Clinical pathways for chronic cough in children

Process of diagnosis and treatment of chronic cough in children at primary hospitals

Objective

This study aimed to establish a process for the diagnosis and treatment of chronic cough in children suitable at primary hospitals and improve the treatment efficacy rate and improve health economic indicators.

Methods

Children who visited the Department of Pediatrics, Affiliated Zhou Pu Hospital of the Shanghai Health Medical College from January to December 2021 were randomly assigned to the intervention group (n = 206), in which the diagnosis and treatment process proposed here was applied, and a control group (n = 211) that did not follow the intervention pathway and followed a pathway with the doctors usual practice based on his/her previous experience. Patients were followed up and data were collected at weeks 0 (time of enrollment), 2, 4, 8, and 12 to evaluate the efficacy rate and clinical value.

Results

(1) No significant differences were detected between the two groups in baseline characteristics, including gender, age, duration of cough (weeks), history of allergy in children and parents, and smoking of family members living in the same household (p > 0.05); (2) During the follow-up, all cough symptom scores of the intervention group were lower than the control group. Additionally, at week 12, the treatment efficacy rate of the intervention group (91.70%) was significantly higher than the control group (69.20%) (p < 0.05); (3) The quality of life of children in both groups at week 12 was improved compared to the first visit. However, the total score of the intervention group was significantly higher than the control group (p < 0.05); (4) At week 12, the referral rate was significantly lower in the intervention group (11.17%) than in the control group (21.33%); (5) The intervention group was better than the control group for the mean monthly medication costs, number of days on errors in childhood, and number of days mistakenly worked by family members at week 12 (p < 0.05).

Conclusion

The current process of diagnosis and treatment of chronic cough in children at primary hospitals can improve the effective diagnosis and treatment rate, the quality of life, and other parameters, with good effectiveness and feasibility.

The perceived and objectively measured effects of clinical pathways' implementation on medical care in China

Introduction

Substantial resources have been expended on clinical pathways (CPs), but the reported effects of CPs on medical care vary considerably. This study sought to determine the effects of CPs on medical care in Chinese hospitals, including the perceived effects of CPs on medical care and the objectively measured patient outcomes.

Methods

Study data were obtained from 54 public hospitals in three provinces of China in 2015. Hospital questionnaires, employee surveys, and chart reviews were used to collect data related to hospital characteristics, the implementation of CPs and compliance status, perceived effects of CPs, and objectively measured patient outcomes. Logistic regression models and linear regression models were adopted in this study.

Results

The effects of CPs were not highly perceived by the hospitals or by the managers and physicians in China. The relatively low involvement in the implementation of and adherence to CPs resulted in CPs having no significant effects on hospital medical care as a whole. However, a chart review of 5 conditions in Chinese hospitals demonstrated that compliance with national CPs reduced the length of stay (LOS) and inpatient medical costs.

Conclusions

CPs should be implemented widely and followed closely to improve hospital medical care as a whole, and further studies should be conducted to identify the key elements of the effects of CPs on patient clinical outcomes.

Unknown vascular compression of the airway in patients with congenitalheart disease and persistent lower respiratory symptoms

Background/aim: Airway compression (AC) by vascular structures is an important complication of congenital heart disease (CHD) that often goes unrecognized. It is not easy to identify whether CHD patients require additional invasive examinations or not. Therefore, the present study aims to develop an AC diagnostic algorithm for CHD patients. Materials and methods: CHD patients with persistent respiratory symptoms that were treated between January 2007 and December 2015 were retrospectively reviewed. The following data were recorded for all CHD patients with AC: age, cardiac anomalies, the compressed structure, the airway diameter ratio (ADR), the compressing structure(s), treatment, and follow-up.Results: During the 8-year study period, 62 of 253 CHD patients had persistent respiratory symptoms, of which 11 cases were diagnosed as AC via bronchoscopy and/or thoracic computed tomography angiography. The most frequently affected structures were the left main bronchus and trachea, and the most common compressing structure was the right pulmonary artery. The ADR was near total compression in 3 patients and >0.50 in 3 patients. During follow-up, 5 of the 11 patients with AC underwent surgery, 2 died, and 4 were followed clinically. Patients with ADR of >0.50 did not require surgery and were followed clinically. Conclusion: CHD patients with persistent respiratory symptoms associated with lower respiratory airway obstruction should be evaluated via invasive examination. An AC diagnostic algorithm for pediatric CHD patients was developed.

