Specialists Reach a Consensus on Chronic Cough Assessment and Diagnosis

Medical specialists agreed upon several items surrounding the initial assessment and referral process for patients with chronic cough (CC) in primary care, according to a study published in Therapeutic Advances in Respiratory Disease.

Before this study, the researchers found that primary care professionals (PCPs) lacked guidance on the ideal diagnosis, assessment, and referral process for patients with CC. Consequently, they conducted a study evaluating the consistency of responses across PCPs, pulmonologists, allergists, and ear, nose, and throat (ENT) specialists on the best CC assessment and referral processes.

A committee of 5 experts (2 PCPs, 1 pulmonologist, 1 allergist, and 1 ENT specialist) formulated 74 debatable statements addressing CC assessment in primary care and patient referral based on their literature review of English and Spanish articles from 2010 to 2020. The committee sent the statements to a panel of 77 experts (18 PCPs, 24 pulmonologists, 22 allergists, and 13 ENT specialists) for evaluation through 2 rounds of voting. All panelists worked within the National Spanish Healthcare System, were affiliated with a Spanish Scientific Society related to their field, and had seen at least 1 patient with CC every other week.

To assess the statements, panelists used a 9-point Likert-type ordinal scale. The researchers considered a score between 1 and 3 a disagreement, a score between 4 and 6 neither an agreement nor disagreement, and a score between 7 and 9 an agreement. Thus, statements that reached consensuses received a median score between 7 and 9 or 1 and 3; higher scores indicated agreement and lower scores indicated disagreement. To reach a consensus, researchers also required less than one-third of panelists to have voted outside these ranges and the IQR to be less than 4.

After the first round, the panelists agreed upon 62 of the 74 proposed statements. They reached a consensus on another statement in the second round after the reevaluation of those they disagreed upon. A total of 63 of the 74 proposed statements reached a consensus (85.1%). With these results, the scientific committee created a practical algorithm to aid in decision-making during the assessment and referral of patients with CC.

A statement highlighted by the researchers was for PCPs to utilize the terms “refractory chronic cough” and “unexplained chronic cough” to diagnose patients with a cough that persists after the underlying disease is controlled or a cough without a final diagnosis after a complete work-up. The panelists also agreed that PCPs should evaluate the patient’s quality of life and perform a chest x-ray. Additionally, they encouraged substituting cough-inducing drugs, introducing anti-reflux measures, and performing spirometry with a bronchodilator test and hemogram if an etiological diagnosis was not reached.

The researchers emphasized an additional 3 consensus items to prepare for dealing with CC diagnosis effectively. They noted that all patients should undergo a complete work-up until a diagnosis is made, no matter if it is CC caused by underlying pathology, unexplained CC, or refractory CC. They also emphasized that doctors should ask patients to have patience during the evaluation process as it can be difficult and time-consuming. Lastly, the researchers noted that it is necessary to be aware that CC may be a disease in some cases, not just a symptom of another pathology.

Limitations to this study included that it did not mention panelists’ individual opinions, did not discuss items in depth, and potentially overlooked some issues. Also, some may consider the evaluations of specialists to be subjective. Additionally, because the researchers utilized individuals with experience in the Spanish public health system and CC field, the findings may not apply to health systems with different structures or functions. In addition, because the number of specialists from each group on the panel was not homogenous, some groups may have influenced the consensus in their favor.

Lastly, the researchers acknowledged that experts’ opinions are not ideal to base recommendations on, but they are vital when no other evidence is available.

“It was not the authors’ aim to establish recommendations, but to explore consistency or opinions regarding the different addressed topics, which can be useful for future consensus guidelines,” they wrote.

Reference

Domingo C, Gonzálvez J, Dávila I, et al. Basic assessment of chronic cough in primary care and referral pathways of patients to different specialists. Ther Adv Respir Dis. 2023;17. doi:10.1177/17534666231178694