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Wiltingh H, Marchant JM, Goyal V. Cough in Protracted Bacterial Bronchitis and Bronchiectasis. J Clin Med 2024; 13:3305. [PMID: 38893016 PMCID: PMC11172502 DOI: 10.3390/jcm13113305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 05/20/2024] [Accepted: 05/23/2024] [Indexed: 06/21/2024] Open
Abstract
Chronic cough in children is a common condition for which patients seek medical attention, and there are many etiologies. Of the various causes of chronic cough in children, protracted bacterial bronchitis (PBB) is one of the commonest causes, and bronchiectasis is one of the most serious. Together, they lie on different ends of the spectrum of chronic wet cough in children. Cough is often the only symptom present in children with PBB and bronchiectasis. This review highlights the role of cough as a marker for the presence of these conditions, as well as an outcome endpoint for treatment and research.
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Affiliation(s)
- Hinse Wiltingh
- Department of Respiratory and Sleep Medicine, Queensland Children’s Hospital, Brisbane, QLD 4101, Australia; (H.W.); (J.M.M.)
| | - Julie Maree Marchant
- Department of Respiratory and Sleep Medicine, Queensland Children’s Hospital, Brisbane, QLD 4101, Australia; (H.W.); (J.M.M.)
- Australian Centre for Health Services Innovation, Queensland University of Technology, Brisbane, QLD 4000, Australia
| | - Vikas Goyal
- Department of Respiratory and Sleep Medicine, Queensland Children’s Hospital, Brisbane, QLD 4101, Australia; (H.W.); (J.M.M.)
- Australian Centre for Health Services Innovation, Queensland University of Technology, Brisbane, QLD 4000, Australia
- Department of Pediatrics, Gold Coast Health, Gold Coast, QLD 4215, Australia
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2
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Rajvanshi N, Kumar P, Goyal JP. Evaluation of Chronic Cough in Children Using Management Algorithm: A Prospective Cohort Study. Indian J Pediatr 2024; 91:337-343. [PMID: 37289310 DOI: 10.1007/s12098-023-04632-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 03/17/2023] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To assess the use of a standardized evaluation algorithm [American College of Chest Physician (ACCP) 2006] in children with chronic cough. METHODS In this prospective cohort study, children with chronic cough were evaluated as per the ACCP 2006 diagnostic algorithm. All children were followed regularly at an interval of 2-4 wk. The study's endpoint was for the patient being cough free for four weeks either following treatment or naturally. RESULTS The mean age of the 87 studied children (52 male, 35 female) was 11.9±3 y. Forty children (45.9%) had specific cough pointers on history and examination. Radiograph showed abnormalities in 12 (13.8%) children, and spirometry showed a reversible obstructive pattern on spirometry in 6 (6.9%) among 47 (54%) children without specific cough pointers. After a detailed evaluation, 16 (18.3%) children had no remarkable findings and were reviewed after two weeks. Spontaneous resolution of cough occurred in 6 children. A trial of inhalational corticosteroids (ICS) (9 children) or antibiotics (1 child) was given to the rest of the ten children. Specific underlying diagnoses could be established in 80 (91.9%) children. The most common etiology identified in the study was asthma and asthma-like illnesses (n = 52; 59.8%), followed by upper airway cough syndrome (n = 13; 14.9%) and tuberculosis (n = 9; 10.4%). Eighty-four (96.5%) children had complete resolution of cough during follow-up. The mean time to resolution in the study was 33.6±16.8 d. CONCLUSIONS This study demonstrated that the ACCP 2006 algorithm is effective in establishing the underlying etiology and managing children with chronic cough.
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Affiliation(s)
- Nikhil Rajvanshi
- Department of Pediatrics, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Prawin Kumar
- Department of Pediatrics, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Jagdish Prasad Goyal
- Department of Pediatrics, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India.
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3
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Manoharan A, Jat KR. Decoding Pediatric Cough: Navigating the Path to Effective Management with Standard Algorithms. Indian J Pediatr 2024; 91:321-322. [PMID: 38175495 DOI: 10.1007/s12098-023-05016-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Accepted: 12/28/2023] [Indexed: 01/05/2024]
Affiliation(s)
- Aravindhan Manoharan
- Department of Pediatrics, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029, India
| | - Kana Ram Jat
- Department of Pediatrics, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029, India.
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Marchant JM, Chang AB, Kennedy E, King D, Perret JL, Schultz A, Toombs MR, Versteegh L, Dharmage SC, Dingle R, Fitzerlakey N, George J, Holland A, Rigby D, Mann J, Mazzone S, O'Brien M, O'Grady KA, Petsky HL, Pham J, Smith SM, Wurzel DF, Vertigan AE, Wark P. Cough in Children and Adults: Diagnosis, Assessment and Management (CICADA). Summary of an updated position statement on chronic cough in Australia. Med J Aust 2024; 220:35-45. [PMID: 37982357 DOI: 10.5694/mja2.52157] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 09/18/2023] [Indexed: 11/21/2023]
Abstract
INTRODUCTION Cough is the most common symptom leading to medical consultation. Chronic cough results in significant health care costs, impairs quality of life, and may indicate the presence of a serious underlying condition. Here, we present a summary of an updated position statement on cough management in the clinical consultation. MAIN RECOMMENDATIONS Assessment of children and adults requires a focused history of chronic cough to identify any red flag cough pointers that may indicate an underlying disease. Further assessment with examination should include a chest x-ray and spirometry (when age > 6 years). Separate paediatric and adult diagnostic management algorithms should be followed. Management of the underlying condition(s) should follow specific disease guidelines, as well as address adverse environmental exposures and patient/carer concerns. First Nations adults and children should be considered a high risk group. The full statement from the Thoracic Society of Australia and New Zealand and Lung Foundation Australia for managing chronic cough is available at https://lungfoundation.com.au/resources/cicada-full-position-statement. CHANGES IN MANAGEMENT AS A RESULT OF THIS STATEMENT Algorithms for assessment and diagnosis of adult and paediatric chronic cough are recommended. High quality evidence supports the use of child-specific chronic cough management algorithms to improve clinical outcomes, but none exist in adults. Red flags that indicate serious underlying conditions requiring investigation or referral should be identified. Early and effective treatment of chronic wet/productive cough in children is critical. Culturally specific strategies for facilitating the management of chronic cough in First Nations populations should be adopted. If the chronic cough does not resolve or is unexplained, the patient should be referred to a respiratory specialist or cough clinic.
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Affiliation(s)
- Julie M Marchant
- Australian Centre for Health Services Innovation, Queensland University of Technology, Brisbane, QLD
- Queensland Children's Hospital, Brisbane, QLD
| | - Anne B Chang
- Australian Centre for Health Services Innovation, Queensland University of Technology, Brisbane, QLD
- Queensland Children's Hospital, Brisbane, QLD
- Menzies School of Health Research, Darwin, NT
| | - Emma Kennedy
- Rural and Remote Health, Flinders University, Darwin, NT
| | | | - Jennifer L Perret
- Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC
| | - Andre Schultz
- Wal-yan Respiratory Research Centre, Perth, WA
- Perth Children's Hospital, Perth, WA
| | | | | | - Shyamali C Dharmage
- Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC
| | | | | | - Johnson George
- Centre for Medicine Use and Safety, Monash University, Melbourne, VIC
| | - Anne Holland
- Alfred Health, Melbourne, VIC
- Monash University, Melbourne, VIC
- Institute for Breathing and Sleep, University of Melbourne, Melbourne, VIC
| | - Debbie Rigby
- University of Queensland, Brisbane, QLD
- Queensland University of Technology, Brisbane, QLD
| | - Jennifer Mann
- Institute for Breathing and Sleep, University of Melbourne, Melbourne, VIC
- Austin Health, Melbourne, VIC
| | | | | | - Kerry-Ann O'Grady
- Australian Centre for Health Services Innovation, Queensland University of Technology, Brisbane, QLD
| | | | | | | | | | - Anne E Vertigan
- Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW
- John Hunter Hospital, Newcastle, NSW
| | - Peter Wark
- Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW
- John Hunter Hospital, Newcastle, NSW
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Boonjindasup W, Marchant JM, McElrea MS, Yerkovich ST, Newcombe PA, Chang AB. Clinical determinants for State-Trait Anxiety Inventory of the parents of children with respiratory problems. Pediatr Pulmonol 2024; 59:31-40. [PMID: 37750592 PMCID: PMC10952396 DOI: 10.1002/ppul.26702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Accepted: 09/14/2023] [Indexed: 09/27/2023]
Abstract
BACKGROUNDS Understanding factors associated with anxiety of parents/carers of children with respiratory problems is clinically important yet there is relative paucity of data. In 106 children seen in the respiratory clinic of a pediatric hospital, we evaluated (a) the determinants for parental anxiety and (b) whether the anxiety scores correlate with quality-of-life (QoL) scores in the subset with chronic cough. METHODS We opportunistically re-analyzed data of our main study that examined the benefits of using spirometry for pediatric respiratory consultation where parents completed an anxiety questionnaire (State-Trait Anxiety Inventory, STAI) pre- and postconsultation. A subset (children with chronic cough) also completed the parent-proxy quality-of-life (PC-QoL) tool. We computed the association between clinical characteristics and anxiety scores using multivariable regression and between the two patient-reported outcome measures using Spearman's correlation. RESULTS The majority of parents/carers were women (n = 89, 84%). Most children (mean age = 10.9 years, SD = 3.7 years) were previously seen at the clinic (n = 67, 63.2%). In multivariate regression, parental anxiety score was significantly associated with reported presence of cough [coefficient β = 17.31 (95% confidence interval 9.62, 25.1)] and lower forced expiratory volume in first second (FEV1 )/forced vital capacity (FVC) [-3.88 (-7.05, -0.71)] at preconsultation, but associated with cough only [coefficient β = 12.04 (5.24, 18.84)] at postconsultation, all p < .05. STAI strongly correlated with PC-QoL scores at pre- but only modestly at postconsultation (rs = -.63 and -.39, respectively, p < .05). CONCLUSION Parental anxiety levels of children attending respiratory clinics are influenced by the presence of cough and low FEV1 /FVC of their child and are associated with poorer QoL. These highlight the need for on-going research to reduce parental anxiety focusing on cough and lung function indices.
