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Dr. GH - Khanbabaee
Pediatric Pulmonologist
MOFID Children’s Hospital
SBMU
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Cough in children
Common symptom
Most caused by self-limited RTI
Not an illness by itself, but a cardinal indicator
Defensives mechanisms of Lung
Specialized epithelial barriers
Immune responses
Neural reflex responses : cough reflex
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What makes a child cough
StimuliMechanical
Touch, pressure,
Deformation
Chemical
Smoke, mediators
Cough receptorsPharynx, larynx,
Ttrachea, main bronchus
Nose, Paranasal sinus
External ear, Pericardium
Pleura, Diaphragm
Afferent fibersVagal,Trigeminal,
Glossopharyngeal
Cough centerUpper brainstem, Pons
Efferent fibersVagal, Phrenic,
Spinal motors nerves
MusclesLaryngeal, Diaphragmatic,
Thoracic,Abdominal
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Nose and sinuses
Posterior pharynx
Pericardium
Diaphragm
Trachea
Bronchi
Esophagus
Pleura
Ear canals
Ear drums
Stomach
Expiratory muscles
Diaphragm
Larynx
Trachea
Bronchi
Medullary cough
center
Receptor Effector
Nerve Nerve
Trigeminal
Glosso Pharyngeal
Spinal motorPhrenic
Phrenic
Vagus
Vagus
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Deep breath
1/5-2 TV
Glottic closure
Contraction
muscles
Relaxation
muscles
Glottic opening
Explosive
exhalation
Inspiratory
Compressive
Expressive
Relaxation
Phases
1
2 4
3
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Cough related to acute URTI resolves within 1 to 3 w
10% > 25 days
Hay AD, Wilson AD. The natural history of acute cough in children aged 0 to 4 years in primary
care: a systematic review. Br J Gen Pract 2002; 52:401–409
DEFINITION
Cough lasting for > 4 ws
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Specific
cough
Normal or
expected
cough
Non-
specific
cough
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Normal or
expected
cough
Specific
cough
Non-
specific
cough
Rubin BK. Evaluation of the child with recurrent chest infections. Pediatr Infect Dis 1985
Normal but unlucky child
6-10 URT infections/ yrs : common
Growth, development : N
CxR, ph exam between episodes : N
No family history of severe infections
No serious extrapulmomary infections
Reassurance parents
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Specific
cough
Normal or
expected
cough
Non-
specific
cough
Presence of specific pointers
Symptoms and signs of an underlying
respiratory or systemic disease
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Non-
Specific
cough
Specific
cough
Normal or
expected
cough
Absence of identifiable
respiratory disease or
known aetiology
Most :
No serious aetiology
Post viral cough
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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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RED FLAGS
Respiratory distress
Known foreign body
Cardiac failure
Infant
EVALUATION
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Complications of severe cough
Cough syncope
Air-leak syndrome
pneumothorax
pneumomediastinum
subcutaneous emphysema
superior vena - caval syndrome
RED FLAGS
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EVALUATION OF PATIENTS
Personal history : Neonatal problem,feeding H, allergy H, previous
infection or illness, vaccination,Growth, development, appetite, activity
Family history : atopy, CF, ID
Quality : nonproductive (dry) , productive (wet)
Timing : supine position, nocturnal, upon awakening
Trigger factors : Exercise, temperature changes seasonal variation
Previous therapy
Environmental factors : Smoke, pets
Physical examination
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Infancy Early childhood Late childhood
GER
Infection
Congenital malformation
Passive smoking
Environmental pollusion
Asthma
Post viral AHR
Asthma
Passive smoking
GER
Foreign body
Bronchiectasis
Asthma
PND
Smoking
TB
Bronchiectasis
Psychogenic cough
EVALUATION OF PATIENTS
Age of onset : specific causes may uniquely affect certain age ranges
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Cough specific pointersSigns, symptoms of underlying Dz
Auscultatory findings : wheeze, crepitation
Cardiac abnormalities : AW abnormalities, cardiac failure
Dyspnea or tachypnea : AW or parenchymal Dz
Chest wall deformity : AW or parenchymal Dz
Digital clubbing : suppurative lung Dz
Neurodevelopmental abnormalities : aspiration lung Dz
FTT : cystic fibrosis
Hypoxia/cyanosis : AW or parenchymal Dz, cardiac Dz
Recurrent pneumonia : immunodeficiency, suppurative lung Dz,congenital lung abnormalities
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Cough specific pointersSigns, symptoms of underlying Dz
Cough caracteristics
Barking or brassy cough : croup, tracheomalacia ®
Cough productive casts : plastic bronchitis
Paroxysmal (with or without whoop) : pertussis, parapertussis
Staccato : chlamydia in infants
Honking : psychogenic
®1
®2
®3
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1. 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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PRACTICAL APPROACH TO
CHRONIC COUGH1. Snoring/ Mouth Breathing
2. Persistent Spasmodic
3. Recurrent, nocturnal, Seasonal, related to
feeding
4. Infants
5. Murmurs
6. 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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Cough > 4 ws
History - Examination
Presence of specific pointers
CxR Specific
cough
PFTs
Non-
specific
cough
NR
R
N AN
Asthma
TTT
??
No Yes
N AN
No resolved
Asthma!
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Watch, Wait and review
Review in 1-2 ws ®
Usually postinfectious cough ®.
GER ®
Missed Foreign body inhalation
Nonasthmatic eosinophilic bronchitis
Medication : ACE, IS, ICS
Environmental irritant : smoke, Air pollution(O3, SO2, NO2, V exhaust)
Non specific cough
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Watch, Wait and review
Review in 1-2 ws
Resolved
Specific
pointers?
No resolved
Trial of therapy
Non specific
cough
Discharge
Specific
cough
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Dry cough Wet cough
IICS 400 mic g/d
budesonide
Review in 2-3 ws
Resolving ?
Asthma
®Period effect
No
ATB 10 days
Review in 2-3 ws
Resolving ?
Protracted
Bronchitis
®
No
Trial of
therapy
yesyes
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CBC, ESR, Sweat test, Immune work up
Sinus radiography
CxR (inspi, expi)
CT chest with mediastinal window
Ba swallow, PH monitor
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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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Treatment
Should be based on aetiology
AAP recommends against the use of medication
containing codeine or dextromethorphan
Antihistamines, Antihistamines+degongestant : no
benefit over placebo
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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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CONCLUSION
Very common in children
Careful history +physical examination+ appropriate investigation
enable the correct diagnoses
In majority : reflective of expected childhood respiratory infection
In minority : representative of serious disorder
Should be treated based on aetiology
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THANK YOU
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