel.1 Most notably, the current guidelines expand on the previous consensus by recommending that the use of suppressants be guided by the physician's specific knowledge of the disorder that is eliciting cough.
The previous guideline1 identified a number of different drugs as effective cough suppressants, particularly in patients with
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