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Affiliation(s)
- Wicharn Boonjindasup
- Child Health Division, Menzies School of Health Research, NHMRC Centre for Research Excellence in Paediatric Bronchiectasis (AusBREATHE)Charles Darwin UniversityDarwinNorthern TerritoryAustralia
- Australian Centre for Health Services Innovation, Centre for Healthcare TransformationQueensland University of TechnologyBrisbaneQueenslandAustralia
- Department of Pediatrics, Faculty of MedicineChulalongkorn UniversityBangkokThailand
| | - Julie M. Marchant
- Australian Centre for Health Services Innovation, Centre for Healthcare TransformationQueensland University of TechnologyBrisbaneQueenslandAustralia
- Department of Respiratory & Sleep MedicineQueensland Children's HospitalBrisbaneQueenslandAustralia
| | - Margaret S. McElrea
- Australian Centre for Health Services Innovation, Centre for Healthcare TransformationQueensland University of TechnologyBrisbaneQueenslandAustralia
- Department of Respiratory & Sleep MedicineQueensland Children's HospitalBrisbaneQueenslandAustralia
| | - Stephanie T. Yerkovich
- Child Health Division, Menzies School of Health Research, NHMRC Centre for Research Excellence in Paediatric Bronchiectasis (AusBREATHE)Charles Darwin UniversityDarwinNorthern TerritoryAustralia
- Australian Centre for Health Services Innovation, Centre for Healthcare TransformationQueensland University of TechnologyBrisbaneQueenslandAustralia
| | - Peter A. Newcombe
- School of PsychologyUniversity of QueenslandBrisbaneQueenslandAustralia
| | - Anne B. Chang
- Child Health Division, Menzies School of Health Research, NHMRC Centre for Research Excellence in Paediatric Bronchiectasis (AusBREATHE)Charles Darwin UniversityDarwinNorthern TerritoryAustralia
- Australian Centre for Health Services Innovation, Centre for Healthcare TransformationQueensland University of TechnologyBrisbaneQueenslandAustralia
- Department of Respiratory & Sleep MedicineQueensland Children's HospitalBrisbaneQueenslandAustralia
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Fujiki RB, Wright ML, Fujiki AE, Thibeault SL. Factors influencing behavioral cough suppression therapy in children with nonspecific chronic cough. Pediatr Pulmonol 2023; 58:3466-3477. [PMID: 37737562 PMCID: PMC10872587 DOI: 10.1002/ppul.26677] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 08/25/2023] [Accepted: 08/30/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND Behavioral cough suppression therapy (BCST) with a speech-language pathologist is a common treatment for chronic nonspecific cough (a.k.a., tic cough) in children. Yet, the outcomes and duration of pediatric BCST have eluded formal investigation. This study examined whether BCST improves cough in children with nonspecific cough and factors that predict the course of treatment. Additionally, the cough characteristics and comorbidities associated with the condition were examined. METHODS A retrospective, observational cohort design was utilized. Cough characteristics, medical history, and BCST treatment details and outcomes for 151 children were extracted from the electronic medical record of a large outpatient pediatric otolaryngology clinic. RESULTS Cough was dry and onset unaccompanied by illness in most cases. Roughly half of patients reported gradual onset and cough proceeded by tickle. On average, patients experienced symptoms for 19 months (SD = 20.09) before diagnosis. Rates of comorbid General Anxiety Disorder were elevated compared to pediatric norms. Additionally, high rates of asthma (22.1%), reflux (62.3%), and disordered sleep breathing (19.2%) were observed. Common findings on laryngoscopy included interarytenoid edema and erythema. Vocal fold changes were observed in 22.9% of children. BCST reduced cough in 92.5% of patients following an average of 1.7 sessions. Comorbid behavioral health diagnoses (p = 0.013) or induced laryngeal obstruction symptoms (p = 0.025) were significant predictors of increased therapy sessions. Cough proceeded by tickle significantly predicted fewer sessions in therapy (p = 0.011). INTERPRETATION Although randomized clinical trials are needed, these data suggest that BCST is a low-risk, effective treatment for children with nonspecific cough.
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Affiliation(s)
| | - Miranda L Wright
- Department of Otolaryngology-Head & Neck Surgery, University of Utah, Salt Lake City, Utah, USA
- Department of Communication Sciences & Disorders, University of Utah, Salt Lake City, Utah, USA
| | - Amanda E Fujiki
- Department of Psychiatry - Child and Adolescent Division, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Susan L Thibeault
- Department of Surgery, University of Wisconsin - Madison, Madison, Wisconsin, USA
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Chang AB, Irwin RS, O’Farrell HE, Dicpinigaitis PV, Goel S, Kantar A, Marchant JM. Cough Hypersensitivity Syndrome: Why Its Use Is Inappropriate in Children. J Clin Med 2023; 12:4879. [PMID: 37568280 PMCID: PMC10419757 DOI: 10.3390/jcm12154879] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 07/17/2023] [Accepted: 07/18/2023] [Indexed: 08/13/2023] Open
Abstract
In children and adults, chronic cough is a common symptom presenting to health professionals worldwide. It is internationally accepted that children with chronic cough should be managed with pediatric specific management guidelines. The newly proposed clinical entity of 'cough hypersensitivity syndrome' has gained significant attention in adult literature. Given the significant differences between childhood and adult chronic cough, including in respiratory physiology and anatomy, and cough sensitivity, we address the suitability of the use of cough hypersensitivity syndrome in children. We explore these differences between childhood and adult chronic cough, explain what cough hypersensitivity is and highlight why the term cough hypersensitivity syndrome should not be used in children.
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Affiliation(s)
- Anne B. Chang
- Australian Centre for Health Services Innovation, Queensland University of Technology, Brisbane, QLD 4059, Australia
- Department of Respiratory and Sleep Medicine, Queensland Children’s Hospital, Brisbane, QLD 4101, Australia
- NHMRC Centre for Research Excellence in Paediatric Bronchiectasis (AusBREATHE), Child Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT 0810, Australia
| | - Richard S. Irwin
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, UMass Memorial Medical Center, Worcester, MA 01605, USA
| | - Hannah E. O’Farrell
- Australian Centre for Health Services Innovation, Queensland University of Technology, Brisbane, QLD 4059, Australia
- NHMRC Centre for Research Excellence in Paediatric Bronchiectasis (AusBREATHE), Child Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT 0810, Australia
| | - Peter V. Dicpinigaitis
- Division of Critical Care Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY 10461, USA
| | - Suhani Goel
- Australian Centre for Health Services Innovation, Queensland University of Technology, Brisbane, QLD 4059, Australia
- Somerville House, South Brisbane, QLD 4101, Australia
| | - Ahmad Kantar
- Pediatric Asthma and Cough Centre, Istituti Ospedalieri Bergamaschi, University and Research Hospitals, via Forlanini 15, Ponte San Pietro-Bergamo, 24036 Bergamo, Italy
| | - Julie M. Marchant
- Australian Centre for Health Services Innovation, Queensland University of Technology, Brisbane, QLD 4059, Australia
- Department of Respiratory and Sleep Medicine, Queensland Children’s Hospital, Brisbane, QLD 4101, Australia
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Lai K, Satia I, Song WJ, Wang G, Niimi A, Pattemore P, Chang AB, Gibson PG, Chung KF. Cough and cough hypersensitivity as treatable traits of asthma. THE LANCET. RESPIRATORY MEDICINE 2023; 11:650-662. [PMID: 37336227 DOI: 10.1016/s2213-2600(23)00187-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 04/21/2023] [Accepted: 05/03/2023] [Indexed: 06/21/2023]
Abstract
Cough is a common and troublesome symptom in people with asthma and is often associated with poorer asthma control and exacerbations. Apart from asthma, other causes or comorbidities might underlie cough in asthma, such as rhinosinusitis and bronchiectasis. Eosinophilic inflammation and bronchoconstriction can lead to an acute episode of cough or worsen chronic cough. Cough hypersensitivity with laryngeal paraesthesia, allotussia, and hypertussia might underlie the cough of asthma through augmented sensory nerve excitability of upper-airway vagal sensory nerves. Cough associated with bronchoconstriction and type 2 inflammation should respond to inhaled corticosteroids and long-acting β-adrenoceptor agonist therapy. For cough hypersensitivity in adults, speech and language therapy and neuromodulators (eg, gabapentin) could be considered. In children, there is no consistent association of asthma with cough sensitivity or between cough and asthma severity. Further research is needed to realise the potential of cough as a measure of asthma control, to understand the mechanisms of cough in asthma, and to develop safe, effective treatments and a precision-medicine approach to the management of cough in asthma in children and adults.
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Affiliation(s)
- Kefang Lai
- The First Affiliated Hospital of Guangzhou Medical University, National Center of Respiratory Medicine, State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Health, Guangzhou, China
| | - Imran Satia
- Department of Medicine, McMaster University, Hamilton, ON, Canada; Firestone Institute for Respiratory Health, St Joseph's Healthcare, Hamilton, ON, Canada
| | - Woo-Jung Song
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Gang Wang
- Department of Respiratory and Critical Care Medicine, Clinical Research Center for Respiratory Disease, West China Hospital & Laboratory of Pulmonary Immunology and Inflammation, Frontiers Science Center for Disease-related Molecular Network, Sichuan University, Chengdu, China
| | - Akio Niimi
- School of Medical Sciences, Nagoya City University, Nagoya, Japan
| | - Philip Pattemore
- Department of Paediatrics, University of Otago, Christchurch, New Zealand
| | - Anne B Chang
- Australian Centre for Health Services Innovation, Queensland University of Technology, Brisbane, QLD, Australia; Department of Respiratory and Sleep Medicine, Queensland Children's Hospital, Brisbane, QLD, Australia; Child Health Division, Menzies School of Health Research, Darwin, NT, Australia
| | - Peter G Gibson
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | - Kian Fan Chung
- National Heart and Lung Institute, Imperial College London, London, UK; Royal Brompton and Harefield Hospitals, London, UK.
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Vogelberg C, Cuevas Schacht F, Watling CP, Upstone L, Seifert G. Therapeutic principles and unmet needs in the treatment of cough in pediatric patients: review and expert survey. BMC Pediatr 2023; 23:34. [PMID: 36670372 PMCID: PMC9860236 DOI: 10.1186/s12887-022-03814-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 12/20/2022] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND There are evidence gaps in the management of pediatric cough, particularly for acute pediatric cough. This study had two aims: to identify therapeutic principles and unmet needs in the treatment of cough in pediatric patients (internationally), and to consider the evidence required to address these unmet needs. METHODS A MEDLINE/PubMed database search was performed to identify articles describing therapeutic principles in the treatment of pediatric cough. An online survey of international pediatric cough experts was conducted, with questions on the definitions, diagnosis, treatment, and unmet needs in pediatric cough management. RESULTS Cough guidelines have differing definitions of pediatric patients (≤12-18 years), acute pediatric cough (< 2-3 weeks), and chronic pediatric cough (> 4-8 weeks). Similarly, among 18 experts surveyed, definitions varied for pediatric patients (≤10-21 years), acute pediatric cough (< 3-5 days to < 6 weeks), and chronic pediatric cough (> 2-8 weeks). Guidelines generally do not recommend over-the-counter or prescription cough medicines in acute pediatric cough, due to lack of evidence. In the expert survey, participants had differing opinions on which medicines were most suitable for treating acute pediatric cough, and noted that effective treatments are lacking for cough-related pain and sleep disruption. Overall, guidelines and experts agreed that chronic pediatric cough requires diagnostic investigations to identify the underlying cough-causing disease and thereby to guide treatment. There are unmet needs for new effective and safe treatments for acute pediatric cough, and for randomized controlled trials of existing treatments. Safety is a particular concern in this vulnerable patient population. There is also a need for better understanding of the causes, phenotypes, and prevalence of pediatric cough, and how this relates to its diagnosis and treatment. CONCLUSIONS Whereas pediatric cough guidelines largely align with regard to the diagnosis and treatment of chronic cough, there is limited evidence-based guidance for the management of acute cough. There is a need for harmonization of pediatric cough management, and the development of standard guidelines suitable for all regions and patient circumstances.
