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Research ArticleOriginal ResearchA

How Long Does a Cough Last? Comparing Patients’ Expectations With Data From a Systematic Review of the Literature

Mark H. Ebell, Jerold Lundgren and Surasak Youngpairoj
The Annals of Family Medicine January 2013, 11 (1) 5-13; DOI: https://doi.org/10.1370/afm.1430
Mark H. Ebell
1Department of Epidemiology and Biostatistics, College of Public Health, The University of Georgia, Athens, Georgia
2Institute for Evidence-Based Practice in the Health Professions, College of Public Health, The University of Georgia, Athens, Georgia
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  • For correspondence: ebell@uga.edu
Jerold Lundgren
3Franklin College, The University of Georgia, Athens, Georgia
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Surasak Youngpairoj
4College of Public Health, The University of Georgia, Athens, Georgia
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  • Cough Duration: Method and Theory
    Bruce Barrett
    Published on: 21 February 2013
  • Author response: What is the denominator?
    Mark Ebell
    Published on: 21 February 2013
  • Mismatch between patient expectations and clinical data?
    Pal Gulbrandsen
    Published on: 20 February 2013
  • A new tool to decrease unnecessary antibiotic use.
    John Hickner
    Published on: 21 January 2013
  • Published on: (21 February 2013)
    Page navigation anchor for Cough Duration: Method and Theory
    Cough Duration: Method and Theory
    • Bruce Barrett, Associate Prof.
    • Other Contributors:

    To the editor:
    This is a significant paper describing a well-designed study investigating evidence and expectations regarding the duration of "acute cough illness" (ACI).[1] It actually describes two sub-studies, one a random digit dial telephone survey carried out in the U.S. state of Georgia, the other a systematic review of literature regarding the duration of ACI. The main reported finding is that there "is a...

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    To the editor:
    This is a significant paper describing a well-designed study investigating evidence and expectations regarding the duration of "acute cough illness" (ACI).[1] It actually describes two sub-studies, one a random digit dial telephone survey carried out in the U.S. state of Georgia, the other a systematic review of literature regarding the duration of ACI. The main reported finding is that there "is a mismatch between patients' expectations regarding the duration of ACI and the actual duration based on the best available evidence." The authors suggest that this "mismatch" may be a factor contributing to inappropriate antibiotics prescriptions for ACI.

    This is all quite reasonable, and this paper is clearly an important contribution to the literature. Nevertheless, there are limitations, alternative interpretations, and unresolved questions deserving of consideration. Let us begin with two quotes from Arthur Kleinman: A) "Modern physicians diagnose and treat diseases (abnormalities in the structure and function of body organs and systems), whereas patients suffer illnesses (experiences of disvalued changes in states of being and in social function; the human experience of sickness);"[2] and B) "Two levels of academic endeavor in primary care should develop if family medicine and the other primary care disciplines are to become viable academic enterprises: (1) practical applied studies of discrete salient health care problems ... and (2) concepts, theoretical models and research approaches that can contribute to a unique scholarly discourse on primary care and that can provide the intellectual foundation for self-contained research programs which together create a science of clinical medicine."[3]

    Where better to focus attention than acute illness characterized by cough? Cough is a discrete salient health problem experienced by patients and investigated by scientists. Cough has a central place in the theoretical and applied science of acute respiratory infection. So, what exactly is "acute cough illness," and how long do ACI episodes last? The search strategy used by these authors focuses on acute infectious reasons for cough, with "bronchitis," "respiratory infection," and "chest cold," as inclusion terms, and "asthma," "allergies," "sinusitis," "pneumonia," and "chronic lung disease" as exclusions. Identified studies shown in their Table 1 include adults and older children typically described as having "bronchitis" or "productive cough."

    While the people in these published studies may be similar to many of the patients who present in clinic with prolonged productive cough, they may not represent all people having acute illness with cough. It might be that people whose coughs are more severe or last longer are more likely to seek medical care (and to enter bronchitis studies) than the general population of people experiencing coughing illness. Additionally, there may be other factors to consider. A study of resource use and ACI costs in 13 European countries found wide variation in antibiotic prescribing.[4] Health systems specifics, including incentivized compensation plans and availability of advanced diagnostic testing, were implicated, along with general medical culture and practice.

