Cough in Children and Adults: Diagnosis, Assessment and Management (CICADA). Summary of an updated position statement on chronic cough in Australia

To the Editor: The recent publication in this Journal of the position statement summary on cough in children and adults is welcome and timely.1 Much has changed in the understanding of chronic cough since the last Australian guideline was published in 2010, reflected not least in the recent approval in Europe of gefapixant, the first successful drug developed specifically for chronic cough.2 Compared with other international guidance on cough,3,4 the unique strength of the current document is the separation of evidence‐based strategies for children and adults, and for a local readership, a focus on Australian First Nations people, who have been underserved specifically regarding chronic wet cough.1

However, much remains to be understood in the epidemiology, mechanisms, and natural history of chronic cough. For this reason, there is still uncertainty, and valid alternatives exist in aspects of the clinical approach to the condition. It is important that this uncertainty is emphasised. For example, in contrast to the position statement, other recent recommendations for investigating chronic cough in adults do not suggest bronchial provocation testing without other evidence for asthma (either clinically, on spirometry, or on testing for peripheral eosinophilia or fractional exhaled nitric oxide).4 Neither are gastro‐oesophageal studies advocated in the absence of specific clinical features of reflux.4 For treatment of refractory chronic cough, morphine is an option recommended by others.3,4 The phenomenon of cough reflex hypersensitivity may be more commonplace in chronic cough than alluded to in the statement, often most noticeable to the patient in the larynx, but probably also affecting airway receptors elsewhere.5 Rather than absolute causes for cough in themselves, conditions associated with cough may be thought of more as treatable traits exacerbating an underlying increased tendency to cough.3,4 This hypersensitivity may be the hallmark of chronic cough, perhaps considered a disease in its own right.

We hope the position statement not only increases interest and debate surrounding chronic cough in Australia but leads to better outcomes for patients who experience a condition that is often extremely detrimental to quality of life yet is frequently regarded as low priority by clinicians and funders alike.