Download guidelines for evaluating chronic cough in pediatrics

WALTER REED JOURNAL CLUB
HOW TO USE A CLINICAL PRACTICE
GUIDELINE (JAMA)
Jennifer S. Kicker, MD
30 January 2007
Morning Clinic
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6mo male presents to clinic with “barking cough.”
9mo male with paroxysms of cough and emesis.
7yo female with known RAD presents with cough
and wheezing.
12yo male with remote history of URI has been
“coughing since Thanksgiving.”
15yo female with cough for past month, noticed by
parents that only occurs after home from school.
AGENDA
• Cough fast facts.
• Article introduction.
• Literature review of recommendations.
a.) Diagnostic approaches
b.) Etiology
c.) Treatment
• Strength of evidence.
• Applicable for our clinical practice?
COUGH
“A rapid expulsion of air from the lungs typically in
order to clear the lung airways of fluid, mucus, or
irritating material. Often occurs in succession.”
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Within the top 5 for number of doctor’s visits/yr
Money spent OTC/home remedies: ~$40 billion/yr
Lost time from work and school
Sleep disturbances
ARTICLE OF INTEREST
Chang AB, Glomb WB. Guidelines for Evaluating Chronic Cough in
Pediatrics: ACCP Evidence-Based Clinical Practice Guidelines.
Chest 2006; 129: 260S-283S.
Objective: To review relevant literature and present
evidence-based guidelines to assist general and
specialist medical practitioners in the evaluation and
management of children who present with chronic
cough.
INCLUSION CRITERIA
• Articles on cough diagnosis, etiology, treatment, and
complications were searched separately.
• Children 0-14 years with cough >4 weeks duration.
• English articles published Jan 1966 – Dec 2003.
• Cochrane Register (CENTRAL), PubMed, EMBASE.
• September 1 – December 5, 2003: abstracts identified and
reviewed by single author.
• 274 articles for full review.
• Last search Cochrane: November 7, 2004.
• Accepted for publication: December 5, 2004.
NOT SMALL ADULTS
(CAUTION WITH EXTRAPOLATING ADULT
LITERATURE)
• Viruses responsible for common cold in adults may cause
serious respiratory illness in kids.
• Maturational differences in airway anatomy, respiratory
musculature, chest wall structure.
• Differences in medication response.
• Medical history in young kids is limited by parental
perception and availability.
“Children should be managed according to the studies and
guidelines for children (when available), because etiologic factors
and treatments in children are sometimes different from those in
adults.” (B)
DIAGNOSTIC APPROACHES
“Children with chronic cough require careful and systematic
evaluation for the presence of specific diagnostic indicators.”
(E/A)
“In children with chronic cough, the etiology should be
defined and treatment should be etiologically based.” (E/A)
“Children with chronic productive purulent cough should
always be investigated to document the presence or absence
of bronchiectasis and to identify underlying and treatable
causes such as cystic fibrosis and immune deficiency.” (B)
History and physical exam first:
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Specific pointers suggestive of specific cough.
DIAGNOSTIC APPROACHES
Pointers to the Presence of Specific Cough (Table 1)
• Auscultatory findings, wheeze, crepitations
• Cardiac abnormalities
• Chest pain
• Chest wall deformity
• Digital clubbing, FTT (CF)
• Neurodevelopmental (potential for aspiration)
“In children with nonspecific cough, cough may spontaneously
resolve, but children should be reevaluated for the emergence
of specific etiologic pointers.” (B)
DIAGNOSTIC APPROACHES
• Cough quality is suggestive of etiology, but no
published studies on “dry cough” vs. “wet cough”
• Most cough characteristics recognized as classical
have not been formally evaluated.
• 6mo male presents to clinic with “barking cough.”
• 9mo male with paroxysms of cough and emesis.
DIAGNOSTIC APPROACHES
DIAGNOSTIC APPROACHES
• 12yo male with remote history of URI has been “coughing
since Thanksgiving.”
“Children with chronic cough should undergo, as a minimum, CXR
and spirometry, if age appropriate.” (E/B)
• CXR quick, readily attainable.
• Spirometry reliably performed in kids > 6 yrs (often >3 yrs,
with appropriate personnel).
DIAGNOSTIC APPROACHES
Also considered:
• Chest or sinus CT
a.) HRCT as current gold standard for eval of small
airway anatomy.
b.) Lifetime cancer risk is age and dose dependent.
c.) Single Chest CT scan ~ 5.8 mSv (CXR ~ 0.02 mSv,
so = 300 CXRs).
• Flexible bronchoscopy
1.) suspicion of airway abnormality.
2.) localized radiology changes.
3.) suspicion of inhaled foreign body.
4.) eval of aspiration lung disease.
5.) micro studies and lavage (BAL).
ETIOLOGY
“In children with specific cough, further investigations may be
warranted, except when asthma is the etiologic factor.” (E/B)
• Cough is the most common presenting symptom in
patients presenting to doctors in US and Australia.
