TOUX CHRONIQUE DE L'ENFANT: ANALYSE DE " NOUVELLES " RECOMMANDATIONS - Plénière 8: " MISE AU POINT EN ASTHMOLOGIE" - SP2A
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
TOUX CHRONIQUE DE L’ENFANT:
ANALYSE DE « NOUVELLES »
RECOMMANDATIONS
Plénière 8: « MISE AU POINT EN ASTHMOLOGIE»
Eglantine HULLO
Pédiatrie Générale et Pneumopédiatrie, CHU Grenoble
CONFLIT D’INTERET 2020 • Intérêts financiers: néant • Liens durables ou permanents: néant • Interventions ponctuelles: GSK ⎼ Participation à des frais de congrès/formation ⎼ Rémunération de formation
PREAMBULE
• Toux chronique de l’enfant:
– Symptôme fréquemment rapporté
– Retentissement familial et social important
– Motif très fréquent de consultation
– Sujet historiquement peu exploré
Ø Prise en charge longtemps basée sur l’application d’algorithmes de prise
en charge «adulte » appliqués à l’enfant
• Travaux de recherche récents:
Ø Amélioration des connaissances
• Mécanismes physiopathologiques de la toux
• Etiologies pédiatriques (PBB, …)
• Evolution et morbidité(s) associée(s)
Ø Elaboration de « nouvelles recommandations » de prise en charge
pédiatriqueEtiologies of Chronic Cough in
Pediatric Cohorts
CHEST Guideline and Expert Panel Report 2017
[ Evidence-Based Medicine ]
Anne B. Chang, MBBS, PhD, MPH; John J. Oppenheimer, MD; Miles Weinberger, MD, FCCP; Cameron C. Grant, PhD;
Bruce K. Rubin, MD; and Richard S. Irwin, MD, Master FCCP; on behalf of the CHEST Expert Cough Panel
Use of Management There is Pathways
no published systematicor
BACKGROUND: Algorithms
review on the etiologies of chronic cough or the
relationship between OSA and chronic cough in children aged # 14 years. We thus undertook a
in Childrensystematic
With Chronic
review based on key questionsCough
(KQs) using the Population, Intervention, Comparison,
CHEST Guideline and Expert Panel Report 2017
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?
Anne B. Chang, MBBS, PhD, MPH; John J. Oppenheimer, MD; Miles M. Weinberger, MD, FCCP; Bruce K. Rubin, MD; ERS OFFICIAL DOCUMENT
We used the CHEST Expert Cough Panel’s protocol and the American College of
METHODS:
Kelly Weir, BSpThy, MSpPath, PhD, CPSP; Cameron C. Grant, MBChB, PhD; Richard S. Irwin, MD, Master FCCP; on behalf ERS GUIDELINES
Chest Physicians (CHEST) methodological guidelines and Grading of Recommendations
of the CHEST Expert Cough Panel Development, and Evaluation framework. Data from the systematic reviews in
Assessment,
conjunction with patients’ values and preferences and the clinical context were used to form
recommendations. Delphi methodology was used to obtain consensus.
studies We undertook systematic
the etiologies of cough reviews to examine
in children various aspects
are different
TASK FORCE
ERS guidelines on the diagnosis and
BACKGROUND: Using management algorithms or pathways potentially improves clinical out-
RESULTS: Combining KQs 1 and 2, we found moderate-level evidence from 10 prospective
comes.that in the generic approach (use
REPORTfrom those in adults and are
treatment of chronic cough in adults
of cough algorithms and tests) to the management
setting dependent. Data from three studies found of
thatchronic cough in
common etiologieschildren (agedin#young
of cough 14 years)
ERS STATEMENT
2017 based on key questions (KQs) using the Population, Intervention, Comparison, Outcome
children were different from those in older children. However, data relating sleep abnor- format.
METHODS: We used
malities to chronic
the AmericanThere
the CHEST
cough
College
Expert
in children were
of Chest Physicians
Cough
foundPanel’s
(CHEST)
only inprotocol
and
case studies.
that methodological guidelineschildren
for the systematic reviews and
andcough
Grading
in of 2020
ERS statement onare different
protracted bacterial
CONCLUSIONS: is moderate-quality evidence common etiologies of chronic
Recommendations
children Assessment,
from Development
those in adults and Evaluation
and are dependent on ageframework. Data
and setting. As from
there arethe
fewsys-
bronchitis in data
children
tematic
bewere
reviews
used toinform
in conjunction with
recommendations.
patients’
Delphi
values and
sleep methodology
preferences
guidelines. was
and
used 2017;
the
to obtain
clinical
relating OSA and chronic cough in children, the panel suggested that these children should context
the final grading.
managed accordance with pediatric CHEST 152(3):607-617 1
Alyn H. Morice , Eva Millqvist2, Kristina Bieksiene3, Surinder S. Birring4,5,
6
Ahmad
RESULTS: Combining data from systematic reviews addressing
Kantar1,13, AnneKEY WORDS:2,3,4,13
B. Chang cough;, Mike
evidence-based 5
medicine;
D. Shields , Julie M. Marchant2,3,
pediatrics Peter
five KQs,Dicpinigaitis
we found high- , Christian Domingo Ribas7, Michele Hilton Boon 8,
Keith[ Grimwood
Evidence-Based6 quality
Medicine
, Jonathan Grigg ] 7, Kostas N. Priftis8, Renato Cutrera9,
evidence that a systematic approach to the management of chronic cough
Ahmad Kantar , Kefang Lai10,21, Lorcan McGarvey11, David Rigau12,
9
improves 11 clinical outcomes. Although there was evidence from several pathways, 13,14 the highest
, Jacky Smith15, Woo-Jung Song 16,22, Thomy Tonia17, Jan
10 12
Fabio Midulla ,CHEST
ABBREVIATIONS: Paul =L.P. BrandCollege
American andof Mark L. Everard Auckland, Auckland, New Zealand; and Imran
Chest Physicians; Satia
the Department of Pediatrics W.
