Chronic Cough Due to Chronic

Bronchitis
ACCP Evidence-Based Clinical Practice Guidelines
Sidney S. Braman, MD, FCCP

Background: Chronic bronchitis is a disease of the bronchi that is manifested by cough and sputum
expectoration occurring on most days for at least 3 months of the year and for at least 2 consecutive
years when other respiratory or cardiac causes for the chronic productive cough are excluded. The
disease is caused by an interaction between noxious inhaled agents (eg, cigarette smoke, industrial
pollutants, and other environmental pollutants) and host factors (eg, genetic and respiratory
infections) that results in chronic inflammation in the walls and lumen of the airways. As the disease
advances, progressive airflow limitation occurs, usually in association with pathologic changes of
emphysema. This condition is called COPD. When a stable patient experiences a sudden clinical
deterioration with increased sputum volume, sputum purulence, and/or worsening of shortness of
breath, this is referred to as an acute exacerbation of chronic bronchitis as long as conditions other
than acute tracheobronchitis are ruled out. The purpose of this review is to present the evidence for
the diagnosis and treatment of cough due to chronic bronchitis, and to make recommendations that
will be useful for clinical practice.
Methods: Recommendations for this section of the review were obtained from data using a National
Library of Medicine (PubMed) search dating back to 1950, performed in August 2004, of the
literature published in the English language. The search was limited to human studies, using the
search terms cough, chronic bronchitis, and COPD.
Results: The most effective way to reduce or eliminate cough in patients with chronic bronchitis and
persistent exposure to respiratory irritants, such as personal tobacco use, passive smoke exposure, and
workplace hazards is avoidance. Therapy with a short-acting inhaled -agonist, inhaled ipratropium
bromide, and oral theophylline, and a combined regimen of inhaled long-acting -agonist and an
inhaled corticosteroid may improve cough in patients with chronic bronchitis, but there is no proven
benefit for the use of prophylactic antibiotics, oral corticosteroids, expectorants, postural drainage, or
chest physiotherapy. For the treatment of an acute exacerbation of chronic bronchitis, there is
evidence that inhaled bronchodilators, oral antibiotics, and oral corticosteroids (or in severe cases IV
corticosteroids) are useful, but their effects on cough have not been systematically evaluated. Therapy
with expectorants, postural drainage, chest physiotherapy, and theophylline is not recommended.
Central cough suppressants such as codeine and dextromethorphan are recommended for short-term
symptomatic relief of coughing.
Conclusions: Chronic bronchitis due to cigarette smoking or other exposures to inhaled noxious
agents is one of the most common causes of chronic cough in the general population. The most
effective way to eliminate cough is the avoidance of all respiratory irritants. When cough persists
despite the removal of these inciting agents, there are effective agents to reduce or eliminate cough.
(CHEST 2006; 129:104S115S)
Key words: acute exacerbation of COPD; chronic bronchitis; chronic cough; cigarette cough; COPD; cough phlegm
syndrome; mucous hypersecretion
Abbreviations: GOLD Global Initiative for Chronic Obstructive Lung Disease; IL interleukin

hronic bronchitis is a cough phlegm syndrome.

C The
term was introduced into the medical literature early in the 19th century and was recognized as
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an inflammatory disease of the airways.1 However,

no accepted definition of this term was established
until the mid-20th century following the developDiagnosis and Management of Cough: ACCP Guidelines

ment of the British Medical Research Council Respiratory Questionnaire on Respiratory Symptoms.
Based on responses to epidemiologic surveys, the
term chronic bronchitis was defined as a disease of
the bronchi that manifested by cough and sputum
expectoration occurring on most days for at least 3
months of the year and for at least 2 consecutive
years when other pulmonary or cardiac causes for
the chronic productive cough are excluded.2 4 In
1958, a group of international experts participating in
the Ciba Foundation Guest Symposium, proposed a
definition of chronic bronchitis as a condition of
subjects with chronic or recurrent excessive mucous
secretion in the bronchial tree.4 Because earlier
studies suggested that chronic mucous hypersecretion did not cause airflow obstruction, evidence of
airflow limitation was not incorporated into these
earlier definitions. In 1986, chronic bronchitis and
emphysema were acknowledged in an American
Thoracic Society statement5 as the two main components of COPD, which became a preferred term for
both diagnoses. Evidence of expiratory flow limitation that did not change markedly over time was
included in the definition of COPD.
The recently published Global Initiative for
Chronic Obstructive Lung Disease (GOLD) guidelines,6 sponsored by the National Heart, Lung, Blood
Institute and the World Health Organization, provides a definition of COPD that differs from previous consensus statements. It does not incorporate
the terms chronic bronchitis and emphysema into
the definition, as does the American Thoracic Society statement. Instead, it defines COPD as a disease
state that is characterized by airflow obstruction that
is no longer fully reversible and is usually progressive. The disease is caused by an interaction between
noxious inhaled agents (eg, cigarette smoke, industrial pollutants, and other environmental pollutants)
and host factors (eg, genetic factors and respiratory
infections) that results in chronic inflammation in the
walls and lumen of the airways. The pathology of
COPD, as well as the symptoms, the pulmonary
function abnormalities, and complications all can be
explained on the basis of the underlying inflammation. While the GOLD document6 does not specifically include chronic bronchitis and emphysema in
the definition of COPD, it is clear that they are
considered to be the predominant causes. For instance, GOLD defines the earliest stage of COPD,
stage 0, by evidence of chronic cough and sputum
Reproduction of this article is prohibited without written permission
from the American College of Chest Physicians (www.chestjournal.
org/misc/reprints.shtml).
Correspondence to: Sidney S. Braman, MD, FCCP, Division of
Pulmonary and Critical Care Medicine, Rhode Island Hospital, 595
Eddy St, Providence, RI 02903; e-mail: [email protected]
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expectoration in the absence of airflow obstruction

