Wisman Dalimunthe

Cough

 Normal protective reflex

 Mucociliary system responsible

 Airway’s defense mechanism

 Cough receptors exist in the upper and lower airways,

esophagus, pericardium, stomach, diaphragm, ext. ear
 Otherwise healthy school-aged children may cough 10 to 34
times a day.
 Children can have 5 to 8 URTIs a year

 Cough can last on average for up to 3 weeks with 10% lasting

up to 25 days.
Cough receptors

modified from Chung KF, Pavord ID. Lancet. 2008

Cough phases

McCool FD. Chest 2006;129:48S-53S.

 Chronic cough

 > 2 weeks, > 4 weeks, > 8

weeks
 IDAI ; > 2 weeks
 Subdivided into wet, dry, NonSpecific
specific or nonspecific cough Cough

 “specific cough” associated Specific

with symptoms and signs ‘Normal’ or Cough
suggestive of an underlying ‘Expected’
problem, and “nonspecific Cough
cough,” which is a cough in
the absence of an
identifiable etiology.
 Approach of Chronic Cough in Children

 Objectives

 to determine whether a diagnosis can be reached clinically or if it will

require further investigation;

 to determine the most appropriate management based on etiology,

including behavioral therapy and supportive treatment.

 Obtaining a detailed history and a thorough physical

examination are absolutely essential for the investigation, and
often allow the clinician to avoid unnecessary procedures.
 A list of some key questions to ask in the history

1. How and when the cough started?

2. What triggers the cough?
3. Does the cough disappear when the child goes to sleep?
4. What treatments has been tried on and how beneficial?
5. What other medication is used? e.g. ACE inhibitors
6. Family history of respiratory, allergic or infectious disease?
7. Vaccination History?
8. Exposure to cigarettes/smoking?
9. Exposure to infectious disease?  Tb, Pertussis
10. How disruptive is the cough?
 Older children/ teens   adult ; GERD, asthma, and PND

 Observe feedings  aspiration ; tracheo-esophageal fistula,

laryngeal cleft, tracheobronchomalacia, cystic fibrosis, PCD,
lung infection in utero, or perinatal infections
 Time of onset : is it truly a chronic cough or is there a period of
improvement?
 Differentiation between a wet cough and dry cough

 Associated night sweats or weight loss.

 Identify factors that exacerbate (cold air, exercise, feeding,

seasonal) or alleviate (bronchodilators, antibiotics)
 Consider the age of the patient

Data from Urgelles Fajardo E, Barrio Go mez de Agu ero MI, Martinez Carrasco MC, et al. Tos persistente. Protocolos
diagno sticos y Terape uticos de la AEP: Neumologi a. Available at:
http://www.aeped.es/sites/default/files/documentos/9_4.pdf. Accessed: January 15, 2013.
T. Nagendran. Hospital Physician, September 2003
Clinical Pointers

Shields MD, et al. Thorax, 2008

 

Loan, et al. Frontiers of Physiology. August 2014

 Physical Examination

 Assess the general state and nutrition.

 Examine each system ; special focus on the respiratory tract
 Anatomic structures ;
 upper airway, nose examination, pale and swollen turbinates, polyps,
allergic shiners, and Dennie-Morgan lines. Ears, nose, throat : foreign
objects, and wax impaction, PND, erythematous and cobblestoned
posterior pharynx.
 Thorax : inspected, auscultated, and palpated  lung sound & cardiac
evaluation
 Abdominal ; masses, organomegaly
 Skin : dermatitis.
 Extremities examination : swelling, cyanosis, pallor, edema, clubbing
 Neurologic examination ; neurodevelopmental disorders
 Investigation

 Chest Radiograph ;
 Initial status of the lungs,
 Clues for further testing.
 Chest computed tomography ; small airway disease
 Flexible bronchoscopy

 Non invasive assessment  induced sputum

 Spirometry ; identifying reversible airway obstruction.

