Anti-histamines for prolonged non-specific cough in children

Children with non-specific cough are commonly treated with a variety of medications to treat the symptom of cough. The objective of this review was to evaluate the effectiveness of anti-histamines in children with prolonged cough that is not related to an underlying respiratory disease, that is, non-specific chronic cough. We included three therapeutic studies with 182 randomised participants. Two studies found that chronic cough significantly improved in both treatment and placebo groups with no difference between the two groups. One small study however described that children who had chronic cough associated with seasonal allergic rhinitis treated with cetirizine improved significantly more than children on placebo and this difference was evident by two weeks. Four studies that evaluated safety profiles included 3166 randomised participants and described a non significant increase in cough in participants who received the active medication. Despite the limitations of this review, our findings are similar to the review on anti-histamines for acute cough which showed no good evidence for or against the use of anti-histamines. In contrast to recommendations in adults with chronic cough, anti-histamines cannot be recommended as empirical therapy for children with chronic cough. Further research examining the effects of this treatment using child appropriate cough outcome measures is needed

An investigation of the effects of heat and water exchange in the recovery period after exercise in children with asthma

It has been reported that asthma provoked by breathing subfreezing air during exercise is enhanced when air at BTPS is inhaled in the recovery period (1). It was concluded that the rate of airway rewarming is an important event in asthma provoked by exercise. It is also possible, however, that the enhanced response was due to hypo-osmolarity caused by condensation of water from inspired air at BTPS on the cooled mucosa. We examined, in a group of boys with asthma, the response to rapid rewarming of the airways after exercise, with and without the potential for condensation. On two test days, two exercise tests were performed 4 h apart on a cycle ergometer. On Day 1 (n = 17), the inspired air during exercise was −5° C, dry. During recovery, the air was either −5° C, dry or 50° C, 23 mg H1O/L. On Day 2 (n = 11), the inspired air during exercise was −15° C, dry, and during recovery was either −15° C, dry or at BTPS. We did not find enhancement of the response with either condition designed to cause rapid airway rewarming. On Day 1 the mean (± 1 SD) percent fall in FEV1 was 23 ± 22 (−5° C, dry) and 24 ± 21 (50° C, 23 mg H2O/L) (r = 0.92), and on Day 2 it was 19 ± 17 (−15° C, dry) and 18 ± 17 (BTPS) (r = 0.96). To test their response to airway hypo-osmolarity, the boys (n = 15) were tested on a third day with ultrasonically nebulized water. As a group, they were relatively unresponsive. The mean maximal percent fall in FEV1 after 13.9 (± 3.6) ml had been delivered was only 11.7% (± 6.6%). We could not show enhancement of the response to exercise with rapid airway rewarming. Therefore, we were not able to prove or disprove the hypothesis that condensation of water caused the enhanced response observed by McFadden and colleagues (1). Our observations, however, are not consistent with the hypothesis that rapid airway rewarming causes exercise-induced asthma

Does the routine use of spirometry improve clinical outcomes in children? - A systematic review

Spirometry provides a quantitative measure of lung function and its use is recommended as an adjunct to enhance pediatric respiratory healthcare in many clinical practice guidelines. However, there is limited evidence confirming the benefits (or otherwise) of using spirometry from either clinician or patient perspectives. This systematic review aimed to determine the impact of spirometry on change in clinical decision making and patient-reported outcome measures. We searched PubMed, Embase, Cochrane Central Register of Controlled Trials, www.clinicaltrials.gov, and World Health Organization International Clinical Trials Registry Platform, from inception to July 2021. We included randomized controlled trials (RCTs) comparing the use versus non-use of spirometry during standard clinical review in children aged <18 years with respiratory problems in clinics. We used Cochrane methodology. The search identified 3475 articles; 8 full-text articles were reviewed but only 1 study fulfilled the inclusion criteria. The single study involved two cluster RCTs of spirometry for children with asthma in general practice. The included study did not find any significant intergroup difference at the 12-month follow-up for asthma-related quality-of-life and clinical endpoints. However, the findings were limited by methodological weaknesses and high risks of bias. With a paucity of data, the clinical benefits of spirometry remain unclear. Thus, there is a clear need for RCTs that provide high-quality evidence to support the routine use of spirometry in children with suspected or known lung disease. Pending the availability of better evidence, we recommend that clinicians adhere to the current clinical practice recommendations.</p

How Many Maneuvers Should We Do for Maximal Inspiratory and Expiratory Muscle Pressure Testing in Children: A Retrospective Review in Children with Cystic Fibrosis