on pulmonary function testing, not using the term
chronic bronchitis.6 Because chronic cough and sputum expectoration are common in all stages of
COPD, the use of the traditional definition of
chronic bronchitis as cough and sputum expectoration occurring on most days for at least 3 months of
the year and for at least 2 consecutive years is most
appropriate. Recommendations for this section of
the review were obtained from data obtained using a
National Library of Medicine (PubMed) search dating back to 1950, performed in August 2004, of the
literature published in the English language. The
search was limited to human studies, using the
search terms cough, chronic bronchitis, and
COPD.

Recommendations
1. Adults who have a history of chronic cough
and sputum expectoration occurring on most
days for at least 3 months and for at least 2
consecutive years should be given a diagnosis of
chronic bronchitis when other respiratory or
cardiac causes of chronic productive cough are
ruled out. Level of evidence, low; net benefit,
substantial; grade of recommendation, B
2. The evaluation of patients with chronic
cough should include a complete history regarding exposures to respiratory irritants including cigarette, cigar, and pipe smoke; passive smoke exposures; and hazardous
environments in the home and workplace. All
are predisposing factors of chronic bronchitis.
Level of evidence, low; net benefit, substantial;
grade of recommendation, B

Epidemiology
Over the past decade there has been increasing
interest in the pathogenesis and management of
COPD as it has been recognized that the disease is
having a major worldwide impact.6 In the United
States, estimates from national interviews taken by
the National Center for Health Statistics,7 have
shown that 16 million people are afflicted with
COPD; about 14 million are thought to have chronic
bronchitis, while 2 million have emphysema.7 It has
been suggested that these statistics underestimate
the prevalence of COPD by as much as 50%, as
many patients underreport their symptoms and their
conditions remain undiagnosed. On the other hand,
the accuracy of a self-reported diagnosis of chronic
bronchitis and a physician-confirmed diagnosis of
CHEST / 129 / 1 / JANUARY, 2006 SUPPLEMENT

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chronic bronchitis have been questioned.8 Using a

longitudinal population study, patients were surveyed for self-reported chronic bronchitis or physician-diagnosed chronic bronchitis. The survey asked
about symptoms of chronic cough and sputum production and the timing of these symptoms. Seventeen percent of current smokers, 12.4% of former
smokers, and 6% of never-smokers met the criteria
for chronic bronchitis. The vast majority of people
(88.4%) who reported a self-reported or physicianconfirmed diagnoses of chronic bronchitis did not
meet the standard criteria. The overdiagnosis of
chronic bronchitis by patients and physicians may be
very common. Because the term bronchitis is often
used as a common descriptor for a nonspecific and
self-limited cough, many patients assume that they
have had chronic bronchitis. In the Third National
Health and Nutrition Examination Survey, using
surveys, physical examinations, and pulmonary function testing, more accurate prevalence estimates
have been made. Using World Health Organization
definitions, it has been shown that 23.6 million adults
(13.9% of the adult population) have COPD.9,10
Chronic bronchitis is among the most frequent
causes of cough found in community surveys.11