    To shed some light on the issue of cough duration, we looked at our own database of n=1,194 people who participated in four studies in Madison, Wisconsin, over the past decade.[5-8] To be enrolled in these studies participants had to have a Jackson score of 2 or more,[9] an acute nasal and/or throat symptom arising in the previous 48 hours, and state that they "have a cold" or "are coming down with a cold." Two of these studies were observational, designed to test the WURSS questionnaire.[5-6] Two were randomized trials, testing echinacea, placebo, doctor-patient interaction, meditation, and exercise.[7-8,10-11] As most of the interventions tested did not lead to clearly demonstrable effects, we feel that these data can be used to investigate the natural course of acute respiratory infection. Only the meditation group in the latest (and smallest) of these studies[8] showed statistical significance when compared to randomized control.

    The figure portrayed here [annfammed.org/site/misc/TRACK/BarrettFigure.doc] suggests that the vast majority of people with colds also have cough, and that most colds and most coughs resolve within 2 weeks of onset. Of the 915 people who reported cough the day after enrollment, only 136 (15%) were still sick with a cough 2 weeks later. Median cough duration falls between day 8, when 503 still coughed, and day 9, when only 426 reported coughing. Unfortunately, most of our studies followed people only to a maximum of 14 days, complicating the calculation of mean duration. The meditation and exercise study,[8] however, followed people up to 21 days, and found that of 93 colds, 67 had cough on the 1st day, but that only 6 of these people still had a cough 3 weeks later.

    On face value, our data seem more consistent with expectations assessed in the Georgia telephone poll (5 to 9 day ACI duration) than with literature data summarized by Ebell et al. (mean 17.8 days of ACI).[1] There are several ways to explain these discrepancies. Different people in different places have different health behaviors and risks, and are exposed to different varieties of pathogens at different times of the year. Various studies use varying methods to enroll people and to monitor symptoms, employing a variety of definitions, cutoffs and analytic methods. Our own studies took in people with early colds, many of them quite mild. Cough was common, but not required. Very few reported fever and productive cough. The Georgia poll first asked people to "Suppose that you get sick and the main symptom is a cough" and that they were "coughing up yellow mucus and have a slight fever (100.5 degrees)," and then asked them to prognosticate on the duration of illness. Published bronchitis studies enrolled people with more severe and prolonged illness, but did not ask about expectations. We have asked participants to predict duration and severity of acute respiratory illness, and found no evidence they could beat chance in doing so.[12] As far as we can tell, no study to date has been specifically designed to investigate ACI duration as the primary outcome.

    Which brings us back to Kleinman. Three decades have gone by since those words were published. In the interim there have been important advances in knowledge relevant to family medicine and primary care, with numerous "practical applied studies of discrete salient health care problems." There has been some progress toward "theoretical models and research approaches that can contribute to a unique scholarly discourse." One of the greatest achievements has been the movement from a disease- oriented paradigm to one seeking to understand and redress human illness. Landmarks include introduction of the biopsychosocial model,[13] the call for patient-oriented evidence that matters (POEMs),[14] and the increasing use of symptomatic and functional assessments as primary outcomes in clinical trials.[15]

    And yet we are left with huge gaps in both knowledge and method. Data available to answer the basic question "How long does a cough last?" are rudimentary at best. Few of the studies available are large enough to adequate statistical power, and none were designed to be representative of a population. The largest prospective cohort studies were done decades ago,[16-19] before PCD-based viral identification and advanced computerized statistical methods were widely available. These early studies (which seem to have eluded the scrutiny of Drs. Ebell et al.) did examine natural course of illness, but did very little in the way of investigating determinants and mediators. As for treatment effectiveness, apart from the fact that antibiotics are at most marginally efficacacious,[20] we know very little. The most common cough suppressants, such as dextromethorphan, codeine, and benzonatate, have not been tested in large, well-designed randomized trials.[21] In summary, it must be concluded that we lack the most basic knowledge regarding the natural course and treatment effectiveness of ACI. Perhaps even more problematic is the failure to develop appropriate theory and methods to reconcile evidence and perspectives related to patient-oriented illness and scientific disease frameworks of knowledge.

    There is little doubt that experiencing the symptoms of acute coughing illness can have a profound impact on one's quality of life. Among other things, ACI can interrupt sleep, cause one's body to ache, and interfere with any of a number of daily life activities. Life during acute coughing illness can be miserable indeed. It may be that some people are overly optimistic regarding the duration of ACI, and that more realistic expectations might reduce both clinic visits and antibiotic prescriptions. Clearly, there is much to be learned about the nature of ACI, including the duration and severity among various populations and sub-classes of illness. Methodologies and paradigms taking account of both popular and professional perspectives will be needed to build a sound intellectual foundation towards a valid science of clinical medicine.

