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TOUX CHRONIQUE DE L'ENFANT:ANALYSE DE "NOUVELLES» RECOMMANDATIONSEglantine HULLOPédiatrie Générale et Pneumopédiatrie, CHU GrenoblePlénière 8: "MISE AU POINT EN ASTHMOLOGIE»

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 ØPrise en charge longtemps basée sur l'application d'algorithmes de prise en charge "adulte» appliqués à l'enfant•Travaux de recherche récents:ØAmélioration des connaissances•Mécanismes physiopathologiques de la toux •Etiologies pédiatriques (PBB, ...)•Evolution et morbidité(s) associée(s)ØElaboration de"nouvelles recommandations»de prise en charge pédiatrique

ERSguidelineson thediagnosis and

treatmentofchroniccoughin adults andchildren

AlynH.Morice

1 ,EvaMillqvis t 2 ,Kris tinaBieksiene 3 ,SurinderS. Birring 4,5

PeterDicpinigaitis

6 ,Christian DomingoRibas 7 ,Michele HiltonBoon 8

AhmadKantar

9 ,Kefang Lai 10,21 ,Lorcan McGarvey 11 ,Da vidRigau 12

ImranSatia

13,14 ,Jacky Smith 15 ,Woo-Jung Song 16,22 ,ThomyT onia 17 ,JanW .

K.vanden Berg

18 ,Mirjam J.G.vanManen 19 andAngelaZa charasie wicz 20 @ERSpublications NewERSguidelineonchr oniccoughdetails theparadigm shiftinour understanding.Inadults, coughhypersensitivityhas becomethe over archingdiagnosis, andinchildr en,persistentbacterial bronchitisexplainsmost wetcough,changingtrea tmentadvice.http://bit.ly/2kycX8D Citethisarticle as:MoriceAH,Millqvis tE,Bieksiene K,etal.ERSguidelines onthediagnosis and treatmentofchroniccoughin adultsandchildr en.EurRespir J2020;55:1901136 [https://doi.org/10.1183/

13993003.01136-2019].

ABSTRACTTheseguidelinesincorpor ate therecentadvancesinchroniccoughpa thophysiology, diagnosisandtr eatment.The conceptofcoughhypersensitivityhasallowed anumbrella termthat explains theexquisite sensitivityofpatientsto externals timulisucha coldair,perfumes,smokeand bleach.Thus, adultswithchr oniccoughno whavea firmphysical explanationfortheirs ymptomsbasedonvagal afferenthypersensitivity.Differenttr eatabletraitsexis twithcoughvariantasthma (CVA)/eosinophilic bronchitisrespondingtoanti-inflamma torytreatmentand non-acidr efluxbeingtreatedwith promotility agentsra thertheanti-aciddrugs.Analternativ eantitussive strategyisto reducehypersensitivity by neuromodulation.Low-dosemorphineishighly effectiveinasubsetof patientswith coughresis tantto othertrea tments.Gabapentinandpregabalinarealso advocated, butinclinical experiencetheyar elimited byadverse events.Perhapsthe mostpromisingfuture developmentsinpharmacotherapy aredrugs which

tackleneuronalhypersensitivityby blockingexcitabilityofa fferentnerv esbyinhibiting targetssuchas the

ATPreceptor(P2X3).Finally ,coughsuppressionther apywhenperformed bycompetentpractitionerscan behighlyeffectiv e.Children arenotsmalladultsand apursuitofanunderlying causeforcoughis advocated.Thus,intoddlers,inhalation ofafor eignbodyis common.Persis tentbacterialbronchitis isa commonandpr eviouslyunrecognised causeofwetcough inchildren.Antibiotics(drug,dose and durationneedtobedetermined)canbe curativ e.Apaedia tric-specificalgorithm shouldbeused. Thisdocumentw asendorsed bytheERSExecutiveC ommitteeon26 August,2019.

Theguidelinespublished bythe EuropeanR espiratory Society(ERS)incorpo ratedataobtained fromacomprehensive

andsy stematicliteraturereviewofthemostr ecentstudiesavailableatthetime.Health professionalsareencouragedto

taketheguidelinesinto account intheirclinicalpractice. Howev er,therecommendations issuedby thisguidelinema y

notbeappr opriate foruseinallsituations.Itisthe individualresponsibi lityofhealth professionals toconsult other

sourcesofrelevantinforma tion,tomak eappropriateanda ccuratedecisionsin considera tionofeachpatient 'shealth

conditionandin consultationwith thatpa tientandthepatient 'scaregiv erwhereappropriateand/ornecessary ,andto

verifyrulesandregula tionsapplicable todrugsand devicesatthetimeofprescription . Thisarticlehas supplementary materiala vailablefromerj.ersjournals.com. Received:24May2019|Accepted afterr evision:01Aug2019