GERD = gastroesophageal reflux evidence
disease; ILDwas from the
= interstitial lunguse of the CHEST
disease; approach.
(Dr Weinberger), However,
University thereSan
of California, wasDiego,
no or little
Rady evidence
Children’s
KQ = key question; PBB = protracted bacterialsome
bronchitis; PC-QOL Hospital, San Diego, CA.
KQs=Bergamaschi, K. van den Berg18, Mirjam J.G. van Manen19 and Angela Zacharasiewicz20
Affiliations: 1Pediatric Asthma andtoCough
address of Ospedalieri
Centre, Istituti the posed. University and Research
parent cough-specific quality of life; PRISMA = Preferred Reporting Items DISCLAIMER: AmericanHospital,
College of Chest Physician guidelines are
Hospitals, Bergamo, Italy. 2Dept of Respiratory and Sleep Medicine, Lady Cilento Children’s
for Systematic Reviews and Meta-Analyses;
CONCLUSIONS:
Brisbane, Australia. 3Centre for Children’s
QoL Compared
= quality
Health Research,
RCT with
of life;Institute the
= of Health 2006
intended& for Coughinformation
general
Biomedical Guidelines,
Innovation, there
only, are is now
not medical high-quality
advice, and do
Chronic Cough and Gastroesophageal
randomized
Belfast,
Menzies 6
controlled
UK.School
From
Menzies
trial;
Queensland University of Technology,
the
of Health
UACS =
Division
Health Institute
upper
evidence
Research;
of
airway
Brisbane,that
Child
use ofQueensland,
cough
cough
Health
syndrome
Australia. 4
(Dr
management
Child Health
in children
5
Griffith and
the Respiratory
aged
Chang),
not replace
Division,
# 14
ways
professional
Menzies
years
should
Research, Charles Darwin University, Casuarina, Australia. Dept of Child Health, Queen’s University Belfast,
AFFILIATIONS:
protocols
University
Sleep Gold(or
and disclaimer
be
School
with
algorithms)
CoastforHealth, Gold
medical
of Health
chronic
sought for
improves
this guideline
any
Coast,
care and
cough (>
medical
physician
4 weeks’
condition.
advice,
@ERSpublications
clinical
can be accessed
The
atoutcomes,
which al- the
duration),
complete
and cough
http://www.chestnet.
Reflux in Children
Australia. 7
DepartmentBlizard
(Dr Institute, Queen
Chang), Lady Mary
Cilento University
Children’s
management London,
Hospital,
or London,
testingQld Uni UK.
of
algorithms
8
Third Dept
should of Paediatrics,
differ University
depending on the
New ERS guideline on chronic cough details the paradigm shift in our understanding. In adults,
org/Guidelines-and-Resources/Guidelines-and-Consensus-Statements/
associated characteristics
2019
General Hospital
Technology Attikon, School
Queensland, of Medicine,
Australia; National and
the Division Kapodistrian
of Allergy and University of Athens, Athens, Greece.
CHEST-Guidelines. cough hypersensitivity has become the overarching diagnosis, and in children, persistent bacterial
9
Respiratory Unit, UniversityofDept ofof the cough
Pediatrics, and clinical
Bambino Gesu’ history. A
Children’s chest radiograph
Research Hospital, Rome, and, when age
Italy. appropriate, spirometry
…
Immunology, Department Medicine (Dr Oppenheimer), New Jersey
10
CHEST Guideline and Expert Panel Report
Dept of Pediatrics
Medical and Infantile
School, Pulmonary andNeuropsychiatry,
Allergyand
(pre-
“Sapienza”
Associates, University
Morristown,
post-12bSchool
2 agonist)
NJ;
FUNDING/SUPPORT:
shouldMedical
be Child
undertaken.
11 A. B. C. is supported
of Rome, Rome, Italy. Isala Women
Other
Research Council tests
(NHMRC)
bronchitis
should
by explains
a National Health
not fellowship
practitioner be routinely
most wet cough, changing treatment advice. http://bit.ly/2kycX8D
and
[Grantper-
and Children's Hospital, Zwolle, the Netherlands.
the Division of Pulmonary, Allergy, and Critical Care Medicine, of Pediatrics and Health, University of
Western Australia, Princess(Dr Margaret Hospital, Subiaco, Australia. 13 1058213] and holds multiple grants awarded from the NHMRC related
Department of Medicine formed
Irwin), UMassand undertaken
Memorial Medical inBoth
Center, authors contributed
accordance with equally.