    Reference List
    1. Ebell MH, Lundgren J, Youngpairoj S. How long does a cough last? Comparing patients' expectations with data from a systematic review of the literature. Ann.Fam.Med. 2013;11:5-13.
    2. Kleinman A. Culture, illness, and care: Clinical lessons from anthropologic and cross-cultural research. Annals of Internal Medicine 1978;88:251-8.
    3. Kleinman A. The cultural meanings and social uses of illness. The Journal of Family Practice 1983;16:539-45.
    4. Oppong R, Coast J, Hood K, Nuttall J, Smith RD, Butler CC. Resource use and costs of treating acute cough/lower respiratory tract infections in 13 European countries: results and challenges. Eur.J.Health Econ. 2011;12:319-29.
    5. Barrett B, Brown R, Mundt M, Safdar N, Dye L, Maberry R et al. The Wisconsin Upper Respiratory Symptom Survey is responsive, reliable, and valid. Journal of Clinical Epidemiology 2005;58:609-17.
    6. Barrett B, Brown RE, Mundt MP, Thomas GR, Barlow SK, Highstrom AD et al. Validation of a short form Wisconsin Upper Respiratory Symptom Survey (WURSS-21). Health and Quality of Life Outcomes 2009;7.
    7. Barrett B, Brown R, Rakel D, Rabago D, Marchand L, Scheder J et al. Placebo effects and the common cold: a randomized controlled trial. Ann.Fam.Med. 2011;9:312-22.
    8. Barrett B, Hayney MS, Muller D, Rakel D, Ward A, Obasi CN et al. Meditation or exercise for preventing acute respiratory infection: a randomized controlled trial. Ann.Fam.Med 2012;10:337-46.
    9. Jackson GG, Dowling HF, Muldoon RL. Present concepts of the common cold. Am J Public Health 1962;52:940-5.
    10. Barrett B, Brown R, Rakel D, Mundt M, Bone K, Barlow S et al. Echinacea for treating the common cold: a randomized trial. Ann.Intern.Med. 2010;153:769-77.
    11. Rakel DP, Hoeft TJ, Barrett BP, Chewning BA, Craig BM, Niu M. Practitioner empathy and the duration of the common cold. Fam.Med. 2009;41:494-501.
    12. Longmier E, Barrett B, Brown R. Can patients or clinicians predict the severity of duration of an acute upper respiratory infection? Family Practice 2013;Accepted.
    13. Engel GL. The need for a new medical model: A challenge for biomedicine. Science 1977;196:129-36.
    14. Shaughnessy AF,.Slawson DC. POEMs: patient-oriented evidence that matters. Ann.Intern.Med. 1997;126:667.
    15. Guyatt GH, Juniper EF, Walter SD, Griffith LE, Goldstein RS. Interpreting treatment effects in randomised trials. BMJ. 1998;316:690-3.
    16. Dingle JH, Badger GF, Jordan WS. Illness in the home: A study of 25,000 illnesses in a group of Cleveland families. Cleveland: Press of Western Reserve University, 1964.
    17. Fox JP, Hall CE, Cooney MK, Luce RE, Kronmal RA. The Seattle virus watch. II. Objectives, study population and its observation, data processing and summary of illnesses. American Journal of Epidemiology. 1972;96:270-85.
    18. Gwaltney JM, Hendley JO, Simon G, Jordan WS. Rhinovirus infections in an industrial population: II Characteristics of illness and antibody response. JAMA 1967;202:494-500.
    19. Monto AS, Ullman BM. Acute respiratory illness in an American community. JAMA 1974;227:164-9.
    20. Smith SM, Fahey T, Smucny J, Becker LA. Antibiotics for acute bronchitis. The Cochrane Library 2009;CD000245.pub2.
    21. Smith SM, Schroeder K, Fahey T. Over-the-counter (OTC) medications for acute cough in children and adults in ambulatory settings. Cochrane Database Syst.Rev. 2012;8:CD001831.

    Competing interests:   None declared

    Show Less
    Competing Interests: None declared.
  • Published on: (21 February 2013)
    Page navigation anchor for Author response: What is the denominator?
    Author response: What is the denominator?
    • Mark Ebell, Associate Professor

    Thank you for your thoughtful comment. I agree that we have no way of knowing whether the persons seeking care (and therefore ending up in a study of acute bronchitis) are typical of all patients with acute cough illness. It is certainly possible that those with milder symptoms (and perhaps a shorter duration of illness) were less likely to seek care. It is also possible that even if symptoms are milder, the duration is...