Etiology
In developed countries, cigarette smoking is responsible for 85 to 90% of cases of chronic bronchitis
and COPD. Cigarette smoke is composed of a
complex mixture of 400 particles and gases; the
specific etiologic role of each of these constituents
has not been established. Many studies10,1214 have
confirmed the association of cigarette smoking,
chronic cough, and low lung function. The incidence
of chronic bronchitis is directly proportional to the
number of cigarettes smoked. Other risk factors for
chronic mucus hypersecretion that have been identified are increasing age, male gender, childhood
respiratory infections, frequent lower respiratory
tract infections, occupational exposures, and asthma.
Pipe and cigar smoking are also risk factors for both
complications even in the absence of former cigarette smoking.10 The prevalence of chronic cough in
the Third National Health and Nutrition Examination Survey was reported15 in subjects without airflow obstruction and in those with undiagnosed
airway obstruction. Cough was found in 9.3% of
subjects and sputum production was found in 8.3%
of subjects without airflow obstruction. The study
also confirmed the observation that these symptoms
are more common in subjects with more severe
airflow obstruction. In those subjects with mild
airflow obstruction, cough was found in 16.0% of
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those surveyed and sputum production in 17%. With

severe airflow obstruction, using the GOLD staging
criteria, the prevalence of cough increased to 49% of
patients, and sputum production was found in 39.5%
of patients.
The identification of chronic cough and sputum
production due to occupational exposures is not
commonly made by clinicians; yet, it has been estimated that in as many as 15% of patients with
chronic bronchitis and COPD, occupational exposure is the cause.16 There are a number of epidemiologic associations of workplace hazards and chronic
bronchitis. The diagnosis is usually made by finding
a history of exposure in individuals who have no
other identifiable cause of cough. This is often
difficult because many workers are smokers or are
exposed to second-hand smoke. Other workers, such
as those exposed to organic dusts, may present with
chronic cough and a history of asthma-like symptoms
without airway eosinophilia, reversible airflow obstruction, or bronchial hyperresponsiveness.17 This
occurs with chronic exposure to cotton (byssinosis),
jute, hemp, flax, sisal, wood, and various grains.
There is a growing body of literature that has
demonstrated that specific occupational exposures
are associated with the symptoms of chronic bronchitis and, at times, airflow obstruction,18 21 which
are comparable to moderate cigarette smoking.22
The list of agents includes the following: coal; manufactured vitreous fibers; oil mist; cement; silica;
silicates; osmium; vanadium; welding fumes; organic
dusts; engine exhausts; fire smoke; and second-hand
cigarette smoke.23
While the prevalence of passive smoke exposure in
the workplace has been decreasing as laws banning
smoking in public places have been established, it is
still a problem in many communities around the
world. Often, nonsmokers are exposed to cigarette
smoke in the home environment as well. Involuntary
exposure to tobacco smoke is strongly associated
with chronic cough and sputum production, even in
young adults who have been screened for other risk
factors. The risk increases significantly with an increasing duration of daily exposure.24 Another important exposure in the home environment that
increasingly has been recognized as a cause of
chronic bronchitis and fixed airflow obstruction in
underdeveloped countries is exposure to the fumes
of cooking fuels, especially in enclosed spaces with
poor ventilation.

Recommendation
3. Smoke-free workplace and public place
laws should be enacted in all communities.
Diagnosis and Management of Cough: ACCP Guidelines

Level of evidence, expert opinion; net benefit, substantial; grade of recommendation, E/A

Pathology and Pathophysiology

The inflammatory mechanisms of chronic bronchitis and COPD have been extensively reviewed.2528
Structural changes of the airways have been described in otherwise healthy smokers even as young
as 20 to 30 years old. BAL studies in such subjects
have shown an increase in the number of neutrophils
and macrophages; both play an important role in
perpetuating the inflammatory process of chronic
bronchitis. Bronchial biopsy specimens from former
smokers show inflammatory changes that are similar
to those in the active smoker, suggesting that inflammation may persist in the airway once established. A
number of extracellular signaling proteins called
cytokines are important in the pathogenesis of
COPD because they are thought to mediate the
tissue damage and repair that are induced by cigarette smoking. Increased quantities of certain proinflammatory cytokines including interleukin (IL)-8,
IL-1, IL-6, and tumor necrosis factor-, and the
antiinflammatory cytokine IL-10 have been found in
the sputum of smokers with chronic bronchitis, and
even further increased quantities of these cytokines
have been found during acute exacerbations.
Other structural changes in the airways of smokers
include mucus gland hyperplasia, bronchiolar
edema, smooth muscle hypertrophy, and peribronchiolar fibrosis. These changes result in a narrowing
of the small airways ( 2 mm). There is a progressive
worsening of pathologic changes when smokers with
mild COPD and smokers with more severe disease
are compared.29
Neurogenic mechanisms may play an amplifying
role in the pathogenesis of chronic bronchitis.30
Sensory airway nerves contain tachykinins such as
substance P, neurokinin A, and neurokinin B that are
released in the airways in association with inflammation. These tachykinins have been found in the
sputum of patients with chronic bronchitis and are
known to augment airway secretions.
The presence of a gel-like mucus in the airways of
healthy people is essential for normal mucociliary
clearance. The mucus is eliminated by the action of
mucociliary clearance to the hypopharynx, where it is
swallowed and rarely noticed. Normally, about 500
mL of sputum is produced each day, and it is usually
not noticed. Smokers with chronic bronchitis produce larger amounts of sputum each day, as much as
100 mL/d more than normal. This results in cough
and sputum production. The excess mucus occurs as
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a result of an increase in the size and number of the

