The Neuroanatomic Diagnostic Protocol: Evidence for a Necessary Update to the Clinical Framework for Managing Chronic Cough

Background Chronic cough represents a challenging clinical problem and significant unmet global burden. For some patients, cough can be associated with conditions impacting the respiratory system, including asthma, rhinosinusitis, and gastroesophageal reflux disease. This underpinned the rationale for the development of the Anatomic Diagnostic Protocol, an etiology-based algorithm for chronic cough management used in clinical practice for over 50 years. However, despite the value of the Anatomic Diagnostic Protocol, many patients do not respond adequately to the clinical strategies promoted in the existing management framework because they either have no obvious causative disease or their cough is unresolved by standard etiology-based therapies (refractory chronic cough). This, along with the introduction of cough hypersensitivity syndrome as a unifying condition common to most patients with chronic cough, has added additional complexity for physicians in everyday practice. Findings We introduce the Neuroanatomic Diagnostic Protocol and the rationale behind it, a proposed timely and practical update to the classic framework that unifies the known association of cough with common etiological causes, the existence of refractory chronic cough, and the core concepts of cough hypersensitivity syndrome by acknowledging the vagus nerve and its central circuits as a distinct anatomical consideration in the effective assessment and targeted management of chronic cough.