James L.

Alvin Sinaga
Outline
• Introduction • Diagnosis
• Definition • Treatment
• Classification • Complication
• Epidemiology • Prevention
• Pathophysiology • Take home
• Etiology message
Introduction
• Cough is the most common presenting
symptom to GP and most common referal
to Pediatrician & Respiratory physician.
• Cough in children causes Significant
anxiety to parent. And affect quality of
life.
Definition
Chronic cough:
• Adult: cough ≥ 8 weeks (ATS, BTS)
• Pediatric: cough ≥ 8 weeks (BTS)
≥ 4 weeks (ATS)

BMJ (2008)
Classification

1. Based on duration of cough

• Acute ≤ 2 weeks
• Acute prolonged cough 2-4 weeks
• Chronic > 4 weeks
2. On likelihood of an underlying disease or
process
• Expected cough
• Specific cough  pointers
• Non Specific cough
1.
2.

3. On cough quality:
• Barking or brassy
• Honking
• Paroxysmal
• Staccato
• Productive cough
• Chronic wet cough in the morning only

Chest 2006; 129: 260S-

283S.
Epidemiology
• Global prevalence 9,6% (±10%)
• Chronic cough significantly more
frequent in Europe and America than in
Asia and Africa.

• Cough more common in male than

female.

Erj.e rsjournals.com
 … epidemiology
• The prevalence
▫ 22% of preschool children w/o cold.
▫ 50% in children with two smoking parent.
▫ Higher in dump home, poluted area and
low sosio-economic status.
▫ Chronic cough is associated with high
morbidity and mortality.

Front. Physio/ 28 August 2014

http://doi.org/co.3389
Phys 2014.00332
 Pathophysiology
Anatomy of the cough reflex

http://www.dietoflife.com/cure-your-cough-or-inflammation-of-the-lungs-with-this-quick-trick/
 … pathophysiology
Human cough reglex

References: cough 7 (1) :10. November 2011

 … pathophysiology
Causes of Chronic Cough
 Etiology
• The three (triad) most common in adult
are: (GAP) GER, Asthma and PND are
relatively uncommon in children.

The most common cause of chronic

cough in children are:
• Asthma
• RTI
• GERD
Asilsay S, Boyram E, Agin H, Apa H can D2, Gulle S, Alhnoz S. Evaluation
of chronic cough in children. Chest 2008 Dec; 134 (6): 1122-1128
 … etiology
Chronic cough has 5 etiologies

1. Chronic cough in normal child

2. Chronic cough in a child with serious
underlying illness.
3. Upper airway cough syndrome (UACS)
4. Asthma syndrome
5. Psychogenic cough

Alvanic, Reifl G, Gupa A, Fifteen minute consultation: A structured

approach to the Management of Chronic cough in child. Arch Dis Child
Educ Practice Educ. 2018; 103(2): 65-70
 … etiology
Etiology of chronic cough in children
≤ 5 y/o CVA

UACS
• CVA (31,8%)
• UACS (37,6%) Post viral
cough
• Post viral cough (18,8%) GER
• GER (3,5%)
Allergic
• Allergic cough (2,4%) cough
• Unknown (5,9%) Unknown
 Common etiologies of chronic cough based
on child age
Young children (<5 years) Older children (>5 years)

• Infections • Asthma
• Gastroesophageal reflux • Infection
• Congenital malformation
• Post-nasal drip
• Asthma
• Protracted bacterial
• Protracted bacterial
bronchitis
bronchitis
• Passive smoking & • Passive smoking
environmental pollution • Bronchiectasis
• Foreign body inhalation • Psychogenic cough
https://www.sciencedirect.com/science/article/pii/S2352646715000344
 Etiology of Chronic Cough
Recurrent respiratory tract infection
Post viral infection
Protracted bacterial bronchitis
Gastroesophageal reflux
Laryngopharyngeal reflux
Asthma
Upper airway cough syndrome

Pediatric in N Am 60 (2013) 951-967

Diagnosis
• History taking
• Physical examination
• Chest X-Ray & Radiology imaging
• Pulmonary function test
▫ Spirometry
• Allergy testing
▫ SPT
▫ RAST
• Bronchoscope & BAL
History taking
Cough quality and etiology.
Cough quality Etiology
Barking or brassy Croup
Tracheomalacia
Honking Habit, psychogenic cough
Paroxystic Pertussis
Associated or not to whoop Parapertussis
Dry, staccato Chlamydia infection in infants
Productive Sinusitis
Protracted bacterial bronchitis
Bronchiectasis
Cough pointers and etiology.
Cough pointers Etiology
Wheeze Dyspnea on exertion Atopy Asthma
Hemoptysis Interstitial lung disease
Bronchiectasis
Chest deformity Chronic lung disease
Penetration syndrome Foreign body inhalation
Symptom worsening after feeding or when
lying down GORD
Pulmonary aspiration
Auscultatory findings Chronic lung disease
Digital clubbing Systemic immunodeficiency
Failure to thrive Cardiac disease
Medical history of prematurity and neonatal
respiratory intensive care Bronchopulmonary dysplasia
Symptoms present from the first day of life Congenital abnormalities
Indicators of the presence of specific cough.
• Coughing initiates suddenly with a choking episode
• Coughing is progressive
• Shortness of breath – chronic or exertional
• Failure to thrive
• Hypoxemia
• Constitutional symptoms
• Clubbing
• Hemoptysis
• Chest wall abnormality
• Noisy breathing and/or abnormal lung auscultation
• Coughing with a background history of recurrent pneumonia
• Cough initiates in neonatal period
• Swallowing difficulties
• Craniofacial abnormality
• Neuromuscular disorder
• Wet cough lasting more than 3–4 weeks
https://www.sciencedirect.com/science/article/pii/S2352646715000344
Physical examination
• General feature: Fever, clubbing, Ht/Wt, FTT
• HEENT
▫ Allergic shiner
▫ LAD (lymph a denepathy)
• Thorax/Lung
▫ Chest deformity
▫ Wheezing
▫ Ronchi, stridor
▫ Cough observation
• Abdomen
• Extremity
• Skin  Atopic dermatitis (eczema)
Chest X-Ray & Radiology imaging
Pulmonary function test
•Can help to derivate obstructive vs restrictive
•Required in diagnosis of Asthma child must be
≥ 6 y/o and cooperative
Allergy testing
Bronchoscope & BAL
Use full if suspicion for
foreign body is high
UACS / Upper airway cough syndrome
Diagnosis:
• Feeling of drainage in the
posterior pharynx
• Frequent throat cleaning
• Nasal discharge
• Cobblestone appearance of the
oropharyngeal mucosa
• Mucopren Eleat secretions in the
oropharynx

