Identifying asthma and chronic obstructive pulmonary disease in patients with persistent cough presenting to general practitioners: descriptive study

Objective: To determine the prevalence of asthma and chronic obstructive pulmonary disease in patients not known to have these disorders, who present in general practice with persistent cough, and to ascertain criteria to help general practitioners in diagnosis.

Isolated Aortitis Presenting with an Annoying Persistent Cough: A Case Report

Objectives: To report a case of idiopathic aortitis presenting with chronic cough. Materials and Methods: the Authors describe the case of a 72-year-old man with dry cough, worsening fatigue, weight loss and elevated systemic inflammatory markers. Results: A PET-CT scan showed diffuse thickening of the thoracic aorta and confirmed the diagnosis of aortitis. Systemic corticosteroid therapy was initiated and complete remission was achieved in six months. Conclusion: Persistent dry cough of unknown origin, especially when associated with systemic inflammation, demands a thorough differential diagnosis and should not be underrated.

The development of chronic cough in children following presentation to a tertiary paediatric emergency department with acute respiratory illness : study protocol for a prospective cohort study

Background Acute respiratory illness, a leading cause of cough in children, accounts for a substantial proportion of childhood morbidity and mortality worldwide. In some children acute cough progresses to chronic cough (> 4 weeks duration), impacting on morbidity and decreasing quality of life. Despite the importance of chronic cough as a cause of substantial childhood morbidity and associated economic, family and social costs, data on the prevalence, predictors, aetiology and natural history of the symptom are scarce. This study aims to comprehensively describe the epidemiology, aetiology and outcomes of cough during and after acute respiratory illness in children presenting to a tertiary paediatric emergency department. Methods/design A prospective cohort study of children aged <15 years attending the Royal Children's Hospital Emergency Department, Brisbane, for a respiratory illness that includes parent reported cough (wet or dry) as a symptom. The primary objective is to determine the prevalence and predictors of chronic cough (>= 4 weeks duration) post presentation with acute respiratory illness. Demographic, epidemiological, risk factor, microbiological and clinical data are completed at enrolment. Subjects complete daily cough dairies and weekly follow-up contacts for 28(+/-3) days to ascertain cough persistence. Children who continue to cough for 28 days post enrolment are referred to a paediatric respiratory physician for review. Primary analysis will be the proportion of children with persistent cough at day 28(+/-3). Multivariate analyses will be performed to evaluate variables independently associated with chronic cough at day 28(+/-3). Discussion Our protocol will be the first to comprehensively describe the natural history, epidemiology, aetiology and outcomes of cough during and after acute respiratory illness in children. The results will contribute to studies leading to the development of evidence-based clinical guidelines to improve the early detection and management of chronic cough in children during and after acute respiratory illness.

A multicenter study on chronic cough in children : burden and etiologies based on a standardized management pathway

Background While the burden of chronic cough in children has been documented, etiologic factors across multiple settings and age have not been described. In children with chronic cough, we aimed (1) to evaluate the burden and etiologies using a standard management pathway in various settings, and (2) to determine the influence of age and setting on disease burden and etiologies and etiology on disease burden. We hypothesized that the etiology, but not the burden, of chronic cough in children is dependent on the clinical setting and age. Methods From five major hospitals and three rural-remote clinics, 346 children (mean age 4.5 years) newly referred with chronic cough (> 4 weeks) were prospectively managed in accordance with an evidence-based cough algorithm. We used a priori definitions, timeframes, and validated outcome measures (parent-proxy cough-specific quality of life [PC-QOL], a generic QOL [pediatric quality of life (PedsQL)], and cough diary). Results The burden of chronic cough (PC-QOL, cough duration) significantly differed between settings (P = .014, 0.021, respectively), but was not influenced by age or etiology. PC-QOL and PedsQL did not correlate with age. The frequency of etiologies was significantly different in dissimilar settings (P = .0001); 17.6% of children had a serious underlying diagnosis (bronchiectasis, aspiration, cystic fibrosis). Except for protracted bacterial bronchitis, the frequency of other common diagnoses (asthma, bronchiectasis, resolved without specific-diagnosis) was similar across age categories. Conclusions The high burden of cough is independent of children’s age and etiology but dependent on clinical setting. Irrespective of setting and age, children with chronic cough should be carefully evaluated and child-specific evidence-based algorithms used.

Does failed chronic wet cough response to antibiotics predict bronchiectasis?

