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Evaluation of Children with Chronic Cough Including Obstructive Sleep Apnea: a Single-Center Experience

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Evaluation of Children with Chronic Cough Including Obstructive Sleep Apnea: a Single-Center Experience European Journal of Pediatrics (2019) 178:189–197 https://doi.org/10.1007/s00431-018-3276-x ORIGINAL ARTICLE Evaluation of children with chronic cough including obstructive sleep apnea: a single-center experience Nisa Eda Cullas Ilarslan1 & Fatih Gunay1 & Zehra Sule Haskologlu2 & Sevgi Kostel Bal2 & Zahide Ciler Tezcaner3 & Ceyda Tuna Kirsaclioglu4 & Selma Firat5 & Cansu Altuntas4 & Bulent Ciftci6 & Ozan Bagis Ozgursoy3 & Nazan Cobanoglu7 Received: 26 June 2018 /Revised: 18 October 2018 /Accepted: 22 October 2018 /Published online: 31 October 2018 # Springer-Verlag GmbH Germany, part of Springer Nature 2018 Abstract Chronic cough in children may be due to a diverse range of etiologies. We aimed to evaluate children with chronic cough following a standardized cough algorithm and assess obstructive sleep apnea (OSA) as a possible etiology. In addition, cough resolution rates of two different treatment protocols in children with non-specific cough were compared. A total of 237 children referred for chronic cough were assessed and classified according to etiologies. Children with non-specific cough were assigned either in the early-arm (group-1, n = 13) or delayed arm (group-2, n = 23). The presence of OSA was evaluated using a pediatric sleep questionnaire, and polysomnography was handled in indicated patients. Asthma (n = 82) and protracted bacterial bronchitis (PBB) (n = 73) were the most frequent etiologies. Cough resolution was higher in group-1 (100%) compared with group-2 (50%) (absolute risk reduction (rr) = 43.48% [95% CI 21.38–65.58%]). Polysomnography revealed mild (n =6),moderate(n = 7), or severe (n = 5) OSA in 18 children, with adenoid/adenotonsillary hypertrophy as the leading cause. Conclusion: We recognized asthma and PBB as the most frequent causes of chronic cough in our cohort. Early treatment of patients with high parental anxiety might be beneficial. We also believe that further studies including larger series might eventuate in incorporation of assessment of OSA to standardized algorithms. What is known? • Chronic cough in children may be due to a diverse range of etiologies, including serious respiratory disorders. Thus, its correct diagnosis and treatment are essential. • Although a well-defined reason of chronic cough in adults, obstructive sleep apnea (OSA) has not been been evaluated so far in children with chronic cough. Presentation This study was presented at the 61th Turkish National Pediatric Congress, November 15th–19th 2017, Antalya, Turkey Communicated by Peter de Winter * Nisa Eda Cullas Ilarslan Selma Firat [email protected] [email protected] Fatih Gunay Cansu Altuntas [email protected] [email protected] Zehra Sule Haskologlu Bulent Ciftci [email protected] [email protected] Sevgi Kostel Bal Ozan Bagis Ozgursoy [email protected] [email protected] Zahide Ciler Tezcaner [email protected] Nazan Cobanoglu [email protected] Ceyda Tuna Kirsaclioglu [email protected] Extended author information available on the last page of the article 190 Eur J Pediatr (2019) 178:189–197 What is new? • We examined OSA for the first time as a possible cause of chronic cough in children and detected OSA with polysomnography in cases who scored high pediatric sleep questionnaire (PSQ) scores. • We believe that studies including larger series might eventuate in incorporation of assessment of OSA to standardized algorithms for children with chronic cough. Keywords Asthma . Children . Chronic cough . Obstructive sleep apnea . Protracted bacterial bronchitis Abbreviations in adults [4]. Chronic cough in OSA is thought to be related with increased risk of aspiration during sleep in the presence ACCP American College of Chest Physicians of airway obstruction and/or stimulation of cough receptors AHI Apnea–hypopnea index because of vibrations which occur during airway collapse FFB Flexible fiber-optic bronchoscopy [28]. To date, studies which have incorporated assessment of GERD Gastroesophageal reflux disease OSA in children with chronic cough do not exist. Ig Immunoglobulin The primary aim of this study was to evaluate children with OSA Obstructive sleep apnea chronic cough following a standardized cough algorithm and OSAS Obstructive sleep apnea syndrome assess OSA for the first time in cases presenting with sugges- PBB Persistent bacterial bronchitis tive signs and symptoms [6]. The secondary aim was compar- Pc-QOL Pediatric cough specific quality of life ison of cough resolution rates of two different treatment pro- PSG Polysomnography tocols (early and delayed arms) in children with chronic non- PSQ Pediatric sleep questionnaire specific cough. UACS Upper airway