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## Complete Summary

#### GUIDELINE TITLE

Chronic cough due to tuberculosis and other infections: ACCP
evidence-based clinical practice guidelines.

#### BIBLIOGRAPHIC SOURCE(S)

Rosen MJ. Chronic cough due to tuberculosis and other infections: ACCP
evidence-based clinical practice guidelines. Chest 2006 Jan;129(1
Suppl):197S-201S. \[41 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16428710)

#### GUIDELINE STATUS

This is the current release of the guideline.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Chronic cough due to tuberculosis and other infections, including:

 Endemic mycoses

 Paragonimiasis

 Syngamosis

#### GUIDELINE CATEGORY

Diagnosis\
Management\
Prevention\
Risk Assessment\
Screening

#### CLINICAL SPECIALTY

Family Practice\
Infectious Diseases\
Internal Medicine\
Pulmonary Medicine

#### INTENDED USERS

Physicians\
Public Health Departments

#### GUIDELINE OBJECTIVE(S)

To review the evidence and make recommendations on the management of
chronic cough due to tuberculosis and other infections

#### TARGET POPULATION

Patients with chronic cough due to tuberculosis and other infections

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  Medical history

2.  Physical examination

3.  Differential diagnosis

4.  Chest radiograph

5.  Sputum smears and culture for acid-fast bacilli

6.  Outbreak prevention (by public health agencies)

    -   Screen for new cases

    -   Maintain surveillance of existing populations

    -   Establish effective diagnostic and treatment programs

#### MAJOR OUTCOMES CONSIDERED

Prevalence and risk of tuberculosis and fungus or parasitic lung
infections

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Hand-searches of Published Literature (Secondary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The evidence review procedures included section-specific targeted
searches as well as a formal systematic review on selected topics.

**Formal Systematic Reviews**

Formal systematic reviews on selected topics covered in the guideline
were performed by the Center for Clinical Health Policy Research at Duke
University Medical Center. For the key questions addressed by the formal
systematic reviews see the section titled \"Methodology and Grading of
the Evidence for the Diagnosis and Management of Cough\" (see
\"Availability of Companion Documents\" field).

*Literature Search Strategy*

The Duke University research team conducted a systematic and
comprehensive literature review that began with searches of MEDLINE from
1966 through August 2003 with limits of articles published in the
English language and with human subjects. Search terms included the
medical subject heading term \"cough\" combined with a published
strategy for identifying randomized controlled trials (RCTs). A separate
search combined the medical subject heading terms \"bronchiectasis,\"
\"cystic fibrosis,\" and \"respiratory therapy\" with the RCT strategy.
However, searches using terms related to the therapeutic use of specific
agents, including \"antitussive agents,\" \"expectorants,\"
\"bronchodilator agents,\" \"ipratropium,\" \"albuterol,\"
\"orciprenaline,\" and \"cromolyn sodium\" had poor specificity in the
absence of the term \"cough,\" and thus were not used. Additional
searches were targeted to double-blind RCTs of nonspecific antitussive
therapy and protussive drugs (e.g., expectorant, mucolytic,
mucus-modifying agents) for all indications other than those listed in
question 2 in the section titled \"Methodology and Grading of the
Evidence for the Diagnosis and Management of Cough\" (see \"Availability
of Companion Documents\" field) that reported on cough clearance or
cough symptoms and had been published since the previous American
College of Chest Physicians cough guidelines were published. The trials
identified in this search were provided to the section authors.

In addition to MEDLINE, the Duke University research team searched the
National Guideline Clearinghouse and the Cochrane Library (including the
Cochrane Database of Systematic reviews, the Cochrane Controlled trial
register, and the Database of Abstracts of Reviews of Effectiveness).
Additional studies were identified from the reference lists of review
articles and by querying experts in the field.

*Inclusion and Exclusion Criteria*

The criteria for the inclusion and exclusion of articles were developed
for each research question and are shown in Table 1 in the section
titled \"Methodology and Grading of the Evidence for the Diagnosis and
Management of Cough (see the \"Availability of Companion Documents\"
field). The abstracts of all articles were reviewed by two physicians
(one with methodological expertise and one with content area expertise),
and those meeting the inclusion criteria were selected for review in
full text.

