Cough in Children and Adults: Diagnosis, Assessment and Management (CICADA). Summary of an updated position statement on chronic cough in Australia.

INTRODUCTION: 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 age > 6 years). 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://lungfoundation.com.au/resources/cicada-full-position-statement. 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.

Family-Centered Care Across Thai Neonatal Intensive Care Units: A National, Cross-Sectional Survey.

BACKGROUND: Implementing family-centered care (FCC) presents challenges to parental-healthcare provider partnership and collaboration in newborn care in neonatal intensive care units (NICUs). AIMS: To explore NICU nurses' perceptions of FCC (respect, collaboration, and support) during the COVID-19 pandemic and to compare these between nurses working in secondary and tertiary/higher care settings. METHODS: A multicenter, cross-sectional exploratory online survey design study was conducted to identify Thai NICU nurses' perceptions. The online survey of the Perceptions of Family-Centered Care-Staff (PFCC-S) was distributed via a Web page and professional networks between July and September 2022. RESULTS: Of the 187 survey respondents, most NICU nurses worked in the NICU for less than 16 years and were employed in tertiary care/higher care settings in southern Thailand. There was a significant difference in perceptions of support subscale between NICU nurses in secondary (mean: 3.32, SD ± 0.53) and tertiary/higher care settings (mean: 3.17, SD ± 0.46) (P < .05). CONCLUSION: Despite the challenges of the visitation restriction of COVID-19 in Thailand, nurses' perceptions of the value of FCC were maintained. RELEVANCE TO CLINICAL PRACTICE: Further research is recommended to investigate how FCC can be implemented where there is a lack of material and infrastructure resources and staff shortage.

Parent and interdisciplinary professional perceptions of family-centered care in Thai NICU: A qualitative study.

BACKGROUND: Family-centered care (FCC) has been successfully incorporated into daily practice in many neonatal intensive care units (NICUs) worldwide. However, the implementation of FCC in lower-resourced settings, such as Thailand, can be challenging and needs to be further explored. AIMS: To identify parents' and interdisciplinary professionals' perceptions of FCC and to describe the opportunities to improve FCC in a Thai NICU. DESIGN: An exploratory qualitative approach was used. METHODS: The data were collected through face-to-face, semi-structured, individual interviews based on an interview guide. This study was conducted before the outbreak of coronavirus disease 2019 (February 2020) in a hospital in southern Thailand. Inductive thematic analysis was used to analyse interview data. RESULTS: Participants were parents (n = 9) and interdisciplinary professionals (n = 8). The results revealed four key themes: (a) Recognizing and responding to individual families' different readiness and their rights and values, (b) working in a parent-interdisciplinary partnership to provide care, (c) lacking resources and motivation and (d) understanding of care requirements and providing help/sympathy. CONCLUSIONS: The interdisciplinary professionals accepted that FCC is necessary for clinical practice, but there are some challenges in the Thai NICUs context because of the system of health care delivery. The findings highlighted that interdisciplinary professionals often viewed parents' involvement as an obstacle to providing neonatal care. RELEVANCE TO CLINICAL PRACTICE: Further research is recommended to investigate how FCC is operationalized by interdisciplinary professionals and how hospital administrators can be supported to implement the FCC approach into clinical practice in Thai NICUs.

Hospital healthcare professionals' knowledge of dementia and attitudes towards dementia care: A cross-sectional study.

AIMS AND OBJECTIVES: To explore hospital healthcare professionals' knowledge and attitudes towards dementia care in China. BACKGROUND: Hospital healthcare professionals deliver most diagnosis and treatment for people with dementia in China. Literature shows that healthcare professionals' knowledge and attitudes are of great importance in providing optimum dementia care. However, there is limited research of healthcare professionals' dementia knowledge and attitudes within hospital contexts in China. DESIGN: A cross-sectional survey was conducted between April and December 2019. METHODS: A self-report questionnaire composed of demographics and knowledge and attitude scales related to dementia was used for doctors and registered nurses working in settings where people with dementia are cared for in eleven public tertiary hospitals in Hebei Province, China. The STROBE checklist was adhered to in this study. RESULTS: In total, 603 healthcare professionals completed the study. The majority of respondents were registered nurses (71.3%). The overall mean knowledge score was 20.7 (SD = 2.9) out of a maximum possible score of 30. The overall mean score for attitudes was 91.3 (SD = 15.9) out of a maximum possible score of 140. Standard multiple linear regression analysis revealed that the highest level of education, the experience of searching for dementia-related information and willingness to receive dementia training or education were significant predictors of knowledge scores. The department, the experience of working with people with dementia, length of dementia care, interest in dementia care and training type were significant predictors of attitude scores. CONCLUSIONS: Deficits in the knowledge of dementia and a low level of positive attitude were identified among the healthcare professionals who work in hospital settings where people with dementia are cared for in China. RELEVANCE TO CLINICAL PRACTICE: Education and training in dementia care should be integrated into undergraduate nursing and medical programmes and provided for healthcare professionals after commencing employment.

