APPROACH TO CHRONIC COUGH

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APPROACH TO CHRONIC COUGH

• DR. HABIB KHAN
• Asst. Professor, Dept. of Pediatrics
• FR. MULLER MEDICAL COLLEGE
• MANGALORE

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• Definitions
• Cough is a protective reflex aimed at
  maintaining a clear airway
• Chronic cough is defined as cough of more than
  four weeks duration

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Receptor
Effector
Nerve
Nerve
Nose and sinuses
Trigeminal
Expiratory muscles
Posterior pharynx
Phrenic
Spinal motor
Pericardium Diaphragm
Medullary cough center
Diaphragm
Phrenic
Trachea Bronchi Esophagus Pleura Ear canals Ear
drums Stomach
Glosso Pharyngeal
Larynx Trachea Bronchi
Vagus
Vagus
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CAUSES

• Aspiration syndromes
• Birth defects
• Compressive / Cardiac
• Defects of mucous clearance
• Environmental lung disease
• Foreign bodies / Functional
• Granulomatous diseases
• Hyper reactive airways
• Infections / Infiltrations

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Aspiration syndromes

• Common
• G E Reflux
• Cleft palate
• Mental retardation
• Epilepsy

• Rare
• H-shaped T E F
• Strictures
• Palato pharyngeal incontinence
• Neuromuscular incoordination

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Birth defects

• Less Common
• Congenital Lobar Emphysema
• Cystic Adenomatoid Malformation
• Sequestration

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Compressive / Cardiac

• Common
• Nodes
• L-R shunts
• Left sided failure
• Rare
• Tumors
• Cysts
• Aberrant vessels

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Defects of mucous clearance

• Cystic fibrosis
• Ciliary dyskinesias
• ( RARE
  )

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Environmental lung disease

• Extrinsic allergic alveolitis
• Eosinophilia (PIE )

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Foreign bodies/Functional

• Foreign body inhalation
• Functional / Habit cough

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Granulomatous diseases

• Sarcoidosis
• Wegeners
• ( Rare )

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Hyper reactive airways

• Asthma
• WALRI
• Post - nasal drip

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Infections/Infiltrations

• Chronic
• Mycobacteria
• Mycoplasma
• Chlamydia
• Pertussis

• Hemosiderosis
• Histiocytosis

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COMMON CAUSES

• Infant Aspiration, birth defects, cardiac
  defects
• Toddler Hyper-reactive airways, infection,
  foreign body
• Schooler / Adolescent Hyper-reactive airways,
  infections, functional

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RED FLAGS
EVALUATION

• Respiratory distress
• Known foreign body
• Cardiac failure
• Infant

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RED FLAGS

• Complications of severe cough
• Cough syncope
• Air-leak syndrome
• pneumothorax
• pneumomediastinum
• subcutaneous emphysema
• superior vena - caval syndrome

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EVALUATION

• Ask
• Duration
• Age at onset
• Periodicity
• Nature
• Aggravated by
• Relieved by
• Associations

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DURATION

• As a general rule, cough less than 2-3 weeks is
  referred to as short duration cough
• cough lasting greater than 4 weeks is designated
  as chronic cough.

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PERIODICITY

• Recurrent cough is characterized by period of
  normalcy between episodes and thus indicates a
  dynamic pathology e.g. asthma
• Persistent symptoms usually indicate a fixed
  pathology e.g. foreign body, pressing nodes or
  tumors

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NATURE OF COUGH

• Infants and young children usually do not
  expectorate
• In older children, presence of copious purulent
  sputum suggests suppurative lung disease

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NATURE OF COUGH

• Hemoptysis is rare in children and when present
  should raise the suspicion of Bronchiectasis or
  hemosiderosis
• Tuberculosis is not a common cause of Hemoptysis
  in the pediatric population

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AGGRAVATING FACTORS

• Feeds - aspiration
• Time of the day - hyper-reactive airways
  (nocturnal)
• Posture - aspiration, post-nasal drip
• Triggers - hyper-reactive airways
• Exercise - hyper-reactive airways

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RELIEVING FACTORS

• Relieved by
• Sleep functional
• Bronchodilators hyper-reactive
• airway
  disease

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ASSOCIATED FEATURES

• Allergic diathesis and markers (Hyper-reactive
  airways)
• Choking (aspiration)
• Snoring/mouth breathing (adenoids)
• Multiple multifocal infections (immunodeficiencies
  )
• Consanguinity (Autosomal recessive disorders)
• Drugs (ACE inhibitors)