**Section-Specific Review**

Articles were selected from a MEDLINE search from 1966 through 2003
(using medical subject heading words \"cough,\" \"tuberculosis,\" and
\"lung infection\"), and World Health Organization and Centers for
Disease Control and Prevention web sites.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Expert Consensus\
Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Quality of the Evidence**

Good = evidence based on good randomized controlled trials (RCTs) or
meta-analyses

Fair = evidence based on other controlled trials or RCTs with minor
flaws

Low = evidence based on nonrandomized, case-control, or other
observational studies

Expert opinion = evidence based on the consensus of the carefully
selected panel of experts in the topic field. There are no studies that
meet the criteria for inclusion in the literature review.

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

**Note from the National Guideline Clearinghouse (NGC)**: The evidence
review procedures included section-specific targeted searches as well as
a formal systematic review on selected topics. Formal systematic reviews
on selected topics covered in the guideline were performed by the Center
for Clinical Health Policy Research at Duke University Medical Center.
For more information see the section titled \"Methodology and Grading of
the Evidence for the Diagnosis and Management of Cough\" (see
\"Availability of Companion Documents\" field).

**Formal Systematic Reviews**

*Synthesis*

Details from \"included\" articles (see the \"Description of Methods
Used to Collect/Select the Evidence\" field) were extracted and recorded
into evidence tables. No quantitative synthesis, such as meta-analysis,
was performed, but aggregated data were described and analyzed
qualitatively.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus\
Expert Consensus (Consensus Development Conference)\
Informal Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

The recommendations were formulated by an international panel of 26
experts representing seven clinical specialties. Many were members of
the American College of Chest Physicians (ACCP), but representatives
from other medical associations, including the American College of
Physicians, Canadian Thoracic Society, and American Thoracic Society,
also participated on the panel. These experts convened on several
occasions, including a panel conference in Boston, MA, in November 2004,
in which they deliberated the final content and recommendations, the
rating of the quality of the evidence, the estimation of benefits to the
patient population, and the grading of the strength of the
recommendations. Authors were selected, or in some cases writing
committees were formed, for each topic to review evidence, write an
article, and draft guidelines. These assignments were made by the
steering committee based on the authors\' known expertise in that
specific area of the diagnosis and treatment of cough, and their
research and writing skills.

The recommendations were graded, by consensus of the panel, using the
ACCP Health and Science Policy Grading System, which is based on the
following two components: quality of the evidence; and the net benefit
of the diagnostic or therapeutic procedure. The quality of evidence is
rated according to the study design and strength of the other
methodologies used in the included studies. The net benefit of the
recommendation is based on the estimated benefit to the specific patient
population described in each recommendation and not for an individual
patient. The authors of each recommendation proposed their best estimate
of the net benefit, and the entire panel considered these choices for
each recommendation. At the conference, the panel revised the
assessments of net benefit for many recommendations to be consistent
across all recommendations.

When there was insufficient evidence, the panel used informal group
consensus techniques to refine or develop recommendations based on the
expert opinion of the panel. Eighty percent of the panel was in
attendance at the final conference to collaborate on the final wording
and grading of the recommendations. Even those recommendations that were
based on expert opinion were considered to be worthy of inclusion, as
they were the recommendations of an international and multidisciplinary
team with considerable expertise in the diagnosis and treatment of
patients with cough.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

**Strength of Recommendations**

A = strong recommendation

B = moderate recommendation

C = weak recommendation

D = negative recommendation

I = no recommendation possible (inconclusive)

E/A = strong recommendation based on expert opinion only

E/B = moderate recommendation based on expert opinion only

E/C = weak recommendation based on expert opinion only

E/D = negative recommendation based on expert opinion only

**Net Benefit**

Substantial = There is evidence of benefit that clearly exceeds the
minimum clinically significant benefit and evidence of little harm

Intermediate = Clear evidence of benefit but with some evidence of
harms, with a net benefit between that defined for \"substantial\" and
\"small/weak\"

Small/weak = There is evidence of a benefit that may not clearly exceed
the minimum clinically significant benefit, or there is evidence of
harms that substantially reduce (but do not eliminate) the benefit such
that it may not clearly exceed the minimum clinically significant
benefit

None = Evidence shows that either there is no benefit or the benefits
equal the harms

Conflicting = Evidence is inconsistent with regard to benefits and/or
harms such that the net benefit is uncertain