Family-centred care change during COVID-19.

BACKGROUND: Family-centred care (FCC) is an approach to promote family and health care provider partnership. This has been incorporated into neonatal intensive care units (NICUs) worldwide. However, FCC in low resource health settings, such as Thailand, is challenging and further impacted by coronavirus disease 2019 (COVID-19). AIMS: To evaluate FCC innovations to improve respect, collaboration and support in a Thai NICU. STUDY DESIGN: A quasi-experimental study was conducted in an NICU in southern Thailand. Pre-implementation was prior to COVID-19, and parental and staff perceptions of FCC were measured via Perceptions of Family Centred Care-Parent (PFCC-P) and -Staff (PFCC-S) survey. The FCC innovations were developed by stakeholders based on the COVID-19 restrictions, pre-survey results, parents' and clinicians' interviews and integrative review, then implemented via a flowchart. Post-implementation evaluation was via repeated surveys. Comparisons were made pre-and post-implementation, with Mann-Whitney U-test statistics for parents and Wilcoxon's Rank Sum for staff. RESULTS: A total of 185 (85 pre; 100 post) parents and 20 (pre and post; paired group) health care professionals participated. Because of COVID-19, many planned interventions were unfeasible, however, other innovations achieved (e.g., structured telephone updates, information booklet revision). There was an increase in parents' perception of respect ([median] 2.50-3.50), collaboration (2.33-3.33) and support (2.60-3.60) domains and overall (2.50-3.43; p < .001; 95% CI: 2.93-3.11). Interdisciplinary professionals' perception of FCC did not significantly change pre-and post-implementation/COVID-19 pandemic for respect (3.00-2.92), collaboration (3.22-3.33), support (3.20-3.20) and overall (3.15-3.20; 95% CI: 3.10-3.25). CONCLUSION: Despite the challenges of COVID-19 restricting NICU access, the provision of FCC was maintained and even improved. RELEVANCE TO CLINICAL PRACTICE: Further research is necessary to develop FCC practice innovations associated with communication, across diverse health care systems and resources.

Does lung function change in the months after an asthma exacerbation in children?

BACKGROUND: There are limited data describing lung function changes in children after an asthma exacerbation. Our hypothesis was that lung function does not fully recover in children in the months following an asthma exacerbation. METHODS: We used a data set of children with asthma where lung function (including FEV1 , FEV1 /FVC ratio and FEF25-75 ) was measured at 3-month intervals over a year. Mixed-level models compared spirometry measured on two occasions 3 months apart before a single exacerbation (assessments 1 and 2) with measurements made on two occasions after the exacerbation (assessments 3 and 4), with adjustment for covariates. Changes in spirometry over a year were also analysed across those with exacerbations in no, one or more than one 3-month periods. RESULTS: For the 113 children who had a single exacerbation, spirometry measured at assessments 1 or 2 did not differ from measurements at assessments 3 or 4 when the whole population was considered. When stratified into tertiles by change in %FEV1 between assessments 2 and 3, those with the greater reduction were more likely to be treated with long-acting beta-agonist, but in this category, %FEV1 at assessment 4 had returned to the value at assessment 1. %FEV1 did not change over a 12-month period within and between the three exacerbation categories (n = 809). CONCLUSION: One or more asthma exacerbation was not associated with a fall in lung function for the whole population. In a subset of individuals, lung function does fall after an exacerbation but returns to pre-exacerbation values after a period of months.

Fundamental movement skill proficiency and objectively measured physical activity in children with bronchiectasis: a cross-sectional study.