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    Thank you for your thoughtful comment. I agree that we have no way of knowing whether the persons seeking care (and therefore ending up in a study of acute bronchitis) are typical of all patients with acute cough illness. It is certainly possible that those with milder symptoms (and perhaps a shorter duration of illness) were less likely to seek care. It is also possible that even if symptoms are milder, the duration is similar. These studies have not been done. Nevertheless, I think it is still useful information for physicians, since by the time a patient does present for illness, we know they are in a population with a mean duration of about 18 days.

    Sincerely,
    Mark H. Ebell MD, MS

    Competing interests:   None declared

    Show Less
    Competing Interests: None declared.
  • Published on: (20 February 2013)
    Page navigation anchor for Mismatch between patient expectations and clinical data?
    Mismatch between patient expectations and clinical data?
    • Pal Gulbrandsen, professor

    In their important study (1), Ebell et al. note that they are unaware of data regarding physician knowledge of the natural history of acute cough illness. I agree, and further: Do we know the natural history of acute respiratory tract infections? In a small study from an isolated population in Norway, we concluded that every tenth episode of respiratory tract infections in children was presented to a doctor (2). The traje...

    Show More

    In their important study (1), Ebell et al. note that they are unaware of data regarding physician knowledge of the natural history of acute cough illness. I agree, and further: Do we know the natural history of acute respiratory tract infections? In a small study from an isolated population in Norway, we concluded that every tenth episode of respiratory tract infections in children was presented to a doctor (2). The trajectories were on average protracted, less than 50% of the patients were recovered at three weeks, which is much longer than you would expect from personal experience with respiratory tract infections in your family and friends. It is highly likely that patients included in the clinical studies included in your excellent review represent a strong selection of more severe illness if they were recruited when making contact with the health care system. Hence, it is reasonable that there is a gap between patient expectations about the duration of cough illness and findings in clinical studies.

    References

    1. Ebell MH, Lundgren BS, Youngpairoj S. How long does a cough last? Comparing patients' expectations with data from a systematic review of the literature? Ann Fam Med 2013; 11: 5-13.

    2. Gulbrandsen P, Fugelli P, Kvarstein G, Moland L. The duration of acute respiratory tract infections in children. Scand J Prim Health Care 1989; 7: 219-23.

    Competing interests:   None declared

    Show Less
    Competing Interests: None declared.
  • Published on: (21 January 2013)
    Page navigation anchor for A new tool to decrease unnecessary antibiotic use.
    A new tool to decrease unnecessary antibiotic use.
    • John Hickner, Physician

    Bravo, Mark.

    I have long suspected that the typical patients I see in the office with an acute respiratory infection cough for more than one week. In fact, when patients see me on, say, day 7 or day 10 of their acute respiratory infection, and after a normal exam of their lungs, I can confidently tell them their illness is following a normal course and will resolve without treatment. Without any hard data to su...

    Show More

    Bravo, Mark.

    I have long suspected that the typical patients I see in the office with an acute respiratory infection cough for more than one week. In fact, when patients see me on, say, day 7 or day 10 of their acute respiratory infection, and after a normal exam of their lungs, I can confidently tell them their illness is following a normal course and will resolve without treatment. Without any hard data to support it, I can tell you that most patients are happy to hear they don't have pneumonia and they just need more time to recover. My success rate with denying inappropriate antibiotic prescriptions, using this bit of information, has already markedly impoved.

    To our colleagues I say "try it, you'll like it."

    John

    Competing interests:   None declared

    Show Less
    Competing Interests: None declared.
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How Long Does a Cough Last? Comparing Patients’ Expectations With Data From a Systematic Review of the Literature
Mark H. Ebell, Jerold Lundgren, Surasak Youngpairoj
The Annals of Family Medicine Jan 2013, 11 (1) 5-13; DOI: 10.1370/afm.1430

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How Long Does a Cough Last? Comparing Patients’ Expectations With Data From a Systematic Review of the Literature
Mark H. Ebell, Jerold Lundgren, Surasak Youngpairoj
The Annals of Family Medicine Jan 2013, 11 (1) 5-13; DOI: 10.1370/afm.1430
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