COUGH

ACUTE COUGH
- Cough is the most common symptom of respiratory disease.
- Identifying if the cough is dry or moist can be helpful diagnostically.
- A dry cough with a prolonged expiratory phase suggests that there is
some narrowing of the small-sized to moderate-sized airways.
- A barking cough suggests a degree of tracheal inflammation, narrowing or
collapse.
- A moist cough suggests that there is either increased mucus secretion or
infection in the lower airway.
- The cough reflex functions to expel unwanted material from the airway
below the glottis.
- In most children, episodes of cough are due to tracheobronchial spread of
URTIs caused by the common cold viruses and do not indicate the presence
of long-term or serious underlying respiratory disease.

CHARACTERSTIC OF COUGH AND OTHER CLINICAL

FEATURES AND POSSIBLE CAUSES
1. Cough characteristics (e.g., cough with choking, cough quality, cough
starting from birth): Congenital airway or lung abnormalities
2. Daily moist or productive cough: Chronic bronchitis, suppurative lung
disease
3. Dyspnea (exertional or at rest): Compromised lung function of any chronic
lung or cardiac disease
4. Chest pain: Asthma, functional, pleuritis
5. Symptoms of upper respiratory tract infection Can coexist or be a trigger
for an underlying problem
6. Failure to thrive: immunodeficiency, cystic fibrosis
7. Feeding difficulties (including choking and vomiting): aspiration, anatomic
disorders
8. Hemoptysis: Bronchitis, foreign body aspiration, suctioning trauma,
pulmonary hemorrhage
9. Medications or drugs: Angiotensin- converting enzyme inhibitors

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10. Neurodevelopmental abnormality: Aspiration
11. Recurrent pneumonia Immunodeficiency, congenital lung problem, airway
abnormality
12. Immune deficiency: Atypical and typical recurrent respiratory or non-
respiratory infections
13. Chest wall deformity: Any chronic lung disease, neuromuscular disorders
14. Digital clubbing: Suppurative lung disease,
15. Auscultatory findings (wheeze, crepitations/ crackles, differential breath
sounds): Asthma, bronchitis, pneumonia
16. Cardiac abnormalities (including murmurs): Any cardiac illness

CLINICAL CLUES ABOUT COUGH

1. Staccato, paroxysmal: Pertussis, cystic fibrosis, foreign body, chlamydia
2. Followed by “whoop”: Pertussis
3. All day, never during sleep; Habit cough
4. Barking, brassy: Croup, habit cough, tracheomalacia, tracheitis, epiglottitis
5. Hoarseness: Laryngeal involvement (croup, recurrent laryngeal nerve
involvement),
6. Abrupt onset: Foreign body, pulmonary embolism
7. During or following exercise: Reactive airway disease
8. Accompanies eating, drinking: Aspiration, gastroesophageal reflux,
tracheoesophageal fistula
9. Throat clearing: Postnasal drip
10. Productive (sputum); Infection, cystic fibrosis, bronchiectasis
11. Night cough: Sinusitis, reactive airway disease, gastroesophageal reflux
12. Seasonal: Allergic rhinitis, reactive airway disease
13. Immunosuppressed patient: Bacterial pneumonia Mycobacterium
tuberculosis , Mycobacterium avium, intracellular , cytomegalovirus, fungi
14.Dyspnea: Hypoxia, hypercarbia
15. Animal exposure Chlamydia psittaci (birds), Q fever (sheep, cattle),
histoplasmosis (pigeons)
16. Geographic: Histoplasmosis (Mississippi), coccidioidomycosis
(Southwest), blastomycosis (North and Midwest)
17. Workdays with clearing on days off: Occupational exposure