Objectives Maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP) could be useful clinical parameters in monitoring many conditions including cystic fibrosis (CF). However, current protocols for undertaking the measurements lack standardization including the number of repeated attempts to achieve best values. We aimed to (a) determine the optimum number of attempts to achieve best MIP/MEP values, and (b) evaluate if the number of attempts is consistent across two different test days. Methods We analyzed data of a previous randomized controlled trial involving the effect of singing on respiratory muscle strength in 35 children with CF. On two different days (T1, T2) children performed MIP/MEP with at least ten attempts each to achieve < 10% repeatability. Results All children achieved repeatable MIP/MEP values within 10–11 attempts with 24 (68.6%) and 26 (74.3%) of these achieving best values of MIP and MEP, respectively, at attempts 6–11. Median values of the pressures by three, five, eight and all attempts significantly increased with more attempts (all p < 0.05). At T2, 56% required fewer attempts to achieve best values, but 32% required more attempts, indicating that the number of attempts required was inconsistent between test days. Conclusion It is likely that at least ten attempts (best two within < 10% variability) is required to achieve best and reliable MIP/MEP in children with CF. A larger sample size in children with CF and various conditions is required to consolidate these findings.N/

Global Lung Function Initiative‐2012 ‘other/mixed’ spirometry reference equation provides the best overall fit for Australian Aboriginal and/or Torres Strait Islander children and young adults

Ethnic-specific reference equations are recommended when performing spirometry. In the absence of appropriate reference equations for Australian Aboriginal and/or Torres Strait Islanders (Indigenous), we determined whether any of the existing Global Lung Function Initiative (GLI)-2012 equations were suitable for use in Indigenous children/young adults.We performed spirometry on 1278 participants (3-25 years) who were identified as Aboriginal, Torres Strait Islander or 'both'. Questionnaires and medical records were used to identify 'healthy' participants. GLI2012_DataConversion software was used to apply the 'Caucasian', 'African-American' and 'other/mixed' equations.We included 930 healthy participants. Mean z-scores for forced expiratory volume in 1 s (FEV ) and forced vital capacity (FVC) were lower than the Caucasian predicted values (range: -0.53 to -0.60) and higher than African-American (range: 0.70 to 0.78) but similar to other/mixed (range: 0.00 to 0.08). The distribution of healthy participants around the upper and lower limits of normal (~5%) fit well for the other/mixed equation compared to the Caucasian and African-American equations.Of the available GLI-2012 reference equations, the other/mixed reference equation provides the best overall fit for Indigenous Australian children and young adults (3-25 years). Healthy data from additional communities and adults around Australia will be required to confirm generalizability of findings

Impact of using spirometry on clinical decision making and quality of life in children : Protocol for a single centre randomised controlled trial

Introduction: Although spirometry has been available for decades, it is underused in paediatric practice, other than in specialist clinics. This is unsurprising as there is limited evidence on the benefit of routine spirometry in improving clinical decision making and/or outcomes for children. We hypothesised that using spirometry for children being evaluated for respiratory diseases impacts on clinical decision making and/or improves patient-related outcome measures (PROMs) and/or quality of life (QoL), compared with not using spirometry. Methods and analysis: We are undertaking a randomised controlled trial (commenced in March 2020) that will include 106 children (aged 4-18 years) recruited from respiratory clinics at Queensland Children's Hospital, Australia. Inclusion criteria are able to perform reliable spirometry and a parent/guardian who can complete questionnaire(s). Children (1:1 allocation) are randomised to clinical medical review with spirometry (intervention group) or without spirometry (control group) within strata of consultation status (new/review), and cough condition (present/absent). The primary outcome is change in clinical decision making. The secondary outcomes are change in PROM scores, opinions regarding spirometry and degree of diagnosis certainty. Intergroup differences of these outcomes will be determined by χ 2 test or unpaired t-test (or Mann-Whitney if not normally distributed). Change in outcomes within the control group after review of spirometry will also be assessed by McNemar's test or paired t-test/Wilcoxon signed-rank test. Ethics and dissemination: The Human Research Ethics Committee of the Queensland Children's Hospital approved the study. The trial results will be disseminated through conference presentations, teaching avenues and publications. Trial registration number: ACTRN12619001686190; Pre-results.</p

Does routine spirometry impact on clinical decisions and patient-related outcome measures of children seen in respiratory clinics: an open-label randomised controlled trial