Prolonged Cough in Pediatric Population First Line Care, Belgian Guidelines

BACKGROUND

The clinical approach to a prolonged cough, i.e. a cough lasting more than three weeks, is challenging for general practitioners as well for primary care pediatricians. What the recommended clinical approach in primary care is, how cough duration or cough characteristics impact the diagnosis, and what the efficiency and safety of antibiotics or symptomatic treatments are remain in question for primary care physicians.

OBJECTIVE

The last Belgian guidelines were published in 2006 and needed to be reviewed. Those background questions were used to conduct our guideline updating procedure.

METHODS

We systematically performed a pyramidal literature search between the periods 2006-2014 in order to write evidence based guidelines. The data of the literature was summarized, discussed by the authors, experts and the Belgian primary care guidelines committee. Recommendations were formulated and scored following the GRADE classification.

RESULTS

The consultation history as well as the physical examination should be directed towards searching for warning signs (GRADE 1B) and towards the common etiologies depending on cough duration (GRADE 2C). If the cough lasts for more than eight weeks, chest radiography and spirometry should be considered (GRADE 2C). An antibiotic is recommended for a prolonged wet cough (over eight weeks) if prolonged bacterial bronchitis is suspected (GRADE 1B). In the absence of clinical signs of a specific etiology of a cough, no drug can be recommended (GRADE 1B). For all cases, it is initially suggested to avoid irritants (GRADE 1C) as well as to take into account the concerns of parents and inform them about the natural development of a cough.

CONCLUSIONS

More research is needed to provide evidence on the clinical pathway on prolonged cough for primary care. Cough duration of more than eight weeks and prolonged wet cough are the most useful cough characteristics. Regarding a specific cough treatment, no medication has proved any effect greater than placebo. Attention to environmental triggers and patient-centered care remain the keystones of interventions.

Etiologies of Chronic Cough in Pediatric Cohorts: CHEST Guideline and Expert Panel Report

BACKGROUND

There is no published systematic review on the etiologies of chronic cough or the relationship between OSA and chronic cough in children aged ≤ 14 years. We thus undertook a systematic review based on key questions (KQs) using the Population, Intervention, Comparison, Outcome format. The KQs follow: Among children with chronic (> 4 weeks) cough (KQ 1) are the common etiologies different from those in adults? (KQ 2) Are the common etiologies age or setting dependent, or both? (KQ 3) Is OSA a cause of chronic cough in children?

METHODS

We used the CHEST Expert Cough Panel's protocol 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 consensus.

RESULTS

Combining KQs 1 and 2, we found moderate-level evidence from 10 prospective studies that the etiologies of cough in children are different from those in adults and are setting dependent. Data from three studies found that common etiologies of cough in young children were different from those in older children. However, data relating sleep abnormalities to chronic cough in children were found only in case studies.

CONCLUSIONS

There is moderate-quality evidence that common etiologies of chronic cough in children are different from those in adults and are dependent on age and setting. As there are few data relating OSA and chronic cough in children, the panel suggested that these children should be managed in accordance with pediatric sleep guidelines.

Survey on attitudes of Italian pediatricians toward cough

CONTEXT

Children's cough is a daily concern for most pediatricians. The management of both acute and chronic cough requires a systematic and comprehensive approach. Despite the approved protocols for management, the pediatric assessment of cough and the corresponding prescribing attitude frequently do not fit these protocols, which can be affected by parental suggestions - sometimes substantially.

OBJECTIVE

The objective of this study was to investigate both the perception and the behavior of a representative sample of Italian pediatricians toward cough in real life.