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Affiliation(s)
- Christian Vogelberg
- grid.412282.f0000 0001 1091 2917Paediatric Department, University Hospital Carl Gustav Carus Dresden, Technical University Dresden, Dresden, Germany
| | - Francisco Cuevas Schacht
- grid.419216.90000 0004 1773 4473Department of Pulmonology and Thoracic Surgery, National Institute of Paediatrics, Mexico City, Mexico
| | | | | | - Georg Seifert
- grid.6363.00000 0001 2218 4662Department of Paediatric Oncology/Haematology, Otto-Heubner Centre for Paediatric and Adolescent Medicine (OHC), Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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10
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Raynes-Greenow C, Billah SM, Islam S, Rokonuzzaman SM, Tofail F, Kirkwood EK, Alam A, Chartier R, Ferdous TE, El Arifeen S, Dibley MJ, Homaira N, Hayes A, Thornburg J, Kelly P. Reducing household air pollution exposure to improve early child growth and development; a randomized control trial protocol for the "Poriborton-Extension: The CHANge trial". Trials 2022; 23:505. [PMID: 35710445 PMCID: PMC9205063 DOI: 10.1186/s13063-022-06342-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 04/23/2022] [Indexed: 11/10/2022] Open
Abstract
Background Globally, household air pollution (HAP) is a leading environmental cause of morbidity and mortality. Our trial aims to assess the impact of liquefied petroleum gas (LPG) for cooking to reduce household air pollution exposure on child health outcomes, compared to usual cooking practices in Bangladesh. The primary aim is to evaluate if reduced exposure to HAP through the provision of LPG for cooking from early gestation through to age 2 improves child anthropometry, health, and neuro-cognitive developmental outcomes, compared to children exposed to emissions from usual practice. Methods Two-arm parallel cluster randomized controlled trial (cCRT). We will extend the intervention and follow-up of our existing “Poriborton” trial. In a subset of the original surviving participants, we will supply LPG cylinders and LPG stoves (intervention) compared to usual cooking practices and extend the follow-up to 24 months of age. The expected final sample size, for both (intervention and control) is 1854 children with follow-up to 2 years of age available for analysis. Discussion This trial will answer important research gaps related to HAP and child health and neuro-cognitive developmental outcomes. This evidence will help to understand the impact of a HAP intervention on child health to inform policies for the adoption of clean fuel in Bangladesh and other similar settings. Trial registration The Poriborton: Change trial: Household Air Pollution and Perinatal and early Neonatal mortality is registered with the Australian New Zealand Clinical Trials Registry, ACTRN12618001214224, original trial registered on 19th July 2018, extension approved on 23rd June 2021. www.anzctr.org.au.
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Affiliation(s)
| | - Sk Masum Billah
- The University of Sydney, School of Public Health, Sydney, Australia.,Maternal and Child Health Division, icddr,b, Dhaka, Bangladesh
| | - Sajia Islam
- Maternal and Child Health Division, icddr,b, Dhaka, Bangladesh
| | | | - Fahmida Tofail
- Maternal and Child Health Division, icddr,b, Dhaka, Bangladesh.,Nutrition and Clinical Services Division, icddr,b, Dhaka, Bangladesh
| | | | - Ashraful Alam
- The University of Sydney, School of Public Health, Sydney, Australia
| | - Ryan Chartier
- RTI International, Research Triangle Park, NC, 27707, USA
| | | | | | - Michael J Dibley
- The University of Sydney, School of Public Health, Sydney, Australia
| | | | - Alison Hayes
- The University of Sydney, School of Public Health, Sydney, Australia
| | | | - Patrick Kelly
- The University of Sydney, School of Public Health, Sydney, Australia
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11
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Sojak J, Durdik P, Omar Mohamedova E, Grendar M, Lucanska M, Pec MJ, Tatar M, Pecova R. Changes in Cough Reflex Sensitivity in Children After Removal of Hypertrophied Adenoid Tissue. J Asthma Allergy 2022; 15:517-524. [PMID: 35469259 PMCID: PMC9034841 DOI: 10.2147/jaa.s347355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 03/16/2022] [Indexed: 11/25/2022] Open
Abstract
Purpose The co-occurrence of adenoids and chronic cough is common in children. The goal of this research was to specify changes in cough reflex sensitivity as a result of adenoid tissue removal. Patients and Methods The sample group consisted of 17 children (six boys and 11 girls, aged 4–12 years, mean age 6.24 years), all of them possessing symptoms of chronic cough and adenoids, confirmed by nasal fiberoptic endoscopy. This sample group underwent cough reflex sensitivity assessment, which took place both prior to and after endoscopic adenoidectomy. The definition of the cough reflex sensitivity is the lowest capsaicin concentration that caused two (C2) or five (C5) coughs. Capsaicin aerosol in ascending concentrations (from 0.61 to 1250 µmol/L) was inhaled by a single-breath method (KoKo DigiDoser), with the addition of an inspiratory flow regulator valve (RIFR). Results Concentrations of capsaicin causing two (C2) and five coughs (C5) were reported. Cough sensitivity (geometric mean with 95% CI) for C2 was 31.86 (12.98–78.18) µmol/L preoperatively and 11.97 (6.16–23.26) µmol/L postoperatively (P=0.064). Cough sensitivity for C5 was 234.91 (97.19–567.77) µmol/L preoperatively and 69.13 (29.08–164.35) µmol/L postoperatively (P=0.022). The children’s pulmonary function was within the normal range. Conclusion In our study, adenoidectomy significantly increased cough reflex sensitivity in non-atopic children suffering from chronic cough.
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Affiliation(s)
- Jan Sojak
- Clinic of Otorhinolaryngology and Head and Neck Surgery, Faculty of Medicine, Slovak Medical University in Bratislava, Central Military Hospital in Ruzomberok, Ruzomberok, Slovak Republic
| | - Peter Durdik
- Clinic of Children and Adolescent, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, University Hospital Martin, Martin, Slovak Republic
| | - Eva Omar Mohamedova
- Outpatient Department of Clinical Immunology and Allergology in Ruzomberok, Ruzomberok, Slovak Republic
| | - Marian Grendar
- Biomedical Center, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Miroslava Lucanska
- Clinic of Otorhinolaryngology and Head and Neck Surgery, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, University Hospital Martin, Martin, Slovak Republic
| | - Martin Jozef Pec
- Clinic of Internal Medicine I, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, University Hospital Martin, Martin, Slovak Republic
| | - Milos Tatar
- Department of Pathological Physiology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Renata Pecova
- Department of Pathological Physiology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
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12
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Mukerji SS, Yenduri NJS, Chiou E, Moonnumakal SP, Bedwell JR. A multi‐disciplinary approach to chronic cough in children. Laryngoscope Investig Otolaryngol 2022; 7:409-416. [PMID: 35434349 PMCID: PMC9008181 DOI: 10.1002/lio2.778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 01/02/2022] [Accepted: 01/31/2022] [Indexed: 11/20/2022] Open
Abstract
Objectives (1) To highlight the important causes of chronic and recurrent cough in children. (2) To discuss multidisciplinary approach to management of chronic/recurrent pediatric cough. Methods Review of scholarly articles, guidelines, expert panels via PubMed and Google Scholar. Conclusion Chronic cough (CC) in children is mainly attributed to persistent bacterial bronchitis, asthma, nonspecific cough, and gastroesophageal reflux disease (GERD) symptoms. A multi‐disciplinary approach is cost‐effective and aids with earlier diagnosis and appropriate treatment. Congenital or acquired narrowing of the subglottis is the leading ENT cause for recurrent croup (RC) in children. Laryngeal cleft‐type 1 is commonly seen in children with recurrent aspiration and CC. Children are usually referred to pulmonologists for wet cough not responding to treatment. Eosinophilic esophagitis (EoE) and GERD should be considered in the differential diagnosis of CC in children with both respiratory symptoms and failure to thrive. Level of Evidence: 2a
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Affiliation(s)
- Shraddha S. Mukerji
- Department of Otolaryngology Head Neck Surgery Baylor College of Medicine, Texas Children's Hospital Houston Texas USA
| | - Naga Jaya Smitha Yenduri
- Department of Pulmonary Medicine and Critical Care Baylor College of Medicine, Texas Children's Hospital Houston Texas USA
| | - Eric Chiou
- Department of Gastroenterology and Nutrition Baylor College of Medicine, Texas Children's Hospital Houston Texas USA
| | - Siby P. Moonnumakal
- Department of Pulmonary Medicine and Critical Care Baylor College of Medicine, Texas Children's Hospital Houston Texas USA
| | - Joshua R. Bedwell
- Department of Otolaryngology Head Neck Surgery Baylor College of Medicine, Texas Children's Hospital Houston Texas USA
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13
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Shen HQ, Zhang YH, Zhang J, Sheng QM. Process of diagnosis and treatment of chronic cough in children at primary hospitals. Front Pediatr 2022; 10:1018924. [PMID: 36589155 PMCID: PMC9795405 DOI: 10.3389/fped.2022.1018924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Accepted: 11/28/2022] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE This study aimed to establish a process for the diagnosis and treatment of chronic cough in children suitable at primary hospitals and improve the treatment efficacy rate and improve health economic indicators. METHODS Children who visited the Department of Pediatrics, Affiliated Zhou Pu Hospital of the Shanghai Health Medical College from January to December 2021 were randomly assigned to the intervention group (n = 206), in which the diagnosis and treatment process proposed here was applied, and a control group (n = 211) that did not follow the intervention pathway and followed a pathway with the doctors usual practice based on his/her previous experience. Patients were followed up and data were collected at weeks 0 (time of enrollment), 2, 4, 8, and 12 to evaluate the efficacy rate and clinical value. RESULTS (1) No significant differences were detected between the two groups in baseline characteristics, including gender, age, duration of cough (weeks), history of allergy in children and parents, and smoking of family members living in the same household (p > 0.05); (2) During the follow-up, all cough symptom scores of the intervention group were lower than the control group. Additionally, at week 12, the treatment efficacy rate of the intervention group (91.70%) was significantly higher than the control group (69.20%) (p < 0.05); (3) The quality of life of children in both groups at week 12 was improved compared to the first visit. However, the total score of the intervention group was significantly higher than the control group (p < 0.05); (4) At week 12, the referral rate was significantly lower in the intervention group (11.17%) than in the control group (21.33%); (5) The intervention group was better than the control group for the mean monthly medication costs, number of days on errors in childhood, and number of days mistakenly worked by family members at week 12 (p < 0.05). CONCLUSION The current process of diagnosis and treatment of chronic cough in children at primary hospitals can improve the effective diagnosis and treatment rate, the quality of life, and other parameters, with good effectiveness and feasibility.