submucosal glands and an increase in the number of
goblet cells on the surface epithelium. Mucous gland
enlargement and hyperplasia of the goblet cells are,
therefore, the pathologic hallmark of chronic bronchitis. Goblet cells are normally absent in the small
airways, and their presence there (often referred to
as mucous metaplasia) is important to the development of COPD. In the larger airways in patients with
chronic bronchitis, there is a reduction in the serous
acini of the submucosal glands. This depresses local
defenses to bacterial adherence, because these
glands are known to produce microbial deterrents
such as lactoferrin, antiproteases, and lysozyme.
Other epithelial alterations that are seen in patients
with chronic bronchitis are a decrease in the number
and length of the cilia, and squamous metaplasia.
The mucociliary abnormalities of chronic bronchitis
cause the formation of a continuous sheet or blanket
of mucus lining the airways instead of the discreet
deposits of mucus seen in normal airways. The
pooling of secretions also may occur. This provides
an additional cause of bacterial growth, which in turn
causes a release of toxins that are further damaging
to the cilia and epithelial cells. Bacterial exoproducts
are known to stimulate mucus production and slow
ciliary beating, to impair immune effector cell function, and to destroy local Igs. This cycle is especially
seen in current smokers, as opposed to former smokers.
Based on these extensive observations regarding
the pathogenesis of chronic bronchitis, it is recognized that the cause of cough in patients with chronic
bronchitis is multifactorial. Airway inflammation and
excessive bronchial secretions are likely to activate
the afferent limb of the cough reflex.31 There is
evidence that the cough receptors are heightened in
patients with chronic bronchitis as it has been demonstrated that capsaicin induced cough is increased.32 When airflow obstruction is present, it
often leads to an ineffective cough as a result of
decreased expiratory flow,33 and this coupled with
impaired mucociliary clearance results in the further
retention of secretions and a vicious cycle of chronic
recurrent coughing.34,35 Even in the absence of
airflow obstruction and with a short smoking history,
impaired mucociliary clearance has been shown in
young smokers. This occurs because of abnormal
clearance in the small airways. Patients with advanced disease and evidence of airway obstruction
have mucus retention in the small peripheral airways
and larger central airways.36,37 This cycle is further
worsened during episodes of acute viral and bacterial
infections, which are common in patients with
chronic bronchitis.38
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Airway Infection/Acute Exacerbation of

Chronic Bronchitis
Patients with chronic bronchitis have a greater
frequency of acute respiratory infections than those
without bronchitis, and with symptoms of an acute
upper respiratory infection they are more likely to
have signs of infection in the lower airways than are
healthy control subjects.39 During these attacks or
exacerbations, cough and sputum production increase and the sputum may become purulent. The
exacerbations may also cause worsening shortness of
breath; therefore, clinicians should be aware that
other conditions such as heart failure and pulmonary
embolism could mimic an acute exacerbation of
chronic bronchitis. While there is no uniformly
accepted definition of an acute exacerbation of
chronic bronchitis, most have acknowledged that this
condition is due to a sudden deterioration in the
condition of a stable patient with symptoms of
increased sputum volume, sputum purulence, and/or
worsening of shortness of breath due to acute tracheobronchitis. An exacerbation is often preceded by
symptoms of an upper respiratory tract infection. An
important element of this definition is that causes of
respiratory deterioration other than acute tracheobronchitis, such as pneumonia, pulmonary embolism, exacerbation of bronchiectasis, pneumothorax,
and congestive heart failure, are excluded. Evidence
of a viral infection is found in approximately one
third of episodes. Common viral infections in the
outpatient setting are rhinovirus, coronavirus, influenza B, and parainfluenza.40,41 Viral respiratory infections predispose the airways to bacterial superinfection because they interfere with mucociliary
clearance, impair bacterial killing by pulmonary macrophages, and increase the risk of aspirating secretions containing bacteria from the upper airways.
Whether bacterial overgrowth or infection alone, in
the absence of acute viral infection, is the cause of an
acute exacerbation of chronic bronchitis has been
controversial. During stable periods, many patients
with chronic bronchitis, and especially current smokers, are colonized with bacteria such as Streptococcus pneumoniae, Moraxella catarrhalis, and Haemophilus influenzae, and these same organisms have
been found in patients during an acute exacerbation.
However, the molecular typing of sputum isolates
has shown that acute exacerbations of COPD are
frequently associated with a new strain of a preexisting organism. This supports a causative role for
bacteria in the acute exacerbations of COPD.42
Although most such episodes of acute exacerbations
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ciated with substantial decrements in the quality of

