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

In reply: We thank Turner and Birring1 for their interest in our updated position statement on cough in children and adults,2 particularly for identifying its strength in separating evidence‐based strategies for children and adults. We also appreciate their comments on our efforts to highlight the importance of identifying and treating chronic cough in Australian First Nations people.

We agree and acknowledge the many gaps in the current evidence, particularly those relating to the algorithmic management of chronic cough in adults. In childhood chronic cough, multicentre randomised controlled trials of the recommended management algorithm,3 including community‐based studies,4 have found that using the algorithm improves clinical outcomes. However, no such direct evidence exists in adults. The adult algorithm in our updated position statement is new,2 and we are aware that it is not currently supported by high quality evidence. We agree and advocate for an approach that focuses on investigations based on clinical probability and recommend that clinicians commence with history and then pursue a hierarchy of investigations. In the case of asthma, bronchial provocation testing should be done only if there is still uncertainty following spirometry and exhaled nitric oxide testing. In the case of asthma and gastro‐oesophageal reflux disease, we emphasise the need to make a diagnosis and not rely on treatment trials that are largely ineffective. The expert panel did not agree with using morphine to treat refractory cough in adults in Australian primary care settings, given the problems associated with its use as well as practicalities of access, and we cannot routinely recommend it for long term use in any setting.

There is little doubt that, as highlighted by Turner and Birring,1 the concept of cough hypersensitivity (as a feature in refractory/unexplained chronic cough in adults) is important in our current era. However, although we did mention cough hypersensitivity, in the context that the statement aims to assist in management of chronic cough in primary care, it is essential that treatable causes of chronic cough are identified before assigning this diagnosis. We highlight that cough hypersensitivity should not be used in childhood chronic cough, for sound reasons explained in a review article.5

We agree with the suggestion that increased interest and further research into adult chronic cough would be a positive outcome. We also hope that the statement will raise awareness of the importance of chronic cough, and that its use will lead to better outcomes for patients who experience chronic cough and its associated poor quality of life.