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 CAUSES PERSISTENT OR RECURRENT COUGH
1. Recurrent respiratory infections
2. Following specific respiratory infections (e. g. pertussis, respiratory
syncytial virus
3. Asthma
4. Persistent lobar collapse following pneumonia
5. Suppurative lung diseases (e.g. cystic fibrosis, ciliary dyskinesia or immune
deficiency)
6. Recurrent aspiration
7. Inhaled foreign body
8. Cigarette smoking (active or passive)
9. Tuberculosis
10. Habit cough
11. Airway anomalies (e.g. trachea- bronchomalacia, tracheoesophageal fistula)

PNEUMONIA
- The incidence of pneumonia peaks in infancy and old age, but is relatively
high in childhood.
- It is a major cause of childhood mortality in low and middle-income
countries.
- It is caused by a variety of viruses and bacteria,
- Over 50% of cases no pathogen is identified.
- Viruses are the most common in younger children
- Bacteria are more common in older children.
- In clinical practice, it is difficult to distinguish between viral and bacterial
pneumonia.

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AETIOLOGY
A. Newborn: organisms from the mother’s genital tract as group B
streptococcus, Gram-negative enterococci and bacilli.
B. Infants and young children: respiratory viruses, RSV are most common,
bacterial infections include Streptococcus pneumonia or H. influenzae
Bordetella pertussis, chlamydia trachomatis
- Staphylococcus aureus is infrequent serious cause
C. Children over 5 years: Mycoplasma pneumoniae, Strep pneumoniae , and
Chlamydia pneumoniae .
CLINICAL FEATURES
- Fever, cough and rapid breathing are the most common presenting
symptoms.
- These are usually preceded by a URTI.
- Other symptoms include lethargy, poor feeding, and an ‘unwell’ child.
- Some children do not have a cough at presentation.
- Localized chest, abdominal, or neck pain is a feature of pleural irritation
and suggests bacterial infection.
EXAMINATION
- Examination reveals tachypnoea, nasal flaring and chest indrawing.
- The most sensitive clinical sign of pneumonia in children is increased
respiratory rate, and pneumonia can sometimes be missed if the respiratory
rate is not measured in a febrile child (so-called silent pneumonia).
- There may be end-inspiratory coarse crackles over the affected area
- Oxygen saturation may be decreased.

- N.B: the classic signs of consolidation with dullness on percussion,

decreased breath sounds and bronchial breathing over the affected area are
often absent in young children.
- N.B: Consider pneumonia in children with neck stiffness or acute
abdominal pain

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INVESTIGATION
- A chest X-ray may confirm the diagnosis but cannot reliably differentiate
between bacterial and viral pneumonia.
- In a small proportion of children, the pneumonia is associated with a pleural
effusion, where there may be blunting of the costophrenic angle on the CXR
- CBC and acute-phase reactants are generally unhelpful in differentiating
between a viral and bacterial cause.

A, Radiographic findings characteristic of

- respiratory syncytial virus pneumonia in a 6-mo. Old
infant with rapid respirations and fever.
- Anteroposterior radiograph of the chest shows
hyper expansion of the lungs with bilateral fine
air space disease and streaks of density, indicating
the presence of both pneumonia and atelectasis.
- ETT is in place.
B, One day later, the anteroposterior radiograph of
the chest shows increased bilateral pneumonia.
---------------------------------------------------------------------
- Radiographic findings characteristic of in a 14 yrs.
pneumococcal pneumonia old boy with cough and fever.
- Posteroanterior (A) and lateral (B) chest radiographs reveal consolidation in the
right lower lobe, strongly suggesting bacterial pneumonia.