Copyright©ERS2020

ERSOFFICIALDOCUMENT

ERSGUIDELINES

UseofManagement Pathwaysor Algorithms

inChildrenWith ChronicCough

CHESTGuidelineand ExpertPanelReport

AnneB.Chang, MBBS,PhD, MPH;JohnJ. Oppenheimer,MD;Miles M.Weinberger,MD, FCCP;BruceK. Rubin,MD;

KellyWeir,BSpThy, MSpPath,PhD, CPSP;CameronC. Grant,MBChB,PhD; RichardS.Irwin, MD,MasterFCCP; onbehalf

oftheCHEST ExpertCough Panel BACKGROUND:Usingmanagement algorithmsorpathwayspotentiall yimprovesclinicalout- METHODS:Weusedthe CHESTExpert CoughPan el'sprotocol forthesystematicrevie wsand theAmerican CollegeofChestPhy sicians(CHEST)methodological guidelinesand Gradingof RecommendationsAssessment,Developmentand Evaluationframework.Datafrom thesys- tematicreviewsinconjuncti onwithpatients'valuesandpreferen cesand theclinicalcontext RESULTS:Combiningdatafromsystematic reviews addressing!veKQs,we foundhigh- qualityevidencethata systematicapproachto themanagement ofchroniccough improvesclinicaloutc omes.Althoughtherewasevidenc efromseveralpathways,thehighest evidencewasfromthe useofthe CHESTapproach. However,there wasnoor littleevidence toaddress someoftheKQsposed. CONCLUSIONS:Comparedwiththe2006 CoughGuidelines,thereis nowhigh-quality evidencethatinchildren aged#14yearswith chronic cough(>4weeks'duration),the useofcough managementprotoc ols(oralgorithms) improvesclinicaloutcomes ,andcough managementortestingalgorithmsshoul ddiffer dependingon theassociated characteristics ofthecough andclini calhistory. Achestradiogr aphand,whenageappropriate, spirometry (pre-andpost- b 2 agonist)should beundertaken.Othertests shouldnotbe routinelyper- formedandundertakenin accordancewith theclinicalsettingandthe child'sclinical symptomsandsigns(eg,tests fortube rculosiswhenthe childhasbeen exposed).

CHEST2017;151(4):875 -883

KEYWORDS:cough;evidence-basedmedicine; guidelines;pediatrics ABBREVIATIONS:ACCP=American CollegeofChest Physicians; AHR=airway hyperresponsiveness; KQ=key question;LR=likeli- hoodratio;PC-QOL =ParentCough-Speci !cQualityof Life; PedsQL=Pediatric Qualityof LifeInventory;PICO =Population, Intervention,Comparison, Outcome;PV=predictivevalue; QoL= qualityoflife; RCT= randomizedcontrolledtrial AFFILIATIONS:FromtheMenzies SchoolofHealth Research(Dr Chang),RespiratoryDepartment, LadyCilento Children'sHospital, andQueenslandUniversity ofTechnology,QLD, Australia;New JerseyMedicalSchool (DrOppenhei mer)andPulmonary andAllergy Associates,Morristown, NJ;UMassMemorialMedicalCenter (Dr Irwin),Worcester,MA; LadyCilento Children'sHospital(Dr Weir), Brisbane,Australia;Children 'sHospitalof Richmondat Virginia CommonwealthUniversity(DrRubin), Richmond,VA; Departmentof Paediatrics,Childand YouthHealth (DrGrant),Faculty ofMedicine andHealthSciences, TheUniversity ofAuckland, Auckland,New Zealand;andPediatric Allergy,Immunol ogy,andPulmon ologyDivi- sion(DrWeinberger) ,University ofIowaChildren'sHospital,Iowa

City,IA.

DISCLAIMER:AmericanCollegeof ChestPhysician guidelinesare intendedforgeneral information only,arenot medicaladvice,anddo notreplaceprofessiona lmedicalcare andphysicianadvice,which alwaysshouldbe soughtforany medicalcondition.The complete disclaimerforthis guidelinecan beaccessedat http://www.chestnet.

CHEST-Guidelines.