 Allergy testing – skin prick testing or IgE specific tests

 Tuberculosis screening
 Sweat test
Differential diagnoses

J C de Jongste and M D Shields. Thorax 2003;58;998-1003

 Chronic Cough
 Most Common Causes
 Postinfectious Cough
 Recurrent Respiratory Tract
Infections
 Protracted (Persistent)
Bacterial Bronchitis
 Asthma
 Cough varian Asthma
 Allergic Rhinitis
 Less Common Causes
 GER
 Bronchiectasis
 Foreign body aspiration
 PND
 Smoking smoke
 Habitual cough
 Pertussis
 Cystic Fibrosis
Ahmad Kantar. Lung. 2015. DOI 10.1007/s00408-015-9815-6
Asilsoy S. Chest, Desember 2008
Chang AB, et al. Chest 142:943–950, 2012.
 Postinfectious Cough

 Long-lasting effects of a previous viral airway infection

 Epithelial disruption / inflammation  production of mucus

 stimulating the cough receptors
 Affects the patient during the day and night

 > 3 weeks, but usually less than 8 weeks.

 Up to 40% of school-age children Continue coughing 10 days

after a common cold
 10% of preschool children having a persistent cough after 25
days.
 Recurrent Respiratory Tract Infections

 The main cause of chronic cough in ‘healthy children’ esp.

preschool age.
 Child has not fully recovered from a previous URI and acquires
a different virus causing similar symptoms  prolonged.
 Increase during winter
 Crowded living conditions

 Exposure to environmental pollution

 Incidence for URIs in children < 4 yrs : 5 to 8 episodes, and

between 10 and 14 yrs : 2.4 to 5 episodes.
L. McGarvey et al., Pulmonary Pharmacology & Therapeutics 2009; 22: 59-64).
 Protracted Bacterial Bronchitis (PBB)

 Chronic wet cough > 4 weeks

 Absence of underlying respiratory disorders

 Three criteria:
1. History of chronic wet cough,
2. Positive BAL culture
3. Response to antimicrobial treatment
 Etiology : S. Pneumoniae, H. Influenzae, M. Catarrhalis.

 Bronchoscopy is desired, a reasonable approach is a trial with

antibiotics.
 Pediatric population ???
 A prospective study (median age of 2.6 years)
 PBB (40%)
 UACS, asthma, and GERD < 10% of cases.
Marchant JM, et al. Thorax 2006;61(8):694–8.

 Zgherea and colleagues (0–3 years of age) with wet cough

 Result :
 56% of cases had purulent findings on bronchoscopy
  46% positive bacterial cultures
 H influenzae (49%), S pneumoniae (20%), M catarrhalis (17%),
Staphylococcus aureus (12%)

Zgherea D, et al. Pediatrics 2012;129(2):e364–9

 Asthma
 Chronic airway inflammatory
 Associated with bronchial hyperresponsiveness and
reversible airway obstruction.
 Characterized by cough, wheezing, shortness of breath, and
chest tightness.
 Atopic features such as allergic rhinitis, eczema, allergic
conjunctivitis, and urticaria
 Diagnosis :
 strong atopic history
 rapid improvement with antiasthma medication,
 Relapse after such medication is stopped.
 Supported by allergic testing (eg, skin prick) and spirometry.
 Nocturnal cough
 Cough Varian Asthma (CVA)

 Diagnosed in a child with persistent isolated non-

specific coughing who has one or more of:
 airways hyperresponsiveness,

 airways eosinophilic inflammation,

 atopy (personal in the immediate family),

 whose cough responds rapidly to anti-asthma medication.

 Allergic rhinitis

 Common paediatric condition

 The prevalence between 14 – 16 yo was 14.6%
 Characterised by rhinorrhoea, nasal obstruction,
epiphora, and nasal itching
 Eosinophilic bronchitis

 Stemming from allergic reaction

 Allergic cough is characterized by :
 the presence of marked familial history,
 past history and/or concomitant allergic conditions,
 sensitivity to allergens readily demonstrable by skin testing,
 Cause of chronic cough in adults, not in children.
 Inconsistent findings regarding cough and atopy
 The mechanism of cough in the child with asthma is
likely to be due to CRS
 Hygiene Hypothesis

•Presence of older siblings • Overuse of Antibiotic

•Early exposure to Tb, • Western lifestyle
measles, Hepatitis A • Urban Environment
•Rural Environment • Sensitization to HDM
& cockroach
The role of allergen in the initiation of airway inflamation