life43 and impose a considerable financial burden on
the health-care system.43

Recommendation
4. Stable patients with chronic bronchitis
who have a sudden deterioration of symptoms
with increased cough, sputum production, sputum purulence, and/or shortness of breath,
which are often preceded by symptoms of an
upper respiratory tract infection, should be
considered to have an acute exacerbation of
chronic bronchitis, as long as conditions other
than acute tracheobronchitis are ruled out or
are considered unlikely. Level of evidence, expert
opinion; net benefit, substantial; grade of recommendation, E/A

Progressive Airflow Obstruction

The role of chronic mucous hypersecretion and
cough in the pathogenesis of airflow obstruction has
been another area of controversy. The lack of association between chronic mucous hypersecretion and
pulmonary function decline or mortality has been
reported in a number of studies.44 47 Other studies
have examined this question, and have shown an
association between chronic mucous hypersecretion
and overall mortality48,49 as well as mortality from
COPD.50,51 The association between chronic mucous hypersecretion and the development of COPD
also has been established. Both an excessive FEV1
decline and an increased rate of hospitalization have
been shown in patients with established COPD who
have cough and excessive mucous production. It is
likely that this is due to recurrent bronchial infections.52,53

Comorbid Illnesses
It should always be kept in mind that when the
character of the cough changes for prolonged periods in a patient with chronic bronchitis, the possibility of bronchogenic carcinoma or another complication should be considered. Prospective studies54 of
middle-aged cigarette smokers have shown that the
incidence of lung cancer in this group is very high.

Treatment
While the most effective treatment of chronic
cough due to chronic bronchitis is the avoidance of
Diagnosis and Management of Cough: ACCP Guidelines

respiratory irritants, often patients refuse to avoid

them or find it impossible to do so because of
conditions at home or in the workplace. The use of
pharmacologic therapy at times may be helpful, but
the evidence that these agents are effective often
comes from clinical trials that do not evaluate cough
as a primary outcome. The use of these agents in the
treatment of stable patients with chronic disease and
for episodes of acute exacerbation of chronic bronchitis will be reviewed. An American College of
Chest Physicians/American College of PhysiciansAmerican Society of Internal Medicine evidencebased report55 on the treatment of acute exacerbations of COPD is a useful guideline.
Avoidance
The most effective means for controlling cough
and sputum production in patients with chronic
bronchitis is the avoidance of environmental irritants. During an acute exposure to respiratory irritants at home or in the workplace, patients may
experience symptoms of increased cough, sputum
production, and shortness of breath that are similar
to those of an exacerbation due to infection. With
respect to chronic cough, several nonrandomized
trials have studied the effect of smoking cessation on
this troubling symptom. Cough has been shown56 to
disappear or markedly decrease in 94 to 100% of
patients after smoking cessation, and in approximately half of the subjects this occurred within 1
month. The Lung Health Study57 investigated the
effects of smoking cessation in smokers with mildto-moderate airflow obstruction. It was a 5-year
randomized prospective trial57 of intensive smoking
intervention compared to a control group of smokers
who received usual care. At the end of 5 years, 22%
of those in the intervention group had stopped
smoking for the entire study period. The beneficial
effects, including a reduction of chronic cough and
sputum production, occurred in the first year of
smoking cessation. It was sustained throughout the
entire study period. Ninety percent of those patients
who had chronic cough at the beginning of the study
and stopped smoking reported no cough by the end
of the study. Similar findings were reported regarding sputum production. However, in patients with
more severe degrees of airflow obstruction chronic
cough is more likely to persist despite the avoidance
of cigarettes or other respiratory irritants.
Recommendation
5. In patients with chronic cough who have
chronic exposure to respiratory irritants, such
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as personal tobacco use, passive smoke exposure, and workplace hazards, avoidance should
always be recommended. It is the most effective
means to improve or eliminate the cough of
chronic bronchitis. Ninety percent of patients
will have resolution of their cough after smoking cessation. Level of evidence, good; net benefit,
substantial; grade of recommendation, A

