modul1.pdf

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Dr. H. I.Dr. H. I. BoedimanBoediman,, Sp.ASp.A(K)(K)

Born:Born: AmbarawaAmbarawa,, October 11,October 11, 19431943

ucation:ucation:

1.1. Faculty of medicine University of Indonesia, 1967Faculty of medicine University of Indonesia, 1967

.. ,,UniversitasUniversitas Indonesia, 1972Indonesia, 1972

3.3. PediatricPediatric PulmonoloPulmonolo Subs ecialt , Facult of MedicineSubs ecialt , Facult of MedicineUniversitasUniversitas Indonesia, 1987Indonesia, 1987

ecent pos t onecent pos t on :: ta mem er o v s on o esp ro ogyLecturer on Pediatric Pulmonology and

Faculty of Medicine University ofIndonesia


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oe manYAPNAS SUDDHAPRANA


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CoughCough: daily phenomenon, the most

common clinical s m tom

Cough & cold medication

the most cost expenses, compared

w ac e pa n rugs


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Cough

De ense mec anism o respiratory tractclears the airway from:

n a e ore gn ma er a s

Lar e amount of mucusAbnormal substances

.-

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


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CoughDifferent from other respiratory tract

reflex (sneeze, hiccu )

Not stereotype in pattern

,voluntarily

Widdicombe J. Cough. Blackwell publishing 2004; 17-23


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time: 2 weeks; 3 weeks; 8 weeks; 12 weeks

acute : 4 weeks or >8 weeks

IDAI: BKB chronic: >2 weeks AND/OR recurrent: 3 episodes in 3 months

n c ren, reso ve n s wee , n n Not a final diagnosis, leading to a group of


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atop ys o ogy

It has a reflex arc that consist of:

Afferent nerveCough control center

Efferent nerve

Respiratory muscles



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Cerebralcortexough model reflexough model reflexVoluntarycontrolofcough

Placeboeffect

Sensationof

Exogenousopioids

Coughcontrolcentre

irritation

Respiratoryarea

of

brainstem

Vagus nerve

Airwayirritation Respiratorymuscles

COUGHWiddicombe J. Cough. Blackwell publishing 2004; 20


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Cou h Reflex ArcReceptor Afferent Coughcenter Efferent Efector

branch

Muscle,

Larynx,trachea,and bronchusTrachea

VagalnerveBronchusEar

Distributedevenlyinmedullanearbytheres irator

Gastric center:Underthehighercontrolcenter

Nose Phrenicus nerve, Diaphragm;

Intercostal,Sinusparanasal

lumbaris bdominal&lumbalmuscles

Pharynx Glossopharyngeal

nerveTrigeminal,Facial,Hippoglosus nerve,etc

RespiratorytractmusclesMusclesinvolvein

Pericardium

diaphragm

Phrenicus nerve

ChangAB.Cough2005;7:115.


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Distributed under/in the epithelium ofrespiratory tract

Types of receptors:

ap a ap ng s re c

Proximal respiratory tract is moreen ve o mec an ca mu anDistal respiratory tract is more

c emo e veC-Fiber neurogenic inflammation



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Schematic diagram the potential roles C-Fibre & RAR

Brainstem EAASP/NKA

Generalanaesthesia

Central

sensitization

Respiratory

muscles

Cough

RARAcetylcholineCfiber

Centralreflex

Axonreflex

SP/NKA

BreathingObstruction

BronchospasmMucussecretionPlasmaleakage

Capsaicin

Widdicombe J.Cough.Blackwellpublishing2004;167

IrritationInflammation


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Stimuli to C-Fiber receptors & RARs RARsBronchial

Pulmonary

InflationInflationMechanical

DustMucusForeign bodies

Foreign bodies

rr an gasesCigarette smokeCapsaicin

Volatile anesthetics

em ca Irritant gasesCigarette smokeCapsaicin

ce y c o neHistamineSerotoninProstaglandins

s am neSerotoninProstaglandinsBradykinin

ce y c o neHistamineSerotoninProstaglandins

Substance PSubstance PAnaphylaxisMicroembolism

Diseases Pulmonary congestionMicroembolismPulmonar oedema

e ec as sBronchoconstriction

Pulmonary oedema

Pulmonary congestionPneumonia

WiddicombeJG,EurRespirJ1995;8:1193


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receptors always lead to cough?

