Table 1 Health questions and key recommendations of the adapted CPG
N | Health questions In evaluating children aged ≤ 14 years with chronic cough: | Guideline | Recommendation statements | Level of evidence | Grade of recommendation |
|---|---|---|---|---|---|
Q1 | What is the value of estimating the duration of a cough? | ACCP 2020 | For patients seeking medical care complaining of cough, clinicians suggest that estimating the duration of the cough is the first step in narrowing the list of potential diagnoses | C | (Grade 2) |
Q2 | Should history include specific cough pointers? | ACCP 2020 | History should include cough characteristics and the associated clinical history such as using specific cough pointers like the presence of productive/wet cough | A | (Grade 1) |
Q3 | Should history include red flags? | GPP | History should include symptoms of red flags or other potentially life-threatening symptoms and if present, they should be immediately addressed and evaluated | Glashan and Mahmoud, 2019 [25] | |
Q4 | What is the value of a detailed history to determine environmental exposure to respiratory irritants? | ERS 2019 | Exposure to airborne irritants (e.g., tobacco exposure, combustions, traffic-related exposure), allergens, or infection may be a reason for dry chronic cough | E O | |
Q5 | Is history suggestive of OSA (mouth breathing, snoring, restless sleep, morning somnolence, daytime sleepiness, and poor academic achievement) important for the diagnosis? | Korean 2016 | In unexplained or unresponsive chronic cough, obstructive sleep apnea should be included in the differential diagnosis | EO | |
Q6 | Is a history of drug intake important to evaluate cough? | ERS 2019 | Detailed history of drug intake is needed including ACEI and other drugs such as bisphosphonates or calcium channel antagonists andprostanoid eye drops | EO | |
Q7 | What is the importance of clinical evaluation of upper airway cough syndrome due to a rhinosinus condition, gastroesophageal reflux disease, and/or asthma before starting any empiric therapy for these conditions? | ACCP 2020 | We recommend basing the management on the etiology of the cough. An empirical approach aimed at treating upper airway cough syndrome due to a rhinosinus condition, gastroesophageal reflux disease, and/or asthma should not be used unless other features consistent with these conditions are present | A | (Grade 1) |
Q8 | 8a- How to suspect asthma from history? | ACCP 2020 | Diagnosis of asthma is suggested by the presence of risk factors and/or response to a short (2–4 weeks) therapeutic trial of 400 μg/day of beclomethasone equivalent may be warranted, and these children should be evaluated in 2–4 weeks | Ungraded Consensus-Based Statement | |
8 b- How to suspect cough variant asthma by history? | ERS 2019 Korean 2016 | Cough variant asthma (CVA) was originally described as asthma with cough as the sole symptom and where treatment with bronchodilators improved coughing | EO EO | ||
Q9 | How to suspect TB by history? | ACCP 2020 | Patients with cough with or without fever, night sweats, hemoptysis, weight loss, and/or contact with TB case and -who are at risk of pulmonary TB in a community high in TB prevalence | Consensus | |
Investigations | |||||
Q10 | 10a-Should the clinician recommend chest radiography? | ACCP 2006–2020 | The clinician should recommend chest radiography | B | (Grade 1) |
10b- Should chest CT scan be routinely performed for children with normal physical examination and plain chest X-ray? | ERS 2019 | The clinician should not routinely perform a chest CT scan in patients who have normal physical examinations and chest X-rays | Very low | Conditional recommendation | |
Q11 | 11a- When age is appropriate, should the clinician recommend spirometry (pre- and post-β2 agonist)? | ACCP 2006–2020 | The clinician should recommend spirometry (pre- and post-β2 agonist) when age is appropriate | B | (Grade 1) |
11b- For children aged > 6 years and asthma is clinically suspected, should the clinician suggest a test for airway hyper-responsiveness? | ACCP 2006–2020 | The clinician should suggest a test for airway hyper-responsiveness (mannitol or methacholine inhalation) | C | (Grade 2) | |
11c- Should FeNO (if available)/blood eosinophil count be used in aiding the diagnosis or predicting the treatment response when asthma is clinically suspected? | ERS 2019 | This recommendation places a relatively higher value on the predictability of the treatment response and the impact on the treatment decision | Very low | ||
Q12 | Should the clinician perform additional tests (e.g., skin prick test, Mantoux, bronchoscopy, chest CT)? | ACCP 2006–2020 | Clinicians should not routinely perform additional tests These should be individualized and undertaken according to the child’s clinical symptoms and signs | B | (Grade 1) |
Q 13 | Should the clinician suggest undertaking tests for evaluating recent Bordetella pertussis infection when pertussis is clinically suspected? | ACCP 2020 | The clinician should suggest undertaking tests for evaluating recent Bordetella pertussis infection when pertussis is clinically suspected (if there is post-tussive vomiting, paroxysmal cough, or inspiratory whoop) | Ungraded Consensus-Based Statement | |
Q14 | 14a- Should the clinician suggest further investigations when a wet cough (unrelated to the underlying disease and with no specific cough pointers) persists after 4 weeks of appropriate antibiotics? | ACCP 2006–2020 | The clinician should suggest further investigations (e.g., flexible bronchoscopy with quantitative culture and sensitivity with or without chest CT assessment for aspiration) to be undertaken | B | (Grade 1) |
14b- Should the clinician recommend evaluation of immunologic competence for children with wet cough unrelated to underlying disease and with specific cough pointers? | ACCP 2006 | The clinician should recommend an evaluation of the immunologic competence in the presence of criteria suspicious of immunodeficiency (appendix) to assess for an underlying disease | B | (Grade 1) | |
