A Cough Algorithm for Chronic Cough in Children: A Multicenter, Randomized Controlled Study
ABSTRACT OBJECTIVES:The goals of this study were to: (1) determine if management according to a standardized clinical management pathway/algorithm (compared with usual treatment) improves clinical outcomes by 6 weeks; and (2) assess the reliability and validity of a standardized clinical management pathway for chronic cough in children.METHODS:A total of 272 children (mean ± SD age: 4.5 ± 3.7 years) were enrolled in a pragmatic, multicenter, randomized controlled trial in 5 Australian centers. Children were randomly allocated to 1 of 2 arms: (1) early review and use of cough algorithm ("early-arm"); or (2) usual care until review and use of cough algorithm ("delayed-arm"). The primary outcomes were proportion of children whose cough resolved and cough-specific quality of life scores at week 6. Secondary measures included cough duration postrandomization and the algorithm's reliability, validity, and feasibility.RESULTS:Cough resolution (at week 6) was significantly more likely in the early-arm group compared with the delayed-arm group (absolute risk reduction: 24.7% [95% confidence interval: 13-35]). The difference between cough-specific quality of life scores at week 6 compared with baseline was significantly better in the early-arm group (mean difference between groups: 0.6 [95% confidence interval: 0.29-1.0]). Duration of cough postrandomization was significantly shorter in the early-arm group than in the delayed-arm group (P = .001). The cough algorithm was reliable (κ = 1 in key steps). Feasibility was demonstrated by the algorithm's validity (93%-100%) and efficacy (99.6%). Eighty-five percent of children had etiologies easily diagnosed in primary care.CONCLUSIONS:Management of children with chronic cough, in accordance with a standardized algorithm, improves clinical outcomes irrespective of when it is implemented. Further testing of this standardized clinical algorithm in different settings is recommended.
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ABSTRACT: Cough can persist despite exhaustive diagnostic and therapeutic effort and has been termed 'idiopathic' or 'unexplained' but perhaps 'difficult to treat' cough is a more appropriate description. In this article the reasons for poor treatment response are discussed. These include a lack of physician fidelity to management guidelines, patient non-adherence and the lack of effective medicines. A number of randomized controlled trials have been undertaken including low dose opiate therapy, the use of a speech pathology intervention, oral antibiotics and antidepressants. The success or otherwise of such interventions will be discussed. A number of approaches to deal with the problem of 'difficult to treat cough' will be considered.Pulmonary Pharmacology & Therapeutics 05/2013; 26(5). DOI:10.1016/j.pupt.2013.05.001 · 2.57 Impact Factor
Article: Commentary.Current problems in pediatric and adolescent health care 07/2013; 43(6):157-8. DOI:10.1016/j.cppeds.2013.05.002 · 1.56 Impact Factor
Article: Mechanisms of cough.[Show abstract] [Hide abstract]
ABSTRACT: To review recent developments in the mechanisms of chronic cough. Although cough prevalence is similar across the world, there are significant regional differences in the diseases associated with cough. This may represent regional differences in diet, environmental exposure, and diagnostic assessment and labelling. Cough can be reliably measured using several validated questionnaires and objective tools that monitor cough frequency and cough reflex sensitivity. Cough with eosinophilic bronchitis responds to anti-inflammatory therapy with corticosteroids and montelukast. The absence of airway hyperresponsiveness may be because of the release of a bronchoprotective mediator, prostaglandin E2. Cough with neutrophilic bronchitis is associated with rhinitis and gastroesophageal reflux disease. Laryngeal hypersensitivity (LHS) is an important new concept that explains cough mechanisms, identifies potentially new pharmacotherapies that target neural pathways and also transient receptor channels, and demonstrates how behavioural therapies can be effective in refractory cough. The concept also explains symptoms in a variety of related syndromes such as vocal cord dysfunction. New insights into cough mechanisms that focus on LHS help explain cough symptoms and the place of effective therapies including speech pathology intervention and neuromodulators.Current Opinion in Allergy and Clinical Immunology 12/2013; DOI:10.1097/ACI.0000000000000027 · 3.66 Impact Factor