Chest
SupplementDiagnosis and Management of Cough: ACCP Evidence-Based Clinical Practice GuidelinesChronic Upper Airway Cough Syndrome Secondary to Rhinosinus Diseases (Previously Referred to as Postnasal Drip Syndrome): ACCP Evidence-Based Clinical Practice Guidelines
Section snippets
DEFINITION AND OVERVIEW
Postnasal drip (PND) is the drainage of secretions from the nose or paranasal sinuses into the pharynx. Clinically, the diagnosis of PND syndrome (PNDS) largely rests on the reporting of the patient of this sensation of having something drip down into the throat, nasal discharge, or frequent throat clearing. The presence on examination of the nasopharynges or oropharynges of mucoid or mucopurulent secretions, or cobblestoning of the mucosa also is suggestive. The problem, however, encountered
RECOMMENDATION
1. In patients with chronic cough related to upper airway abnormalities, the committee considers the term UACS to be more accurate, and therefore it should be used instead of PNDS. Level of evidence, expert opinion; benefit, substantial; grade of recommendation, E/A
PREVALENCE
In multiple prospective, descriptive studies of adults,1, 2, 3, 4 UACS due to a variety of upper respiratory conditions has been shown, either singly or in combination with other conditions, to be the most common cause of chronic cough. UACS has also been shown to be a principal cause of cough that is associated with the common cold.5 It follows, therefore, that, because the common cold is the most common condition afflicting mankind, UACS is the most common cause of acute cough as well.
PATHOGENESIS
Clinical studies have suggested that the pathogenesis of cough from UACS is due to the mechanical stimulation of the afferent limb of the cough reflex in the upper airway.6 One proposed mechanism is that cough receptors located in the hypopharynx or larynx are stimulated by secretions emanating from the nose and/or sinuses dripping down into these areas.6 There is, however, also some evidence that suggests that in patients with UACS-induced cough that the cough reflex in the upper airway is
CLINICAL PRESENTATION
The clinical presentation of patients with UACS, in addition to cough, commonly involves complaints (or at least an affirmative response to questioning) of a sensation of something draining into the throat, a need to clear the throat, a tickle in the throat, nasal congestion, or a nasal discharge. Patients sometimes complain of hoarseness. A medical history containing an upper respiratory illness (eg, a cold) is often present. A history of wheeze is also common. Most patients with UACS cough
DIAGNOSIS
A prospective study of chronic cough in adults8 demonstrated that a careful medial history including the character and timing of cough and the complications associated with cough is of little diagnostic value. This certainly is true regarding UACS cough. The symptoms and signs of UACS are nonspecific, and a definitive diagnosis cannot be made from the medical history and physical examination alone. Furthermore, the absence of any of the usual clinical findings does not rule out a response to
DIFFERENTIAL DIAGNOSIS OF UACS-INDUCED COUGH
The differential diagnosis includes allergic rhinitis, perennial nonallergic rhinitis, postinfectious rhinitis, bacterial sinusitis, allergic fungal sinusitis, rhinitis due to anatomic abnormalities, rhinitis due to physical or chemical irritants, occupational rhinitis, rhinitis medicamentosa, and rhinitis of pregnancy. Because gastroesophageal reflux disease (GERD) is frequently associated with upper respiratory symptoms, GERD may mimic a UACS-induced cough.
RECOMMENDATION
2. In patients with chronic cough, the diagnosis of UACS-induced cough should be determined by considering a combination of criteria, including symptoms, physical examination findings, radiographic findings, and, ultimately, the response to specific therapy. Because it is a syndrome, no pathognomonic findings exist. Level of evidence, low; benefit, substantial; grade of recommendation, B
TREATMENT
The treatment options for UACS-induced cough are somewhat dependent on the specific subcategory of disease that is present. In patients in whom the cause of the UACS-induced cough is apparent specific therapy that is directed at this condition should be instituted (see below). When a specific etiology of cough, however, is not apparent, empiric therapy for UACS should be applied using drugs that have been specifically studied and have been shown to be efficacious in the treatment of this
RECOMMENDATIONS
3. In patients in whom the cause of the UACS-induced cough is apparent, specific therapy directed at this condition should be instituted. Level of evidence, low; benefit, substantial; grade of recommendation, B
4. For patients with chronic cough, an empiric trial of therapy for UACS should be administered because improvement or resolution of cough in response to specific treatment is the pivotal factor in confirming the diagnosis of UACS as a cause of cough. Level of evidence, low; benefit,
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