the clinical settingCite andthis
to diseases associated with pediatric cough. The views expressed in thisthearticle
child’sas: Morice AH, Millqvist E, Bieksiene K, et al. ERS guidelines on the diagnosis and
clinical
Anne B.MA;
Worcester, Chang, MBBS, PhD,
the Department MPH; John
of Pediatrics J. Oppenheimer,
(Dr Rubin), Children’s MD; Peter J.areKahrilas, MD; Ahmad Kantar,
treatment MD;of
the chronic cough in adults and children. Eur Respir J 2020; 55: 1901136 [https://doi.org/10.1183/
Correspondence: Ahmad Kantar,symptoms and
Pediatric Asthma signs (eg, tests
and Cough for
Centre, tuberculosis
publication
Istituti Ospedalieri when
those the
of the child
authors
Bergamaschi, hasdo
and been exposed).
not reflect views of the
Hospital
Bruceand
University
of
K.Richmond
Rubin,
Research
atHospitals,
MD; Virginia Commonwealth
Miles Weinberger,
via Forlanini MD,
University,
FCCP;San
15, Ponte
Rich-
and Richard
Pietro, S. Irwin,
NHMRC.
Bergamo, MD,
Italy. Master
E-mail: FCCP; CHEST
kantar@ 13993003.01136-2019].
on behalf of the151(4):875-883
CHEST Expert
mond, VA; the Department of Paediatrics: Child and Youth Health, 2017;
centropediatricotosse.com
Cough
Faculty Panel* and Health Sciences (Dr Grant), The University of
of MedicineDEFINITION
• « Toux chronique de l’enfant »: DUREE?
Ø Recommandations internationales discordantes :
− American College of Chest Physicians: durée ≥ 4 semaines
Chang et al. Guidelines for evaluation chronic cough in pediatrics: ACCP evidence-based
clinical practice guideline. Chest 2006;129:Suppl.1,260S-283S
− British Thoracic Society:
• Toux « chronique »: durée ≥ 8 semaines
• Toux « aigue prolongée»: [3-8] semaines
= temps « attendu » de résolution d’une toux post-infectieuse
Shields et al. BTS guidelines: Recommendations for the assessment and management of cough in children.
Thorax 2008;63:Suppl.3,iii1-15.
Ø Littérature récente:
• Toux chronique de l’adulte: ≥ 8 semaines
• Toux chronique de l’enfant: ≥ 4 semaines
Morice et al. ERS Guidelines on the diagnosis and treatment of chronic cough in adults and children.
Eur Respir J 2020;55:1901136• « Toux chronique de l’enfant »: PERIODICITE?
Ø « For children aged ≤14 years, we suggest defining chronic cough as
the presence of DAILY COUGH of at least 4 WEEKS in duration »
(Ungraded, Consensus Based Statement )
Chang et al. Use of Management Pathways or Algorithms in Children with Chronic Cough.
Chest 2017;151(4):875-883
Ø Infections de VAS récidivantes et rapprochées peuvent donner
l’impression de signes continus
• « Toux chronique de l’enfant »: AGE?
Ø Etudes et recommandations: non homogènes…to 43 weeks [median (IQR) = 12 (6–19.5) weeks] who were data. In comparison with other studies, these results con-
referred by community pediatricians for chronic cough. firm, as mentioned above, that the prevalence of various
Chronic cough was defined as a cough lasting more than etiologies of chronic cough depends on numerous factors.
ETIOLOGIES
4 weeks. Thirty-four of the children had a wet cough, and 19
presented wheezing. The diagnostic protocol employed at
our center is based on a modified Australian chronic cough Future Management and Prevention
protocol [38]. The diagnostic approach was patient centered,
and the parents shared in the diagnostic approach and Respiratory infections and their sequelae appear to be the
• TRAVAUX RECHERCHE récents chez l’enfant:
management. The study was approved by Local Ethical principal cause of chronic cough in children. This con-
Committee and parents gave informed consent. clusion suggests various possibilities for both treatment and
The approach was based on an initial detailed medical
history and physical examination. This step was followed by
20
Ø Amélioration des connaissances
first-phase investigations that included one or more of the
following assessments: chest radiograph, laboratory exami-
18
16
⎼ Physiopathologie
nation (immunoglobulins; IgE; markers for pertussis,
% of total cases
14
mycoplasma, and chlamydia infections; sweat test; Alpha-1-
antitrypsin; Epidémiologie
⎼ Mantoux or Quantiferon tests), skin prick test
12
10
(n = 60), oscillometry (n = 13), spirometry (n = 47), 8
FeNO (n = 44), induced sputum (n = 32; children 6
[5Ø LUNG,
years), 2016:for ciliary analysis (n = 10), and
nasal brushing 4
psychological evaluation (n = 16). The first exam per- 2
formed was 64 enfants,
• selected 2011-2012
based on the patient’s clinical profile 0
and the nature of cough. In the second phase, CT scanning
• 2 perdus
(Dual Source de vue
Flash Spiral; n = 21), pH impedance
(n = 16), and/or flexible bronchoscopy (n = 10) were per-
• 1 patient « sans étiologie
formed. These tests were conducted if the initial investiga- Diagnosis
identifiée
tion did not lead » and the cough persisted. In
to a diagnosis
Fig. 1 Frequency (%) of the primary diagnosis in 64 children with
two patients, esophagogastroscopy was also performed.
chronic cough, defined as cough [4 weeks duration. Protracted
A primary diagnosis was obtained for 61 children, who bacterial bronchitis (PBB), gastroesophageal reflux (GER), and upper
were followed up for 6 months (Fig. 1). Among these airway cough syndrome (UACS)
Kantar A. Update on Pediatric Couch. Lung 2016;194:9-14
123• RECOMMANDATIONS: ETIOLOGIES chez l’enfant
− DIFFERENTES // chez l’adulte (IB)
[ Evidence-Based Medicine ]
Ø « Hypersensibilité à la toux » chez l’enfant?