Platter / R. Chest 2006 Jan; 129 (isuppl;635-725)

 CVA / Cough Variant Asthma
• The only symptom is chronic dry cough at
night, no wheezing.
• Diagnosis: PFT  Spirometry
Bronchoprovocation test by methacholine
and histamine.
• Therapy: inhaled c0nticosteroid

http://wallsviews.co/asthma-dry-cough-chest-pain/
Asthma
Diagnosis:
• History of respiratory symptom such as
wheeze, shortness of breath chest
tightness & cough that very over time.
• Variable expiratory airflow
Therapy:
• Bronchodilator
• ICS
• LRTA
Post Infectious cough
Common pathogen
• Viral RSV, Parainfluenza Virus
• M-pneumoniae, C-pneumoniae,
B-pertussis
Result of airway inflammation
CXR: (N)
Therapy : Macrolide for Bacterial
ICS
Inhaled Ipratropium
Cough suppressant ≥ 4 y/o
GER / Gastroesophageal Reflux
• The respiratory manifestation: cough,
wheezing, sore throat, hoarseness, throat
clearing, choking and throat irritation.
• Therapy : PPI
▫ H2 blocker
▫ Laparoscopic fundoplication
▫ Life style and Diet therapy
Cough and Allergic diseases
Allergic cough has certain characteristics
that are common to all allergic diseases
such as
 Presence of a family history of allergy
 History of past and/or concomitant
allergic conditions (such as
urticaria, eczema)
 Sensitivity to allergens that can be
elicited by skin testing
 Therapeutic response to epinephrine
 Periodic nature of the allergic condition.

Indian Journal of Clinical Practice, Vol. 24, No. 11, April 2014
Treatment
Allergic Rhinitis
• Nasal Corticosteroid
• Antihistamine
• Nasal Decongestant
• Ipratropium Nasal Spray

Non allergic Rhinitis

• Rhinitis treatment
• In general
• Varies according to symptom
 …treatment
Sinusitis
• Antibiotic

Asthma:
• Bronchodilator
• Corticosteroid
• Antihistamine

Cough Variant Asthma

• LTRA
• ICS
• Bronchodilator
 …treatment
Pertusis  AB (Macrolide)
• Erythromycin
• Clarithromycin
• Azithromycin

GERD:
• PPI
• Diet therapy
• Life style

Bronchiolitis
• Low dose macrolide
 …treatment
Chronic bronchitis
• Mucus active agent
• Inhaled SABA/LABA
• Theophylline
• Codein (in adult)

NAEB: Non Asthmatic Eosinophilic

Bronchitis
• Low dose bronchodilator
Algorithm management of chronic cough

Pediatrics, May 2013, volume 131 / issue 5

Red flags

The following features indicate a

positive serious cause of cough

History
• FHx of lung disease
• Neonatal onset
• Sudden onset
• Haemoptysis
• Cough with feeding, dysphasia, severe
Vomiting
• Chronic moist cough with sputum
• Night sweat / Weight loss
• Continues unremitting or worsening cough

Sign:
• Sign of CLD
• FTT
• Abnormal Voice
• Focal chest abnormality

Recommendations for the assessment and management of

cough in children. BMJ (2008), Chest 2008 Aug 134(2): 303-9
 Referral
When to consider referral for sub-specialist advice?
General practitioners should consider referring a child to
a pediatric pulmonologist for further evaluation in the
following situations:
• Chronic wet cough unresponsive to antimicrobial
therapy.
• Specific-cough indicating an underlying disease (e.g.,
cystic fibrosis or primary ciliary dyskinesia).
• Uncertain diagnosis of chronic non-specific cough.
• Partially resolved, prolonged (>3 months) or recurrent
protracted bronchitis (>2 times/year).
• Suspicion of foreign body inhalation.
• Suspicion of congenital/developmental defect.
• Chronic cough associated with persistent hypoxemia.
 Complication

• Bronchospasm
• Rib fracture
• Air leak
(pneumomediastinum)
or pneumothorax
• Syncope
• Vomiting  FTT
Prevention

• Unpreventable:
▫ Genetic
• Preventable:
▫ Environment
 Allergen
 Pollutant
 Take home message
• Chronic cough in children is different from adult.
• The Etiology of cough is different in each country,
region and continental.
• Pathophysiology must be understood to understand
the occurrence of chronic cough
• The Treatment based on etiology.
• Bronchodilator , ICS, anti histamine are drug that
are often used in the treatment of chronic cough.
• In cased of referral Patient, Chest X-Ray, Sinus CT-
Scan, Allergy Test & Bronchoscope are required to
confirm diagnosis.
• Good treatment can avoid complication.
• Avoidance of environmental factor can prevent
chronic coughing.
•

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