BACKGROUND: Bronchiectasis is a major contributor to respiratory morbidity and healthcare utilization in children. Children with bronchiectasis exhibit low levels of physical activity (PA) and poor fundamental movement skills (FMS) may be a contributing factor. However, there are no data on FMS's in this population. The current study assessed FMS proficiency in children with bronchiectasis and examined associations with objectively measured PA. METHODS: Forty-six children with bronchiectasis (mean age 7.5 ± 2.6 year, 63% Male) were recruited from the Queensland Children's Hospital, Brisbane. PA was measured using the ActiGraph GT3X + accelerometer. Raw accelerometer data were processed into daily time spent in sedentary activities, light-intensity activities and games, walking, running, and moderate-to-vigorous activities and games using a random forest (RF) PA classification algorithm specifically developed for children. Daily MVPA was calculated by summing time spent in walking, running, and moderate-to-vigorous activities and games. FMS were assessed using the Test of Gross Motor Development 2nd Edition (TGMD-2). RESULTS: Fewer than 5% of children demonstrated mastery in the run, gallop, hop, and leap; while fewer than 10% demonstrated mastery for the two-handed strike, overarm throw, and underarm throw. Only eight of the 46 children (17.4%) achieved their age equivalency for locomotor skills, while just four (8.7%) achieved their age equivalency for object control skills. One-way ANCOVA revealed that children achieving their age equivalency for FMS had significantly higher levels of MVPA than children not achieving their age equivalency (51.7 vs 36.7 min/day). When examined by the five activity classes predicted by the RF algorithm, children achieving their age equivalency exhibited significantly greater participation moderate-to-vigorous intensity activities and games (22.1 vs 10.7 min/day). No significant differences were observed for sedentary activities, light-intensity activities and games, walking, and running. CONCLUSION: Children with bronchiectasis exhibit significant delays in their FMS development. However, those who meet their age equivalency for FMS proficiency participate in significantly more daily MVPA than children who do not meet their age-equivalency. Therapeutic exercise programs designed to improve FMS proficiency are thus likely to be beneficial in this population.

Does treatment guided by exhaled nitric oxide fraction improve outcomes in subgroups of children with asthma?

INTRODUCTION: Exhaled nitric oxide fraction (F ENO), a biomarker of eosinophilic airway inflammation, may be useful to guide asthma treatment. F ENO-guided treatment may be more effective in certain subgroups for improving asthma outcomes compared to standard treatment. METHODS: An individual patient data analysis was performed using data from seven randomised clinical trials (RCTs) which used F ENO to guide asthma treatment. The incidence of an asthma exacerbation and loss of control, and the time to first exacerbation and loss of control were described between five subgroups of RCT participants. RESULTS: Data were available in 1112 RCT participants. Among those not treated with leukotriene receptor antagonists (LTRA), but not among those who were treated with LTRA, F ENO-guided treatment was associated with reduced exacerbation risk (OR 0.68, 95% CI 0.49-0.94), longer time to first exacerbation (hazard ratio (HR) 0.76, 95% CI 0.57-0.99) and borderline reduced risk for loss of control (OR 0.70, 95% CI 0.49-1.00). Nonobese children, compared to obese children, were less likely to lose asthma control when treatment was guided by F ENO (OR 0.69, 95% CI 0.48-0.99) and time to loss of control was longer (HR 0.77, 95% CI 0.61-0.99). CONCLUSIONS: Asthma treatment guided by F ENO may be more effective in achieving better asthma outcomes for patients who are not treated with LTRA and who are not obese, compared to standard practice.

A social robot intervention on depression, loneliness, and quality of life for Taiwanese older adults in long-term care.

OBJECTIVES: To investigate the effect of a social robot intervention on depression, loneliness, and quality of life of older adults in long-term care (LTC) and to explore participants' experiences and perceptions after the intervention. DESIGN: A mixed-methods approach consisting of a single group, before and after quasi-experimental design, and individual interview. PARTICIPANTS: Twenty older adults with depression from four LTC facilities in Taiwan were recruited. INTERVENTION: Each participant participated in 8 weeks of observation and 8 weeks of intervention. In the observation stage, participants received usual care or activities without any research intervention. In the intervention stage, each participant was given a Paro (Personal Assistive RobOt) to keep for 24 hours, 7 days a week. MEASUREMENTS: The Geriatric Depression Scale, the UCLA Loneliness Scale Version 3, and the World Health Organization Quality of Life Questionnaire for older adults were administered at four time points. Individual qualitative interviews with thematic analysis followed. RESULTS: A repeated multivariate analysis of variance and Friedman's test showed no significant changes during the observation stage between T1 and T2 for depression and quality of life (p >.5). For the intervention stage, statistically significant changes in decreasing depression and loneliness and improving quality of life over time were identified. Three themes emerged from the interviews: (i) humanizing Paro through referring to personal experiences and engagement; (ii) increased social interaction with other people; and (iii) companionship resulting in improved mental well-being. CONCLUSIONS: There were significant improvements in mental well-being in using Paro. Further research may help us to understand the advantages of using a Paro intervention as depression therapy.