Negative = Expected harms exceed the expected benefits to the population

**Table: Relationship of Strength of the Recommendations Scale to
Quality of Evidence and Net Benefits**

  --------------------------------------------------------------------------------------------------------------
  ** **        **Net Benefit**                                                                    
  ------------ ----------------- ------------------ ---------------- ---------- ----------------- --------------
  **Quality of **Substantial**   **Intermediate**   **Small/Weak**   **None**   **Conflicting**   **Negative**
  Evidence**                                                                                      

  Good         A                 A                  B                D          I                 D

  Fair         A                 B                  C                D          I                 D

  Low          B                 B                  C                I          I                 D

  Expert       E/A               E/B                E/C              I          I                 E/D
  Opinion                                                                                         
  --------------------------------------------------------------------------------------------------------------

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

The executive committee of the panel extensively reviewed each section
of the guideline manuscript during the writing process. The November
2004 conference provided an opportunity for the entire panel to review
the latest drafts. Following final revisions and one final review by the
executive committee, each section of the guidelines was reviewed and
approved by the Clinical Pulmonary Medicine, Respiratory Care, Pediatric
Chest Medicine, Environmental and Occupational and Airways Disorders
NetWorks of the American College of Chest Physicians (ACCP), as well as
the ACCP Health and Science Policy Committee, and subsequently by the
ACCP Board of Regents.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

Definitions for the level of evidence, strength of recommendation, and
net benefit follow the \"Major Recommendations.\"

1.  In areas where there is a high prevalence of tuberculosis (TB),
    chronic cough should be defined as it is in the World Health
    Organization Practical Approach to Lung Health (PAL) program as
    being 2 to 3 weeks in duration. **Level of evidence, low; benefit,
    substantial; grade of recommendation, B**

2.  In patients with chronic cough who live in areas with a high
    prevalence of TB, this diagnosis should be considered, but not to
    the exclusion of the more common etiologies. Sputum smears and
    cultures for acid fast bacilli and a chest radiograph should be
    obtained whenever possible. **Level of evidence, low; benefit,
    substantial; grade of recommendation, B**

3.  In patients with suspected TB, future investigations are needed to
    refine the criteria for suspecting TB and initiating a diagnostic
    evaluation, to utilize resources in a cost-effective manner and to
    improve patient and caregiver adherence to diagnostic
    recommendations. **Level of evidence, expert opinion; benefit,
    substantial; grade of recommendation, E/A**

4.  In populations at increased risk of becoming infected with TB and
    transmitting it to others by cough (e.g., those persons in prisons
    and nursing homes), special measures to prevent outbreaks must be
    made by public health agencies to screen for new cases, maintain
    surveillance of existing populations, and establish effective
    diagnostic and treatment programs early in the evaluation. **Level
    of evidence, good; benefit, substantial; grade of recommendation,
    A**

5.  In patients with unexplained chronic cough who have resided in areas
    of endemic infection with fungi or parasites, a diagnostic
    evaluation for these pathogens should be undertaken when more common
    causes of cough have been ruled out. **Level of evidence, low;
    benefit, substantial; grade of recommendation, B**

**[Definitions]{.underline}**:

**Quality of the Evidence**

**Good** = evidence is based on good randomized controlled trials (RCTs)
or meta-analyses

**Fair** = evidence is based on other controlled trials or RCTs with
minor flaws

**Low** = evidence is based on nonrandomized, case-control, or other
observational studies

**Expert opinion** = evidence is based on the consensus of the carefully
selected panel of experts in the topic field. There are no studies that
meet the criteria for inclusion in the literature review.

**Strength of Recommendations**

A = strong recommendation

B = moderate recommendation

C = weak recommendation

D = negative recommendation

I = no recommendation possible (inconclusive)

E/A = strong recommendation based on expert opinion only

E/B = moderate recommendation based on expert opinion only

E/C = weak recommendation based on expert opinion only

E/D = negative recommendation based on expert opinion only

**Net Benefit**

Substantial = There is evidence of benefit that clearly exceeds the
minimum clinically significant benefit and evidence of little harm

Intermediate = Clear evidence of benefit but with some evidence of
harms, with a net benefit between that defined for \"substantial\" and
\"small/weak\"