Antibiotics
The use of antibiotics for treatment of an acute
exacerbation of chronic bronchitis is recommended
as it has been shown to shorten the course of the
illness. The use of antibiotics is most effective in
patients with purulent sputum and in those with a
greater severity of illness that includes all three of
the cardinal symptoms (ie, increased cough; increased sputum volume; and increased dyspnea55,58,59) and in those with more severe airflow
obstruction at baseline.60 An opinion expressed by
the US Food and Drug Administration61 in November 2002 suggested that the randomized placebocontrolled trials of antibiotic therapy for the acute
exacerbation of chronic bronchitis that have been
conducted over the past 40 years have been methodologically flawed and that a definitive decision
regarding antibiotic use cannot be reached. However, based on a metaanalysis of nine studies,58
which included randomized controlled trials, therapy
with antibiotics is recommended, especially in those
patients with more severe illness. The effect that
antibiotics have on cough during an acute exacerbation of COPD has been investigated. There is no
significant effect on cough clearance or cough frequency when compared to therapy with a placebo.60
On the other hand, older trials62 studying the usefulness of prophylactic therapy with antibiotics to
reduce the frequency and/or severity of attacks have
shown a small but statistically significant effect in
reducing the number of days of illness during an
acute exacerbation of chronic bronchitis. However,
therapy with antibiotics is currently not recommended for stable patients with chronic bronchitis
because of concerns about antibiotic resistance and
the potential side effects of the drugs.

Recommendations
6. In stable patients with chronic bronchitis,
there is no role for long-term prophylactic therapy with antibiotics. Level of evidence, low; benefit, none; grade of recommendation, I
7. In patients with acute exacerbations of
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chronic bronchitis, the use of antibiotics is recommended; patients with severe exacerbations
and those with more severe airflow obstruction
at baseline are the most likely to benefit. Level
of evidence, fair; net benefit, substantial; grade of
recommendation, A
Bronchopulmonary Hygiene
The use of bronchopulmonary hygiene physical
therapy for chronic bronchitis recently has been the
subject of review.63 The clinical benefits of postural
drainage and chest percussion have not been proven,
and their use in stable patients with chronic disease63
or during an acute exacerbation of chronic bronchitis55 cannot be recommended.
Recommendations
8. In stable patients with chronic bronchitis,
the clinical benefits of postural drainage and
chest percussion have not been proven, and
they are not recommended. Level of evidence,
fair; net benefit, conflicting; grade of recommendation, I
9. In patients with an acute exacerbation of
chronic bronchitis, the clinical benefits of postural drainage and chest percussion have not
been proven, and they are not recommended.
Level of evidence, fair; net benefit, conflicting; grade
of recommendation, I
Bronchodilators
The effects of therapy with short-acting inhaled
-agonists in patients with chronic bronchitis have
been extensively studied,64 and have been shown to
improve pulmonary function, breathlessness, and
exercise tolerance. There is some evidence that
chronic cough improves with the regular use of a
short-acting inhaled -agonist,65 but the results in
the literature are not consistent.66,67 There is no
significant improvement in sputum production with
this therapy.67,68 The long-term effects of ipratropium bromide therapy have been evaluated in stable
patients with chronic bronchitis. With this agent,
patients coughed fewer times, and their cough was
less severe. In addition, the volume of sputum
expectorated decreased significantly.69 On the other
hand, trials70 of a once-daily regimen of inhaled
anticholinergic tiotropium in patients with COPD
showed significant bronchodilatation and relief of
dyspnea when compared to placebo, but no effect on
cough using diaries to assess daily symptom scores.
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The use of oral theophylline for the treatment of

COPD has declined over the last several decades
because of concerns over side effects, especially in
elderly patients, and issues regarding interactions
with other drugs. Therapy with oral theophylline
does improve cough in stable patients with chronic
bronchitis.71 During an acute exacerbation of
chronic bronchitis, there is good evidence that bronchodilator therapy improves outcomes55; however,
the effect on cough has not been systematically
studied.

Recommendations
10a. In stable patients with chronic bronchitis, therapy with short-acting -agonists should
be used to control bronchospasm and relieve
dyspnea; in some patients, it may also reduce
chronic cough. Level of evidence, good; net benefit, substantial; grade of recommendation, A
10b. In stable patients with chronic bronchitis, therapy with ipratropium bromide should
be offered to improve cough. Level of evidence,
fair; net benefit, substantial; grade of recommendation, A
10c. In stable patients with chronic bronchitis, treatment with theophylline should be considered to control chronic cough; careful monitoring for complications is necessary. Level of
evidence, fair; net benefit, substantial; grade of recommendation, A
11. For patients with an acute exacerbation
of chronic bronchitis, therapy with short-acting
-agonists or anticholinergic bronchodilators
should be administered during the acute exacerbation. If the patient does not show a prompt
response, the other agent should be added after
the first is administered at the maximal dose.
Level of evidence, good; net benefit, substantial;
grade of recommendation, A
12. For patients with an acute exacerbation
of chronic bronchitis, theophylline should not
be used for treatment. Level of evidence, good;
net benefit, none; grade of recommendation, D