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Affiliation(s)
- Hua-Qin Shen
- Department of Pediatric Medicine, Affiliated Zhou Pu Hospital of the Shanghai Health Medical College, Shanghai, China
| | - Yan-Han Zhang
- Department of Pediatric Medicine, Affiliated Zhou Pu Hospital of the Shanghai Health Medical College, Shanghai, China
| | - Jing Zhang
- Department of Respiratory Medicine for Children, Shanghai Children's Medical Center Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Qiu-Ming Sheng
- Department of Pediatric Medicine, Affiliated Zhou Pu Hospital of the Shanghai Health Medical College, Shanghai, China
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14
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McGarvey L, Rubin BK, Ebihara S, Hegland K, Rivet A, Irwin RS, Bolser DC, Chang AB, Gibson PG, Mazzone SB. Global Physiology and Pathophysiology of Cough: Part 2. Demographic and Clinical Considerations: CHEST Expert Panel Report. Chest 2021; 160:1413-1423. [PMID: 33905678 PMCID: PMC8692102 DOI: 10.1016/j.chest.2021.04.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 04/15/2021] [Accepted: 04/18/2021] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Cough characteristics vary between patients, and this can impact clinical diagnosis and care. The purpose of part two of this state-of-the-art review is to update the American College of Chest Physicians (CHEST) 2006 guideline on global physiology and pathophysiology of cough. STUDY DESIGN AND METHODS A review of the literature was conducted using PubMed and MEDLINE databases from 1951 to 2019 using prespecified search terms. RESULTS We describe the demographics of typical patients with cough in the clinical setting, including how cough characteristics change across age. We summarize the effect of common clinical conditions impacting cough mechanics and the physical properties of mucus on airway clearance. INTERPRETATION This is the second of a two-part update to the 2006 CHEST cough guideline; it complements part one on basic phenomenology of cough by providing an extended clinical picture of cough along with the factors that alter cough mechanics and efficiency in patients. A greater understanding of the physiology and pathophysiology of cough will improve clinical management.
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Affiliation(s)
- Lorcan McGarvey
- Wellcome-Wolfson Institute of Experimental Medicine, Queen's University Belfast, Belfast, Northern Ireland.
| | - Bruce K Rubin
- Department of Pediatrics, Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, VA
| | - Satoru Ebihara
- Department of Internal Medicine and Rehabilitation Science, Tohoku University Graduate School of Medicine, Sendai, Japan; Department of Rehabilitation Medicine, Toho University Graduate School of Medicine, Tokyo, Japan
| | - Karen Hegland
- Department of Speech, Language and Hearing Sciences, University of Florida, Gainesville, FL
| | - Alycia Rivet
- Department of Speech, Language and Hearing Sciences, University of Florida, Gainesville, FL
| | - Richard S Irwin
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Massachusetts Medical School and UMass Memorial Medical Center, Worcester, MA
| | - Donald C Bolser
- Department of Physiological Sciences, University of Florida, Gainesville, FL
| | - Anne B Chang
- Division of Child Health, Menzies School of Health Research, Darwin, NT, Australia; Department of Respiratory and Sleep Medicine, Queensland Children's Hospital, Queensland's University of Technology, Brisbane, QLD, Australia
| | - Peter G Gibson
- Hunter Medical Research Institute, Newcastle, NSW, Australia; Department of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle, NSW, Australia
| | - Stuart B Mazzone
- Department of Anatomy and Neuroscience, The University of Melbourne, Melbourne, VIC, Australia
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15
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Prime SJ, Carter HE, McPhail SM, Petsky HL, Chang AB, Graves N, Marchant JM. Chronic wet cough in Australian children: Societal costs and quality of life. Pediatr Pulmonol 2021; 56:2707-2716. [PMID: 33939893 DOI: 10.1002/ppul.25438] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 03/13/2021] [Accepted: 04/12/2021] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Children with chronic wet cough regularly use the health system, experience considerable variability in care, have reduced quality of life (QoL), and, left untreated, poorer health outcomes. Despite this, little is known about the associated economic burden. This study aimed to quantify the cost of chronic wet cough among Australian children from the perspectives of families and the health system. METHODS A cost of illness study was conducted at the Queensland Children's Hospital, Brisbane, using data on 91 children newly referred to a respiratory specialist between July 2015 and January 2017 with a history of chronic wet cough (>4 weeks) of unknown etiology. Administrative and parent-reported data were used to estimate costs (reported in 2019 Australian Dollars [AUD]) for up to 12 months before and following initial pulmonology consultation. QoL was assessed for the same periods. RESULTS Mean cost per child-month during the average 9.8 months of observation preceding pulmonology consultation was AUD689 (95% confidence interval [CI] 534-844) increasing to AUD1339 (95% CI 1051-1628) during the average 11.9 months following pulmonology consultation. This translated to a total of AUD1.9 million across the study period, with families bearing 26.4% of costs. Aspiration and bronchiectasis were associated with higher total costs. For all etiologies, cough-specific QoL improved following pulmonology consultation, while direct medical costs declined. CONCLUSION Childhood chronic wet cough is associated with substantial societal costs. The observed cost decrease after specialist diagnosis suggests that early referral to a respiratory specialist may have economic benefits, in addition to the known health benefits.
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Affiliation(s)
- Samantha J Prime
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Hannah E Carter
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Steven M McPhail
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia.,Clinical Informatics Directorate, Metro South Health, Woolloongabba, Queensland, Australia
| | - Helen L Petsky
- School of Nursing and Midwifery, Griffith University and Menzies Health Institute Queensland, Brisbane, Queensland, Australia
| | - Anne B Chang
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia.,Department of Respiratory and Sleep Medicine, Queensland Children's Hospital, Brisbane, Queensland, Australia.,Child Health Division, Menzies School of Health Research, Darwin, Northern Territory, Australia
| | - Nicholas Graves
- Health Service and Systems Research Program, Duke-NUS Medical School, Singapore
| | - Julie M Marchant
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia.,Department of Respiratory and Sleep Medicine, Queensland Children's Hospital, Brisbane, Queensland, Australia
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16
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Kennedy AA, Anne S, Hart CK. Otolaryngologic Management of Chronic Cough in School-aged Children: A Review. JAMA Otolaryngol Head Neck Surg 2020; 146:1059-1064. [PMID: 33022062 DOI: 10.1001/jamaoto.2020.2945] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Importance The causes of pediatric chronic cough are numerous and span across several medical subspecialties. In addition to the vast array of underlying causes, there are also several different ways to approach and evaluate chronic cough. Given the frequency with which children present to otolaryngology clinics with this problem, a review of common otolaryngologic causes and an algorithm for evaluation and treatment can be beneficial. Observations The primary 3 causes of pediatric chronic cough presenting to an otolaryngologist include infectious causes, reflux, and airway hyperreactivity. In these cases and other instances of specific cough, treatment should be directed at the underlying cause-which may include supportive care, antibiotics, antireflux medication, bronchodilators, inhaled steroids, or other intervention. Patients with nonspecific cough should be treated according to pediatric-specific cough algorithms. Conclusions and Relevance Appropriate workup and treatment of chronic cough can lead to higher cure rates, shorter cough duration, and improved quality of life for both patients and caregivers. A systematic approach using cough algorithms can help otolaryngologists effectively manage this common yet complex problem.
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Affiliation(s)
- Aimee A Kennedy
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Samantha Anne
- Department of Otolaryngology-Head and Neck Surgery, Cleveland Clinic, Cleveland, Ohio.,Section Editor, JAMA Otolaryngology-Head & Neck Surgery
| | - Catherine K Hart
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
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17
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Weinberger M, Hurvitz M. Diagnosis and management of chronic cough: similarities and differences between children and adults. F1000Res 2020; 9. [PMID: 32765833 PMCID: PMC7385707 DOI: 10.12688/f1000research.25468.1] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/15/2020] [Indexed: 11/20/2022] Open
Abstract
Cough is a natural process that protects the airway. Cough can occur spontaneously or voluntarily. It is considered chronic when it is present for longer than 4 weeks in children or 8 weeks in adults. In both, chronic cough causes patient distress and increased healthcare utilization. Etiologies of pediatric chronic cough include asthma, protracted bacterial bronchitis, tracheomalacia, habit cough, and various systemic disorders. While some diagnoses are identifiable by careful history alone, others require testing guided by specific pointers. Flexible fiberoptic bronchoscopy has been an important tool to identify etiologies of chronic cough that were not otherwise apparent. In adults, asthma and bronchitis are well-defined etiologies of chronic cough, but much chronic cough in adults is largely a conundrum. Reviews of adult chronic cough report that at least 40% of adults with chronic cough have no medical explanation. Gastroesophageal reflux and upper airway cough syndrome (a.k.a. post-nasal drip) have been common diagnoses of chronic cough, but those diagnoses have no support from controlled clinical trials and have been subjected to multiple published critiques. Cough hypersensitivity is considered to be an explanation for chronic cough in adults who have no other confirmed diagnosis. Gabapentin, a neuromodulator, has been associated with a modest effect in adults, as has speech pathology. While habit cough has not generally been a diagnosis in adults, there is evidence for a behavioral component in adults with chronic cough. Treatment for a specific diagnosis provides a better outcome than trials of cough suppression in the absence of a specific diagnosis. More data are needed for chronic cough in adults to examine the hypothesized cough hypersensitivity and behavioral management. This article reviews etiologies and the treatment of chronic cough in children and the conundrum of diagnosing and treating chronic cough in adults.
