xRead - Globus and Chronic Cough (April 2024)

14. For children aged £ 14 years with chronic cough, we suggest that parental (and when appropriate the child ’ s) expectations be determined, and their speci fi c concerns sought and addressed (Ungraded Consensus Based Statement). Chronic Cough Associated With Speci fi c Etiologies Wet Cough and PBB: The validity of wet cough in young children in clinical practice has been con fi rmed. 4 In older children who can expectorate, productive cough is the preferred term. The presence of chronic wet/ productive cough leads to a divergent pathway within the algorithm 32 (Fig 3). The evidence using antibiotics for a chronic wet cough when there no other symptoms and signs (eg, dysphagia or digital clubbing) suggesting PBB, is now strong. 73 While many questions remain, PBB as a clinical entity is also now widely accepted. 73,113-115 15. For children aged £ 14 years with chronic ( > 4 weeks duration) wet or productive cough unrelated to an underlying disease and without any other speci fi c cough pointers (eg, coughing with feeding, digital clubbing), we recommend 2 weeks of antibiotics targeted to common respiratory bacteria ( Streptococcus pneumoniae, Haemophilus in fl uenzae, Moraxella catarrhalis ) targeted to local antibiotic sensitivities (Grade 1A). 4 16. For children aged £ 14 years with chronic ( > 4 weeks duration) wet or productive cough unrelated to an underlying disease and without any other speci fi c cough pointers (eg, coughing with feeding, digital clubbing) and whose cough resolves within 2 weeks of treatment with antibiotics targeted to local antibiotic sensitivities, we recommend that the diagnosis of PBB be made (Grade 1C). 4 17. For children aged £ 14 years with chronic ( > 4 weeks duration) wet or productive cough unrelated to an underlying disease and without any other speci fi c cough pointers (eg, coughing with feeding, digital clubbing), when the wet cough persists after 2 weeks of appropriate antibiotics, we recommend treatment with an additional 2 weeks of the appropriate antibiotic(s) (Grade 1C). 4 18. For children aged £ 14 years with chronic ( > 4 weeks duration) wet or productive cough unrelated to an underlying disease and without any other speci fi c cough pointers (eg, coughing with feeding, digital clubbing), when the wet cough

persists after 4 weeks of appropriate antibiotics, we suggest that further investigations (eg, fl exible bronchoscopy with quantitative cultures and sensitivities with or without chest CT) be undertaken (Grade 2B). 4 19. For children aged £ 14 years with PBB with lower airway (BAL or sputum) con fi rmation of clinically important density of respiratory bacteria ( ‡ 10 4 cfu/ mL), we recommend that the term ‘ microbiologically based-PBB ’ (or PBB-micro) be used to differentiate it from clinically-based-PBB (PBB without lower airway bacteria con fi rmation) (Grade 1C). 4 Chronic productive purulent cough is always pathological, re fl ective of conditions such as bronchiectasis, diffuse panbronchiolitis 116 and aspiration. The workup usually involves detailed evaluation that includes the spectrum of available investigations to outline structure and function of the respiratory system as well as evaluation for immunological causes and to exclude cystic fi brosis and other underlying systemic abnormalities. These investigations may include chest CT scans, fl exible bronchoscopy, barium swallow, video fl uoroscopic evaluation of swallowing, echocardiography, complex sleep polysomnography, and nuclear medicine scans. When bronchiectasis is suspected, children should be evaluated using an appropriate pathway. 113 20. For children aged £ 14 years with chronic wet or productive cough unrelated to an underlying disease and with speci fi c cough pointers (eg, coughing with feeding, digital clubbing), we recommend that further investigations (eg, fl exible bronchoscopy and/or chest CT, assessment for aspiration and/or evaluation of immunologic competency) be undertaken to assess for an underlying disease (Grade 1B). 4 GERD: Unlike in adults, 117 GERD is not commonly identi fi ed as the cause of pediatric chronic cough. 2 Indeed in children, there is little current convincing evidence that GER is a common cause of isolated chronic cough (ie, without GI-related GERD symptoms). However, proving causality is dif fi cult 118,119 for several reasons that include the absence of a gold standard diagnostic tool for the diagnosis of GERD in infants and children. 6,7 Also, there are a wide array of possible interventions for GERD and some of these may result in more potential harm than bene fi t (eg, surgery 120 and proton pump inhibitors 121,122 ).

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