Mucokinetic Agents and Corticosteroids

There is limited evidence to justify the use of
mucokinetic agents or inhaled corticosteroids to
control cough in patients with chronic bronchitis.
Combined therapy with a long-acting -agonist and
an inhaled corticosteroid has been shown72 to reduce
the exacerbation rate in patients with COPD and
also to reduce cough in long-term trials in patients
Diagnosis and Management of Cough: ACCP Guidelines

with COPD. Therapy with inhaled corticosteroids

are recommended when airflow obstruction is severe
or very severe (ie, FEV1 50%) and when there is a
history of frequent exacerbations of chronic bronchitis.73,74 The beneficial effects of expectorants have
not been proven for the treatment of cough in
patients with chronic bronchitis. The oral mucolytic
agent N-acetylcysteine has been studied75 in stable
patients with chronic bronchitis, and it has been
shown to improve overall symptoms and to reduce
the risk of exacerbations. It is not approved for use in
the United States. The use of oral corticosteroids in
patients has been discouraged.6 There is no evidence
of benefit in stable patients with chronic bronchitis,
and the well-known side effects will preclude any
long-term trials in the future.
Therapy with mucokinetic agents is not useful
during an acute exacerbation of chronic bronchitis.55
There is considerable evidence55,76 that patients who
have an exacerbation of COPD will benefit from
systemic therapy with corticosteroids. Studies of the
effect of therapy with corticosteroids on acute exacerbations of chronic bronchitis have not specifically
evaluated cough as an outcome.73 Treatment failure
and lung function (FEV1) have been the most frequently assessed end points. In the largest trial,73
there was equivalence between an 8-week trial and a
2-week trial of corticosteroids. Because of the significant potential for side effects with these agents, a
2-week trial is recommended.73

serious side effects are high. Level of evidence,

expert opinion; net benefit, negative; grade of recommendation, E/D
17. For patients with an acute exacerbation
of chronic bronchitis, there is no evidence that
the currently available expectorants are effective, and therefore they should not be used.
Level of evidence, low; net benefit, none; grade of
recommendation, I
18. For patients with an acute exacerbation
of chronic bronchitis, a short course (10 to 15
days) of systemic corticosteroid therapy should
be given; IV therapy in hospitalized patients
and oral therapy for ambulatory patients have
both proven to be effective. Level of evidence,
good; net benefit, substantial; grade of recommendation, A

Antitussive Agents
Occasionally, the cough of chronic bronchitis is so
troublesome that temporary cough suppression is
required. When needed, codeine and dextromethorphan (but not pipazethate) are effective for treating
cough in patients with chronic bronchitis. While
studies7779 have shown that they suppress cough
counts by 40 to 60%, these studies were conducted
with very small patient populations.

Recommendation
Recommendations
13. For stable patients with chronic bronchitis, there is no evidence that the currently
available expectorants are effective and therefore they should not be used. Level of evidence,
low; net benefit, none; grade of recommendation, I
14. In stable patients with chronic bronchitis,
treatment with a long-acting -agonist when
coupled with an inhaled corticosteroid should
be offered to control chronic cough. Level of
evidence, good; net benefit, substantial; grade of
recommendation, A
15. For stable patients with chronic bronchitis and an FEV1 of < 50% predicted or for those
patients with frequent exacerbations of chronic
bronchitis, inhaled corticosteroid therapy
should be offered. Level of evidence, good; net
benefit, substantial; grade of recommendation, A
16. For stable patients with chronic bronchitis, long-term maintenance therapy with oral
corticosteroids such as prednisone should not
be used; there is no evidence that it improves
cough and sputum production, and the risks of
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19. In patients with chronic bronchitis, central cough suppressants such as codeine and
dextromethorphan are recommended for shortterm symptomatic relief of coughing. Level of
evidence, fair; benefit, intermediate; grade of evidence, B

Summary of Recommendations
1. Adults who have a history of chronic
cough and sputum expectoration occurring
on most days for at least 3 months and for at
least 2 consecutive years should be given a
diagnosis of chronic bronchitis when other
respiratory or cardiac causes of chronic
productive cough are ruled out. Level of
evidence, low; net benefit, substantial; grade of
recommendation, B
2. The evaluation of patients with chronic
cough should include a complete history
regarding exposures to respiratory irritants
including cigarette, cigar, and pipe smoke;
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passive smoke exposures; and hazardous