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Affiliation(s)
- Miles Weinberger
- Rady Children's Hospital, University of California San Diego, San Diego, CA, USA
| | - Manju Hurvitz
- Rady Children's Hospital, University of California San Diego, San Diego, CA, USA
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18
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Chang AB, Oppenheimer JJ, Irwin RS, Adams TM, Altman KW, Azoulay E, Blackhall F, Birring SS, Bolser DC, Boulet LP, Braman SS, Brightling C, Callahan-Lyon P, Chang AB, Cowley T, Davenport P, El Solh AA, Escalante P, Field SK, Fisher D, French CT, Grant C, Harding SM, Harnden A, Hill AT, Irwin RS, Kahrilas PJ, Kavanagh J, Keogh KA, Lai K, Lane AP, Lilly C, Lim K, Lown M, Madison JM, Malesker MA, Mazzone S, McGarvey L, Molasoitis A, Murad MH, Narasimhan M, Oppenheimer J, Russell RJ, Ryu JH, Singh S, Smith MP, Tarlo SM, Vertigan AE. Managing Chronic Cough as a Symptom in Children and Management Algorithms. Chest 2020; 158:303-329. [DOI: 10.1016/j.chest.2020.01.042] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 12/11/2019] [Accepted: 01/09/2020] [Indexed: 12/12/2022] Open
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19
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Morice AH, Millqvist E, Bieksiene K, Birring SS, Dicpinigaitis P, Domingo Ribas C, Hilton Boon M, Kantar A, Lai K, McGarvey L, Rigau D, Satia I, Smith J, Song WJ, Tonia T, van den Berg JWK, van Manen MJG, Zacharasiewicz A. ERS guidelines on the diagnosis and treatment of chronic cough in adults and children. Eur Respir J 2020; 55:1901136. [PMID: 31515408 PMCID: PMC6942543 DOI: 10.1183/13993003.01136-2019] [Citation(s) in RCA: 371] [Impact Index Per Article: 92.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 08/01/2019] [Indexed: 01/07/2023]
Abstract
These guidelines incorporate the recent advances in chronic cough pathophysiology, diagnosis and treatment. The concept of cough hypersensitivity has allowed an umbrella term that explains the exquisite sensitivity of patients to external stimuli such a cold air, perfumes, smoke and bleach. Thus, adults with chronic cough now have a firm physical explanation for their symptoms based on vagal afferent hypersensitivity. Different treatable traits exist with cough variant asthma (CVA)/eosinophilic bronchitis responding to anti-inflammatory treatment and non-acid reflux being treated with promotility agents rather the anti-acid drugs. An alternative antitussive strategy is to reduce hypersensitivity by neuromodulation. Low-dose morphine is highly effective in a subset of patients with cough resistant to other treatments. Gabapentin and pregabalin are also advocated, but in clinical experience they are limited by adverse events. Perhaps the most promising future developments in pharmacotherapy are drugs which tackle neuronal hypersensitivity by blocking excitability of afferent nerves by inhibiting targets such as the ATP receptor (P2X3). Finally, cough suppression therapy when performed by competent practitioners can be highly effective. Children are not small adults and a pursuit of an underlying cause for cough is advocated. Thus, in toddlers, inhalation of a foreign body is common. Persistent bacterial bronchitis is a common and previously unrecognised cause of wet cough in children. Antibiotics (drug, dose and duration need to be determined) can be curative. A paediatric-specific algorithm should be used.
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Affiliation(s)
- Alyn H Morice
- Respiratory Research Group, Hull York Medical School, University of Hull, Hull, UK
| | - Eva Millqvist
- Dept of Internal Medicine/Respiratory Medicine and Allergology, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
| | - Kristina Bieksiene
- Dept of Pulmonology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Surinder S Birring
- Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- Dept of Respiratory Medicine, King's College Hospital, London, UK
| | - Peter Dicpinigaitis
- Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, USA
| | - Christian Domingo Ribas
- Pulmonary Service, Corporació Sanitària Parc Taulí (Sabadell), Dept of Medicine, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Michele Hilton Boon
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK
| | - Ahmad Kantar
- Pediatric Cough and Asthma Center, Istituti Ospedalieri Bergamaschi, University and Research Hospitals, Bergamo, Italy
| | - Kefang Lai
- Dept of Clinical Research, State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Health, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
- Representing the Chinese Thoracic Society
| | - Lorcan McGarvey
- Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - David Rigau
- Iberoamerican Cochrane Centre, Barcelona, Spain
| | - Imran Satia
- Dept of Medicine, Division of Respirology, McMaster University, Hamilton, ON, Canada
- University of Manchester, Division of Infection, Immunity and Respiratory Medicine, Manchester Academic Health Science Centre, Manchester, UK
| | - Jacky Smith
- University of Manchester, Division of Infection, Immunity and Respiratory Medicine, Manchester University NHS Foundation Trust, Manchester, UK
| | - Woo-Jung Song
- Airway Sensation and Cough Research Laboratory, Dept of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Representing the Asia Pacific Association of Allergy, Asthma and Clinical Immunology (APAAACI)
| | | | | | - Mirjam J G van Manen
- Dept of Respiratory Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Angela Zacharasiewicz
- Dept of Pediatrics, Teaching Hospital of the University of Vienna, Wilhelminen Hospital, Vienna, Austria
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20
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Au-Yeung YT, Chang AB, Grimwood K, Lovie-Toon Y, Kaus M, Rablin S, Arnold D, Roberts J, Parfitt S, Anderson J, Toombs M, O'Grady KAF. Risk Factors for Chronic Cough in Young Children: A Cohort Study. Front Pediatr 2020; 8:444. [PMID: 32903491 PMCID: PMC7435047 DOI: 10.3389/fped.2020.00444] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 06/26/2020] [Indexed: 11/13/2022] Open
Abstract
Background and Objective: Data on the predictors of chronic cough development in young children are scarce. Our primary objective was to examine the factors associated with young children developing a chronic cough, with a focus on childcare attendance. Methods: A secondary analysis of data collected in a prospective cohort study of children presenting to three emergency departments and three primary healthcare centers in southeast Queensland, Australia. Eligible children where those aged <6-years presenting with cough and without known underlying chronic lung disease other than asthma. Children were followed for 4 weeks to ascertain cough duration. The primary outcome was persistent cough at day-28. Logistic regression models were undertaken to identify independent predictors of chronic cough including sensitivity analyses that accounted for children with unknown cough status at day-28. Results: In 362 children, 95 (26.2%) were classified as having chronic cough. In models that included only children for whom cough status was known at day-28, symptom duration at enrolment, age <12 months [adjusted odds ratio (aOR) 4.5, 95% confidence interval (CI) 1.1, 18.7], gestational age (aOR 3.2, 95%CI 1.4, 7.9), underlying medical conditions (aOR 2.6, 95% CI 1.3, 5.5), a history of wheeze (aOR 2.6, 95% CI 1.4, 4.8) and childcare attendance (aOR 2.3, 95% CI 1.2, 4.4) were independent predictors of chronic cough. Amongst childcare attendees only, 64 (29.8%) had chronic cough at day-28. The strongest predictor of chronic cough amongst childcare attendees was continued attendance at childcare during their illness (aOR = 12.9, 95% CI 3.9, 43.3). Conclusion: Gestational age, underlying medical conditions, prior wheeze and childcare attendance are risk factors for chronic cough in young children. Parents/careers need to be aware of the risks associated with their child continuing to attend childcare whilst unwell and childcare centers should reinforce prevention measures in their facilities.
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Affiliation(s)
- Yin To Au-Yeung
- Australian Center for Health Services Innovation@ Centre for Healthcare Transformation, Queensland University of Technology, South Brisbane, QLD, Australia
| | - Anne B Chang
- Australian Center for Health Services Innovation@ Centre for Healthcare Transformation, Queensland University of Technology, South Brisbane, QLD, Australia.,Child Health Division, Menzies School of Health Research, Tiwi, NT, Australia.,Department of Respiratory Medicine, Queensland Children's Hospital, South Brisbane, QLD, Australia
| | - Keith Grimwood
- School of Medicine, Griffith University, Southport, QLD, Australia.,Menzies Health Institute Queensland, Griffith University, Southport, QLD, Australia.,Department of Paediatrics, Gold Coast Health, Southport, QLD, Australia
| | - Yolanda Lovie-Toon
- Australian Center for Health Services Innovation@ Centre for Healthcare Transformation, Queensland University of Technology, South Brisbane, QLD, Australia
| | - Michelle Kaus
- Australian Center for Health Services Innovation@ Centre for Healthcare Transformation, Queensland University of Technology, South Brisbane, QLD, Australia
| | - Sheree Rablin
- Australian Center for Health Services Innovation@ Centre for Healthcare Transformation, Queensland University of Technology, South Brisbane, QLD, Australia
| | - Dan Arnold
- Australian Center for Health Services Innovation@ Centre for Healthcare Transformation, Queensland University of Technology, South Brisbane, QLD, Australia
| | - Jack Roberts
- Australian Center for Health Services Innovation@ Centre for Healthcare Transformation, Queensland University of Technology, South Brisbane, QLD, Australia
| | - Sarah Parfitt
- Australian Center for Health Services Innovation@ Centre for Healthcare Transformation, Queensland University of Technology, South Brisbane, QLD, Australia
| | | | - Maree Toombs
- Carbal Health Services, Toowoomba, QLD, Australia.,UQ Rural Clinical School, The University of Queensland, Toowoomba, QLD, Australia
| | - Kerry-Ann F O'Grady
- Australian Center for Health Services Innovation@ Centre for Healthcare Transformation, Queensland University of Technology, South Brisbane, QLD, Australia
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21
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Whited TM, Garner DD. An 8-Month-Old With a Chronic Cough. J Pediatr Health Care 2020; 34:63-66. [PMID: 31303543 DOI: 10.1016/j.pedhc.2019.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 06/06/2019] [Accepted: 06/08/2019] [Indexed: 10/26/2022]
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22
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O'Grady KAF, Grimwood K, Torzillo PJ, Rablin S, Lovie-Toon Y, Kaus M, Arnold D, Roberts J, Buntain H, Adsett D, King A, Scott M, Anderson J, Toombs M, Chang AB. Effectiveness of a chronic cough management algorithm at the transitional stage from acute to chronic cough in children: a multicenter, nested, single-blind, randomised controlled trial. THE LANCET CHILD & ADOLESCENT HEALTH 2019; 3:889-898. [PMID: 31635952 DOI: 10.1016/s2352-4642(19)30327-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 09/02/2019] [Accepted: 09/16/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Chronic (lasting at least 4 weeks) cough in children is an important cause of morbidity. An algorithmic approach to the management of coughs in children evaluated in observational studies and a randomised controlled trial (RCT) enrolled children referred with median cough duration of 16 weeks to specialist centres. We investigated whether applying an evidence-based cough management algorithm in non-specialist settings earlier, once cough persisted for more than 4 weeks, improved cough resolution compared with usual care. METHODS We undertook a multicentre, single-blind RCT nested within a prospective cohort study of children (<15 years) in Australia presenting to three primary care or three hospital emergency departments with an acute respiratory illness with cough. Children were excluded if they had a known diagnosis of an underlying chronic medical condition (excluding asthma) or had an immunosuppressive illness or were taking immunomodulating drugs for more than 2 weeks in the preceding 30 days, or had severe symptoms requiring inpatient hospitalisation. Children were followed up for 8 weeks; those with a persistent cough at day 28 were randomly assigned to the cough management algorithm or to usual care. Randomisation was stratified by reason for presentation, study site, and cough duration (4 weeks to <6 weeks vs ≥6 weeks) using computer-generated permuted blocks (block size of four) with a 1:1 allocation. The primary outcome was the proportion of children with cough resolution at day 56 (defined as resolved if the child did not cough for at least 3 days and nights since day 28 or a more than 75% reduction in their average day and night cough score). Absolute risk differences (RDabsolute) were calculated by modified intention-to-treat analysis (ITT). This trial is registered with the Australia New Zealand Clinical Trials Registry, ACTRN12615000132549. FINDINGS Between July 7, 2015, and Oct 31, 2018, 1018 children were screened, 509 were enrolled in the cohort study, and of 115 children in the ITT analysis, 57 were randomly assigned to the intervention group and 58 to the control group. Children had a median age of 1·6 years (IQR 1·0-4·5); 45 (39%) of 115 were Indigenous, and 59 (51%) were boys. By day 56, 33 (58%) of 57 children in the intervention group achieved cough resolution compared with 23 (40%) 58 in the control group; cough resolution was unknown in 12 (21%) of 57 children receiving the intervention and in 13 (22%) of 58 receiving the control. The RDabsolute assuming children with an unknown cough outcome were still coughing at day 56 was 18·3% (95% CI 0·3-36·2); the number needed-to-treat for benefit was five (95% CI 3-364); the adjusted odds ratio was 1·5 (95% CI 1·3-1·6), favouring the intervention group. INTERPRETATION This study suggests an evidence-based cough management algorithm improves cough resolution in community-based children in the early phases of chronic cough. However, larger studies to confirm these findings in primary care are required. FUNDING National Health and Medical Research Council.