Ø CAUSES SPECIFIQUES: Etiologies of Chronic Cough in
Pediatric Cohorts
⎼ PBB CHEST Guideline and Expert Panel Report 2017
⎼ CEB Anne B. Chang, MBBS, PhD, MPH; John J. Oppenheimer, MD; Miles Weinberger, MD, FCCP; Cameron C. Grant, PhD;
Bruce K. Rubin, MD; and Richard S. Irwin, MD, Master FCCP; on behalf of the CHEST Expert Cough Panel
⎼ Toux psychogène 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
− Toux = le + svt SYMPTÔME d’une pathologie sous-jacente
Assessment, Development, and Evaluation framework. Data from the systematic reviews in
ERS OFFICIAL DOCUMENT
conjunction with patients’ values and preferences and the clinical context were used to form
ERS GUIDELINES
recommendations. Delphi methodology was used to obtain consensus.
Combining KQs 1 and 2, we found moderate-level evidence from 10 prospective
Ø Présentations cliniques différentes
RESULTS:
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
ERS guidelines on the diagnosis and children were different from those in older children. However, data relating sleep abnor-
Ø Etiologies variables selon
malities to chronic cough in children were found only in case studies.
treatment of chronic cough in adults 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
• Age and children
data relating OSA and chronic cough in children, the panel suggested that these children should
be managed in accordance with pediatric sleep guidelines.
2020
CHEST 2017; 152(3):607-617
KEY WORDS: cough; evidence-based medicine; pediatrics
• Contexte/Environnement ABBREVIATIONS: CHEST = American 1 College of Chest Physicians;
Alyn H. Morice , Eva Millqvist , Kristina Bieksiene
(Dr Weinberger),
2 3
GERD = gastroesophageal reflux disease; ILD = interstitial lung disease;
6
Peter Dicpinigaitis , Christian Domingo
KQ = key question; PBB = protracted bacterial
Ribas 7
Hospital, San Diego,
, CA.
Michele
bronchitis; PC-QOL =
Auckland, Auckland, New Zealand; and the Department of Pediatrics
, Surinder
University S.Diego,
of California, San
Hilton
Birring
Boon
4,5
,
Rady Children’s
8
,
parent cough-specific quality of life; PRISMA = Preferred Reporting Items
DISCLAIMER: American College of Chest Physician guidelines are
• Durée de la toux
9 QoL = quality of life;10,21 11 only, are not medical 12
Ahmad Kantar , Kefang Lai , Lorcan
for Systematic Reviews and Meta-Analyses;
McGarvey
intended for RCT =
, David Rigau advice,
general information
randomized controlled trial; UACS = upper airway cough syndrome
, and do
not replace professional medical care and physician advice, which al-
13,14 15 16,22 17
Imran Satia , Jacky Smith , Woo-Jung Song
ways should
AFFILIATIONS: From the Division of Child Health (Dr Chang),be sought for any, Thomy ToniaThe
medical condition. ,complete
Jan W.
Menzies School of Health Research; disclaimer
19for this guideline can be accessed at http://www.chestnet.
18 the Respiratory and Sleep
K. van den Berg , Mirjam J.G. van Manen and Angela Zacharasiewicz20
org/Guidelines-and-Resources/Guidelines-and-Consensus-Statements/
Department (Dr Chang), Lady Cilento Children’s Hospital, Qld Uni of
Technology Queensland, Australia; the Division of Allergy and CHEST-Guidelines.
Immunology, Department of Medicine (Dr Oppenheimer), New Jersey FUNDING/SUPPORT: A. B. C. is supported by a National Health and
Medical School, Pulmonary and Allergy Associates, Morristown, NJ; Medical Research Council (NHMRC) practitioner fellowship [GrantStatement).
chest CT
3. For children aged £ 14 years with chronic cough, we underta
recommend
Summary of using pediatric-specific cough
Recommendations/Suggestions the chil
appropr
management
1. For children aged £ or
protocols 14 algorithms (Gradedefining
1B).
DEMARCHE DIAGNOSTIQUE
years, we suggest underta
11. For
chronic
4. cough as
For children the£presence
aged 14 yearsofwith
daily cough cough,
chronic of at least
we chronic
9. For ch
4 weeks in duration
recommend taking a (Ungraded, Consensus(such
systematic approach Basedas suggest
suggest
Statement).
using a validated guideline) to determine the cause of (AHR)
pertussis
the cough (Grade
2. For children 1A).
aged £ 14 years with chronic cough, we suspecte
Chronic
suggest
5. that an aged
For children assessment of thewith
£ 14 years effect of cough
chronic on
cough, impaired
10. For
• UTILISATION D’ALGORITHMES Pédiatriques: we recommend basing the management or testingthe
the child and the family be undertaken as part of adverse
we recom
clinical consultation
algorithm (Ungraded, Consensus
on cough characteristics and theBased Also, (eg
it
tests
Statement).clinical history, such as using specific
associated as bronc
chest CT
– DUREE (?) cough pointers like presence
3. For children aged £ 14 years with chronic cough, weof productive/wet early dia
underta
(eg, child
fore
cough
recommend (Gradeusing 1A). pediatric-specific cough the
– CARACTERISTIQUES de la toux: management
6. For childrenprotocols aged £ 14oryears algorithms
with chronic (Gradecough, 1B). we
morbidi
11.
