New chronic cough advice ‘well worth bookmarking’

Jolyon Attwooll

22/11/2023 2:22:43 PM

A ‘comprehensive’ update to chronic cough advice suggests child‐specific management will improve clinical outcomes.

Mother with coughing child
Authors describe the cough as ‘the most common symptom leading to medical consultation’.

Using separate algorithms to manage children who present with a chronic cough is likely to improve clinical outcomes, new recommendations suggest.
The advice is contained in an updated position statement, Cough in Children and Adults: Diagnosis, Assessment and Management (CICADA), a summary of which was published in The Medical Journal of Australia this week.
It cites a cough as ‘the most common symptom leading to medical consultation,’ warning that chronic cough ‘may indicate the presence of a serious underlying condition’.
‘High quality evidence supports the use of child‐specific chronic cough management algorithms to improve clinical outcomes, but none exist in adults,’ it states.
Dr Kerry Hancock, Chair of RACGP Specific Interests Respiratory Medicine, said the update is a welcome one, describing it as ‘a great resource for GPs’ that is ‘well worthwhile bookmarking’.
‘There are some very useful, clear algorithms that can be used to assist with diagnosis and assessment of adults and children who present with chronic cough,’ she told newsGP.
‘Of course, a good history and examination and initial investigation with CXR [chest x-ray] and spirometry – the latter for those over about six years old – is important for all patients presenting with chronic cough.
‘The tables listing the red flags and cough pointers [indicators of serious pathology] are really useful as well.’
Dr Hancock said a multi-disciplinary approach is recommended, with care often involving medical and allied health such as speech and language therapists, to assess, diagnose and manage patients with chronic cough.
‘There is a crucial role that the GP plays in coordinating that team of health practitioners to achieve the best outcome for our patients, especially where a multi-disciplinary chronic cough clinic is not readily available,’ she said.
The position statement describes early and effective treatment of chronic wet/productive cough in children as ‘critical’.
It also recommends the adoption of culturally specific strategies to help manage chronic cough in Aboriginal and Torres Strait Islander people.
‘Due to multiple factors, chronic wet cough in children of Australian First Nations heritage is often incorrectly considered normal by both families and health practitioners,’ the document states.
‘First Nations Australians who have been symptomatic since childhood are more likely to have significantly poorer clinical outcomes – suggesting that poorly managed respiratory illness in childhood can have serious flow-on effects into adulthood.’
Dr Hancock welcomed the separate section. 
‘[This is] an important issue since there is a profound mortality gap of 22 years between First Nations and non-First Nations Australians with bronchiectasis,’ she said.
Updated advice about gastro-oesophageal reflux disease (GORD) is included, with Dr Hancock noting advice against the empiric use of acid suppressive therapy for chronic cough without a history of reflux, or without evidence of reflux on objective testing such as 24-hour pH monitoring.
Previous guidelines had suggested an empirical trial of high-dose proton-pump inhibitor (PPI) therapy if there was a reasonable suspicion of GORD contributing to adult chronic cough.
It is the first time the initial CICADA position statement has been updated since it was published in 2010.
The authors use the GRADE approach to rate the strength of the evidence, with labels including ‘strong’, ‘weak’, and ‘no specific recommendation’.
The full updated position statement is available through on the Lung Foundation website.
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