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Affiliation(s)
- Kerry-Ann F O'Grady
- Institute of Health and Biomedical Innovation, Centre for Children's Health Research, Queensland University of Technology, South Brisbane, QLD, Australia.
| | - Keith Grimwood
- School of Medicine, Menzies Health Institute Queensland, Griffith University, Gold Coast, QLD, Australia; Departments of Infectious Diseases and Paediatrics, Gold Coast Health, Gold Coast, QLD, Australia
| | - Paul J Torzillo
- Central Clinical School, University of Sydney, Sydney, NSW, Australia; Department of Respiratory Medicine, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Sheree Rablin
- Institute of Health and Biomedical Innovation, Centre for Children's Health Research, Queensland University of Technology, South Brisbane, QLD, Australia
| | - Yolanda Lovie-Toon
- Institute of Health and Biomedical Innovation, Centre for Children's Health Research, Queensland University of Technology, South Brisbane, QLD, Australia
| | - Michelle Kaus
- Institute of Health and Biomedical Innovation, Centre for Children's Health Research, Queensland University of Technology, South Brisbane, QLD, Australia
| | - Daniel Arnold
- Institute of Health and Biomedical Innovation, Centre for Children's Health Research, Queensland University of Technology, South Brisbane, QLD, Australia
| | - Jack Roberts
- Institute of Health and Biomedical Innovation, Centre for Children's Health Research, Queensland University of Technology, South Brisbane, QLD, Australia
| | - Helen Buntain
- Wesley Medical Centre, Auchenflower, QLD, Australia; Department of Respiratory Medicine, Queensland Children's Hospital, South Brisbane, QLD, Australia
| | - Don Adsett
- 78 Margaret Street, Toowoomba, QLD, Australia
| | - Alex King
- The Toowoomba Hospital, Toowoomba, QLD, Australia
| | - Mark Scott
- Caboolture Hospital, Caboolture, QLD, Australia
| | - Jennie Anderson
- Caboolture Community Medical Centre, Caboolture, QLD, Australia
| | - Maree Toombs
- UQ Rural Clinical School, University of Queensland, Toowoomba, QLD, Australia
| | - Anne B Chang
- Institute of Health and Biomedical Innovation, Centre for Children's Health Research, Queensland University of Technology, South Brisbane, QLD, Australia; Menzies School of Health Research, Charles Darwin University, Darwin Northern Territory, Australia; Department of Respiratory Medicine, QLD Children's Hospital, South Brisbane, QLD, Australia
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Mohan D. Controversies in Cough Management: An Indian Perspective. Indian J Community Med 2019; 44:303-306. [PMID: 31802789 PMCID: PMC6881895 DOI: 10.4103/ijcm.ijcm_174_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 09/23/2019] [Indexed: 11/06/2022] Open
Abstract
Chronic cough is one of the most common symptoms for patients-seeking consultation in an outpatient clinic. It is associated with substantial psychological, physical, and social burdens and impaired quality of life. This review highlights some of the major diagnostic and management challenges confronted in the field of cough with a special focus on the Indian perspective. Heterogeneity in definitions and classifications and challenges associated with over-the-counter drug use and irrational drug use are some of the major controversies. Streamlined diagnostic approach involving a combination of subjective and objective tools, evidence-based amendments in clinical practice, and stringent implementation of regulatory guidelines are mandatory to address controversies in cough management in developing countries.
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Affiliation(s)
- Dhanya Mohan
- ChanRe Rheumatology and Immunology Center, Bengaluru, Karnataka, India
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24
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Hirai K, Nukaga M, Tabata H, Enseki M, Furuya H, Niimura F, Yamaguchi K, Mochizuki H. Objective measurement of nocturnal cough in infants with acute bronchiolitis. Respir Investig 2019; 57:605-610. [PMID: 31327680 DOI: 10.1016/j.resinv.2019.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 04/10/2019] [Accepted: 06/10/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVES The objective measurement of the cough severity and the assessment of the pattern of nocturnal coughing could be useful in the treatment of respiratory diseases in children. STUDY DESIGN In children with respiratory syncytial virus (RSV)-induced acute bronchiolitis, coughs were recorded using our original system with a microphone and accelerometer, and analyzed using our customized software program. The number of coughs in every 30-minute interval was measured in patients with acute bronchiolitis (n = 20), and their results were compared with those of infants with asthma exacerbation (n = 16). RESULTS The cough count in children with acute bronchiolitis (median: 108.0/night) was almost as high as that in children with asthma exacerbation (median: 119/night). However, the time-dependent pattern of overnight cough was different in infants with acute bronchiolitis and those with asthma exacerbation. In the infants with asthma exacerbation, cough frequency significantly increased while falling asleep and waking up as compared to midnight (p < 0.001 and p < 0.001, respectively). However, these differences were not found in infants with acute bronchiolitis. CONCLUSIONS Our data demonstrated that the number of coughing events due to acute bronchiolitis was similar to that of acute asthma exacerbation, although the acute bronchiolitis did not show a characteristic overnight cough pattern.
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Affiliation(s)
- Kota Hirai
- Department of Pediatrics, Tokai University Hachioji Hospital, 1838, Ishikawa, Hachioji, Tokyo, 192-0032 Japan.
| | - Mariko Nukaga
- Department of Pediatrics, Tokai University School of Medicine, 143, Shimokasuya, Isehara, Kanagawa, 259-1193 Japan.
| | - Hideyuki Tabata
- Department of Pediatrics, Tokai University School of Medicine, 143, Shimokasuya, Isehara, Kanagawa, 259-1193 Japan.
| | - Mayumi Enseki
- Department of Pediatrics, Tokai University School of Medicine, 143, Shimokasuya, Isehara, Kanagawa, 259-1193 Japan.
| | - Hiroyuki Furuya
- Department of Basic Clinical Science and Public Health, Tokai University School of Medicine, 143, Shimokasuya, Isehara, Kanagawa, 259-1193 Japan.
| | - Fumio Niimura
- Department of Pediatrics, Tokai University School of Medicine, 143, Shimokasuya, Isehara, Kanagawa, 259-1193 Japan.
| | - Koichi Yamaguchi
- Department of Pediatrics, Tokai University Hachioji Hospital, 1838, Ishikawa, Hachioji, Tokyo, 192-0032 Japan.
| | - Hiroyuki Mochizuki
- Department of Pediatrics, Tokai University School of Medicine, 143, Shimokasuya, Isehara, Kanagawa, 259-1193 Japan.
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25
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Korppi M. Review shows paediatric protracted bacterial bronchitis needs an accurate diagnosis and strictly targeted extended antibiotics. Acta Paediatr 2019; 108:823-827. [PMID: 30580451 DOI: 10.1111/apa.14705] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 12/13/2018] [Accepted: 12/18/2018] [Indexed: 12/31/2022]
Abstract
AIM In 2017, the European Respiratory Society task force stated that protracted bacterial bronchitis (PBB) was a distinct clinical entity and outlined the diagnostic criteria and principles for treatment. However, this guidance was based on data from Australia and the USA. This mini review evaluated the data and addressed the lack of research-based data from Europe. METHODS We supplemented the 2017 report by conducting a nonsystematic review of the literature on prolonged wet or productive cough and on PBB in children up to September 2018. RESULTS Our review confirmed the lack of European data on PBB. Based on the available literature, and the 2017 European guidance, PBB is a wet or productive cough that lasts for four or more weeks, with no signs or symptoms, known as specific cough pointers, which suggest an underlying illness. PBB usually recovers with appropriate antibiotics for two weeks. Failing that radiological investigations or lung function measurements are needed. If PBB occurs three times over 12 months, then computerised tomography can diagnose bronchiectasis and determine other permanent changes. CONCLUSION More data are needed on PBB, especially in Europe. The implementation of PBB may help clinicians to prescribe antibiotics more effectively and reduce their inappropriate use.