leadsFor
to
• Sèche recommend basing the management on the etiology of
4. For children aged £ 14 years with chronic cough, we
the cough. An empirical approach aimed at treating
recommend taking a systematic approach (such as
chronic
resolutio
suggest
Use of c
• Productive upper airway cough syndrome due to a rhinosinus
using a validated guideline) to determine the cause of
condition, gastroesophageal reflux disease, and/or
the cough (Grade 1A).
(AHR)
lead to b
unneces
e
asthma should not be used unless other features Chronic
– SIGNES d’ALERTE et d’ORIENTATION 5. For children
consistent with these £ 14 years are
aged conditions withpresentchronic cough,
chronic
impaired
we recommend
(Grade 1A). basing the management or testing adverse
• Histoire clinique algorithm on cough characteristics and the
7. For children aged £ 14 years with chronic cough, we
In the m
Also, it
than 4 w
associated clinical history, such as using specific as bronc
• Examen physique suggest that if an empirical trial is used based on
cough pointers like presence of productive/wet
features consistent with a hypothesized diagnosis, the
to confir
early dia
investiga
cough (Grade 1A). (eg, fore
trial should be of a defined limited duration in order issues an
morbidit
6. confirm
to For children aged £the
or refute 14hypothesized
years with chronic diagnosis cough, we consider
leads to
Ø BILAN SYSTEMATIQUE: recommendConsensus
(Ungraded, basing theBased management
Statement). on the etiology of function
resolutio
the cough. An empirical approach aimed at treating young c
8. For children aged £ 14 years with chronic cough, we Use of c
upper airway cough syndrome due to a rhinosinus pulmon
• ? + E clinique + Q de vie recommend that a chest radiograph and, when age
condition, gastroesophageal reflux disease, and/or
lead to e
challeng
unnecess
Summary of Recommendations/Suggestions appropriate,
[asthma shouldspirometry
not be used (pre- unless
and post- otherb2 agonist)
features be laborato
• Radiographie Pulmonaire
1. For children aged £ 14 years, we suggest defining
Evidence-Based Medicine ]
undertaken (Grade 1B).
consistent with these conditions are present
FUNDING/SUPPORT: The authors have reported to CHEST that no
chronic
adverse
chronic cough as the presence of daily cough of at least (Grade 1A). may req
• EFR (pré/postBD)
funding
9. was
For children received
aged for £this
14study.
years with chronic cough, we In the m
4 weeks in duration (Ungraded, Consensus Based aged <
Use of undertaking
7.Respiratory
of
Management
For children and Sleep
Pathways
CORRESPONDENCE TO: Anne B. Chang, MBBS, PhD, MPH, Department
suggest agedtests £ 14evaluating
Medicine, years
Ladywith
or
Cilento
Algorithms
recent
chronic Bordetella
Children’s cough, we
Hospital, than 4 w
Statement). in Children With Chronic Cough
pertussis infection when pertussistrialisis clinically to confir
Ø REEVALUATION ET SUIVI 2017
South
suggest Brisbane,
thatQLD 4101,
if and
an Australia;
empirical e-mail: annechang@ausdoctors.net
used based on
CHEST Guideline Expert Panel The 200
2. For children aged £ 14 years with chronic cough, we suspected
Copyright !(Ungraded,
2017 American Consensus
College of Report
Based
Chest Statement).
Physicians. Published by investiga
features
Elsevier consistent with
Inc. All rights reserved. a hypothesized diagnosis, the (CHEST
suggest that an assessment of the effect of cough on Anne B. Chang, MBBS, PhD, MPH; John J. Oppenheimer, MD; Miles M. Weinberger, MD, FCCP; Bruce K. Rubin, MD;
trial should bePhD,of a defined limited duration in Master
order issues an
10.