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MANAGEMENT
1. Most affected children can be managed at home
2. indications for admission include
1. Oxygen saturation <92%
2. Recurrent apnea
3. Grunting
4. and/or an inability to maintain adequate fluid/ feed intake.
3. General supportive care should include oxygen for hypoxia and analgesia
if there is pain.
4. Intravenous fluids should be given if necessary, to correct dehydration and
maintain adequate hydration and sodium balance.
5. Physiotherapy has no proven role.
6. The choice of antibiotic is determined by the child’s age and the severity
of illness.
a) Newborns require broad spectrum IV AB
b) Most older infants can be managed with oral amoxicillin, with
broader spectrum antibiotics such as co-amoxiclav reserved for
complicated or unresponsive pneumonia.
c) For children over 5 years of age, either amoxicillin OR an oral
macrolide such as erythromycin is the treatment of choice.
7. There is no advantage in giving intravenous rather than oral treatment in
mild/moderate pneumonia
8. Small parapneumonic effusions occur in up to one third of children with
pneumonia and may resolve with appropriate antibiotics,
9. Persistent fever despite 48 hours of antibiotics suggests a pleural collection
which requires drainage
PROGNOSIS AND FOLLOW UP
A. Follow-up is not generally required for children with simple consolidation
on chest X-ray and who recover clinically.
B. Those with evidence of lobar collapse or atelectasis should have a repeat
chest X- ray after 4–6 weeks to check that the lung fields look normal.
C. Virtually all children with pneumonia, even those with empyema, make a
full recovery.

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 SLEEP DISODER BREATHING
- During REM (rapid eye movement) sleep, the control of breathing becomes
unstable and there is relaxation of voluntary muscles in the upper airway and
chest.
- This makes upper airway collapse more likely.
Sleep-disordered breathing occurs either due to
1. airway obstruction
2. central hypoventilation
3. a combination of these.
- Up to 12% of prepubertal school children snore, but true estimates of the
prevalence of obstructive sleep apnea resulting in gas- exchange abnormalities
range from 0.7–3%.
Key aspects of the history include:
a) Loud snoring c) Witnessed pauses in breathing (apneas)
b) Restlessness d) Disturbed sleep.
Obstructive sleep apnea leads to:
a) Excessive daytime sleepiness or hyperactivity
b) Learning and behavior problems
c) Faltering growth
d) In severe cases, pulmonary hypertension.

Predisposing causes of sleep-disordered breathing are:

1. Neuromuscular disease
2. Craniofacial abnormalities (e.g. Pierre Robin sequence)
3. Dystonia of upper airway muscles (e.g. cerebral palsy)
4. Severe obesity.
5. Children with Down syndrome as they have anatomical upper airway
restriction and hypotonia.
6. In childhood, adenotonsillar hypertrophy lead to upper airway obstruction
secondary to

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INVESTIGATION:
1. The most basic assessment is overnight pulse oximetry, which can be
performed in the child’s home.
- The frequency and severity of periods of desaturation can be quantified.
- Normal oximetry does not exclude the condition, but means that severe
physical consequences are unlikely.

2. Polysomnography is required in more complex cases to monitoring of heart

rate, respiratory effort, airflow, CO2 measurement

MANAGEMENT
1. In children with adenotonsillar hypertrophy, adenotonsillectomy usually
dramatically improves their condition.
2. For children with other sleep-related breathing disorders, nasal or face mask
continuous positive pressure (CPAP) or BiPAP (bilevel positive airway
pressure) to maintain their upper airway may be required at night.
3. Congenital central hypoventilation syndrome is a rare congenital condition
resulting in disordered central control of breathing as well as another autonomic
dysfunction.
4. In severe cases, life-threatening hypoventilation occurs during sleep, which
may result in death in infancy.
5. Long-term ventilation, either continuous or only during sleep is the mainstay
of treatment

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 PNEUMOTHORAX
- DEF.: Pneumothorax is the accumulation of extrapulmonary air within the
chest, most commonly from leakage of air from within the lung.
• Air leaks can be primary or secondary
• It can be spontaneous, traumatic, or iatrogenic
Causes of Pneumothorax in Children
A. SPONTANEOUS
1. Primary Idiopathic (no underlying lung disease)
- Spontaneous rupture of subpleural blebs
2. Secondary (underlying lung disease)
a. Congenital lung disease
- Congenital cystic adenomatoid malformation
- Pulmonary hypoplasia
b. Conditions associated with increased intrathoracic pressure
- Asthma - Cystic fibrosis - Bronchiolitis
- Airway foreign body
- Smoking (cigarettes, marijuana, cocaine)
c. Infection
- Tuberculosis -Pneumatocele
- Lung abscess -Bronchopleural fistula
d. Lung disease
- Pulmonary fibrosis -Rheumatoid arthritis