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Affiliation(s)
- Matti Korppi
- Center for Child Health Research Tampere University and University Hospital Tampere Finland
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26
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Chang AB, Fong SM, Yeo TW, Ware RS, McCallum GB, Nathan AM, Ooi MH, de Bruyne J, Byrnes CA, Lee B, Nachiappan N, Saari N, Torzillo P, Smith-Vaughan H, Morris PS, Upham JW, Grimwood K. HOspitalised Pneumonia Extended (HOPE) Study to reduce the long-term effects of childhood pneumonia: protocol for a multicentre, double-blind, parallel, superiority randomised controlled trial. BMJ Open 2019; 9:e026411. [PMID: 31023759 PMCID: PMC6502017 DOI: 10.1136/bmjopen-2018-026411] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 12/06/2018] [Accepted: 01/08/2019] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Early childhood pneumonia is a common problem globally with long-term complications that include bronchiectasis and chronic obstructive pulmonary disease. It is biologically plausible that these long-term effects may be minimised in young children at increased risk of such sequelae if any residual lower airway infection and inflammation in their developing lungs can be treated successfully by longer antibiotic courses. In contrast, shortened antibiotic treatments are being promoted because of concerns over inducing antimicrobial resistance. Nevertheless, the optimal treatment duration remains unknown. Outcomes from randomised controlled trials (RCTs) on paediatric pneumonia have focused on short-term (usually <2 weeks) results. Indeed, no long-term RCT-generated outcome data are available currently. We hypothesise that a longer antibiotic course, compared with the standard treatment course, reduces the risk of chronic respiratory symptoms/signs or bronchiectasis 24 months after the original pneumonia episode. METHODS AND ANALYSIS This multicentre, parallel, double-blind, placebo-controlled randomised trial involving seven hospitals in six cities from three different countries commenced in May 2016. Three-hundred-and-fourteen eligible Australian Indigenous, New Zealand Māori/Pacific and Malaysian children (aged 0.25 to 5 years) hospitalised for community-acquired, chest X-ray (CXR)-proven pneumonia are being recruited. Following intravenous antibiotics and 3 days of amoxicillin-clavulanate, they are randomised (stratified by site and age group, allocation-concealed) to receive either: (i) amoxicillin-clavulanate (80 mg/kg/day (maximum 980 mg of amoxicillin) in two-divided doses or (ii) placebo (equal volume and dosing frequency) for 8 days. Clinical data, nasopharyngeal swab, bloods and CXR are collected. The primary outcome is the proportion of children without chronic respiratory symptom/signs of bronchiectasis at 24 months. The main secondary outcomes are 'clinical cure' at 4 weeks, time-to-next respiratory-related hospitalisation and antibiotic resistance of nasopharyngeal respiratory bacteria. ETHICS AND DISSEMINATION The Human Research Ethics Committees of all the recruiting institutions (Darwin: Northern Territory Department of Health and Menzies School of Health Research; Auckland: Starship Children's and KidsFirst Hospitals; East Malaysia: Likas Hospital and Sarawak General Hospital; Kuala Lumpur: University of Malaya Research Ethics Committee; and Klang: Malaysian Department of Health) have approved the research protocol version 7 (13 August 2018). The RCT and other results will be submitted for publication. TRIAL REGISTRATION ACTRN12616000046404.
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Affiliation(s)
- Anne B Chang
- Child Health Division, Menzies School of Health Research, Charles Darwin Univ, Darwin, Northern Territory, Australia
- Qld Children's Hospital, Brisbane, Queensland, Australia
| | | | - Tsin Wen Yeo
- Global and Tropical Health Division, Menzies School of Health Research, Darwin, Northern Territory, Australia
| | - Robert S Ware
- School of Population Health, The University of Queensland, Brisbane, Queensland, Australia
| | - Gabrielle B McCallum
- Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | | | - Mong H Ooi
- Universiti Malaysia Sarawak, Kuching, Malaysia
| | | | | | - Bilawara Lee
- Charles Darwin University, Darwin, Northern Territory, Australia
| | | | | | - Paul Torzillo
- Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Heidi Smith-Vaughan
- Child Health Division, Menzies School of Health Research, Darwin, Northern Territory, Australia
| | - Peter S Morris
- Menzies School of Health Research, Darwin, Northern Territory, Australia
| | - John W Upham
- School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Keith Grimwood
- Menzies Health Institute Queensland, Griffith University, Southport, Queensland, Australia
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27
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Prime SJ, Marchant J, Chang AB, Petsky HL. Development of a quality improvement audit tool for the primary care of children with chronic wet cough using a modified Delphi consensus approach. J Paediatr Child Health 2019; 55:459-464. [PMID: 30251373 DOI: 10.1111/jpc.14229] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Accepted: 08/27/2018] [Indexed: 01/23/2023]
Abstract
AIM In the absence of quality indicators (QIs) for the management of chronic wet cough, our study's aim was to determine whether consensus on QIs reflecting good primary health care, prior to referral for children with chronic wet cough, can be achieved. METHODS A questionnaire consisting of 10 QIs was developed by a clinical working group based on current evidence and guidelines on the management of chronic wet cough in children. Each indicator reflected the quality of care provided to children with chronic wet cough in primary care prior to referral. A modified Delphi consensus questionnaire was undertaken involving expert paediatric respiratory clinicians and general paediatricians who graded the importance of each indicator for the purposes above. We a priori defined that consensus was considered achieved if >75% agreed on the indicator. RESULTS Twenty-two specialists (from Brisbane, Melbourne, Perth and Canberra) participated in the survey. The cumulative number of years of their respiratory experience was 324 and that of general clinical practice was 504. Consensus was achieved in all 10 QIs, with 6 reaching 100% agreement. Mean agreement for the 10 items was 97%. CONCLUSION As complete consensus was achieved on these QIs, it can be used as a provisional clinical audit tool and can guide the development of a robust audit tool for primary care clinical practice to assist with quality improvement initiatives.
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Affiliation(s)
- Samantha J Prime
- Centre for Children's Health Research, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Julie Marchant
- Centre for Children's Health Research, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia.,Department of Respiratory and Sleep Medicine, Lady Cilento Children's Hospital, Brisbane, Queensland, Australia
| | - Anne B Chang
- Centre for Children's Health Research, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia.,Department of Respiratory and Sleep Medicine, Lady Cilento Children's Hospital, Brisbane, Queensland, Australia.,Child Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Helen L Petsky
- School of Nursing and Midwifery, Menzies Health Institute of Queensland, Griffith University, Brisbane, Queensland, Australia
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28
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Affiliation(s)
- Ajay S Kasi
- Division of Pediatric Pulmonology, Department of Pediatrics, Emory University, Atlanta, GA
| | - Rory J Kamerman-Kretzmer
- Division of Pediatric Pulmonology and Sleep Medicine, Children's Hospital Los Angeles, Los Angeles, CA
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Krishnan S, Ianotti V, Welter J, Gallagher MM, Ndjatou T, Dozor AJ. Bronchodilators, Antibiotics, and Oral Corticosteroids Use in Primary Care for Children With Cough. Glob Pediatr Health 2019; 6:2333794X19831296. [PMID: 30828592 PMCID: PMC6390215 DOI: 10.1177/2333794x19831296] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 12/10/2018] [Accepted: 12/18/2018] [Indexed: 01/16/2023] Open
Abstract
Real-world management decisions for acute cough in children in primary care
practice are not well understood. This study is an analysis of 560 encounters
for children with cough, 19 days to 18 years of age, seen in a predominantly
suburban academic pediatric practice, over 1 year. Past history, cough duration,
and cough characteristics significantly affected treatment decisions. Children
with cough frequently had a history of preterm birth, allergies, asthma, and
neurological conditions. Most common therapies were bronchodilators,
antibiotics, and oral corticosteroids. Children prescribed antibiotics were
older, more likely to have a wet or productive cough, history of sinusitis,
pneumonia or dysphagia, and longer cough duration. Children prescribed oral
corticosteroids were younger, less likely to be wet or productive and more
likely to have history of asthma or dysphagia. Children prescribed
bronchodilators were more likely to have fever, nasal congestion, and wheezing
and history of previous asthma, pneumonia, or dysphagia.
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Affiliation(s)
| | | | | | | | - Tatiana Ndjatou
- NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY, USA
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30
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de Benedictis FM, Carloni I, Comberiati P, Shields MD, Bush A, Chang AB. Wet Cough and Nasal Symptoms in Children: Can We Do Better? Front Pediatr 2019; 7:459. [PMID: 31956642 PMCID: PMC6949513 DOI: 10.3389/fped.2019.00459] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 10/22/2019] [Indexed: 11/13/2022] Open
Abstract
The causes of chronic cough in children are mainly dependent on the setting and age of the child. Protracted bacterial bronchitis is a frequent cause of morbidity in childhood, and antibiotic treatment is beneficial. Prompt recognition and early treatment is important both to prevent inappropriate use of asthma medications and also progression to bronchiectasis, but the diagnosis should not be made uncritically, because chronic wet cough is not necessarily due to lower airway disease. Upper Airway Cough Syndrome (UACS) is considered by some to cause chronic cough in childhood. Underlying UACS are many common conditions, including allergic rhinitis, adenoiditis and rhinosinusitis. Diagnosis relies on a combination of clinical criteria that are relatively sensitive but non-specific. The role of nasal endoscopy in children with chronic cough and signs suggesting UACS is unclear. Nasal saline solution irrigation is commonly used in UACS, but most studies have methodological biases, and efficacy data are scanty. Randomized controlled trials are urgently required. However, if saline washes, rather than oral antibiotics, can effectively treat some children with wet cough associated with upper airway conditions, antibiotic resistance could potentially be reduced. There is a need to further study wet cough and not to assume it to be equivalent to lower airway infection in all children.