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 participants <18 years) or participants. Medical records were manually reviewed. Participants with incomplete data (missing self-reported and/or medical record information) were excluded. Agreement between sources was examined using Cohen's kappa. RESULTS: Of 1097 participants, 889 (97.1% <18 years) had sufficient self-reported and medical record histories for comparison. Asthma was self-reported by 15.7% of participants and was reported in medical records for 10.3% (κ = 0.53, 95% confidence interval (CI) 0.45-0.61). For bronchiectasis, the reported rates were 1.5 and 0.7% (κ = 0.52, 95% CI 0.25-0.80), pneumonia 1.1 and 5.8% (κ = 0.15, 95% CI 0.02-0.27), allergic rhinitis 6.6 and 0.6% (κ = 0.05, 95% CI -0.03, 0.13) and eczema 5.8 and 6.2% (κ = 0.30, 95% CI 0.18-0.42). CONCLUSIONS: Within our cohort, agreement was moderate for asthma and bronchiectasis, fair for eczema and poor for pneumonia and allergic rhinitis. These results highlight the challenges associated with how best to obtain an accurate health history within Australian Indigenous rural/remote communities. Generalisability of findings and contributions of poor health knowledge and/or poor medical record documentation need further exploration.

Amoxicillin-clavulanate versus azithromycin for respiratory exacerbations in children with bronchiectasis (BEST-2): a multicentre, double-blind, non-inferiority, randomised controlled trial.

BACKGROUND: Although amoxicillin-clavulanate is the recommended first-line empirical oral antibiotic treatment for non-severe exacerbations in children with bronchiectasis, azithromycin is also often prescribed for its convenient once-daily dosing. No randomised controlled trials involving acute exacerbations in children with bronchiectasis have been published to our knowledge. We hypothesised that azithromycin is non-inferior to amoxicillin-clavulanate for resolving exacerbations in children with bronchiectasis. METHODS: We did this parallel-group, double-dummy, double-blind, non-inferiority randomised controlled trial in three Australian and one New Zealand hospital between April, 2012, and August, 2016. We enrolled children aged 1-19 years with radiographically proven bronchiectasis unrelated to cystic fibrosis. At the start of an exacerbation, children were randomly assigned to oral suspensions of either amoxicillin-clavulanate (22·5 mg/kg, twice daily) and placebo or azithromycin (5 mg/kg per day) and placebo for 21 days. We used permuted block randomisation (stratified by age, site, and cause) with concealed allocation. The primary outcome was resolution of exacerbation (defined as a return to baseline) by 21 days in the per-protocol population, with a non-inferiority margin of -20%. We assessed several secondary outcomes including duration of exacerbation, time to next exacerbation, laboratory, respiratory, and quality-of-life measurements, and microbiology. This trial was registered with the Australian/New Zealand Registry (ACTRN12612000010897). FINDINGS: We screened 604 children and enrolled 236. 179 children had an exacerbation and were assigned to treatment: 97 to amoxicillin-clavulanate, 82 to azithromycin). By day 21, 61 (84%) of 73 exacerbations had resolved in the azithromycin group versus 73 (84%) of 87 in the amoxicillin-clavulanate group. The risk difference showed non-inferiority (-0·3%, 95% CI -11·8 to 11·1). Exacerbations were significantly shorter in the amoxicillin-clavulanate group than in the azithromycin group (median 10 days [IQR 6-15] vs 14 days [8-16]; p=0·014). Adverse events were attributed to the trial medication in 17 (21%) of 82 children in the azithromycin group versus 23 (24%) of 97 in the amoxicillin-clavulanate group (relative risk 0·9, 95% CI 0·5 to 1·5). INTERPRETATION: By 21 days of treatment, azithromycin is non-inferior to amoxicillin-clavulanate for resolving exacerbations in children with non-severe bronchiectasis. In some patients, such as those with penicillin hypersensitivity or those likely to have poor adherence, azithromycin provides another option for treating exacerbations, but must be balanced with risk of treatment failure (within a 20% margin), longer exacerbation duration, and the risk of inducing macrolide resistance. FUNDING: Australian National Health and Medical Research Council.

Objectively measured physical activity and sedentary behaviour in children with bronchiectasis: a cross-sectional study.

