2023+澳大利亚立场声明：儿童和成人咳嗽的诊断、评估和管理（英文更新版）.pdf

MJA 20231Position statement summaryCough in Children and Adults:Diagnosis,Assessment and Management(CICADA).Summary of an updated position statement on chronic cough in AustraliaJulie M Marchant1,2,Anne B Chang1,2,3,Emma Kennedy4,David King5,Jennifer L Perret6,Andre Schultz7,8,Maree R Toombs9,Lesley Versteegh3,Shyamali C Dharmage6,Rebecca Dingle10,Naomi Fitzerlakey10,Johnson George11,Anne Holland12,13,14,Debbie Rigby5,15,Jennifer Mann14,16,Stuart Mazzone17,Mearon OBrien10,Kerry-Ann OGrady1,Helen L Petsky18,Jonathan Pham19,Sheree MS Smith20,Danielle F Wurze21,Anne E Vertigan22,23,Peter Wark22,23Cough is a common condition leading to clinical consultation and results in significant health care costs.Guidelines seek to standardise and assist in diagnosis,investigation and management of cough.1,2 Cough in Children and Adults:Diagnosis,Assessment and Management(CICADA)is an updated Australian position statement on the clinical assessment and management of chronic cough that highlights the burden of chronic cough,including the disproportionate burden in our First Nations population.We provide recommendations for initial assessment of chronic cough in clinical practice,including red flags in history and examination,and CICADA diagnostic management algorithms for use in paediatrics(Box1)and adults(Box2).As there is high quality evidence that the common aetiologies of chronic cough in children and adults are not the same,we discuss the management of paediatric and adult chronic cough separately.3MethodCICADA was developed by a multidisciplinary expert committee that convened to undertake a systematic literature review and discuss updated recommendations.A total of 6395 articles were screened and 277 new studies since 2010(the previous CICADA update)4 were included in the updated full statement(Box3 provides details of the guideline development process).Throughout the position statement(in the main text and in the box summarising the recommendations and their level of evidence and strength),the GRADE of evidence6 refers to evidence of the efficacy of treatment recommendations for cough in association with the respective conditions.The full statement can be found at https:/lungf ounda .au/resou rces/cicada-full-posit ion-state ment.We plan to update the statement every 2 years.Burden of chronic coughIn 2015,the prevalence of chronic cough in adults was estimated to be 9.6%(95%CI,7.6 11.7%)globally,7 and 8.8%in Australia.8 The prevalence of chronic cough gradually increases to peak in the sixth decade9 and has been estimated to occur in 3%of never smokers,4%of former smokers and 8%of current smokers.10 Overall,chronic cough presents more commonly in middle-aged women.2There are limited Australian studies on population prevalence of chronic cough in children.11 In a recent study of Australian children presenting to emergency departments,7.5%had chronic cough,and 20 23%had persistent cough at day 28 irrespective of duration of cough on presentation.12 The prevalence of chronic wet cough in children living in Indigenous communities is higher(around 13%).131 Australian Centre for Health Services Innovation,Queensland University of Technology,Brisbane,QLD.2 Queensland Childrens Hospital,Brisbane,QLD.3 Menzies School of Health Research,Darwin,NT.4 Rural and Remote Health,Flinders University,Darwin,NT.5 University of Queensland,Brisbane,QLD.6 Melbourne School of Population and Global Health,University of Melbourne,Melbourne,VIC.7 Wal-yan Respiratory Research Centre,Perth,WA.8 Perth Childrens Hospital,Perth,WA.9 University of Sydney,Sydney,NSW.10 Lung Foundation Australia,Brisbane,QLD.11 Centre for Medicine Use and Safety,Monash University,Melbourne,VIC.12 Alfred Health,Melbourne,VIC.13 Monash University,Melbourne,VIC.14 Institute for Breathing and Sleep,University of Melbourne,Melbourne,VIC.15 Queensland University of Technology,Brisbane,QLD.16 Austin Health,Melbourne,VIC.17 University of Melbourne,Melbourne,VIC.18 Griffith University,Brisbane,QLD.19 Alfred Health,Melbourne,VIC.20 Western Sydney University,Sydney,NSW.21 Royal Childrens Hospital,Melbourne,VIC.22 Hunter Medical Research Institute,University of Newcastle,Newcastle,NSW.23 John Hunter Hospital,Newcastle,NSW.jm.marchantqut.edu.au doi:10.5694/mja2.52157AbstractIntroduction:Cough is the most common symptom leading to medical consultation.Chronic cough results in significant health care costs,impairs quality of life,and may indicate the presence of a serious underlying condition.Here,we present a summary of an updated position statement on cough management in the clinical consultation.Main recommendations:Assessment of children and adults requires a focused history of chronic cough to identify any red flag cough pointers that may indicate an underlying disease.Further assessment with examination should include a chest x-ray and spirometry(when age6years).Separate paediatric and adult diagnostic management algorithms should be followed.Management