B. TRAUMATIC
1. Non-iatrogenic
- Penetrating trauma -Blunt trauma
2. Iatrogenic
- Thoracotomy, Thoracoscopy, thoracentesis
- Tracheostomy
- Tube or needle puncture
- Mechanical ventilation

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Clinical Manifestations
- The onset is usually abrupt
- Severity of symptoms depends on the extent of the lung collapse
- May cause dyspnoea, chest pain, and cyanosis.
- Moderate pneumothorax may cause little displacement of the intrathoracic
organs and few or no symptoms.
- The severity of pain usually does not directly reflect the extent of the collapse.

Examination
- There is respiratory distress with retractions, markedly decreased breath
sounds, and a tympanitic percussion over the involved side.
- The larynx, trachea, and heart may be shifted toward the unaffected side.
- When fluid is present, there is usually a sharply limited area of tympany above
a level of flatness to percussion.
- The presence of bronchial breath sounds or, gurgling sounds synchronous with
respirations suggests an open fistula connecting with air-containing tissues.

Treatment
a) Therapy varies with the extent of the collapse, nature and severity of the
underlying disease.
b) A small or even moderate-sized pneumothorax in normal child may resolve
spontaneously within 1 wk.
c) Administering 100% O2 may hasten resolution
d) Needle aspiration into the 2nd intercostal space in the midclavicular line
required on an emergency basis for tension pneumothorax
e) Tube thoracostomy for primary spontaneous pneumothorax.

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 PLEURAL EFFUSION
Aetiology
1. Serofibrinous pleurisy is defined as fibrinous exudate on the pleural surface
and an exudative effusion of serous fluid into the pleural cavity.
2. It is often preceded by the dry pleurisy
3. It is associated with infections of the lung or with inflammatory conditions
of the abdomen or mediastinum
4. It is occasionally found with connective tissue diseases such as lupus
erythematosus
5. It may be seen with primary or metastatic neoplasms of the lung, pleura, or
mediastinum.
- Tumors are commonly associated with a hemorrhagic pleurisy.

Clinical Manifestations
- Symptoms of dry pleurisy.
1. Pleural pain is described as a dull ache, which is less likely to vary with
breathing.
a) The pain is often localized over the chest wall and is referred to the
shoulder or the back.
b) Pain with breathing is responsible for grunting and guarding of
respirations, and the child often lies on the affected side in an attempt to
decrease respiratory excursions
c) Pain may disappear with fluid accumulation.
2. The patient may become asymptomatic if the effusion remains small, or
there may be only signs and symptoms of the underlying disease.
3. Large fluid collections can produce cough, dyspnea, retractions, tachypnea,
orthopnoea, or cyanosis.
4. In infants, physical signs are less definite, and bronchial breathing may be
heard instead of decreased breath sounds.

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Examination
a) There is a diminution in tactile fremitus, a shift of the mediastinum away
from the affected side, and, occasionally, fullness of the intercostal spaces.
b) Dullness to flatness on percussion.
c) Breath sounds are decreased or absent
d) If extensive pneumonia is present, crackles and rhonchi may also be audible.
e) Friction rubs are usually detected only during the early or late stage.
Diagnosis
a) CXR shows a generally homogeneous density obliterating the normal
markings of the underlying lung.
b) Small effusions may cause obliteration of only the costophrenic or
cardiophrenic angles or a widening of the interlobar septa.
b) Examinations should be performed with the patient both supine and upright,
to demonstrate a shift of the effusion with a change in position; the
decubitus position may be helpful.
c) Examination of the fluid is essential to differentiate exudates from
transudates
- Exudates usually have at least 1 of the following features:
1. Protein level >3.0 g/dL, with pleural fluid: serum protein ratio >0.5
2. Pleural fluid LDH values >200 IU/L or Fluid: serum LDH ratio >0.6.
3. pH < 7.20.
4. The finding of many small lymphocytes and a pH < 7.20 suggest
tuberculosis.