cough syndrome Methods Introduction This prospective cohort study was conducted in a tertiary hos- pital between January 2016 and January 2017. The study pro- Chronic cough is defined as cough lasting > 4 weeks in chil- tocol was approved by the local Institutional Ethics ≥ dren < 15 years and > 8 weeks for adolescents 15 years [6]. Committee (Approval number: 19-800-15; Dec 2015). It represents amongst the most common reasons for respirato- Writteninformedconsentwasobtainedfromeachparent. ry physician visits [11]. Data concerning the frequency of chronic cough in children is restricted and studies report a prevalence of 1–3% [15, 27]. Estimated values are probably Selection criteria much higher as many cases do not seek medical care, and – might be as high as 10–25% [22]. Children, aged 1 month 14 years, who admitted with chronic The most frequent etiologies of chronic cough in children cough to the primary care clinic of our tertiary hospital were < 14 years are protracted bacterial bronchitis (PBB) and asth- included. Exclusion criteria were outlined as previously diag- ma [1]. By adolescence, adult causes such as gastroesophageal nosed chronic respiratory illness by a pediatric respiratory/ reflux disease (GERD), asthma, and upper airway cough syn- allergy physician (e.g., bronchectasis, cystic fibrosis, asthma), drome (UACS) are encountered predominantly [19]. congenital/acquired heart disease, neuromuscular disease, im- Chronic cough might be a symptom of a serious respiratory mune deficiency, syndromes, prematurity (< 37 weeks), low disorder which may cause progressive lung damage if not birth weight (< 2500 g), and missing informed consent. diagnosed [9]. Thus, its correct diagnosis and intervention are of utmost importance. Study protocol The first pediatric guideline concerning chronic cough was released by American College of Chest Physicians (ACCP) All patients were evaluated by the same primary care pedia- (CHEST guideline) and was followed by several guidelines trician and pediatric pulmonology physician, consecutively, [6, 8, 26]. These algorithms facilitate earlier diagnosis, im- using a standardized cough algorithm (Fig. 1)[6]. As it was prove clinical outcomes, and increase quality of life. not planned as a randomized clinical study, grouping of chil- Childhood obstructive sleep apnea (OSA) is a disorder dren with chronic non-specific cough according to clinical mostly related to adenotonsillary hypertrophy in children approaches was mainly based on parental concerns (anxiety [28]. If left untreated, OSA may cause impairment of cogni- and demand for treatment) and less predominantly cough di- tion, attention and growth, low school performance, and cor aryscores.Thephysicianswerenotblindedtoeachotheras pulmonale [2, 14]. It is a well-defined reason of chronic cough comparison of clinical approaches was not amongst the aims. Eur J Pediatr (2019) 178:189–197 191 Children referred Excluded (n=76) with chronic cough Refused to participate (n= 34) (n=313) Carried exclusion criteria (n=14) Lost to follow-up (n=28) Study population (n=237) Presence of specific cough pointers Yes Evaluation for specific Chest X-ray and spirometry (for >6 cough (n=110, %46.4) years able to cooperate) No Amoxicillin-clavulanate Wet cough Yes (50 mg/kg/day,14 days) (n=66) No Non-specific cough? (n=36) Resolved (n=61) Persistent (n=5) Evaluate: 1. Exposure of tobacco and other pollutants Protracted 2. Child’s activity, parental expectations and concerns Re-evaluated for bacterial specific cough bronchitis (n=61) pointers Yes Review in 1-2 weeks Resolved Persistent Diagnosis of asthma (n=5) Natural resolution Discuss options with parents (n=0) (n= 36) Group 1 (Early arm; trial of therapy (n=13) Group 2 (Delayed arm; watch, wait and review (n=23) Natural resolution Dry cough: 200- Wet cough: Amoxicillin- Persistent (n=10) 400 mcg/day clavulanate (50 (n=13) budesonide mg/kg/day,14 days) (n=6) (n=7) Dry cough: 200-400 Wet cough: Amoxicillin- mcg/day budesonide (n=5): clavulanate (n=5) Cough resolution in all: Cough resolution in all: Cough resolution(n=7): Cough resolution (n=6): Asthma PBB Asthma PBB Fig. 1 Pathway of management of chronic cough (ACCP evidence-based clinical practice guideline for evaluating chronic cough in pediatrics) 192 Eur J Pediatr (2019) 178:189–197 Initial evaluation syndrome (OSAS) is defined as AHI ≥ 2orAHI≥ 1inthe context of sleep disordered breathing symptoms [18]. The History and physical examination Adetailedhistorywasob- severity of obstructive sleep apnea is based on AHI (mild tained with particular attention on specific cough pointers. [1–5], moderate [6–9], and severe [≥ 10]). As children tend The duration and characteristics of the cough, wheezing, al- to have clinical complications related with OSAS with lower lergy history, accompanying symptoms, signs of GERD, si- AHI than adults, same AHI measures
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