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Affiliation(s)
| | - Ines Carloni
- Department of Child and Mother Health, Salesi Children's Hospital, Ancona, Italy
| | - Pasquale Comberiati
- Section of Paediatrics, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Michael D Shields
- Centre for Experimental Medicine, Royal Belfast Hospital for Sick Children, Queen's University of Belfast, Belfast, United Kingdom
| | - Andrew Bush
- Department of Paediatric Respiratory Medicine, Imperial School of Medicine, National Heart and Lung Institute, Royal Brompton Hospital, London, United Kingdom
| | - Anne B Chang
- Child Health Division, Menzies School of Health Research, Casuarina, NT, Australia.,Department of Respiratory and Sleep Medicine, Queensland Children's Hospital, Brisbane, QLD, Australia.,Queensland University of Technology, Brisbane, QLD, Australia
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31
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Kazachkov M, Kapoor BC, Malecha PW, Wu BG, Li Y, Levine J, Erkman J, Fitzgerald K, Moy L, Segal LN. Aerodigestive dysbiosis in children with chronic cough. Pediatr Pulmonol 2018; 53:1288-1298. [PMID: 29984544 DOI: 10.1002/ppul.24115] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 06/11/2018] [Indexed: 12/31/2022]
Abstract
UNLABELLED In pediatric patients with chronic cough, respiratory culture techniques commonly yield negative results. Studies using culture-independent methods have found a high relative abundance of oral microbes in the lower airways, suggesting that the topographical continuity, and dynamics of the intraluminal contents of the aerodigestive system likely influence the lower airway microbiota. We hypothesize that in subjects with chronic cough, clinical diagnosis will correlate with distinct microbial signatures detected using culture-independent methods. STUDY DESIGN AND METHODS We enrolled 36 pediatric subjects with chronic cough in a cross-sectional study. Subjects were categorized into four clinical groups: asthma, bacterial bronchitis, neurologically impaired-orally fed, and neurologically impaired enterally fed. Samples from the aerodigestive tract were obtained through bronchoscopy and upper endoscopy. 16S rRNA gene sequencing compared the microbiota from bronchoalveolar lavage (BAL), tracheal, supraglottic, esophageal, gastric, and duodenal samples. RESULTS We observed that the lower airway microbiota of asthma subjects had higher α diversity as compared with the other groups. β diversity analysis of BAL samples revealed significant differences between the groups. Among the taxonomic differences found, most differentially enriched taxa were upper airway organisms such as Rothia, Gemellaceae (u.g. or uncharacterized genus), and Granulicatella in asthma, Prevotella in bacterial bronchitis, and Veillonella in neurologically impaired orally fed subjects. Greater dissimilarity between the upper airway and lower airway microbiota was associated with increased neutrophilic airway inflammation. CONCLUSIONS Distinct dysbiotic signatures can be identified in the lower airway microbiota of pediatric subjects with chronic cough that relates to the degree and type of inflammation.
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Affiliation(s)
- Mikhail Kazachkov
- Division of Pediatric Pulmonary Medicine, New York University School of Medicine, New York, New York
| | - Bianca C Kapoor
- Division of Pediatric Pulmonary Medicine, New York University School of Medicine, New York, New York
| | - Patrick W Malecha
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Benjamin G Wu
- Division of Pulmonary and Critical Care Medicine, New York University School of Medicine, New York, New York
| | - Yonghua Li
- Division of Pulmonary and Critical Care Medicine, New York University School of Medicine, New York, New York
| | - Jeremiah Levine
- Division of Pediatric Gastroenterology, New York University School of Medicine, New York, New York
| | - Jessica Erkman
- Division of Pediatric Pulmonary Medicine, New York University School of Medicine, New York, New York
| | - Kathryn Fitzgerald
- Division of Pediatric Pulmonary Medicine, New York University School of Medicine, New York, New York
| | - Libia Moy
- Division of Pediatric Gastroenterology, New York University School of Medicine, New York, New York
| | - Leopoldo N Segal
- Division of Pulmonary and Critical Care Medicine, New York University School of Medicine, New York, New York
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33
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Song DJ, Song WJ, Kwon JW, Kim GW, Kim MA, Kim MY, Kim MH, Kim SH, Kim SH, Kim SH, Kim ST, Kim SH, Kim JK, Kim JH, Kim HJ, Kim HB, Park KH, Yoon JK, Lee BJ, Lee SE, Lee YM, Lee YJ, Lim KH, Jeon YH, Jo EJ, Jee YK, Jin HJ, Choi SH, Hur GY, Cho SH, Kim SH, Lim DH. KAAACI Evidence-Based Clinical Practice Guidelines for Chronic Cough in Adults and Children in Korea. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2018; 10:591-613. [PMID: 30306744 PMCID: PMC6182199 DOI: 10.4168/aair.2018.10.6.591] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 05/24/2018] [Indexed: 12/13/2022]
Abstract
Chronic cough is common in the community and causes significant morbidity. Several factors may underlie this problem, but comorbid conditions located at sensory nerve endings that regulate the cough reflex, including rhinitis, rhinosinusitis, asthma, eosinophilic bronchitis, and gastroesophageal reflux disease, are considered important. However, chronic cough is frequently non-specific and accompanied by not easily identifiable causes during the initial evaluation. Therefore, there are unmet needs for developing empirical treatment and practical diagnostic approaches that can be applied in primary clinics. Meanwhile, in referral clinics, a considerable proportion of adult patients with chronic cough are unexplained or refractory to conventional treatment. The present clinical practice guidelines aim to address major clinical questions regarding empirical treatment, practical diagnostic tools for non-specific chronic cough, and available therapeutic options for chronic wet cough in children and unexplained chronic cough in adults in Korea.
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Affiliation(s)
- Dae Jin Song
- Department of Pediatrics, Korea University College of Medicine and Environmental Health Center for Childhood Asthma, Korea University Anam Hospital, Seoul, Korea
| | - Woo Jung Song
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Woo Kwon
- Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Gun Woo Kim
- Department of Internal Medicine, St. Carollo General Hospital, Suncheon, Korea
| | - Mi Ae Kim
- Department of Pulmonology, Allergy and Critical Care Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Mi Yeong Kim
- Department of Internal Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Min Hye Kim
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea
| | - Sang Ha Kim
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Sang Heon Kim
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Sang Hyuck Kim
- Department of Family Medicine, Seoul National University Hospital, Seoul, Korea
| | - Sun Tae Kim
- Department of Otorhinolaryngology, Gachon University, Gil Medical center, Incheon, Korea
| | - Sae Hoon Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Bundang, Korea
| | - Ja Kyoung Kim
- Department of Pediatrics, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Joo Hee Kim
- Department of Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Hyun Jung Kim
- Institute for Evidence-based Medicine Cochrane Korea, Department of Preventive Medicine, Korea University College of Medicine, Seoul, Korea
| | - Hyo Bin Kim
- Department of Pediatrics, Inje University Sanggye Paik Hospital, Seoul, Korea
| | - Kyung Hee Park
- Division of Allergy and Immunology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | | | - Byung Jae Lee
- Department of Medicine, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung Eun Lee
- Respiratory and Allergy Clinic, Pusan National University Yangsan Hospital, Yangsan, Korea
| | | | - Yong Ju Lee
- Department of Pediatrics, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea
| | - Kyung Hwan Lim
- Department of Internal Medicine, Armed Forces Capital Hospital, Seongnam, Korea
| | - You Hoon Jeon
- Department of Pediatrics, Hallym University Dongtan Sacred Heart Hospital, Dongtan, Korea
| | - Eun Jung Jo
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Young Koo Jee
- Department of Internal Medicine, Dankook University College of Medicine, Cheonan, Korea
| | - Hyun Jung Jin
- Department of Internal medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Sun Hee Choi
- Department of Pediatrics, Kyung Hee University School of Medicine, Seoul, Korea
| | - Gyu Young Hur
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Sang Heon Cho
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Sang Hoon Kim
- Department of Internal Medicine, Eulji Hospital, Eulji University School of Medicine, Seoul, Korea.
| | - Dae Hyun Lim
- Department of Pediatrics, Inha University School of Medicine and Environmental Health Center for Allergic Disease, Inha University Hospital, Incheon, Korea.
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Chang AB, Oppenheimer JJ, Weinberger M, Grant CC, Rubin BK, Irwin RS. Etiologies of Chronic Cough in Pediatric Cohorts: CHEST Guideline and Expert Panel Report. Chest 2017. [PMID: 28645463 DOI: 10.1016/j.chest.2017.06.006] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND There is no published systematic review on the etiologies of chronic cough or the relationship between OSA and chronic cough in children aged ≤ 14 years. We thus undertook a systematic review based on key questions (KQs) using the Population, Intervention, Comparison, Outcome format. The KQs follow: Among children with chronic (> 4 weeks) cough (KQ 1) are the common etiologies different from those in adults? (KQ 2) Are the common etiologies age or setting dependent, or both? (KQ 3) Is OSA a cause of chronic cough in children? METHODS We used the CHEST Expert Cough Panel's protocol and the American College of Chest Physicians (CHEST) methodological guidelines and Grading of Recommendations Assessment, Development, and Evaluation framework. Data from the systematic reviews in conjunction with patients' values and preferences and the clinical context were used to form recommendations. Delphi methodology was used to obtain consensus. RESULTS Combining KQs 1 and 2, we found moderate-level evidence from 10 prospective studies that the etiologies of cough in children are different from those in adults and are setting dependent. Data from three studies found that common etiologies of cough in young children were different from those in older children. However, data relating sleep abnormalities to chronic cough in children were found only in case studies. CONCLUSIONS There is moderate-quality evidence that common etiologies of chronic cough in children are different from those in adults and are dependent on age and setting. As there are few data relating OSA and chronic cough in children, the panel suggested that these children should be managed in accordance with pediatric sleep guidelines.
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Affiliation(s)
- Anne B Chang
- Division of Child Health, Menzies School of Health Research, Lady Cilento Children's Hospital, Qld Uni of Technology Queensland, Australia; Respiratory and Sleep Department, Lady Cilento Children's Hospital, Qld Uni of Technology Queensland, Australia.
| | - John J Oppenheimer
- Division of Allergy and Immunology, Department of Medicine, New Jersey Medical School, Pulmonary and Allergy Associates, Morristown, NJ
| | - Miles Weinberger
- Department of Pediatrics, University of California, San Diego, Rady Children's Hospital, San Diego, CA
| | - Cameron C Grant
- Department of Paediatrics: Child and Youth Health, Faculty of Medicine and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Bruce K Rubin
- Department of Pediatrics, Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, VA
| | - Richard S Irwin
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, UMass Memorial Medical Center, Worcester, MA
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Abstract
Chronic cough in children is increasingly defined as a cough that lasts more than four weeks. It is recognized as a different entity than cough in adults. As a result, the diagnostic approach and management of chronic cough in children are no longer extrapolated from adult guidelines. These differences are attributed to the various characteristics of the respiratory tract, immunological system and nervous system in children. Specific paediatric guidelines and algorithms for chronic cough are now widely applied. Post-infectious cough, asthma, bronchiectasis, malacia and protracted bacterial bronchitis (PBB) appear to be the major causes of cough in young children. By adolescence, the causes of cough are more likely to be similar to those in adults, namely, gastroesophageal reflux, asthma, and upper airway syndrome. In a primary setting, it is essential to investigate the underlying disease entity that initiates and sustains chronic cough. The use of cough management protocols or algorithms improves clinical outcomes and should differ depending on the associated characteristics of the cough and the child's clinical history. Performing a thorough history and physical examination is crucial to starting an individualised approach. A correct interpretation of the phenotypic presentation can be translated into guidance for workup. This approach will be helpful for adequate management without the risk of inappropriate investigations or inadequate treatment.
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Affiliation(s)
- Ahmad Kantar
- Paediatric Asthma and Cough Centre, University and Research Hospitals, Gruppo Ospedaliero San Donato, Bergamo, Italy
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