Q15 | For children with chronic productive purulent cough, do you recommend investigations to document the presence or absence of bronchiectasis? | ACCP 2012 | In patients with suspected bronchiectasis without a characteristic chest radiograph finding, a high-resolution CT (HRCT) scan of the chest should be ordered because it is the diagnostic procedure of choice to confirm the diagnosis | Low | (Grade B) |
Q16 | 16a- In patients evaluated for GERD, what are the most sensitive and specific tests for the diagnosis? | ACCP 2006–2020 | A 24-h esophageal pH monitoring test is the most sensitive and specific test | Low | (Grade B) |
16b- Is barium esophagography beneficial for diagnosing GERD as the cause of cough? | ACCP 2012 | Barium esophagography may be beneficial. It can be considered if it is the only available test to reveal that GERD is of potential pathologic significance | Low | (Grade B) | |
16c-In patients with suspected GERD, are the esophagoscopy findings helpful to rule out GERD as the cause of cough? | ACCP 2012 | A normal esophagoscopy finding does not rule out GERD as the cause of the cough | Low | (Grade B) | |
Q17 | 17a- Should the clinician suggest screening for TB to patients in high TB prevalence countries or settings? | ACCP 2020 | The clinician should suggest screening for TB regardless of cough duration | C | (Grade 2) |
17b- Should the clinician suggest an Xpert MTB/RIF test, when available, to replace sputum microscopy as an initial diagnostic test for patients with a high risk of pulmonary TB but a low risk of drug resistance? | ACCP 2020 | The clinician should suggest an Xpert MTB/RIF test, when available, to replace sputum microscopy as an initial diagnostic test | Ungraded Consensus-Based Statement | ||
Q18 | For children with upper airway symptoms, should the clinician advise routine laryngoscopy, rhinoscopy, or CT sinuses? | GPP | In patients who report upper airway symptoms laryngoscopy, rhinoscopy or CT sinuses may be performed but not routinely | O'Hara and Jones 2006 [26] | |
Q19 | For children with non-specific cough, if the cough does not resolve within 2 to 4 weeks, should the child be re-evaluated for the emergence of specific etiological pointers? | ACCP 2020 | For children with non-specific cough, we suggest that if the cough does not resolve within 2 to 4 weeks, the child should be re-evaluated for the emergence of specific etiological pointers | Ungraded Consensus-Based Statement | |
Treatment | |||||
Q20 | 21a-What is the recommended treatment for children aged > 6 years and < 14 years with clinically suspected asthma | ACCP 2020 | When risk factors for asthma are present, a short (2–4 weeks) trial of 400 μg/day of beclomethasone equivalent, and re-evaluated | Fair | (Grade B) |
21b- Should asthma medications be used after acute viral bronchiolitis if the cough persists for more than 4 weeks? | ACCP 2020 | Asthma medications should not be used for cough unless other evidence of asthma is present | Ungraded consensus-based statement | ||
Q21 | Should an empirical approach aiming at treating upper airway cough syndrome due to a rhinosinus condition, gastroesophageal reflux disease, or asthma be used? | ACCP 2020 | 1- An empirical approach should not be used unless other features consistent with these conditions are present 2– If an empirical trial is used, the trial should be of a defined limited duration to confirm or refute the hypothesized diagnosis | A | (Grade 1) Ungraded consensus-based statement 1 |
Q22 | What are the recommendations for wet or productive cough unrelated to underlying disease and without any other specific cough pointers? | ACCP 2020 | 1-Two weeks of antibiotics targeting the common respiratory bacteria (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis) and depending on the local antibiotic sensitivities 2- The diagnosis of PBB be made 3- When the wet cough persists after 2 weeks of appropriate antibiotics, consider treatment with an additional 2 weeks of the appropriate antibiotic(s) 4- When the wet cough persists after 4 weeks of appropriate antibiotics, further investigations as flexible bronchoscopy with quantitative cultures and sensitivities with or without chest CT) can be undertaken | A C B B | (Grade 1) 4 (Grade 1) (Grade 2) (Grade 1) |
Q23 | What is the treatment in children without an underlying lung disease who have symptoms and signs or tests consistent with gastroesophageal pathological reflux? | ACCP 2020 | a) They can be treated for GERD according to evidence-based GERD-specific guidelines (b) Acid suppressive therapy should not be used solely for chronic cough | B C | (Grade1) (Grade 1) |
Q24 | What is the suggested treatment for a child diagnosed with somatic cough disorder? | ACCP 2020 | Non-pharmacological trials of hypnosis or Suggestion therapy or Reassurance and counseling or Referral to a psychologist or psychiatrist | C | (Grade 2) |
Q25 | For children suspected of having OSA, what is the management? | ACCP 2020 | They are managed according to sleep guidelines | Ungraded consensus-based statement | |
Q26 | Should histamine H1-receptor antagonists (H1RAs) be used to treat non-specific chronic coughs? | Korean 2019 GPP | The use of H1RAs in children with non-specific cough must be balanced against well-known adverse events, especially in very young children ACCP is recommended against the empirical use of H1RAs in children with chronic cough unless other features consistent with upper airway cough syndrome due to rhinosinusitis are present | Low | Conditional recommendation Chang et al. 2017 [27] |
Q27 | Should LTRAs be used to treat non-specific chronic coughs? | Korean 2019 | Careful considerations of cost, risk, and benefits are needed until there is sufficient data to determine the efficacy of LTRAs in these children | Very low | Conditional recommendation |
Q28 | Should neuromodulators (opioids, gabapentin or pregabalin,) be used? | GPP | Cough neuromodulators are not used in children due to reported adverse events, possible toxicity, and lack of clinical trials | Gardiner et al. 2016 [28] | |