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Babu KS, Arshad SH. Pediatric Respiratory Reviews 2003. 4. 40-46

The role of allergen in the initiation of airway inflamation

 Allergic sensitisation (allergen specific IgE)  Target organ

specific damage :
 Upper airway  Allergic Rhinitis
 Lower airway  Asthma

 There is little doubt that children with asthma may present

with cough and the majority of children with cough do not
have asthma
 The use of cough as a marker of asthma  controversial

Babu KS, Arshad SH. Pediatric Respiratory Reviews 2003. 4. 40-46

Chang AB, Asher MI. A review of cough in children. J Asthma 2001; 38:299 –309
Clough JB, et al. Am Rev Respir Dis 1991; 143:755–760
Seear M, Wensley D. Chronic cough and wheeze in children: do they all have asthma? Eur Respir J 1997; 10:342–345
Thomson F, Masters IB, Chang AB. Persistent cough in children: overuse of medications. J Paediatr Child Health 2002; 38:578 –581
Gastroesophageal Reflux/Laryngopharyngeal Reflux

 A physiologic event in healthy infants & children

 Peaks : 1 to 4 months of age
 Resolving spontaneously by 12 months
 Dysfunction of the lower esophageal sphincter
 The theory is not clear :
 Irritation  bronchoconstriction
 Acidification  stimulates cough receptors

 A detailed history and physical examination

 Diagnostic testing is not usually necessary.
  Barium contrast, pH monitoring, endoscopy.
 Bronchiectasis

 Widening of the airway accompanied by destruction of

the bronchial and peribronchial tissue.
 Radiological diagnosis.
 Irreversible  early bronchiectasis can resolve ?
 Causes : post infectious, CF, PCD, immunodeficiency,
post-obstructive and chronic aspiration.
 Productive cough, wheeze, chest pain, shortness of
breath and haemoptysis.
 Other Less Common Causes

Inhalation of Foreign Body

 Most commonly in children between 1 and 3 yo
 Coughing will occur acutely and promptly
 Vegetable matter: popcorn and peanuts
 A history suggestive of foreign-body aspiration
 Nonvegetable and small objects  chronic cough  potentially
leading to a missed diagnosis
 A missed case can lead to permanent lung damage.
 Recurrent pneumonia
 Treatment w/ antibiotics, cough medicines, antihistamines, and
an inhaled corticosteroid were all without benefit.
 Flexible/rigid bronchoscopy
 Other Less Common Causes

Habitual or psychogenic cough

 Repetitive, habitual ; after an URI has cleared

 Bizarre, explosive cough, ‘honking’

 Troublesome during the day but is rarely during sleep

 Become more prominent in the presence of parents, doctors or

teachers.
Post Nasal Drips (PND)
 PND causes cough in children  ? ; paucity evidence

 PND can cause a sensation that causes repeated throat clearing

 different from a true cough
 Pertussis

 Whooping cough
 Still often miss the diagnosis
 Paroxysms of cough, vomiting

 Regardless of immunisation status

 Vaccination may shorten the duration of symptoms but it does

not prevent the disease
 Coughed just over 100 days.
 Approximately 20% of fully immunised children with confirmed
Pertussis infection
 Cystic Fibrosis

 Breathing problem, persistent cough, wheezing, lung infection

 Developmental abnormalities

 Meconium Ileus

 Bronchiectasis

 Finger clubing, nasal prolaps, polips

Treatment
 Take home message

 Cough is a protective physiological reflex that aids the clearance of airway

secretions and aspirated materia

 Chronic cough in children has been defined as a cough that lasts more than 2
weeks

 A detailed history followed by a thorough physical examination is necessary to

guide further testing and to avoid unnecessary procedures for the presence of
specific diagnostic indicator

 Children with chronic cough should undergo, as a minimum, a chest radiograph

and spirometry (if age appropriate)

 Allergic airway inflamation is an important aspect, but allergy contributed to 60-

70% of asthma in children and allergic rhinitis

 Antihistamin for the chronic cough still need a conclisive data