METHODS

A specific questionnaire consisting of 18 questions was prepared. The questionnaire was completed by 300 pediatricians (all members of PAIDOSS: Italian National Observatory on Health of Childhood and Adolescence) who represented ~300,000 children.

RESULTS

A vast majority of children have cough throughout the year (99.3% of respondents have cough during autumn/winter and 64.7% in spring/summer). Allergic disease is the most frequent suspected cause of chronic cough in children (53%), and this is supported by the high demand for consultations: 73% seek the opinion of allergologists, 62% of otorhinolaryngologists and only 33% of pulmonologists. The majority of pediatricians (92%) reported that they prescribe therapy in acute cough regardless of cough guidelines. Moreover, the survey pointed out the abuse of aerosol therapy (26% in acute cough and 38% in chronic cough) and of antibiotics prescription (22% in acute cough and 42% in chronic cough).

CONCLUSION

Our survey suggests that some Italian pediatricians' therapeutic attitudes should be substantially improved in order to achieve better management of cough in children and to minimize the burden of cough.

Evaluation of 563 children with chronic cough accompanied by a new clinical algorithm

BACKGROUND

This study aims to evaluate the children with chronic cough and to analyze their etiological factors according to the age groups.

METHOD

Five hundred sixty-three children with chronic cough were included. The last diagnosis were established and were also emphasized according to the age groups.

RESULTS

The mean age was 5.4 ± 3.8 years (2-months-17-years) and 52 % of them were male. The most common final diagnosis from all the participants were: asthma (24.9 %), asthma-like symptoms (19 %), protracted bacterial bronchitis (PBB) (11.9 %), and upper airway cough syndrome (9.1 %). However, psychogenic cough was the second most common diagnosis in the subjects over 6 years of age.

CONCLUSION

Asthma and asthma-like symptoms were the most common diagnosis in children. Different age groups in children may have a different order of frequencies. Psychogenic cough should be thought of in the common causes especially in older children.

Diagnostic Support for Selected Paediatric Pulmonary Diseases Using Answer-Pattern Recognition in Questionnaires Based on Combined Data Mining Applications--A Monocentric Observational Pilot Study

Background

Clinical symptoms in children with pulmonary diseases are frequently non-specific. Rare diseases such as primary ciliary dyskinesia (PCD), cystic fibrosis (CF) or protracted bacterial bronchitis (PBB) can be easily missed at the general practitioner (GP).

Objective

To develop and test a questionnaire-based and data mining-supported tool providing diagnostic support for selected pulmonary diseases.

Methods

First, interviews with parents of affected children were conducted and analysed. These parental observations during the pre-diagnostic time formed the basis for a new questionnaire addressing the parents’ view on the disease. Secondly, parents with a sick child (e.g. PCD, PBB) answered the questionnaire and a data base was set up. Finally, a computer program consisting of eight different classifiers (support vector machine (SVM), artificial neural network (ANN), fuzzy rule-based, random forest, logistic regression, linear discriminant analysis, naive Bayes and nearest neighbour) and an ensemble classifier was developed and trained to categorise any given new questionnaire and suggest a diagnosis. For estimating the diagnostic accuracy, we applied ten-fold stratified cross validation.

Results

All questionnaires of patients suffering from CF, asthma (AS), PCD, acute bronchitis (AB) and the healthy control group were correctly diagnosed by the fusion algorithm. For the pneumonia (PM) group 19/21 (90.5%) and for the PBB group 17/18 (94.4%) correct diagnoses could be reached. The program detected the correct diagnoses with an overall sensitivity of 98.8%. Receiver operating characteristics (ROC) analyses confirmed the accuracy of this diagnostic tool. Case studies highlighted the applicability of the tool in the daily work of a GP.

Conclusion

For children with symptoms of pulmonary diseases a questionnaire-based diagnostic support tool using data mining techniques exhibited good results in arriving at diagnostic suggestions. In the hands of a doctor, this tool could be of value in arousing awareness for rare pulmonary diseases such as PCD or CF.