• Viral URIs, which also cause cough, are said to account
for 80 percent of childhood asthma exacerbations.
• 7yo female with known RAD presents with
cough and wheezing.
ETIOLOGY
Upper Airway Disorders and Cough
• Upper airway cough syndrome (aka post-nasal drip) well
documented in adults.
• In children, relationship between nasal secretions and
cough is more likely linked by common etiology (infection
or inflammation).
• Abnormal sinus radiographs found in 18-82% of
asymptomatic children.
• No RCTs on therapies for upper airway disorders in kids
with improvement of nonspecific cough as outcome
measurement.
ETIOLOGY
GERD and Cough
• PROOF that GERD causes chronic cough in kids is rare.
• Infants often regurgitate, but few well infants cough with
these episodes.
• Available prospective studies of chronic cough in kids
suggest that GERD is infrequently the SOLE cause.
ETIOLOGY
Airway Lesions and Cough
• Prevalence of airway lesions found in asymptomatic
children is unknown.
• Relationship of cough to airway lesion can only be
postulated:
• Airway malacia impedes clearance of secretions;
potential for pneumonic process distal to lesion138
ETIOLOGY
Environmental Pulmonary Toxicants
• Increases susceptibility to respiratory infections143,144
• Increases coughing illnesses146,147
• Close association to tobacco smoke exposure,
especially in association with asthma.
• 15yo female with cough for past month, noticed by
parents that only occurs after home from school.
“In all children with cough, exacerbating factors such as ETS
exposure should be determined and interventional options for
the cessation of exposure advised and initiated.” (B)
ETIOLOGY
Chronic Nocturnal Cough
• Unreliability and inconsistency of reporting.
• Often used as a direct indicator of asthma.
• Community based study revealed only a third of children
with isolated nocturnal cough had asthma.
• No studies that objectively document that nocturnal
cough is worse than daytime cough in uncontrolled
asthmatics.
ETIOLOGY
Respiratory Infections and Postinfectious Cough
• Postviral cough refers to presence of cough after acute
viral URI. Unstudied natural history beyond 25 days.
• Re-infection (when not completely recovered) may result
in appearance of prolonged coughing.
• Total respiratory illnesses per person year ranges 5-8/yr
(<4yrs) and 2.4-5/yr (10-14yrs). 40
• Classic infections (pertussis, Mycoplasma) typically
cause cough with other symptoms, but consider
antibiotics and vaccination as modifiers.
ETIOLOGY
Psychogenic Cough
• AKA habit cough, tic cough, psychogenic cough.
• Behaviorial association.
Inhalation of Foreign Body
• Presentations usually acute, but chronic cough may be
presenting symptom of missed FB inhalation.
• Normal CXR does not exclude.
• Specific history should be sought.
ETIOLOGY
Parental Expectations
• Parental expectations as well as the doctor’s perceptions
(of said expectations) influences consulting rates and
prescription use. 22,199,200
• Use of OTC meds and frequency of doctor’s visits were
less likely with more highly educated mothers.201
• Parental concerns can be extreme and include fear of child
choking and dying, SIDS, asthma attack, permanent chest
damage.
“In children with nonspecific cough, parental expectations should
be determined, and the specific concerns of the parents should be
sought and addressed.” (E/B)
TREATMENT
OTC Cough Medications
• Common unintentional ingestion in kids <5 years of age.
• AAP advises against use of codeine and
dextromethorphan for treating any type of cough.
“In children with cough, cough suppressant and other
OTC cough medicines should not be used as patients,
especially young children, may experience significant
morbidity and mortality.” (D)
TREATMENT
Asthma Therapy
• No evidence to support B2 agonists in children with acute cough but
no evidence of airway obstruction.210
• No evidence to support anticholinergic agents.
• Two RCTs on inhaled corticosteroids for treatment of chronic
nonspecific cough in children.
a.) Low dose ICS have been proven effective in the management of
majority of cases of childhood asthma.219-221
b.) Authors recommend trial of pulmicort (budesonide) 400 ug/d
equivalent dose, with reevaluation in 2-3 weeks. (B)
c.) Cough may resolve due to ICS use, or by spontaneous
resolution.
• No RCTs on oral corticosteroids.
TREATMENT
Antimicrobials
• Two RCT: one with 23% kids coughing >30d and the
second with mean duration of cough 21-28d.
• In both studies, nasopharyngeal colonization showed
predominance of Moraxella catarrhalis, and significant
improvement was seen in treatment arm.
• Cochrane review showed that 10d course of antibiotics
reduces persistence of cough in short to medium term;
NNT=8.
TREATMENT
Antihistamines
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For acute cough, antihistamine and decongestant combos were no
more likely than placebo to reduce acute cough.
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Recent RCT also showed diphenhydramine and dextromethorphan
were no different than placebo in reducing nocturnal cough in kids.
