xRead - Globus and Chronic Cough (April 2024)

Clinical Review & Education Review

Otolaryngologic Management of Chronic Cough in School-aged Children

Figure. Algorithm for Management of Chronic Cough in School-aged Children

Assessment: History and physical examination, tobacco exposure, and association with quality of life; consider chest radiography and spirometry. Determine if cough pointers are present or cough is characteristic.

Nonspecific cough: No cough pointers, cough not characteristic. Recommendation: Observe and reevaluate in 1-2 wk. If cough is persistent, determine if cough is wet or dry.

Are there cough pointers? These include:

Is it a characteristic cough? Cough productive of casts (plastic bronchitis) Paroxysmal cough (pertussis) Barky cough (tracheomalacia, croup, and habit cough)

Cardiac abnormalities Chest pain

Feeding difficulties Hemoptysis Hypoxia Cyanosis Immune deficiency Failure to thrive Recurrent pneumonia

Dyspnea or tachypnea Chest wall deformity Digital clubbing Daily productive cough Neurodevelopmental abnormality

Wet cough

Dry cough

Specific cough

Investigate and treat according to likely diagnosis. Determine if cough has resolved.

Course of antibiotics (7-14 d).

If normal chest radiography and spirometry results, 1-2 weeks of watchful waiting.

Reevaluate in 1-2 wk. If persistent, referral to pulmonologist.

Cough persists: Trial of inhaled corticosteroids and/or referral to pulmonologist.

If cough persists or specific cough is identified, pulmonary referral for evaluation and management.

Cough pointers are defined as specific symptoms that suggest a particular diagnosis (eg, coughing when drinking suggests aspiration; hemoptysis suggests parenchymal lung disease or vascular abnormality).

The Figure presents a modified algorithm that is applicable in oto laryngology practices. A Cochrane review in 2014 evaluated whether these clinical pathways are effective. 69 The review identified 1 multicenter ran domized clinical trial in which children were randomized to either early or delayed referral to respiratory specialists who used a cough management pathway. The study found that the patients in the early pathway group had significantly fewer clinical failures, a shorter du ration of cough, and higher disease-specific quality of life. These data suggest that using clinical algorithms and implementing them early in the disease course is more effective in improving chronic cough. Conclusions Most otolaryngologists will care for a pediatric patient with chronic cough at some point in their practice. The most common causes seen by otolaryngologists include infection/upper airway cough syn drome, reflux, and airway hyperreactivity. Careful history and physi cal examination can often lead to identification of the cause, and treatment should then be directed toward that specific cause. In the case of nonspecific cough, evaluation and treatment should follow pediatric-specific cough algorithms, as these have been shown to lead to higher rates of cough resolution, shorter cough duration, and improved disease-specific quality of life.

Treatment Algorithms and Effectiveness To assist clinicians in management of pediatric chronic cough, the American College of Chest Physicians published guidelines and an algorithm in 2006. 7,68 Since then, studies have evaluated the effi cacy of following these guidelines in the pediatric population, gen erally concluding that following the algorithm improves clinical outcomes. 4-6 The 2006 algorithm first divides patients between those with specific cough pointers and patients without cough pointers. Cough pointers essentially signify an identifiable cause or more severe illness. 68 When pointers are present, this is referred to as a specific cough, such as those caused by upper airway cough syndrome, infection, reflux, and asthma. When there are cough pointers or specific cough, the underlying cause should be addressed. Cough lacking specific pointers is referred to as nonspe cific cough. For nonspecific cough, the recommendation is to obtain a chest radiograph and spirometry (if age appropriate). If findings of these studies are normal, the recommendation is obser vation for 1 to 2 additional weeks because most coughs will self resolve over time. If the cough does not resolve, dry cough can be treated with low-dose inhaled steroid therapy to see if there is improvement, or the patient can be referred for evaluation and management by a pediatric pulmonologist. If there is a wet cough, the algorithm suggests administration of a course of antibiotics.

Author Affiliations: Division of Pediatric Otolaryngology–Head and Neck Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio (Kennedy, Hart); Department of Otolaryngology–

ARTICLE INFORMATION Accepted for Publication: August 5, 2020. Published Online: October 1, 2020. doi:10.1001/jamaoto.2020.2945

Head and Neck Surgery, Cleveland Clinic, Cleveland, Ohio (Anne); Section Editor, JAMA Otolaryngology– Head & Neck Surgery (Anne); Department of Otolaryngology–Head and Neck Surgery, University

1062 JAMA Otolaryngology–Head & Neck Surgery November 2020 Volume 146, Number 11 (Reprinted)

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