of the underlying condition(s)should follow specific disease guidelines,as well as address adverse environmental exposures and patient/carer concerns.First Nations adults and children should be considered a high risk group.The full statement from the Thoracic Society of Australia and New Zealand and Lung Foundation Australia for managing chronic cough is available at https:/lungf ounda .au/resou rces/cicada-full-posit ion-state ment.Changes in management as a result of this statement:Algorithms for assessment and diagnosis of adult and paediatric chronic cough are recommended.High quality evidence supports the use of child-specific chronic cough management algorithms to improve clinical outcomes,but none exist in adults.Red flags that indicate serious underlying conditions requiring investigation or referral should be identified.Early and effective treatment of chronic wet/productive cough in children is critical.Culturally specific strategies for facilitating the management of chronic cough in First Nations populations should be adopted.If the chronic cough does not resolve or is unexplained,the patient should be referred to a respiratory specialist or cough clinic.MJA 20232Position statement summary1 Algorithm for diagnosis and assessment of a child with chronic cough PBB=protracted bacterial bronchitis 2 Algorithm for diagnosis and assessment of an adult with chronic coughACE=angiotensin-converting enzyme;COPD=chronic obstructive pulmonary disease;CT=computed tomography;ENT=ear,nose and throat;ICS=inhaled corticosteroids;FeNO=fractional exhaled nitric oxide;GORD=gastro-oesophageal reflux disease;ppb=parts per billion;RAST=radioallergosorbent test;SPT=skin prick test.13265377,0,Downloaded from https:/ by CochraneChina,Wiley Online Library on 20/11/2023.See the Terms and Conditions(https:/ Wiley Online Library for rules of use;OA articles are governed by the applicable Creative Commons License MJA 20233Position statement summaryFirst Nations Australians are disproportionately affected by conditions that present with chronic wet cough,such as protracted bacterial bronchitis and bronchiectasis.The mortality difference between First Nations and non-First Nations Australians with bronchiectasis is about 22 years.14 In 180 First Nations children aged 4 weeks in children,3 and 8 weeks in adults(Box5).22 The initial assessment for chronic cough relies on history and examination to identify any red flags indicators that may signal an underlying disease or systemic exposure(Box 6).Probability-based algorithms are an important clinical decision tool and are presented for both children(Box 1)and adults(Box 2)separately.Initial assessment should always include a chest x-ray and spirometry(age,6 years).2,3,22 Although a primary diagnosis may be made,it should be remembered that many common conditions co-exist.An assessment of risk factors and modification of such exposures is essential to the optimal management of chronic cough(Box7).These risk factors are mostly common to both children and adults.Diagnosis and management in childrenIn children,“specific cough”refers to a cough that occurs with a condition known to be associated with or cause a chronic cough.Identification of the conditions associated with chronic cough forms the basis of specific treatment and investigation.These conditions can usually be identified by cough characteristics and reviewing red flags(Box6),a probability-based diagnostic approach(Box8),and consideration of important conditions not to be missed(Box9).This approach has been validated in children.3There is high quality evidence that using children-specific cough management algorithms improves clinical outcomes,as shown in a systematic review that focused on chronic cough managed by specialists.26 This approach was supported by a randomised controlled trial(RCT)applying the cough management algorithm in community-based children.12 Box 1 shows the paediatric algorithm,adapted from international ones.3,27,28Causes of paediatric specific coughProtracted bacterial bronchitis.This condition is considered in children with a chronic wet cough in the absence of other specific cough diagnoses or red flags.24 Chest x-ray and spirometry 3 Guideline development process From Jan 2021 to December 2022,members of the CICADA committee regularly convened(email,face-to-face,virtual meetings)to undertake an extensive literature review and discuss recommendations.The committee included several working groups(children,adult,epidemiology and prevention,overall approach)who undertook systematic searches for relevant literature published since 2010(the previous CICADA update),4 including but not limited to“all RCTs,systematic reviews,guidelines,position statements in any setting”.Databases searched included OVID MEDLINE,PubMed,the Cochrane Library,and Embase.Search results were then screened(total 6395 abstracts);a total of 277 new studies were included in this statement.The search strategies,PRISMA diagrams,full reference