Aim: To determine whether a child with chronic wet cough and poor response to at least 4 weeks of oral antibiotics is more likely to have bronchiectasis. Methods: All chest multi-detector computerised tomography (MDCT) scans at a single paediatric tertiary hospital from April 2010 to August 2012 were reviewed retrospectively so as to identify those ordered by respiratory physicians for assessment of children with a chronic wet cough. Information regarding age, sex, ethnicity, indication for imaging and the response to at least 4 weeks of antibiotics before having the scan were recorded from their charts. The data were analysed using simple and multiple logistic regression. Results: Of the 144 (87 males) eligible children, 106 (65 males, 30 Indigenous) aged 10–199 months had MDCT scan evidence of bronchiectasis. Antibiotic data were available for 129 children. Among the 105 children with persistent cough despite at least 4 weeks of antibiotics, 88 (83.8%) had bronchiectasis, while of the 24 children whose cough resolved after antibiotics, only six (25.0%) received this diagnosis (adjusted OR 20.9; 95% CI 5.36 to 81.8). Being Indigenous was also independently associated with radiographic evidence of bronchiectasis (adjusted OR 5.86; 95% CI 1.20 to 28.5). Conclusions: Further investigations including a MDCT scan should be considered in a child with a chronic wet cough that persists following 4 weeks of oral antibiotics. However, while reducing the likelihood of underlying bronchiectasis, responding well to a single prolonged course of antibiotics does not exclude this diagnosis completely.

Cough and ARI outcomes in urban Indigenous Children

Aim To identify cough epidemiology and outcomes in urban Indigenous children Methods An ongoing prospective cohort study of Indigenous children aged <5 years registered with at an urban Indigenous primary health care centre, Brisbane. Detailed baseline data are collected and, children are followed monthly for 12 months to capture ARI events. Children who develop cough as a symptom at any time over the 12 months have weekly follow-up for four weeks to ascertain cough outcomes. Results To date, 118 children have been enrolled (535 child-months of observation); Respiratory illnesses accounted for 23 (19 %) of overall reported reasons for presentation, however respiratory symptoms were present in 41 (35%) of all visits; a dry cough in 22 (18%), wet cough in 31 (26%). To date, 99 ARI’s have been recorded with an incidence of 18.4 episodes/100 child months. Seventeen children (14.4%) had persistent cough at day 28. Conclusion This is the first study to comprehensively describe the incidence and outcomes of cough in urban Indigenous children. Early data suggest respiratory illnesses are the most common illnesses for which these children seek medical advice and there is a high prevalence of wet cough.

Pertussis: A significant cause of prolonged acute cough in previously vaccinated school-aged children

No abstract available: Commentary on:
Wang KFry NKCampbell Het al. Whooping cough in school age children presenting with persistent cough in UK. BMJ 2014;348:g3668

The relationship between chronic cough and paradoxical vocal fold movement: A review of the literature

Chronic cough (CC) and paradoxical vocal fold movement (PVFM) are debilitating conditions. PVFM has been given many labels,(1) including vocal cord dysfunction, Munchausen's stridor, functional inspiratory stridor, nonorganic functional or psychogenic upper airway obstruction, factitious asthma, psychogenic stridor, emotional laryngeal wheezing, and episodic laryngeal dyskinesia. 3 Although CC and PVFM have been considered separate entities in many reports, there is preliminary support for the notion that there may be an underlying link between these two conditions. Speech pathologists have become increasingly involved in the treatment of these patients and therefore need to understand the theoretical background of these disorders, the pathophysiological links between the two, and the impact of voice disorders on these populations. The aim of this article is to review the current literature on CC and PVFM from a speech pathology perspective to provide a model for defining and conceptualizing the disorders and to provide a framework for management and future research.