DOI:
Kelly For
Weir, children
BSpThy, MSpPath, aged
CPSP; £ 14C.years
http://dx.doi.org/10.1016/j.chest.2016.12.025
Cameron Grant, with
MBChB, PhD;chronic
Richard S. Irwin,cough,
MD, advocate
FCCP; on behalf
the child and the family be undertaken as part of the of the CHEST Expert Cough Panel
to recommend
confirm or refute the hypothesized consider
we not routinely performingdiagnosis additionalDetailed history [11]
Detailed history
Clinical [11]
presentation of cough#
Clinical presentation of cough
Physical #
examination
Physical
Identify examination
symptoms and signs suggestive of
Identify symptoms andspecific disease of
¶,+
signs suggestive
specific disease¶,+
Perform chest radiography
Perform
Performchest radiography
spirometry in collaborative children
aged >5 years
Perform spirometry in collaborative children
aged >5 years
Symptoms and signs of specific Symptoms and signs of specific
Symptoms and disease
signs of specific
present¶,+ Symptoms and signs of specific
disease absent
disease present¶,+ disease absent
Specific pointers identified Specific pointers not identified
Specific pointers identified Specific pointers not identified
Investigate and treat accordingly Wet cough Dry cough
Investigate and treat accordingly Wet cough Dry cough
Wet cough Dry cough
Wet cough Dry cough
Attempt sputum culture Check for irritants
Attempt sputum culture Check for irritants
Allergy testing§
Allergy testing§
Rule out precedent infection
Rule out precedent infection
Treat with antibiotics as for PBB
Treat with antibiotics as for PBB
(according
(according to ERSto ERS document)
document) [69] [69]
No recurrence
No recurrence Follow for 4Follow
weeks for 4 weeks Resolution Follow-up for Follow-up for
Resolution
recurrence recurrence
Not resolved Resolved
Resolved
Not resolved Treat andTreat and
after prolonged
after prolonged follow-upfollow-up Spontaneous 4–8-week trial
Recurrence Spontaneous
Persistent Persistent
4–8-week trial
coursecourse Recurrence closely forclosely for regressionregression with ICS with ICS
(according
(according to ERSto ERS sequelae sequelae
document)
document) [69] [69]
Persistent Investigate for Investigate for
Persistent
Follow until
Follow until underlying underlying
spontaneousspontaneous disease disease
Investigate
Investigate for for resolution resolution
underlying
underlying
disease
disease + +
FIGURE 2 Cough
FIGURE assessment
2 Cough flow chart
assessment flow for children.
chart PBB: protracted
for children. bacterial bacterial
PBB: protracted bronchitis;bronchitis;
ERS: European
ERS: Respiratory Society; ICS:Society;
European Respiratory inhaled ICS: inhaled
#
corticosteroids. : how#:and
corticosteroids. howwhen
and the cough
when started,
theMorice time-course
cough started, of cough,ofnature
time-course cough, and quality
nature of cough,
and quality symptoms
ofand
cough, associated
symptoms with cough, triggers
associated with cough,intriggers
of cough, diurnal
of cough, and nocturnal
diurnal variations,
and nocturnal variations,
et
cough associated
al. ERS
cough associated
Guidelines
with indoorwithand
on
outdoor
indoor
the diagnosis
andirritants;
¶
: chest pain,
outdoor irritants; ¶ treatment
history
: chest
of
suggestive
pain, history of
chronic cough
inhaled foreign
suggestive
adults and children.
of inhaled foreign
body,body,
dyspnoea, exertional
dyspnoea, dyspnoea,
exertional haemoptysis,
dyspnoea, failure tofailure
haemoptysis, thrive,tofeeding
thrive,difficulties (including (including
feeding difficulties choking/vomiting), Eur Respir J 2020;55:1901136
cardiac or neurodevelopmental
choking/vomiting), cardiac or neurodevelopmentalgestions appropriate, spirometry (pre- and post-b2 agonist) be
st defining undertaken (Grade 1B).
s Based • IMPORTANCE
gh of at least
de
9. For children aged £ 14 years with poser
chronic un CADRE DIAGNOSTIQUE pour
cough, we
suggest undertaking tests evaluating recent Bordetella
guider les EXPLORATIONS NON SYSTEMATIQUES:
[ Evidence-Based Medicine ]
pertussis infection when pertussis is clinically
ic cough, we suspected (Ungraded, Consensus Based Statement).
f cough on
10. For children aged £ 14 years with chronic cough,
part of the Use of Management Pathways or Algorithms
we recommend not routinely performing additional
s Based
tests (eg, skin prick test, Mantoux, bronchoscopy,
in Children With Chronic Cough
CHEST Guideline and Expert Panel Report
chest CT); these should be individualized and
ic cough, we undertaken in accordance with the clinical setting and Anne B. Chang, MBBS, PhD, MPH; John J. Oppenheimer, MD; Miles M. Weinberger, MD, FCCP; Bruce K. Rubin, MD;
Kelly Weir, BSpThy, MSpPath, PhD, CPSP; Cameron C. Grant, MBChB, PhD; Richard S. Irwin, MD, Master FCCP; on behalf
h the child’s clinical symptoms and signs (Grade 1B). of the CHEST Expert Cough Panel
ade 1B).
11. For children aged > 6 years and £ 14 years with
ic cough, we
Ø Pas d’indication de TDM systématique si bilan initial normal…
chronic cough and asthma clinically suspected, we
BACKGROUND: Using management algorithms or pathways potentially improves clinical out-
comes. We undertook systematic reviews to examine various aspects in the generic approach (use
(such as Morice
suggest that a test for airway et al. ERS Guidelines on the diagnosis and ofbased
hyperresponsiveness treatment of chronic cough in adults and children.
cough algorithms and tests) to the management of chronic cough in children (aged # 14 years)
on key questions (KQs) using the Population, Intervention, Comparison, Outcome format.
the cause of (AHR) be considered (Grade 2C). METHODS: We used the CHEST Expert EurCough
RespirPanel’sJ protocol
2020;55:1901136
for the systematic reviews and
the American College of Chest Physicians (CHEST) methodological guidelines and Grading of
Chronic cough among children is associated with Recommendations Assessment, Development and Evaluation framework. Data from the sys-
1 2 tematic reviews in conjunction with patients’ values and preferences and the clinical context
onic cough, impaired quality of life, multiple physician visits, and
• Evaluation de la PSYCHOMORBIDITE:
were used to form recommendations. Delphi methodology was used to obtain the final grading.
or testing adverse effects from inappropriate use of medications.3 RESULTS: Combining data from systematic reviews addressing five KQs, we found high-
quality evidence that a systematic approach to the management of chronic cough
he Also, it may signify a serious underlying disease such improves clinical outcomes. Although there was evidence from several pathways, the highest
specific – Permanente
as bronchiectasis or an inhaled foreign body.1 Further, evidence was from the use of the CHEST approach. However, there was no or little evidence
to address some of the KQs posed.
ve/wet early diagnosis is important, as delayed diagnosis CONCLUSIONS: Compared with the 2006 Cough Guidelines, there is now high-quality
– Diminue avec le suivi d’un traitement efficace!