environments in the home and workplace.
All are predisposing factors of chronic bronchitis. Level of evidence, low; net benefit, substantial; grade of recommendation, B
3. Smoke-free workplace and public
place laws should be enacted in all communities. Level of evidence, expert opinion; net
benefit, substantial; grade of recommendation,
E/A
4. Stable patients with chronic bronchitis
who have a sudden deterioration of symptoms with increased cough, sputum production, sputum purulence, and/or shortness of
breath, which are often preceded by symptoms of an upper respiratory tract infection,
should be considered to have an acute exacerbation of chronic bronchitis, as long as
conditions other than acute tracheobronchitis are ruled out or are considered unlikely.
Level of evidence, expert opinion; net benefit,
substantial; grade of recommendation, E/A
5. In patients with chronic cough who
have chronic exposure to respiratory irritants, such as personal tobacco use, passive
smoke exposure, and workplace hazards,
avoidance should always be recommended.
It is the most effective means to improve or
eliminate the cough of chronic bronchitis.
Ninety percent of patients will have resolution of their cough after smoking cessation.
Level of evidence, good; net benefit, substantial;
grade of recommendation, A
6. In stable patients with chronic bronchitis, there is no role for long-term prophylactic
therapy with antibiotics. Level of evidence, low;
benefit, none; grade of recommendation, I
7. In patients with acute exacerbations of
chronic bronchitis, the use of antibiotics is
recommended; patients with severe exacerbations and those with more severe airflow
obstruction at baseline are the most likely to
benefit. Level of evidence, fair; net benefit,
substantial; grade of recommendation, A
8. In stable patients with chronic bronchitis, the clinical benefits of postural drainage and chest percussion have not been
proven, and they are not recommended. Level
of evidence, fair; net benefit, conflicting; grade of
recommendation, I
9. In patients with an acute exacerbation
of chronic bronchitis, the clinical benefits of
postural drainage and chest percussion

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have not been proven, and they are not

recommended. Level of evidence, fair; net
benefit, conflicting; grade of recommendation, I
10a. In stable patients with chronic bronchitis, therapy with short-acting -agonists
should be used to control bronchospasm
and relieve dyspnea; in some patients, it
may also reduce chronic cough. Level of
evidence, good; net benefit, substantial; grade of
recommendation, A
10b. In stable patients with chronic bronchitis, therapy with ipratropium bromide
should be offered to improve cough. Level of
evidence, fair; net benefit, substantial; grade of
recommendation, A
10c. In stable patients with chronic bronchitis, treatment with theophylline should
be considered to control chronic cough;
careful monitoring for complications is necessary. Level of evidence, fair; net benefit, substantial; grade of recommendation, A
11. For patients with an acute exacerbation of chronic bronchitis, therapy with
short-acting -agonists or anticholinergic
bronchodilators should be administered
during the acute exacerbation. If the patient does not show a prompt response, the
other agent should be added after the first
is administered at the maximal dose. Level of
evidence, good; net benefit, substantial; grade of
recommendation, A
12. For patients with an acute exacerbation of chronic bronchitis, theophylline
should not be used for treatment. Level of
evidence, good; net benefit, none; grade of
recommendation, D
13. For stable patients with chronic bronchitis, there is no evidence that the currently available expectorants are effective
and therefore they should not be used. Level
of evidence, low; net benefit, none; grade of
recommendation, I
14. In stable patients with chronic bronchitis, treatment with a long-acting -agonist when coupled with an inhaled corticosteroid should be offered to control
chronic cough. Level of evidence, good; net
benefit, substantial; grade of recommendation,
A
15. For stable patients with chronic bronchitis and an FEV1 of < 50% predicted or
for those patients with frequent exacerbations of chronic bronchitis, inhaled corticosteroid therapy should be offered. Level of

Diagnosis and Management of Cough: ACCP Guidelines

evidence, good; net benefit, substantial; grade of

recommendation, A
16. For stable patients with chronic bronchitis, long-term maintenance therapy with
oral corticosteroids such as prednisone
should not be used; there is no evidence
that it improves cough and sputum production, and the risks of serious side effects are
high. Level of evidence, expert opinion; net
benefit, negative; grade of recommendation,
E/D
17. For patients with an acute exacerbation of chronic bronchitis, there is no evidence that the currently available expectorants are effective, and therefore they
should not be used. Level of evidence, low; net
benefit, none; grade of recommendation, I
18. For patients with an acute exacerbation of chronic bronchitis, a short course (10
to 15 days) of systemic corticosteroid therapy should be given; IV therapy in hospitalized patients and oral therapy for ambulatory patients have both proven to be
effective. Level of evidence, good; net benefit,
substantial; grade of recommendation, A
19. In patients with chronic bronchitis,
central cough suppressants such as codeine
and dextromethorphan are recommended
for short-term symptomatic relief of coughing. Level of evidence, fair; benefit, intermediate; grade of evidence, B

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