Clinical utility of exhaled nitric oxide

Lower airway inflammation is generally classified as eosinophilic or neutrophilic. In conditions where eosinophilic inflammation predominates such as asthma in children, corticosteroids are usually beneficial. Traditionally, lower airway eosinophilia is measured using cellular count (through bronchoalveolar lavage or induced sputum). Both methods have limited applicability in children. When instruments to measure fractional exhaled nitric oxide (FeNO) became available, it presented an attractive option as it provided a non-invasive method of measuring eosinophilic inflammation suitable for children and adult. Not surprisingly, proposals have been made that FeNO measurement can be clinically used in many scenarios including monitoring the response to anti-inflammatory medications, to verify the adherence to treatment, and to predict upcoming asthma exacerbations. This thesis addresses the utility of FeNO levels in various scenarios, specifically in relation to asthma control and cough, a contentious aspect of the diagnosis of asthma. The thesis consists of a series of systematic reviews (related to the main question) and original studies in children. The over-arching aim of the thesis is to determine if FeNO is a clinically useful tool in the management of asthma and common asthma symptoms. The specific aims of the thesis were, to: 1. Determine if children with asthma have more severe acute respiratory symptoms at presentation with an asthma exacerbation and at days 7, 10 and 14 using validated scales. We also examined if children with asthma were more likely to have a persistent cough on day 14 than children with protracted bronchitis and/or controls. 2. Evaluate the efficacy of tailoring asthma interventions based on sputum analysis in comparison to clinical symptoms (with or without spirometry/peak flow) for asthma related outcomes in children and adults. 3. Evaluate the efficacy of tailoring asthma interventions based on exhaled nitric oxide in comparison to clinical symptoms (with or without spirometry/peak flow) for asthma related outcomes in children and adults. 4. Determine if adjustment of asthma medications based on FeNO levels (compared to management based on clinical symptoms) reduces severe exacerbations in children with asthma. 5. Examine the relationship between FeNO and exercise induced broncho-constriction and cough in children The aims above are addressed in respective chapters and all but one has been published/submitted. A synopsis of the findings are: In study-1 (Aim 1), we found that children with protracted bronchitis had the most severe acute respiratory infection symptoms and higher percentage of respiratory morbidity at day 14 in comparison to children with asthma and healthy controls. The systematic review of study-2 (Aim 2) included 246 randomised adult participants (no children) with 221 completing the trials. In the meta-analysis, a significant reduction in number of participants who had one or more asthma exacerbations occurred when treatment was based on sputum eosinophils in comparison to clinical symptoms. In the systematic review of study-3 (Aim 3), we found no significant difference between the intervention group (treatment adjusted based on FeNO) and control group (treatment adjusted based on clinical symptoms) for the primary outcome of asthma exacerbations or for the other outcomes (clinical symptoms, FeNO level and spirometry). In post-hoc analysis, a significant reduction in mean final daily dose ICS per adult was found in the group where treatment was based on FeNO in comparison to clinical symptoms. In contrast, in the paediatric studies, there was a significant increase in ICS dose in the FeNO strategy arm. Thus, controversy remains of the benefit or otherwise of utilising exhaled nitric oxide (FeNO) in routine clinical practice. FeNO levels are dependent on atopy and none of the 7 published trials have considered atopic status in FeNO levels when medications were adjusted. In study-4 (Aim 4), 64 children with asthma were recruited. Their asthma medications were adjusted according to either FeNO levels or usual clinical care utilising a management hierarchy taking into account atopy. It was concluded that tailoring of asthma medications in accordance to FeNO levels (compared to usual management), taking into account atopy status, reduced the number of children with severe exacerbations. However, a FeNO-based strategy resulted in higher daily ICS doses and had no benefit on asthma control. In study-5 (Aim 5), 33 children with cough and 17 controls were recruited. They were randomised to undertake an exercise challenge on day 1, or dry powder mannitol challenge on day 1 (with alternative challenge being done on day 2). In addition, a 24 hour cough meter, skin prick test, capsaicin cough sensitivity test and cough diary were undertaken. The change in cough frequency post exercise was significantly increased in the children with cough. FeNO decreases post exercise regardless of whether EIB is present or not. Limitations in the studies were addressed in the respective chapters. In summary, the studies from this thesis have provided new information on: • The severity of respiratory symptoms was increased in the early phase of the asthma exacerbation but not in the later recovery phase when compared with controls. • The utility of FeNO in the management of children with asthma. • The relationship of FeNO, cough and EIB in children. • Systematic reviews on the efficacy of tailoring asthma interventions based on eosinophilic inflammatory markers (sputum analysis and FeNO) in comparison to clinical symptoms.

Lung sickness in Murri kids : a cohort study in urban Indigenous children

QLD, 4Murri Health Group, Caboolture, QLD Introduction Respiratory illnesses with cough as a symptom are predominant causes of morbidity in young Australian Indigenous children. With the exception of ear disease, there are limited studies that have addressed burden and outcome. Also, there are no studies that are specific to urban Indigenous children. Aim: We aim to comprehensively investigate the incidence, aetiology, risk factors for and outcomes of acute respiratory illnesses (ARIs) in this population. Methods A cohort study of Indigenous children aged less than 5 years registered with an urban Indigenous primary health care service. Comprehensive baseline data are collected and children are followed monthly for 12 months to capture ARI events. ARI events are subsequently followed weekly for 4 weeks to determine cough outcomes, with review by a paediatric respiratory physician if cough has not resolved within 28 days. Results To date, 58 children (57% female) have been enrolled and 46 ARIs have been captured over 907 child weeks of observation (5.1 events per 100 child weeks, 95%CI 3.7–6.8). 13 ARIs (28.3%) have resulted in persistent cough for >28 days following onset. Conclusion Our early findings suggest an excess incidence of ARI in this population. The proportion of ARIs resulting in persistent cough for more than 4 weeks is the highest yet reported. Key Words: Indigenous, acute respiratory illness, paediatric.