Treatment
1. If the effusion is less than 10 mm in size on a chest x-ray, then there is no
need for drainage.
2. With a large effusion, draining the fluid makes the patient more
comfortable.
3. When a diagnostic thoracentesis is performed, as much fluid as possible
should be removed for therapeutic purposes.
4. Rapid removal of ≥1 L of pleural fluid may be associated with the
development of reexpansion pulmonary edema

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 Pulmonary Oedema
DEF.: Pulmonary oedema is an abnormal fluid collection in the interstitium
and air spaces of the lung resulting in oxygen desaturation, decreased lung
compliance, and respiratory distress.
- The condition is common in the acutely ill child.
Aetiology
1. INCREASED PULMONARY CAPILLARY PRESSURE
- Cardiogenic, such as left ventricular failure
- Noncardiogenic, as in pulmonary venoocclusive disease, pulmonary
venous fibrosis, mediastinal tumours
2.INCREASED CAPILLARY PERMEABILITY
- Bacterial and viral pneumonia
- Acute respiratory distress syndrome
- Vasoactive substances such as histamine, leukotrienes, thromboxane
- Diffuse capillary leak syndrome, as in sepsis
- Immunologic reactions, such as transfusion reactions
- Smoke inhalation
- Aspiration pneumonia/pneumonitis
- Drowning and near drowning
- Radiation pneumonia
- Uremia
3.LYMPHATIC INSUFFICIENCY
- Congenital and acquired
4.DECREASED ONCOTIC PRESSURE
- Hypoalbuminemia, as in renal and hepatic diseases and malnutrition
5.INCREASED NEGATIVE INTERSTITIAL PRESSURE
- Upper airway obstructive lesions, such as croup and epiglottitis
- Reexpansion pulmonary edema
6.MIXED OR UNKNOWN CAUSES
- Neurogenic pulmonary edema
- High-altitude pulmonary edema
- Eclampsia
- Pancreatitis
- Pulmonary embolism
- Heroin (narcotic) pulmonary edema
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Clinical Manifestations
- The clinical features depend on the mechanism of oedema formation.
- The earliest clinical signs of pulmonary oedema include increased work
of breathing, tachypnoea, and dyspnoea.
- As fluid accumulates in the alveolar space, auscultation reveals fine
crackles and wheezing, especially in dependent lung fields.
- In cardiogenic pulmonary oedema, a gallop may be present, as well as
peripheral oedema and jugular venous distention.
CXR findings
1. Peribronchial and perivascular cuffing.
2. Diffuse streakiness reflects interlobular edema and distended pulmonary
lymphatics.
3. Diffuse, patchy densities, the so-called butterfly pattern, represent bilateral
interstitial or alveolar infiltrates and are a late sign.
4. Cardiomegaly is often seen with cardiogenic causes of pulmonary edema.
5. Heart size is usually normal in noncardiogenic pulmonary edema
Treatment
1. The treatment of a patient with non-cardiogenic pulmonary edema is largely
supportive, with the primary goal to ensure adequate ventilation and
oxygenation.
2. Additional therapy is directed toward the underlying cause.
3. Patients should receive supplemental oxygen
4. Patients with pulmonary oedema of cardiogenic causes should be managed
with diuretics, inotropic agents, and systemic vasodilators to reduce left
ventricular afterload
5. Diuretics are valuable in the treatment of pulmonary oedema associated with
total body fluid overload (sepsis, renal insufficiency).
6. Morphine as a vasodilator and a mild sedative.
7. Positive airway pressure improves gas exchange in patients with pulmonary
oedema by Non-invasive forms of ventilation or mechanical ventilation

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