Introduction There is limited evidence on the efficacy of using spirometry routinely in paediatric practice for improving outcomes.Objective To determine whether the routine use of spirometry alters clinical decisions and patient-related outcome measures for children managed by respiratory paediatricians.Methods We undertook a parallel open-label randomised controlled trial involving children (aged 4–18 years) able to perform spirometry in a specialist children’s hospital in Australia. Children were randomised to either routine use of spirometry (intervention) or clinical review without use of spirometry (control) for one clinic visit. The primary outcomes were the (a) proportion of children with ‘any change in clinical decisions’ and (b) ‘change score’ in clinical decisions. Secondary outcomes were change in patient-related outcome measures assessed by State–Trait Anxiety Inventory (STAI) and Parent-Proxy QoL questionnaire for paediatric chronic cough (PC-QoL).Results Of 136 eligible children, 106 were randomised. Compared with controls, the intervention group had significantly higher proportion of children with ‘any change in clinical decisions’ (n=54/54 (100%) vs n=34/52 (65.4%), p&lt;0.001) and higher clinical decision ‘change score’ (median=2 (IQR 1–4) vs 1 (0–2), p&lt;0.001). Also, improvement was significantly greater in the intervention group for overall STAI score (median=−5 (IQR −10 to –2) vs −2.5 (−8.5, 0), p=0.021) and PC-QoL social domain (median=3 (IQR 0 to 5) vs 0 (−1, 1), p=0.017).Conclusion The routine use of spirometry in children evaluated for respiratory issues at clinical outpatient review is beneficial for optimising clinical management and improving parent psychosocial well-being.Registration Australia and New Zealand Clinical Trials Registry ACTRN1261900168619

Development and validation of a bronchoscopically defined bronchitis scoring tool in children

Introduction/Aim: A validated tool for scoring bronchitis during flexible bronchoscopy (FB) is potentially useful for clinical practice and research. We aimed to develop a bronchoscopically defined bronchitis scoring system in children (BScore) based on our pilot study. Methods: Children undergoing FB were prospectively enrolled. Their FB was digitally recorded and assessed (two clinicians blinded to each other and clinical history) for six features: secretion amount (six-point scale), secretion color (BronkoTest, 0-8), mucosal oedema (0-3), ridging (0-3), erythema (0-3), and pallor (0-3) based on pre-determined criteria. We correlated (Spearman's rho) each feature with bronchoalveolar lavage (BAL) neutrophil percentage (neutrophil%). BScore was then derived using models with combinations of the six features that best related to airway BAL neutrophil%. The various models of BScore were plotted against BAL neutrophil% using receiver operating characteristic (ROC) curves. Results: We analyzed 142 out of 150 children enrolled. Eight children were excluded for unavailability of BAL cytology or FB recordings. Chronic/recurrent cough was the commonest indication for FB (75%). The median age was 3 years (IQR, 1.5-5.3 years). Secretion amount (r = 0.42) and color (r = 0.46), mucosal oedema (r = 0.42), and erythema (r = 0.30) significantly correlated with BAL neutrophil%, P 10%). Conclusion: This prospective study has developed the first validated bronchitis scoring tool in children based on bronchoscopic visual inspection of airways. Further validation in other cohorts is however required.</p

Fractional Exhaled Nitric Oxide Values in Indigenous Australians 3 to 16 Years of Age

Background: Fractional exhaled nitric oxide (FENO) levels can identify eosinophilic asthma phenotypes. We aimed to determine FENO values of healthy Aboriginal and/or Torres Strait Islander (Indigenous) Australians, differences between these Indigenous ethnic groups, and appropriateness of published cutoff values. Methods: We measured FENO levels in 1,036 Indigenous Australians (3-16 years of age). Participants were classified into healthy (ie, no asthma or atopy history) or asthmatic and/or atopic groups. Results: Median FENO values and distribution did not differ between Indigenous ethnicities. For healthy participants 50 ppb) appears the most appropriate for identifying healthy Indigenous children but requires confirmation from a larger study

How does parent/self-reporting of common respiratory conditions compare with medical records among Aboriginal and Torres Strait Islander (Indigenous) children and young adults?

Aim: Self-reporting and/or data from medical records are frequently used in studies to ascertain health history. Data on the discrepancies between these information sources is lacking for Indigenous Australians. This study reports such data for selected respiratory and atopic conditions common among Indigenous Australians. Methods: Data were extracted from the Indigenous respiratory reference value study, a multicentre cross-sectional study of Indigenous children and young adults (3–25 years) between June 2015 and November 2017. Only those living in rural/remote regions were included. Self-reported history was collected from parents (if participant