BACKGROUND: Bronchiectasis is a major contributor to respiratory morbidity and health care utilization in children and youth. Current treatment guidelines for bronchiectasis recommend participation in regular physical activity (PA) to improve aerobic fitness and quality of life (QoL). However, no previous study has assessed physical activity and sedentary behavior in this patient group, and the extent to which children with bronchiectasis meet guidelines for PA is unknown. In the absence of such data, we objectively measured the PA of children with bronchiectasis and compared them to current guidelines. METHODS: Forty-six children with bronchiectasis between 4 to 14 years (mean age 7.5 ± 2.6 years) were recruited from the Queensland Children's Hospital, Brisbane. Daily time in sedentary, light, and moderate-to-vigorous PA (MVPA) was measured objectively over 7 days using the ActiGraph GT3X+ accelerometer and compared their values to current guidelines (minimum 60 min of MVPA daily). Compliance with the daily guideline and average daily steps counts were compared to normative data from two population-based health surveys of healthy children. RESULTS: We had complete measurements from 36 children. On average, they accumulated 48.6 min of MVPA daily and were sedentary for ~ 7 h/day. There was no statistical difference in these values between sexes or weekdays vs. weekends. Only 2 (5.6%) children met the 60-min daily MVPA recommendation compared to 42.1% of healthy children. Children with bronchiectasis accumulated 8229 steps/day (boys: 8422 ± SD 473, girls: 8037 ± 594), well below the recommended 12,000 steps/day. In comparison, daily step counts in healthy children ranged from 11,500-14,500 steps/day. CONCLUSION: Children with bronchiectasis are insufficiently active for health benefit and would substantially benefit from programs to promote PA and reduce sedentary behavior.

Development of a quality improvement audit tool for the primary care of children with chronic wet cough using a modified Delphi consensus approach.

AIM: In the absence of quality indicators (QIs) for the management of chronic wet cough, our study's aim was to determine whether consensus on QIs reflecting good primary health care, prior to referral for children with chronic wet cough, can be achieved. METHODS: A questionnaire consisting of 10 QIs was developed by a clinical working group based on current evidence and guidelines on the management of chronic wet cough in children. Each indicator reflected the quality of care provided to children with chronic wet cough in primary care prior to referral. A modified Delphi consensus questionnaire was undertaken involving expert paediatric respiratory clinicians and general paediatricians who graded the importance of each indicator for the purposes above. We a priori defined that consensus was considered achieved if >75% agreed on the indicator. RESULTS: Twenty-two specialists (from Brisbane, Melbourne, Perth and Canberra) participated in the survey. The cumulative number of years of their respiratory experience was 324 and that of general clinical practice was 504. Consensus was achieved in all 10 QIs, with 6 reaching 100% agreement. Mean agreement for the 10 items was 97%. CONCLUSION: As complete consensus was achieved on these QIs, it can be used as a provisional clinical audit tool and can guide the development of a robust audit tool for primary care clinical practice to assist with quality improvement initiatives.

Tailoring asthma treatment on eosinophilic markers (exhaled nitric oxide or sputum eosinophils): a systematic review and meta-analysis.

BACKGROUND: Asthma guidelines guide health practitioners to adjust treatments to the minimum level required for asthma control. As many people with asthma have an eosinophilic endotype, tailoring asthma medications based on airway eosinophilic levels (sputum eosinophils or exhaled nitric oxide, FeNO) may improve asthma outcomes. OBJECTIVE: To synthesise the evidence from our updated Cochrane systematic reviews, for tailoring asthma medication based on eosinophilic inflammatory markers (sputum analysis and FeNO) for improving asthma-related outcomes in children and adults. DATA SOURCES: Cochrane reviews with standardised searches up to February 2017. STUDY SELECTION: The Cochrane reviews included randomised controlled comparisons of tailoring asthma medications based on sputum analysis or FeNO compared with controls (primarily clinical symptoms and/or spirometry/peak flow). RESULTS: The 16 included studies of FeNO-based management (seven in adults) and 6 of sputum-based management (five in adults) were clinically heterogeneous. On follow-up, participants randomised to the sputum eosinophils strategy (compared with controls) were significantly less likely to have exacerbations (62 vs 82/100 participants with ≥1 exacerbation; OR 0.36, 95% CI 0.21 to 0.62). For the FeNO strategy, the respective numbers were adults OR 0.60 (95% CI 0.43 to 0.84) and children 0.58 (95% CI 0.45 to 0.75). However, there were no significant group differences for either strategy on daily inhaled corticosteroids dose (at end of study), asthma control or lung function. CONCLUSION: Adjusting treatment based on airway eosinophilic markers reduced the likelihood of asthma exacerbations but had no significant impact on asthma control or lung function.

Caseworker-assigned discharge plans to prevent hospital readmission for acute exacerbations in children with chronic respiratory illness.