list of included evidence,and complete guideline document are available on the Australian Lung Foundation website at https:/lungf ounda .au/resou rces/cicada-full-posit ion-state ment/.The recommendations use the principles of evidence-based medicine5 and the GRADE approach to guide recommendations to inform the strength of the evidence:strong,weak,or no specific recommendation.6 The implications of strong recommendation are:for patients most people in your situation would want the recommended course of action and only a small proportion would not;suggest request discussion if the intervention is not offered for clinicians most patients should receive this recommended course of action for policy makers the recommendation can be adopted as a policy in most situations.The implications of a weak recommendation are:for patients some people in your situation would want the recommended course of action,but many would not for clinicians you should recognise that different choices will be appropriate for different patients and that you must help each patient to arrive at a management decision consistent with their values and preferences for policy makers policy making will require substantial debate.4 Specific recommendations for addressing chronic cough in First Nations peopleRecommendationsLevel of evidence*Strength of recommendationAddress environmental factors:air quality(airborne particulate matter),cigarette smoke exposure(patient,parental,household)19GoodStrongProvide culturally secure health information to facilitate detection of chronic wet cough:accurate history taking in First Nations settings,provision of appropriate health information in a culturally secure way,community engagement at a local level20SatisfactoryStrongImplement strategies in health systems that include targeted training of clinicians;implementation programs that include targeted training of clinicians,health system changes and the provision of culturally secure health information tools have been shown to improve physician assessment of chronic cough and appropriate antibiotic prescription20SatisfactoryStrongUtilise chronic cough management algorithms;randomised controlled trials including First Nations children have shown the effectiveness of management algorithms for chronic cough,usual care12,21ExcellentStrong*NHMRC additional levels of evidence and grades for recommendations for developers of guidelines.5 The GRADE(Grading of Recommendations Assessment,Development and Evaluation)system was used to grade the strength of recommendations.6 13265377,0,Downloaded from https:/ by CochraneChina,Wiley Online Library on 20/11/2023.See the Terms and Conditions(https:/ Wiley Online Library for rules of use;OA articles are governed by the applicable Creative Commons LicenseMJA 20234Position statement summaryare usually normal.Two to four weeks of antibiotic treatment(typically amoxicillin clavulanate if no history of allergy)should lead to complete cough resolution29,30 GRADE:Strong.The diagnosis can only be definitive when patients become asymptomatic with treatment.24,31 A significant proportion of children with protracted bacterial bronchitis have ongoing symptoms at 5-year follow-up,including bronchiectasis in 9.6%;these children therefore require careful follow-up and specialist referral if episodes recur more than three times per year or treatment fails(Box1).32Asthma.Asthma may cause a cough that is episodic and associated with other features such as expiratory wheeze and/or exertional dyspnoea.The diagnosis and management of asthma should be undertaken in accordance with paediatric asthma management guidelines.Treatment is expected to reduce symptoms within 2 4 weeks GRADE:Strong.In children,chronic cough in the absence of other symptoms/signs is seldom due to asthma,and inhaled corticosteroids are not indicated unless there are specific features to suggest asthma.When used,the trial period should be of a defined duration(eg,one month)to confirm or refute the provisional diagnosis.27Allergic rhinitis.The evidence that postnasal drip is a significant cause of cough in children is not fully established,and when present,likely reflects co-existing upper airway disease.Some paediatric studies reported upper airways cough syndrome as the aetiology of chronic cough,33 but we did not find high quality RCTs on therapies for upper airway disorders in children with cough,and in children,antihistamines have not been shown to be efficacious for the treatment of chronic cough.3 Allergic rhinitis can be diagnosed by symptoms of nasal itching,nasal blockage,or nasal discharge.Management should follow current guidelines GRADE:Weak.34Chronic rhinosinusitis.Chronic cough may occur concurrently in children with chronic rhinosinusitis.25 However,any association between rhinosinusitis and cough does not necessarily indicate causality.Notably,the bacterial pathogens associated with chronic rhinosinusitis are the same as those of protracted bacterial bronchitis,hence treat