(eg, foreign body) may cause chronic respiratory
4
evidence that in children aged # 14 years with chronic cough (> 4 weeks’ duration), the
use of cough management protocols (or algorithms) improves clinical outcomes, and cough
morbidity, whereas early diagnosis of chronic disease management or testing algorithms should differ depending on the associated characteristics
ic cough, we leads to appropriate management and subsequent of the cough and clinical history. A chest radiograph and, when age appropriate, spirometry
e etiology of Morice et al. ERS Guidelines
resolution of cough and improved quality of life (QoL). 1 on the diagnosis and (pre-
treatment of chronic cough in adults and children.
and post-b2 agonist) should be undertaken. Other tests should not be routinely per-
formed and undertaken in accordance with the clinical setting and the child’s clinical
at treating Use of cough algorithms or pathways can potentially symptoms and signs (eg, tests for Eur Respir
tuberculosis whenJthe
2020;55:1901136
child has been exposed).
CHEST 2017; 151(4):875-883
hinosinusPas à pas en Pédiatrie. Toux chronique de l’enfant.
G. Benoist, G. Thouvenin, 20191. ASTHME:
Ø « Test before treating, wherever possible »
Ø Patients « COUGH-VARIANT ASTHMA»:
1. Eliminer un diagnostic différentiel
2. Caractéristiques de la toux:
1. Toux sèche persistante + hyperréactivité bronchique
2. Prédominance nocturne
3. EFR parfois normale => variabilité+++
Ø ENFANT ≥ 6 ans:
• EFR (VEMS/CVF12%)
• Etude de la variabilité:
o DEP x2/jour, 2 semaines: DEP>13%
o Test d’exercice: FEV>12% ou DEP15%
o Visites médicales: FEV>12% ou DEP>15%
o (Test de provocation bronchique: FEV ≥ 20%)Ø ENFANT ≤ 5 ans:
• Caractéristiques de la toux suggérant un asthme:
⎼ « Recurrent or persistent non-productive cough that may be worse at night or
accompanied by wheezing and breathing difficulties.
⎼ Cough occurring with exercise, laughing, crying or exposure to tobacco smoke,
particularly in the absence of an apparent respiratory infection. »
• Test thérapeutique: CSI + BD ALD, 2-3 mois
• TCA: si > 3 ans, plutôt prédictif de la persistance de l’asthme
GINA 2020
Ø AUTRES EXPLORATIONS COMPLEMENTAIRES?
Ø Test de provocation bronchique: mauvaise VPN
Ø Inflammation eosinophilique :
⎼ LBA, E induite: diagnostic bronchite eosinophilique!
⎼ FeNO: absence de seuil discriminant/diagnostic positif
⎼ NFS: non évalué
Morice et al. ERS Guidelines on the diagnosis and treatment of chronic cough in adults and children.
Eur Respir J 2020;55:19011362. BRONCHITE BACTERIENNE PERSISTANTE (PBB):
Ø Diagnostic = CLINIQUE
Ø Explorations complémentaires : UNIQUEMENT si
• Signes d’alerte
• Absence d’amélioration sous ATB conventionnelle (>4 semaines)
• TDM, Fibroscopie, B immunitaire…
Chang et al. Management of Children with Chronic Wet Cough and Protracted Bacterial Bronchitis.
Chest 2017;151(4):884-890
3. RGO:
Ø 2 examens diagnostiques recommandés:
• pHmétrie (RGO acide)
• pH-Impédancemétrie (RGO acide et non-acide)
Ø Autres explorations non indiquées…
Ø Lien de cause à effet: difficile à démontrer
Ø Test thérapeutique: UNIQUEMENT si symptômes évocateurs de RGO
NASPGHAN – ESPGHAN Pediatric GER Clinical Practice Guidelines, 2018the child and the family be undertaken as part of the w
clinical w
clinical consultation (Ungraded, Consensus
consultation (Ungraded, Consensus Based
Based
Statement). tet
Statement). c
ch
PRISE EN CHARGE THERAPEUTIQUE
3.
3. For
For children
children aged £ 14
aged £ 14 years
years with
withchronic
chroniccough,
cough,wewe uu
recommend using pediatric-specific
recommend using pediatric-specific cough
cough tht
management protocols or
management protocols or algorithms
algorithms (Grade
(Grade 1B).
1B).
11
4.
4. For
For children aged £
children aged £ 14
14 years
years with
withchronic
chroniccough,
cough,wewe c
ch
recommend taking aa systematic
recommend taking systematic approach
approach (such
(suchasas s
su
using
using aa validated guideline) to
validated guideline) to determine
determine the
thecause
causeofof (
(A
the
the cough (Grade 1A).
cough (Grade 1A).
