Chest
Volume 151, Issue 4, April 2017, Pages 875-883
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Evidence-Based Medicine
Use of Management Pathways or Algorithms in Children With Chronic Cough: CHEST Guideline and Expert Panel Report

https://doi.org/10.1016/j.chest.2016.12.025Get rights and content

Background

Using management algorithms or pathways potentially improves clinical outcomes. We undertook systematic reviews to examine various aspects in the generic approach (use of cough algorithms and tests) to the management of chronic cough in children (aged ≤ 14 years) based on key questions (KQs) using the Population, Intervention, Comparison, Outcome format.

Methods

We used the CHEST Expert Cough Panel’s protocol for the systematic reviews 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 the final grading.

Results

Combining data from systematic reviews addressing five KQs, we found high-quality evidence that a systematic approach to the management of chronic cough improves clinical outcomes. Although there was evidence from several pathways, the highest evidence was from the use of the CHEST approach. However, there was no or little evidence to address some of the KQs posed.

Conclusions

Compared with the 2006 Cough Guidelines, there is now high-quality evidence that in children aged ≤ 14 years with chronic cough (> 4 weeks' duration), the use of cough management protocols (or algorithms) improves clinical outcomes, and cough management or testing algorithms should differ depending on the associated characteristics of the cough and clinical history. A chest radiograph and, when age appropriate, spirometry (pre- and post-β2 agonist) should be undertaken. Other tests should not be routinely performed and undertaken in accordance with the clinical setting and the child’s clinical symptoms and signs (eg, tests for tuberculosis when the child has been exposed).

Section snippets

Summary of Recommendations/Suggestions

1. For children aged ≤ 14 years, we suggest defining chronic cough as the presence of daily cough of at least 4 weeks in duration (Ungraded, Consensus Based Statement).

2. For children aged ≤ 14 years with chronic cough, we suggest that an assessment of the effect of cough on the child and the family be undertaken as part of the clinical consultation (Ungraded, Consensus Based Statement).

3. For children aged ≤ 14 years with chronic cough, we recommend using pediatric-specific cough management

Methods

For the CHEST cough guidelines, it was a priori determined that the age cutoff for pediatric and adult components was 14 years. We used a standard method8 as previously described by Vertigan, et al9: “The methodology used by the CHEST Guideline Oversight Committee to select the Expert Cough Panel Chair and the international panel of experts, perform the synthesis of the evidence and develop the recommendations and suggestions has been published.8, 10 Key questions and parameters of eligibility

Results

The first eight recommendations and/or suggestions were derived from systematic reviews that addressed KQs 1 to 3 summarized in e-Tables 1-3 and e-Figures 1-3.7 The subsequent four recommendations/suggestions were derived from systematic reviews that addressed KQs 4 and 5 (all summarized in e-Tables 4 and 5 and e-Figs 4 and 5).

Areas for Further Research

To advance and improve the management of chronic cough in children, suggested areas of research include the following:

  • 1.

    Undertake multicenter cohort studies in various clinical settings (community and hospital) that assess the outcomes of children with acute cough that then progresses to chronic cough.

  • 2.

    Undertake RCTs on the efficacy of cough in various clinical settings, particularly in primary care. When doing so, we suggest that validated cough outcomes, a priori definitions, and “period effect”

Conclusions

In the past decade, the availability of single-center and multicenter studies from several countries has improved the evidence base of the 2006 CHEST Cough Guidelines6 approach. The new recommendations formulated from systematic reviews addressing five KQs were endorsed by the CHEST Expert Cough Panel. Although there is high-quality evidence for some of the new recommendations, many questions remain, particularly in primary care for which there is scarcity of data.

Acknowledgments

Author contributions: A. C., J. O., and R. I. drafted the key questions. A. C. and J. O. selected the studies, extracted data and undertook the bias assessment. A. C. drafted the recommendations and manuscript, had full access to the data and takes responsibility for the integrity of all of the data and the accuracy of the data analysis. J. O. and R. I. contributed to the data analyses and interpretation and critically reviewed the manuscript. B. R. and M. W. critically reviewed the manuscript.

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    DISCLAIMER: American College of Chest Physician guidelines are intended for general information only, are not medical advice, and do not replace professional medical care and physician advice, which always should be sought for any medical condition. The complete disclaimer for this guideline can be accessed at http://www.chestnet.org/Guidelines-and-Resources/Guidelines-and-Consensus-Statements/CHEST-Guidelines.

    FUNDING/SUPPORT: The authors have reported to CHEST that no funding was received for this study.

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