BACKGROUND: Chronic respiratory conditions are major causes of mortality and morbidity. Children with chronic health conditions have increased morbidity associated with their physical, emotional, and general well-being. Acute respiratory exacerbations (AREs) are common in children with chronic respiratory disease, often requiring admission to hospital. Reducing the frequency of AREs and recurrent hospitalisations is therefore an important goal in the individual and public health management of chronic respiratory illnesses in children. Discharge planning is used to decide what a person needs for transition from one level of care to another and is usually considered in the context of discharge from hospital to the home. Discharge planning from hospital for ongoing management of an illness has historically been referral to a general practitioner or allied health professional or self management by the individual and their family with limited communication between the hospital and patient once discharged. Effective discharge planning can decrease the risk of recurrent AREs requiring medical care. An individual caseworker-assigned discharge plan may further decrease exacerbations. OBJECTIVES: To evaluate the efficacy of individual caseworker-assigned discharge plans, as compared to non-caseworker-assigned plans, in preventing hospitalisation for AREs in children with chronic lung diseases such as asthma and bronchiectasis. SEARCH METHODS: We searched the Cochrane Airways Group Specialised Register of Trials, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, trials registries, and reference lists of articles. The latest searches were undertaken in November 2017. SELECTION CRITERIA: All randomised controlled trials comparing individual caseworker-assigned discharge planning compared to traditional discharge-planning approaches (including self management), and their effectiveness in reducing the subsequent need for emergency care for AREs (hospital admissions, emergency department visits, and/or unscheduled general practitioner visits) in children hospitalised with an acute exacerbation of chronic respiratory disease. We excluded studies that included children with cystic fibrosis. DATA COLLECTION AND ANALYSIS: We used standard Cochrane Review methodological approaches. Relevant studies were independently selected in duplicate. Two review authors independently assessed trial quality and extracted data. We contacted the authors of one study for further information. MAIN RESULTS: We included four studies involving a total of 773 randomised participants aged between 14 months and 16 years. All four studies involved children with asthma, with the case-planning undertaken by a trained nurse educator. However, the discharge planning/education differed among the studies. We could include data from only two studies (361 children) in the meta-analysis. Two further studies enrolled children in both inpatient and outpatient settings, and one of these studies also included children with acute wheezing illness (no previous asthma diagnosis); the data specific to this review could not be obtained. For the primary outcome of exacerbations requiring hospitalisation, those in the intervention group were significantly less likely to be rehospitalised (odds ratio (OR) 0.29, 95% confidence interval (CI) 0.16 to 0.50) compared to controls. This equates to 189 (95% CI 124 to 236) fewer admissions per 1000 children. No adverse events were reported in any study. In the context of substantial statistical heterogeneity between the two studies, there were no statistically significant effects on emergency department (OR 0.37, 95% CI 0.04 to 3.05) or general practitioner (OR 0.87, 95% CI 0.22 to 3.44) presentations. There were no data on cost-effectiveness, length of stay of subsequent hospitalisations, or adherence to medications. One study reported quality of life, with no significant differences observed between the intervention and control groups.We considered three of the studies to have an unclear risk of bias, primarily due to inadequate description of the blinding of participants and investigators. The fourth study was assessed as at high risk of bias as a single unblinded investigator was used. Using the GRADE system, we assessed the quality of the evidence as moderate for the outcome of hospitalisation and low for the outcomes of emergency department visits and general practitioner consultations. AUTHORS' CONCLUSIONS: Current evidence suggests that individual caseworker-assigned discharge plans, as compared to non-caseworker-assigned plans, may be beneficial in preventing hospital readmissions for acute exacerbations in children with asthma. There was no clear indication that the intervention reduces emergency department and general practitioner attendances for asthma, and there is an absence of data for children with other chronic respiratory conditions. Given the potential benefit and cost savings to the healthcare sector and families if hospitalisations and outpatient attendances can be reduced, there is a need for further randomised controlled trials encompassing different chronic respiratory illnesses, ethnicity, socio-economic settings, and cost-effectiveness, as well as defining the essential components of a complex intervention.

Antibiotics for prolonged wet cough in children.