The respiratory health of urban Indigenous children aged less than 5 years: Study protocol for a prospective cohort study

Background Despite the burden of acute respiratory illnesses (ARI) among Aboriginal and Torres Strait Islander children being a substantial cause of childhood morbidity and associated costs to families, communities and the health system, data on disease burden in urban children are lacking. Consequently evidence-based decision-making, data management guidelines, health resourcing for primary health care services and prevention strategies are lacking. This study aims to comprehensively describe the epidemiology, impact and outcomes of ARI in urban Aboriginal and Torres Strait Islander children (hereafter referred to as Indigenous) in the greater Brisbane area. Methods/design A prospective cohort study of Indigenous children aged less than five years registered with a primary health care service in Northern Brisbane, Queensland, Australia. Children are recruited at time of presentation to the service for any reason. Demographic, epidemiological, risk factor, microbiological, economic and clinical data are collected at enrolment. Enrolled children are followed for 12 months during which time ARI events, changes in child characteristics over time and monthly nasal swabs are collected. Children who develop an ARI with cough as a symptom during the study period are more intensely followed-up for 28(±3) days including weekly nasal swabs and parent completed cough diary cards. Children with persistent cough at day 28 post-ARI are reviewed by a paediatrician. Discussion Our study will be one of the first to comprehensively evaluate the natural history, epidemiology, aetiology, economic impact and outcomes of ARIs in this population. The results will inform studies for the development of evidence-based guidelines to improve the early detection, prevention and management of chronic cough and setting of priorities in children during and after ARI.

Efectividad de la vacuna acelular antipertussis en adolescentes: una revisión sistemática

La incidencia de la tosferina ha mostrado un incremento en los últimos años; afectando predominantemente a los niños menores de 1 año, adolescentes y adultos. En el 2005 el Comité Asesor de Prácticas en Inmunización (ACIP) recomendó administrar una dosis de refuerzo de la vacuna acelular antipertussis a los adolescentes. Esta estrategia ha sido adoptada por distintos países. Sin embargo hasta el momento no existe una revisión sistemática que evalúe la efectividad de esta medida de prevención primaria. Métodos: Revisión sistemática de la literatura de artículos acerca de la efectividad de la vacuna acelular antipertussis como dosis de refuerzo en adolescentes. Resultados: La búsqueda inicial arrojó un total de 121 resultados, de los cuales solo 4 cumplieron los criterios de selección. Se evaluó en éstos, la inmunogenicidad generada contra tétanos y difteria por la vacuna Tdap vs Td con resultados significativos y similares. Además se documentó la respuesta inmunológica protectora generada por la Tdap contra tosferina. En cuanto a la reactogenicidad, en general fue baja. Discusión: La vacuna Tdap genera inmunogenicidad similar a la Td contra tétanos y difteria. Además proporciona adecuada protección contra la tosferina como dosis de refuerzo en los adolescentes. Conclusión: La evidencia disponible sugiere que se puede recomendar la vacuna Tdap como dosis de refuerzo en adolescentes entre los 10 y los 18 años de edad por su baja reactogenicidad y adecuada inmunogenicidad contra tétanos, difteria y B. Pertussis.

Tosse, uma visão do otorrinolaringologista.

Persistent cough leads individuals to seek for medical assistance. Clinical investigation, however, may not reveal any alteration within the clinic's sphere of action. Often enough, some professionals treat the symptom as a disease, introducing several medicines, unsuccessfully. The author's experience, as an otolaryngologist, allows to state that many of these professionals ignore the upper aerodigestive tract as a cough-generator site. The present work discusses the alterations on the mentioned tract, which may provoke the cough reflex, reviewing, initially, the cough mechanism and the localization of the specific receptors. Cough is produce by stimulus at the receptor level or far from it. In upper and lower parts of the aerodigestive tract secretions may run to several directions. Secretion from the paranasal sinus is a frequent cause of cough. Acute sinusitis may occur insidiously bringing about the chronification of the inflammation with cough being the only great apparent symptom. Nasal and dental alterations favor sinusal infection. Signs and symptoms, even if minimum, may be detected through an accurate anamnesis. Nasal allergy, laryngitis, post nasal dripping and septal deviation may also produce cough. The ORL examination is, therefore, imperative, and no radiologic examination can substitute for it. An inadequate treatment, particularly of the sinusitis, may bring about a worsening and extension of the initial condition.