[Evidence-BasedMedicine ] journal.publications.chestnet.org875

EtiologiesofChronic Coughin

PediatricCohorts

CHESTGuidelineand ExpertPanelReport

AnneB.Chang, MBBS,PhD, MPH;JohnJ. Oppenheimer,MD;Miles Weinberger,MD,FCCP; CameronC.Grant, PhD; BruceK.Rubin, MD;andRichard S.Irwin,MD, MasterFCCP;on behalfof theCHESTExpert CoughPanel BACKGROUND:Thereisnopubl ished systematic reviewontheetiologiesofchro niccoughorthe relationshipbetweenOSAandchronicco ughinchildrenaged#14year s.Wethusunde rtooka Outcomeformat.TheKQs follow:Amongchildren withchron ic(>4week s)cough(KQ1)ar e thecommonet iologiesdiffere ntfromthoseinadults?(KQ2) Arethecommonetiologiesage or settingdependent,or both?(KQ3)IsOSAacauseofchroni ccoug hinchildren? METHODS:Weusedthe CHEST ExpertCoughPan el'sprotocoland theAmerican Collegeof ChestPhysicians(CHEST) methodologicalguidelinesandGrad ingofRecommendations Assessment,Development,and Evaluationframework.Datafromthesystematic reviewsin conjunctionwithpatients'valuesandpreferencesand thecli nicalcontextwereusedtoform recommendations.Delphimethodologywasused toobtainconsen sus. RESULTS:CombiningKQs1and 2,wefoun dmoderate-level evidencefrom 10prospective studiesthattheetio logiesofcough inchildren aredifferentfromthoseinadults andare settingdependent. Datafromthreestudiesfound thatcommon etiologiesof coughinyoung childrenweredifferentfromthose inolder children.Howe ver,datarelating sleepabnor- malitiestochronic coughin childrenw erefoundonly incasestudi es. bemanaged inaccordancewithpediatric sleepguidelines. CHEST2017;152(3):607 -617

KEYWORDS:cough;evidence-basedmedicine; pediatrics

ABBREVIATIONS:CHEST=AmericanCo llege ofChestPhysician s; GERD=gastroe sopha gealre!uxdiseas e;ILD=interstitiallun gdisease; KQ=ke yques tion;PBB =protractedbacterial bronchitis;P C-QOL = forSystemat icReviewsandMeta-Anal yses;QoL=qualityoflif e;RCT= randomizedcontrolledtrial;UACS =upperairwaycoughsyndrome AFFILIATIONS:FromtheDivision ofChildHealth (DrChang), MenziesSchoolof HealthResearch; theRespiratoryand Sleep Department(DrChang), LadyCilento Children'sHospital,Qld Uniof TechnologyQueensland,Australia; theDivision ofAllergyand Immunology,Departmentof Medicine(Dr Oppenheimer),New Jersey MedicalSchool,Pulmonary andAllergy Associates,Morristown, NJ; theDivisionof Pulmonary,Allergy, andCriticalCare Medicine, DepartmentofMedicine (DrIrwin), UMassMemorialMedical Center, Worcester,MA;the Departmentof Pediatrics(DrRubin), Children's HospitalofRichmond atVirginia CommonwealthUniversity ,Rich- mond,VA;the Departmentof Paediatrics:Childand YouthHealth, FacultyofMedicine andHealth Sciences(DrGrant), TheUniversityof Auckland,Auckland,NewZealand;and theDepartment ofPediatrics (DrWeinberger), UniversityofCalifornia,San Diego,RadyChildren 's

Hospital,SanDiego, CA.

DISCLAIMER:AmericanCollegeof ChestPhysicianguidelines are intendedforgeneral information only,arenot medicaladvice,anddo notreplaceprofessional medicalcareand physicianadvice,which al- waysshouldbe soughtfor anymedicalcondition. Thecomplete disclaimerforthis guidelinecan beaccessedat http://www.chestnet.

CHEST-Guidelines.

FUNDING/SUPPORT:A.B.C. issupportedby aNationalHealth and MedicalResearchCounci l(NHMRC)practitioner fellowship[Grant

1058213]andholds multiplegrantsawarded fromtheNHMRC related

todiseases associatedwithpediatriccough.The viewsexpressedinthis publicationarethose ofthe authorsanddo notre!ecttheviews ofthe

NHMRC.

[Evidence-BasedMedicine ] chestjournal.org607

ChronicCoughand Gastroesophageal

Re!uxinChildren

CHESTGuidelineand ExpertPanel Report

AnneB.Chang, MBBS,PhD,MPH; JohnJ. Oppenheimer,MD;Peter J.Kahrilas,MD; AhmadKantar,MD;

BruceK.Rubin, MD;Miles Weinberger,MD,FCCP; andRichardS. Irwin,MD,Master FCCP;onbehalf ofthe CHESTExpert