BACKGROUND: Cough is a frequent symptom presenting to doctors. The most common cause of childhood chronic (greater than fours weeks' duration) wet cough is protracted bacterial bronchitis (PBB) in some settings, although other more serious causes can also present this way. Timely and effective management of chronic wet or productive cough improves quality of life and clinical outcomes. Current international guidelines suggest a course of antibiotics is the first treatment of choice in the absence of signs or symptoms specific to an alternative diagnosis. This review sought to clarify the current evidence to support this recommendation. OBJECTIVES: To determine the efficacy of antibiotics in treating children with prolonged wet cough (excluding children with bronchiectasis or other known underlying respiratory illness) and to assess risk of harm due to adverse events. SEARCH METHODS: We undertook an updated search (from 2008 onwards) using the Cochrane Airways Group Specialised Register, Cochrane Register of Controlled Trials (CENTRAL), MEDLINE, Embase, trials registries, review articles and reference lists of relevant articles. The latest searches were performed in September 2017. SELECTION CRITERIA: We included randomised controlled trials (RCTs) comparing antibiotics with a placebo or a control group in children with chronic wet cough. We excluded cluster and cross-over trials. DATA COLLECTION AND ANALYSIS: We used standard methods as recommended by Cochrane. We reviewed results of searches against predetermined criteria for inclusion. Two independent review authors selected, extracted and assessed the data for inclusion. We contacted authors of eligible studies for further information as needed. We analysed data as 'intention to treat.' MAIN RESULTS: We identified three studies as eligible for inclusion in the review. Two were in the previous review and one new study was included. We considered the older studies to be at high or unclear risk of bias whereas we judged the newly included study at low risk of bias. The studies varied in treatment duration (from 7 to 14 days) and the antibiotic used (two studies used amoxicillin/clavulanate acid and one used erythromycin).We included 190 children (171 completed), mean ages ranged from 21 months to six years, in the meta-analyses. Analysis of all three trials (190 children) found that treatment with antibiotics reduced the proportion of children not cured at follow-up (primary outcome measure) (odds ratio (OR) 0.15, 95% confidence interval (CI) 0.07 to 0.31, using intention-to -treat analysis), which translated to a number needed to treat for an additional beneficial outcome (NNTB) of 3 (95% CI 2 to 4). We identified no significant heterogeneity (for both fixed-effect and random-effects model the I² statistic was 0%). Two older trials assessed progression of illness, defined by requirement for further antibiotics (125 children), which was significantly lower in the antibiotic group (OR 0.10, 95% CI 0.03 to 0.34; NNTB 4, 95% CI 3 to 5). All three trials (190 children) reported adverse events, which were not significantly increased in the antibiotic group compared to the control group (OR 1.88, 95% CI 0.62 to 5.69). We assessed the quality of evidence GRADE rating as moderate for all outcome measures, except adverse events which we assessed as low quality. AUTHORS' CONCLUSIONS: Evidence suggests antibiotics are efficacious for the treatment of children with chronic wet cough (greater than four weeks) with an NNTB of three. However, antibiotics have adverse effects and this review reported only uncertainty as to the risk of increased adverse effects when they were used in this setting. The inclusion of a more robust study strengthened the previous Cochrane review and its results.

Inhaled corticosteroids for bronchiectasis.

BACKGROUND: Bronchiectasis is being increasingly diagnosed and recognised as an important contributor to chronic lung disease in both adults and children in high- and low-income countries. It is characterised by irreversible dilatation of airways and is generally associated with airway inflammation and chronic bacterial infection. Medical management largely aims to reduce morbidity by controlling the symptoms, reduce exacerbation frequency, improve quality of life and prevent the progression of bronchiectasis. This is an update of a review first published in 2000. OBJECTIVES: To evaluate the efficacy and safety of inhaled corticosteroids (ICS) in children and adults with stable state bronchiectasis, specifically to assess whether the use of ICS: (1) reduces the severity and frequency of acute respiratory exacerbations; or (2) affects long-term pulmonary function decline. SEARCH METHODS: We searched the Cochrane Register of Controlled Trials (CENTRAL), the Cochrane Airways Group Register of trials, MEDLINE and Embase databases. We ran the latest literature search in June 2017. SELECTION CRITERIA: All randomised controlled trials (RCTs) comparing ICS with a placebo or no medication. We included children and adults with clinical or radiographic evidence of bronchiectasis, but excluded people with cystic fibrosis. DATA COLLECTION AND ANALYSIS: We reviewed search results against predetermined criteria for inclusion. In this update, two independent review authors assessed methodological quality and risk of bias in trials using established criteria and extracted data using standard pro forma. We analysed treatment as 'treatment received' and performed sensitivity analyses. MAIN RESULTS: The review included seven studies, involving 380 adults. Of the 380 randomised participants, 348 completed the studies.Due to differences in outcomes reported among the seven studies, we could only perform limited meta-analysis for both the short-term ICS use (6 months or less) and the longer-term ICS use (> 6 months).During stable state in the short-term group (ICS for 6 months or less), based on the two studies from which data could be included, there were no significant differences from baseline values in the forced expiratory volume in the first second (FEV1) at the end of the study (mean difference (MD) -0.09, 95% confidence interval (CI) -0.26 to 0.09) and forced vital capacity (FVC) (MD 0.01 L, 95% CI -0.16 to 0.17) in adults on ICS (compared to no ICS). Similarly, we did not find any significant difference in the average exacerbation frequency (MD 0.09, 95% CI -0.61 to 0.79) or health-related quality of life (HRQoL) total scores in adults on ICS when compared with no ICS, though data available were limited. Based on a single non-placebo controlled study from which we could not extract clinical data, there was marginal, though statistically significant improvement in sputum volume and dyspnoea scores on ICS.The single study on long-term outcomes (over 6 months) that examined lung function and other clinical outcomes, showed no significant effect of ICS on any of the outcomes. We could not draw any conclusion on adverse effects due to limited available data.Despite the authors of all seven studies stating they were double-blind, we judged one study (in the short duration ICS) as having a high risk of bias based on blinding, attrition and reporting of outcomes. The GRADE quality of evidence was low for all outcomes (due to non-placebo controlled trial, indirectness and imprecision with small numbers of participants and studies). AUTHORS' CONCLUSIONS: This updated review indicates that there is insufficient evidence to support the routine use of ICS in adults with stable state bronchiectasis. Further, we cannot draw any conclusion for the use of ICS in adults during an acute exacerbation or in children (for any state), as there were no studies.