Small/weak = There is evidence of a benefit that may not clearly exceed
the minimum clinically significant benefit, or there is evidence of
harms that substantially reduce (but do not eliminate) the benefit such
that it may not clearly exceed the minimum clinically significant
benefit

None = Evidence shows that either there is no benefit or the benefits
equal the harms

Conflicting = Evidence is inconsistent with regard to benefits and/or
harms such that the net benefit is uncertain

Negative = Expected harms exceed the expected benefits to the population

**Table: Relationship of Strength of the Recommendations Scale to
Quality of Evidence and Net Benefits**

  --------------------------------------------------------------------------------------------------------------
  ** **        **Net Benefit**                                                                    
  ------------ ----------------- ------------------ ---------------- ---------- ----------------- --------------
  **Quality of **Substantial**   **Intermediate**   **Small/Weak**   **None**   **Conflicting**   **Negative**
  Evidence**                                                                                      

  Good         A                 A                  B                D          I                 D

  Fair         A                 B                  C                D          I                 D

  Low          B                 B                  C                I          I                 D

  Expert       E/A               E/B                E/C              I          I                 E/D
  Opinion                                                                                         
  --------------------------------------------------------------------------------------------------------------

#### CLINICAL ALGORITHM(S)

The following clinical algorithms are provided in the section titled
\"Diagnosis and Management of Cough Executive Summary\" (see
\"Availability of Companion Documents\" field)\"

-   Acute cough algorithm for the management of patients
    [\>]{.underline}15 years of age with cough lasting \<3 weeks

-   Subacute cough algorithm for the management of patients
    [\>]{.underline}15 years of age with cough lasting 3 to 8 weeks

-   Chronic cough algorithm for the management of patients
    [\>]{.underline}15 years of age with cough lasting \>8 weeks

-   Approach to a child \<15 years of age with chronic cough

-   Approach to a child [\<]{.underline}14 years of age with chronic
    specific cough

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified and graded for each
recommendation (see \"Major Recommendations\").

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Appropriate diagnosis and effective management of patients with chronic
cough due to tuberculosis and other infections

#### POTENTIAL HARMS

Not stated

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

-   The information provided in the guideline should be used in
    conjunction with clinical judgment. Although the guideline provides
    recommendations that are based on evidence from studies involving
    various populations, the recommendations may not apply to every
    individual patient. It is important for the physician to take into
    consideration the role of patient preferences and the availability
    of local resources.

-   The American College of Chest Physicians (ACCP) is sensitive to
    concerns that nationally and/or internationally developed guidelines
    are not always applicable in local settings. Further, guideline
    recommendations are just that, recommendations not dictates. In
    treating patients, individual circumstances, preferences, and
    resources do play a role in the course of treatment at every
    decision level. Although the science behind evidence-based medicine
    is rigorous, there are always exceptions. The recommendations are
    intended to guide healthcare decisions. These recommendations can be
    adapted to be applicable at various levels.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Clinical Algorithm

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Living with Illness\
Staying Healthy

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Rosen MJ. Chronic cough due to tuberculosis and other infections: ACCP
evidence-based clinical practice guidelines. Chest 2006 Jan;129(1
Suppl):197S-201S. \[41 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16428710)

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2006 Jan

#### GUIDELINE DEVELOPER(S)

American College of Chest Physicians - Medical Specialty Society

#### SOURCE(S) OF FUNDING

American College of Chest Physicians

#### GUIDELINE COMMITTEE

American College of Chest Physicians (ACCP) Expert Panel on the
Diagnosis and Management of Cough

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Primary Author*: Mark J. Rosen, MD, FCCP

*Panel Members*: Richard S. Irwin, MD, FCCP (Chair); Michael H. Baumann,
MD, FCCP (HSP Liaison); Donald C. Bolser, PhD; Louis-Philippe Boulet,
MD, FCCP (CTS Representative); Sidney S. Braman, MD, FCCP; Christopher
E. Brightling, MBBS, FCCP; Kevin K. Brown, MD, FCCP; Brendan J. Canning,
PhD; Anne B. Chang, MBBS, PhD; Peter V. Dicpinigaitis, MD, FCCP; Ron
Eccles, DSc; W. Brendle Glomb, MD, FCCP; Larry B. Goldstein, MD; LeRoy
M. Graham, MD, FCCP; Frederick E. Hargreave, MD; Paul A. Kvale, MD,
FCCP; Sandra Zelman Lewis, PhD; F. Dennis McCool, MD, FCCP; Douglas C.
McCrory, MD, MHSc; Udaya B.S. Prakash, MD, FCCP; Melvin R. Pratter, MD,
FCCP; Mark J. Rosen, MD, FCCP; Edward Schulman, MD, FCCP (ATS
Representative); John Jay Shannon, MD, FCCP (ACP Representative); Carol
Smith Hammond, PhD and Susan M. Tarlo, MBBS, FCCP