CoughPanel

BACKGROUND:Whethergastroesophagealre !ux(GER)or GERdisease (GERD)caus es chroniccoughinchildren iscontrov ersial.Usingthe Population,Intervention,Comparison, Outcome(PICO)format, weundertookfour systematicreviews.Forchild renwithchronic cough(>4-weeksduration)andwit houtunderlyinglung disease:(1) whodonothave gastrointestinalGERsymptoms, shouldempirical treatmentforGERDbeused? (2)with gastrointestinalGERsymptoms ,doestreatmen tforGERDresolvethecough?(3)w ithor withoutgastrointestinalGERsympto ms,whatGER-basedtherapies shouldbe usedandfor howlong?(4) ifGERD issuspected asthecause, whatinvestigations anddiagnostic criteria bestdetermine GERDasthecauseofthe cough? METHODS:Weusedthe CHEST ExpertCough Panel'sprotocoland American Collegeof ChestPhysicians(CHEST) methodologicalguidelinesandGRADE (GradingofRecom- mendationsAssessment,Development andEvaluation)framework.Delphimethodolo gywas usedtoobt ainconsens us. RESULTS:Fewrandomized controlledtrialsa ddressedthe"rsttwoq uestion sandnone addressedt heothertwo.The singlemeta-analysis(two randomizedcontrolled trials) showednosigni"cantdiff erencebetweentheg roups(anyinterventionforG ERD vsplacebofor coughr esolution;OR, 1.14;95% CI,0.45-2.93;P!.78).P rotonpump inhibitors(vsplacebo)cause dincreased seriousadverse events.Q ualitativedatafrom existingCHEST coughsystem aticr eviewswereconsistentwitht wointernationalGERD guidelines. CONCLUSIONS:Thepanelists endorsedthat:(1)treatme nt(s)forGERDshouldnotbe used whentherea reno clinicalfeaturesofGERD;and (2)pediatric GERDguidelinesshouldbe usedtogui detreatmentand investigations.CHEST2019;156(1):131 -140 KEYWORDS:children;cough;evidence-based medicine;gastroesophageal re!ux ABBREVIATIONS:ESPGHAN=European SocietyforPediatric Gastroenterology,Hepatology,andNutrition; GER=gastroesophag eal re!ux;GERD= gastroesophageal re!uxdisease;KQ =Key Question; NASPGHAN=North AmericanSociety forPediatricGastroen ter- ology,Hepatology,and Nutrition;NICE =NationalInstitute forHealth andCareExcellence; pH-MII= multichannelintralumi nalimpedance withpHmonitorin g;PICO =Population,Intervention,Comparison,

Outcome;PPI= protonpump inhibitor;RCT= randomized

controlledtrial AFFILIATIONS:FromtheDivision ofChild Health(DrChang), MenziesSchoolof HealthResearch, Darwin,NorthernTerritor y, Australia;Respiratoryand SleepDepartment (DrChang),Queensland Children'sHospital,Queensland Universityof Technology,Brisbane, QLD,Australia;Division ofAllergy andImmunology (DrOppen- heimer),Departmentof Medicine,New JerseyMedicalSchool, Pul- monaryandAllergy Associates, Morristown,NJ;Department of Medicine(DrKahrilas) ,Northwestern University'sFeinbergSchool of

Medicine,Chicago,IL; PediatricAsthma andCough

[Evidence-BasedMedicine] chestjournal.org131

ERSsta tementonprotractedbacterial

bronchitisinchildren

AhmadKantar

1,13 ,AnneB. Chang

2,3,4,13

,Mik eD.Shields 5 ,JulieM. Marchant 2,3

KeithGrimwood

6 ,Jonathan Grigg 7 ,Kos tasN.Priftis 8 ,Rena toCutrera 9

FabioMidulla

10 ,Paul L.P.Brand 11 andMarkL. Ever ard 12

Affiliations:

1 PediatricAsthmaandCough Centre,IstitutiOspeda lieriBergamaschi, UniversityandResearch

Hospitals,Bergamo, Italy.

2 DeptofR espira toryandSleepMedicine,LadyCilentoChildren'sHospital,

Brisbane,Austr alia.

3 CentreforChildren'sHealthR esearch, InstituteofHealth&BiomedicalInnova tion, QueenslandUniversityof Technology,Brisbane,Aus tralia. 4

ChildHealthDivision, MenziesSchool ofHealth

Research,CharlesDarwinUniversity,Casuarina ,Austr alia. 5

DeptofChild Health,Q ueen'sUniversity Belfast,

Belfast,UK.

6 MenziesHealthIns tituteQ ueensland,GriffithUniversityandGold CoastHealth,GoldC oast,

Australia.

7 BlizardInstitute, QueenMaryUniversity London,London,UK. 8

ThirdDeptof Paedia trics,University

GeneralHospitalAttikon,School ofMedicine,Na tionalandKapodistrianUniv ersityofAthens, Athens,Gr eece.

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