Tailored interventions based on sputum eosinophils versus clinical symptoms for asthma in children and adults.

BACKGROUND: Asthma severity and control can be measured both subjectively and objectively. Sputum analysis for evaluation of percentage of sputum eosinophilia directly measures airway inflammation, and is one method of objectively monitoring asthma. Using sputum analysis to adjust or tailor asthma medications is potentially superior to traditional methods based on symptoms and spirometry. OBJECTIVES: To evaluate the efficacy of tailoring asthma interventions based on sputum analysis in comparison to traditional methods (usually symptom-based with or without spirometry/peak flow) for asthma-related outcomes in children and adults. SEARCH METHODS: We searched the Cochrane Airways Group Specialised Register of Trials, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, trials' registries, and reference lists of articles. The last search was conducted in February 2017. SELECTION CRITERIA: All randomised controlled comparisons of adjustment of asthma therapy based on sputum eosinophils compared to traditional methods (primarily clinical symptoms and spirometry/peak flow). DATA COLLECTION AND ANALYSIS: Results of searches were reviewed against pre-determined criteria for inclusion. In this update, two reviewers selected relevant studies, independently assessed trial quality and extracted the data. We contacted authors for further information when relevant. We analysed data as 'treatment received' and performed sensitivity analyses. MAIN RESULTS: Three new studies were added in this update, resulting in a total of six included studies (five in adults and one involving children/adolescents). These six studies were clinically and methodologically heterogeneous (use of medications, cut-off for percentage of sputum eosinophils and definition of asthma exacerbation). Of 374 participants randomised, 333 completed the trials. In the meta-analysis, there was a significant reduction in the occurrence of any exacerbations when treatment was based on sputum eosinophil counts, compared to that based on clinical symptoms with or without lung function; pooled odds ratio (OR) was 0.57 (95% confidence interval (CI) 0.38 to 0.86). The risk of having one or more exacerbations over 16 months was 82% in the control arm and 62% (95% CI 49% to 74%) in the sputum strategy arm, resulting in a number needed to treat to benefit (NNTB) of 6 (95% CI 4 to 13).There were also differences between the groups in the rate of exacerbation (any exacerbation per year) and severity of exacerbations defined by requirement for use of oral corticosteroids and hospitalisations: the risk of one or more hospitalisations over 16 months was 24% in controls compared to 8% (95% CI 3% to 21%) in the sputum arm. Data for clinical symptoms, quality of life and spirometry were not significantly different between groups. The mean dose of inhaled corticosteroids per day was also similar in both groups. However sputum induction was not always possible. The included studies did not record any adverse events.One study was not blinded and thus was considered to have a high risk of bias. However, when this study was removed in a sensitivity analysis, the difference between the groups for the primary outcome (exacerbations) remained statistically significant between groups. The GRADE quality of the evidence ranged from moderate (for the outcomes 'Occurrence of any exacerbation' and 'Hospitalisation' ) to low (for the outcome 'Mean dose of inhaled corticosteroids per person per day') due to the inconsistency in defining exacerbations and the small number of hospital admissions. AUTHORS' CONCLUSIONS: In this updated review, tailoring asthma interventions based on sputum eosinophils is beneficial in reducing the frequency of asthma exacerbations in adults with asthma. Adults with frequent exacerbations and severe asthma may derive the greatest benefit from this additional monitoring test, although we were unable to confirm this through subgroup analysis. There is insufficient data available to assess tailoring asthma medications based on sputum eosinophilia in children.Further robust RCTs need to be undertaken and these should include participants with different underlying asthma severities and endotypes.