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LOOK

• Quality
• Respiratory distress
• Failure to thrive
• Malabsorption
• Clubbing
• Murmurs
• Neuromuscular/anatomic defects
• Pressure effects (hernia / prolapse)

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QUALITY

• Whoop Pertussis, adenovirus
• Honking laryngeal pathology
• Dry barking / Brassy pharyngeal pathology, habit
• Feeble neuro -muscular disease
• Moist rattly / Productive suppurative lung
  disease

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2. RESPIRATORY DISTRESS

• Stridor/grunt/wheeze localizes anatomical level
• Stridor suggests upper airway obstruction
• If the voice is hoarse it signifies a glottic or
  supra-glottic problem
• A grunt indicates alveolar disease and wheeze is
  typical of airway disease

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• 3. Failure to thrive -Severe asthma,
  suppurative disease
• 4. Malabsorption / malnutrition -chronic
  disorders, cystic fibrosis
• 5. Clubbing - suppurative disorders

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• 6. Murmurs - cardiac lesions
• 7. Neuro muscular / anatomical defects -
  aspiration
• 8. Pressure effects-hernia, prolapse -
  consequence of violent or chronic cough

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PERFORM

• X-ray chest

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RADIOLOGICAL EVALUATION OF CHRONIC COUGH
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NORMAL / SEEMINGLY NORMAL X-RAY

• Asthma
• Post-nasal drip
• Aspiration
• Vascular compression
• Habit
• Foreign body
• Drugs

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PERSISTENT PATCH AT THE SAME SPOT

• T B
• Congenital anomaly
• Foreign body

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MULTIFOCAL LESIONS OVER TIME

• Aspirations
• Asthma
• Mucociliary / immune defects
• Cardiac disorders

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DIFFUSE INTERSTITIAL LACY PATTERN

• Infections
• Interstitial lung disease

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FOCAL OR MASS LESION

• Nodes
• Tumors
• Cysts

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PRACTICAL APPROACH TO CHRONIC COUGH

• Snoring/ Mouth Breathing
• Persistent Spasmodic
• Recurrent, nocturnal, Seasonal, related to
  feeding
• Infants
• Murmurs
  
• Multiple multifocal Infections

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• Snoring / Mouth Breathing
• X-ray Paranasal Sinuses and lateral Neck
• Antibiotics
• Consider Surgery

Sinusitis Adenoids
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• Persistent Spasmodic
• CBC / Chest X-ray
• No response
• Bronchoscopy

Endo-bronchial TB Pertussis Foreign body
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• Recurrent, nocturnal, Seasonal,
• related to feeding
• Spirometry / Barium studies
• Bronchodilator/ appropriate Management
• No response / surgical causes

Asthma Aspiration syndromes Eosinophilia
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• Infants
• X-ray chest
• Ba. Swallow / HRCT
• Angiography
• Appropriate medical / surgical management

Aspiration syndromes Congenital Anomalies
Sequestrations
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• Murmurs
• X-ray Chest / 2D-ECHO
• Anti failure Therapy/ Surgical Management

Congenital Heart Disease
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• Multiple multifocal Infections/F.T.T./
• Malabsorption /Clubbing
• X-ray chest / HRCT
• CF / immuno - deficiency work Up
• Medical / surgical Management
• Genetic counseling

Suppurative lung disease
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CASE - 1

• Anxious Parents bring a school going child to
  you
• He had a respiratory infection a few weeks ago
• Of late his cough has worsened
• He is not without a honking cough for a single
  minute

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CASE - 1

• His cough disrupts your conversation but when
  asked to open his mouth or breath deep his cough
  lessens
• Uniquely there is no cough when he is asleep and
  it is much lesser when distracted (e.g. when
  reading a book or watching T V )

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• Step 1 - Evaluation and treatment
• Step 2 - Treat PND, antihistamine/decongestant
• Step 3 - Treatment for asthma, bronchodilators
  for 2 weeks
• Step 4 -Treatment of GER for 2 weeks
• Step 5 - Chest X-Ray, Mantoux, sinus CT,
  pulmonary function test, Ba. swallow
• Step 6 - Refer to pulmonologist

American Academy of Allergy, Asthma and Immunology
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In conclusion

• Suspect congenital lung conditions in infants
  with chronic cough
• Asthma / Cough-variant asthma are the most common
  cause of chronic cough in children followed by
  postnasal drip and GERD
• The best way to approach cough is, find the cause
  and treat it!

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THANK YOU