Algorithm for management of chronic cough

Abstract

The importance of chronic cough Chronic cough is one of the most common presenting symptoms to pediatric respiratory specialty physicians. Chronic cough is often dismissed as “only a cough” in the general medical community. However, the burden of the symptom is significant to parents and the children; both in terms of personal cost with impaired quality of life (QoL),1,2 and at a societal level where physician visits, medication expenses as well as absenteeism and presenteeism are substantial. Indeed, a multi-center (n = 346) study2 involving children presenting for the first time to respiratory specialists with chronic cough found that; (a) ∼80% had seen > 5 doctors for their cough and (b) their QoL was as poor as those with cardiac disease. Further, the presence of chronic cough reflects an underlying serious disorder.3 Delayed diagnosis (eg foreign body) may cause chronic respiratory morbidity. Further, early diagnosis of chronic respiratory diseases leading to appropriate management and subsequent resolution of cough and improved QoL2 is important. In the study involving 346 children mentioned above2, ∼12% had a serious underlying illness (eg bronchiectasis). Thus, in the evaluation of children with chronic cough, determining which children require further investigations and/or treatment is a key management strategy. Using a cough algorithm is one such strategy that has the potential to reduce the morbidity of chronic cough, lead to earlier diagnosis of chronic underlying illness and reduce the unnecessary costs and adverse events from medications used. Is there evidence using a cough algorithm improves clinical outcomes? Under the auspices of the American College of Chest Physicians (ACCP), systematic reviews addressing whether the above question was undertaken, in addition to whether the cough management or testing algorithm differs depending on the duration and/or severity? The systematic reviews4 found high quality evidence that using cough management protocols (or algorithms) improves clinical outcomes in children aged ≤ 14 years with chronic cough ( > 4 weeks duration) but there were no studies that addressed whether the management or testing algorithm should depend on the duration and/or severity of chronic cough. The highest evidence for using a chronic cough pathway is that from the ACCP including a randomized controlled trial and several cohort studies whereas the evidence for other pathways was restricted to single cohort studies.4 However, the performance of cough algorithms is likely dependent on the setting (eg study population, expertise of the clinicians, study setting, etc.). What are the key components of a cough algorithm? As described in the ACCP systematic reviews, management of chronic pediatric cough should depend on the associated characteristics of the cough and clinical history.4,5 Pediatric cough management algorithms5,6,7 are largely based on the etiology of the cough i.e. not using an empirical approach aimed at treating upper airway cough syndrome due to a rhinosinus condition, gastroesophageal reflux disease and/or asthma unless other features consistent with these conditions are present. Effectively, differentiating 'specific cough' from 'nonspecific cough' requires a systematic careful elucidation of the cough characteristics and associations, in addition to general pediatric issues. A chest radiograph and spirometry (when age-appropriate) should also be undertaken. Other tests may be required in accordance to the clinical setting and the child's clinical symptoms and signs and not routinely performed and undertaken.L6287108912019-08-05 <br />