Infections

Call for action on unnecessary chronic cough referrals to respiratory specialists


Frequently misdiagnosed and undertreated, protracted bacterial bronchitis (PBB) remains the most common cause of chronic cough in children referred to specialist respiratory care, a WA study shows.

And the fact that little has changed in 15 years indicates that early diagnosis and treatment of PBB by GPs is needed to prevent progress to bronchiectasis, according to Perth-based paediatric respiratory physician, Dr André Schultz.

In a study in the Journal of Paediatrics and Child Health, his team showed that of 124 children referred to the state’s tertiary paediatric outpatient respiratory service between 2018 and 2019, 38% had PBB, while 15% had asthma, 9% had recurring viral infections and 6% had chronic suppurative lung disease or bronchiectasis.

Only four of 37 specialist-identified PBB cases were correctly diagnosed pre-referral. Most cases came from primary care physicians and either had no working diagnosis or were thought to be asthma.

Thirty-one patients had received antibiotics of any duration, 14 had antibiotics for at least two weeks and 18 had been prescribed asthma treatment, the study found.

The study investigators said PBB can be identified and treated without specialist tests and should thus be managed in primary care.

National and international guidelines recommend PBB patients receive an appropriate antibiotic targeted at common respiratory pathogens such as Streptococcus pneumoniae, non-typeable Haemophilus influenzae and Moraxella catarrhalis for two weeks, plus two to four weeks if wet cough persists.

PBB patients should only be referred to specialists if their cough doesn’t resolve after guideline-directed treatment, they experience recurrent PBB or they have other symptoms such as inspiratory crackles, failure to thrive or clubbing, Dr Schultz told the limbic.

Increased awareness and education needed

“In an ideal world, parents will seek help early, before the cough becomes very chronic, primary care clinicians will make a diagnosis and treat PBB and it shouldn’t need referring to specialists most of the time,” he said.

However, the proportion of referred chronic cough cases attributable to PBB had not changed since a previous study done in 2006.

Similarly, there had been no change in the median duration of cough — of 7.5 months — prior to specialist review over this time, the Dr Schultz and his team wrote.

Increased awareness and education about PBB are needed to improve detection, treatment and cough duration in primary care, Dr Schultz said.

“The condition’s always been with us, but it was only formally recognised in Australia in 2006,” he said.

“Only about 30% of medical knowledge reaches clinical practice and it takes about 17 years to do so. So, there are many things that don’t get into clinical practice or medical school and this is one of those things. It’s now being taught at some universities, but not yet widely taught.”

“As respiratory physicians, we need to advocate and participate in training opportunities for primary care physicians if we want to prevent children having bronchiectasis and coming to our clinics with permanent disease,” he said.

Another recent study in regional Australia had shown that primary care clinicians were largely unaware of PBB, the importance of early management or the potential risk for developing bronchiectasis.

“Additionally, normalisation of chronic wet cough (i.e. belief that ongoing wet cough is normal in a child) by the public, and the diagnostic dilemma for chronic wet cough as a symptom in other diseases, such as asthma, may contribute to mis- or underdiagnosis of PBB,” the study authors wrote.

Recently, organisations such as Western Australia Health Translation Network and Telethon Kids Institute have developed PBB educational modules, videos and resources for health professionals and the public, respectively. Updated national cough guidelines are also expected to come out later this year. However “further efforts are required to facilitate timely diagnosis and optimal management of PBB at a primary care level”, the authors wrote.

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