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

The American College of Chest Physicians (ACCP) has a very stringent
approach to the issue of potential or perceived conflicts of interest.
This policy is published on the ACCP Web site at
[www.chestnet.org](http://www.chestnet.org/). All conflicts of interest
within the preceding 5 years were required to be disclosed by all
panelists, including those who did not have writing responsibilities, at
face-to-face meetings, the final conference, and prior to submission for
publication.

The most recent of these are documented in the published guideline
supplement. Furthermore, the panel was instructed in this matter,
verbally and in writing, prior to the deliberations of the final
conference.

#### ENDORSER(S)

American Thoracic Society - Medical Specialty Society\
Canadian Thoracic Society - Medical Specialty Society

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: Available to subscribers of [Chest - The
Cardiopulmonary and Critical Care
Journal](http://www.chestjournal.org/).

Print copies: Available from the American College of Chest Physicians,
Products and Registration Division, 3300 Dundee Road, Northbrook IL
60062-2348.

#### AVAILABILITY OF COMPANION DOCUMENTS

The following are available:

-   Diagnosis and management of cough executive summary: ACCP
    evidence-based clinical practice guidelines. Northbrook, IL: ACCP,
    2006 Jan.

**Background and Methodology Information**

-   Introduction to the diagnosis and management of cough: ACCP
    evidence-based clinical practice guidelines. Northbrook, IL: ACCP,
    2006 Jan.

-   Methodology and grading of the evidence for the diagnosis and
    management of cough: ACCP evidence-based clinical practice
    guidelines. Northbrook, IL: ACCP, 2006 Jan.

**Additional Background Information**

-   Anatomy and neurophysiology of the cough reflex: ACCP evidence-based
    clinical practice guidelines. Northbrook, IL: ACCP, 2006 Jan.

-   Global physiology and pathophysiology of cough: ACCP evidence-based
    clinical practice guidelines. Northbrook, IL: ACCP, 2006 Jan.

-   Complications of cough: ACCP evidence-based clinical practice
    guidelines. Northbrook, IL: ACCP, 2006 Jan.

-   Overview of common causes of chronic cough: ACCP evidence-based
    clinical practice guidelines. Northbrook, IL: ACCP, 2006 Jan.

-   Assessing cough severity and efficacy of therapy in clinical
    research: ACCP evidence-based clinical practice guidelines.
    Northbrook, IL: ACCP, 2006 Jan.

-   Potential future therapies for the management of cough: ACCP
    evidence-based clinical practice guidelines. Northbrook, IL: ACCP,
    2006 Jan.

-   Future directions in the clinical management of cough: ACCP
    evidence-based clinical practice guidelines. Northbrook, IL: ACCP,
    2006 Jan.

Electronic copies: Available to subscribers of [Chest - The
Cardiopulmonary and Critical Care
Journal](http://www.chestjournal.org/).

Print copies: Available from the American College of Chest Physicians,
Products and Registration Division, 3300 Dundee Road, Northbrook IL
60062-2348.

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI on May 4, 2006. The information
was verified by the guideline developer on June 5, 2006.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions.

### DISCLAIMER

#### NGC DISCLAIMER

The National Guideline Clearinghouse™ (NGC) does not develop, produce,
approve, or endorse the guidelines represented on this site.

All guidelines summarized by NGC and hosted on our site are produced
under the auspices of medical specialty societies, relevant professional
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Guidelines represented on the NGC Web site are submitted by guideline
developers, and are screened solely to determine that they meet the NGC
Inclusion Criteria which may be found at
<http://www.guideline.gov/about/inclusion.aspx> .

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Readers with questions regarding guideline content are directed to
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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008