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In metaanalysis of antihistamine treatments for common cold, neither
mono or combo antihistamine therapy was effective in reducing
symptoms in kids.
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No specific studies on cough >4 weeks.
“In children who have started therapy with a medication, if the cough
does not resolve during the medication trial within the expected
response time, the medication should be withdrawn and other
diagnoses considered.” (C)
RATING SCHEME
“Children with chronic cough require careful and systematic evaluation for
the presence of specific diagnostic indicators.” Level of evidence,
expert opinion; benefit, substantial; grade of recommendation, E/A.
Quality of Evidence
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Good = evidence based on good RCTs or metaanalysis.
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Fair = evidence based on other controlled trials or RCTs with minor
flaws.
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Low = evidence based on nonrandomized, case-control, or
observational study.
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Expert opinion = evidence based on consensus of the carefully
selected panel of experts in the topic field.
RATING SCHEME
“Children with chronic cough require careful and systematic evaluation for
the presence of specific diagnostic indicators.” Level of evidence, expert
opinion; benefit, substantial; grade of recommendation, E/A.
Net Benefit
• Substantial = Evidence of benefit that clearly exceeds the minimum
clinically significant benefit, and evidence of little harm.
• Intermediate = Clear evidence of benefit but with some evidence of
harms.
• Small/weak = Evidence of benefit that may not clearly exceed the
minimum clinically significant benefit, or there is evidence of harm that
substantially reduces the benefit.
• None = no benefit or benefits=harm.
• Conflicting = Evidence is inconsistent with regard to benefits or harms.
• Negative = Expected harms exceed the expected benefits.
RATING SCHEME
“Children with chronic cough require careful and systematic evaluation for
the presence of specific diagnostic indicators.” Level of evidence,
expert opinion; benefit, substantial; grade of recommendation, E/A.
Strength of Recommendation
• A = strong
• B = moderate
• C = weak
• D = negative
• I = no recommendation
(inconclusive)
E/A = strong, expert opinion only
E/B = mod, expert opinion only
E/C = weak, expert opinion only
E/D = neg, expert opinion only
ARE THE RECOMMENDATIONS VALID?
Were all important options and outcomes considered?
• YES: Considered way more options than recommended
Was an explicit and sensible process used to identify,
select, and combine evidence?
• YES: Defined a specific objective; defined inclusion
criteria; conducted a comprehensive search
ARE THE RECOMMENDATIONS VALID?
Was an explicit and sensible process used to consider the
relative value of different outcomes? YES
• International panel of 26 experts from 7 clinical specialties.
• Many were ACCP members, but other medical societies
represented.
• Quality of evidence is rated on study design.
• Net benefit is based on estimated benefit to the specific
patient population, not for an individual patient.
• With insufficient evidence, the panel used informal group
consensus techniques to reach an expert opinion.
ARE THE RECOMMENDATIONS VALID?
Is the guideline likely to account for important recent
developments? YES
• 203 of 274 articles were published after 1995
• Few articles cited for things currently being published at
time of printing.
• Date of most recent evidence considered (last search)
November 7, 2004.
• Accepted for publication: December 5, 2004.
ARE THE RECOMMENDATIONS VALID?
Has the guideline been subjected to peer review and
testing?
• YES: internal and external peer review
• Following final revisions, each section of the guideline
was reviewed/approved by:
1.) Clinical Pulmonary Medicine
2.) Respiratory are
3.) Pediatric Chest Medicine
4.) Environmental and Occupational and Airways
Disorders Networks of the ACCP
5.) ACCP Health and Science Policy Committee
6.) ACCP Board of Regents
WHAT ARE THE RECOMMENDATIONS?
Are practical, clinically important, recommendations made?
• YES, BUT recommendations made were conservative,
many vague, blanket statements.
How strong are the recommendations? – FAIR/WEAK
• Only 4 RCTs available for inclusion.
• Much heterogeneity among reviewed studies looking at
the same topic.
• Half (6/13) of the recommendations are based on expert
opinion only.
WHAT ARE THE RECOMMENDATIONS?
What is the impact of uncertainty associated with the
evidence and values used in the guidelines?
• As compared to adult literature, uncertainty exists
regarding similar outcomes (to treatment strategy) in
children.
• Authors free acknowledge the paucity of pediatric
studies.
• Actual outcomes in well designed research may be much
greater, or much less, than their best estimate.
WILL RECOMMENDATIONS HELP
PATIENT CARE
• YES
• This guideline is directed towards primary care.
• Services offered in the subspecialty arena are in the
context of a primary care referral after initial evaluation.
WILL RECOMMENDATIONS HELP
PATIENT CARE
MAYBE
• Not a lot of new info here.
• Reinforces careful and methodic evaluation of chronic cough.
• Rule out serious pathology.
• Opportunity to counsel parents regarding OTCs.
• Recognize parental expectations and address concerns.
• Describes a similar patient population: cough >4 weeks is not
rare.
QUESTIONS?