Ø ACCOMPAGNEMENT, REEVALUATION 5.
SYSTEMATIQUE
5. For
For children aged ££ 14
children aged 14 years
years with
with chronic
chronic cough,
cough,
CC
imi
Ø TOUX SPECIFIQUE = TRAITEMENT ETIOLOGIQUE!
we
we recommend basing the
recommend basing the management
management or
algorithm on cough characteristics
characteristics and
or testing
and the
the
testing aa
AA
associated clinical history,
history, such
such as
as using
using specific
specific aa
cough pointers like presence
presence ofof productive/wet
productive/wet eae
• TRAITEMENT MEDICAMENTEUX: TRAITEMENT D’EPREUVE? cough (Grade 1A). (e(
mm
Ø PRINCIPES GENERAUX: recommend basing the
£ 14
6. For children aged £ 14 years
years with
withchronic
the management
managementon
chroniccough,
onthe
cough,we
theetiology
we
etiologyofof
lel
rer
the cough. An empirical
empirical approach
approach aimed
aimed at at treating
treating UU
upper airway cough syndrome
syndrome due
due to
to aa rhinosinus
rhinosinus
− Si symptomatologie évocatrice condition, gastroesophageal
gastroesophageal reflux
reflux disease,
disease, and/or
and/or
lel
uu
asthma should not bebe used
used unless
unless other
other features
features
associée consistent with these conditions
conditions are
are present
present
chc
− Durée (pré-) déterminée (Grade 1A). InI
7. For children aged £ £ 14
14 years
years with
withchronic
chroniccough,
cough,wewe tht
− Réévaluation nécessaire suggest that if an empirical
empirical trial
trial isis used
used based
basedonon tot
features consistent with ini
with aa hypothesized
hypothesized diagnosis,
diagnosis,the
the
− Utilisation séquentielle trial should
trial should be
be of
of aa defined
defined limited
limited duration
durationin inorder
order
isi
to confirm
confirm or coc
to or refute
refute the
the hypothesized
hypothesized diagnosis
diagnosis
(Ungraded, Consensus fuf
(Ungraded, Consensus Based
Based Statement).
Statement).
Chang et al. Use of Management Pathways or Algorithms in Children with Chronic Cough. Chest 2017;151(4):875-883yy
8. For
8. For children
Morice et al. ERS Guidelines on the diagnosis aged £
children aged
and treatment £ 14
of 14 years with
withchronic
yearscough
chronic chronic cough, we
in adultscough, we
and children.pp
recommend that a chest radiograph
recommend that a chest radiograph Eur Respirand,
and, when age
when age
J 2020;55:1901136 chcØ INDICATIONS:
TRAITEMENT INDICATIONS DUREE RECOMMANDATIONS
CSI + BDCA ALD OUI, si toux 2-3 mois GINA 2020
(faible dose) sèche 2-4 ERS guidelines 2020
ASTHME semaines
CSI + Formotérol ? (> 11 ans)
Antileucotriènes NON (EI)
BDCA ALD NON
ATB PO: OUI, si toux 2 semaines CHEST 2017
BRONCHITE Amoxicilline-A grasse+ RP N + +/- 2 ERS Task Force 2017
BACTERIENNE Clavulanique EFR N semaines ERS guidelines 2020
Ou C2G, C3G, TMP- Réponse // au
PERSISTANTE
SMX, Macrolides délai
d’instauration
du ttt
IPP OUI, si ∑ RGO 4-8 EPSGHAN/NASPGHAN
Ou antagonistes H2 En association semaines 2018
RGO aux mesures HD CHEST 2019
NON, si pas de ∑ ERS guidelines 2020
Prokinétiques NON• TTT NEUROMODULATEUR?
− Chez l’adulte: recommandés
• Morphiniques action rapide, faible dose (5-10 mgx2/j)
• Gabapentine, Prégabaline
− Chez l’enfant: NON recommandés, car
• Etiologies différentes
• Effets secondaires
• Manque d’études
Ø A reconsidérer selon l’âge?...
• APPROCHE NON MEDICAMENTEUSE?
− Absence de recommandation validée
− Kinésithérapie respiratoire/orthophonie, « praticiens expérimentés »
Morice et al. ERS Guidelines on the diagnosis and treatment of chronic cough in adults and children.
Eur Respir J 2020; 55:1901136
• ATTENTE THERAPEUTIQUE?
– Si résolution spontanée attendue
– Toux grasse, en l’absence de signe d’alerte, < 8 semaines
(=toux aiguë prolongée)TAKE HOME MESSAGES • Toux chronique de l’ENFANT ≠ ADULTE ⎼ DEFINITION: ≥ 4 semaines ⎼ ETIOLOGIES: spécifiques Ø TOUX = SYMPTOME d’une pathologie sous-jacente Ø IMPACT = ETIOLOGIE > retentissement de la toux • Utilisation d’ALGORITHMES de prise en charge ⎼ PEDIATRIQUES ⎼ Démarche diagnostique SYSTEMATIQUE Ø Amélioration des résultats cliniques • PRISE EN CHARGE THERAPEUTIQUE ⎼ Toux spécifique: TRAITEMENT ETIOLOGIQUE! ⎼ Toux non spécifique: TRAITEMENT d’EPREUVE? ⎼ Toux attendue: REEVALUATION…
MERCI DE VOTRE ATTENTION
You can also read