The answer is NO!!

the stimulation



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CFibre a saicin Mucus

Role of Tachykinin in Cough

receptor Irritants,etc. MechanicalEpithelium

Tachykinins

MucosaPeptidasesTachykininantagonists

Antipeptidases

Inhibitcough

Excitecough

Cough

Widdicombe JG,Eur Respir J1995;8:1193


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Cough Pattern

Depends on the location of the stimulatedreceptor

In larynx expiration reflex

More distal stimulation ins irationphase as the beginning phase of thecou h


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SoundMechanism of Cough

50

O5.0

6.0 Airvolume

2030

cmH

2

L/s2.0

3.0

.

Subglotticpressure

Flow rates

0

10

0.0

1.0

3Positiveflow phase

Min flowphase

Negativeflow phase

inspiratoryphase

glottisclosure

Expiratory phase(explosive)

Figure 1. Diagrammatic representation of the changes of the following variables during

a representative cough: flow rate, volume, subglottic pressure, and sound level.McCoolFD.Chest2006;129:48S53S.


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Cou h is the most commonclinical manifestation

The most often etiology Infection of upper-respiratory tract and

a a a a o roce ecrea ethe cough threshold

inflammation mediator stimulate thelarynx

: coug as e resu o recep oractivation in distal esophagus

stimulate RAR McCoolFD.Chest2006;129:48S53S.


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the most common in children: ARI, acute cough

diagnostic challenge: chronic recurrent cough singletwo or more etiologies

nonsmoking adult: PND, asthma, GER

many classification, no consensus, differentc ass ca on ase

Children: many condition/diseases chronic

,cough receptors location


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Cou h Etiolo ies in ChildrenInfection

Allergy/inflammationasthma, post viral cough, rhinosinusitis, eosinophilic bronchitis

Airway clearance

Aspiration (CP, vocal cord palsy, bulbar lesion, GERD, fistula T-E)

- -

Lung poison

smoking, particulate matter, gaseous biomass combustion

Primary lung diseaseILD, PH, bronchiolitis obliterans

Non resp ratory

GER without aspiration, psychogenic, habitual


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Infants Under Five Adolescence

Tracheomalacia

Vascular ring

Post infectious Smoking

Infection:

Pertussis, RSV,

Tuberculosis

Pertussis

Post infectious

Infection,adenovirus

Asthma

OMC

GER

Tuberculosis

OMC

AspirationGER

Bronchiectasis BronchiectasisPsychogenic

mo ng umor


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Coug e ectiveness epen s on

The ability of generating high velocities of the airsteam

Dispersion of liquid mucus into the air

stream (misty flow)Increase the waves of mucus

The physical property of the mucus

McCoolFD.

Chest

2006;129:48S

53S.


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Cough Ineffectiveness

Altered cough mechanism Altered mucus rheology

McCoolFD.

Chest

2006;129:48S

53S.


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ACCP: child = adult

Knowledge of cough mechanism and receptorlocation! a causes identification >90%, treatment -

Pediatrician: different, child # small adult a G&D

process, disease pattern, disease symptom thats why: different etiology & management Child: congenital, aspiration, neurological


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No acce ted general consensus of diagnostic

approach of cough in children Classical medical approach:

history,

physical examination, suppor ng exam na on

most common etiology: ARI, self limiting, no need


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,

specific cough & non specific cough non s ecific cou h: isolated a arentl health

specific cough: significant underlying cause

Specific cough: presence of specific clues as sign ofunderlying disease

deJongste,Thorax,2003ChangAB,Cough,2003


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Differential Dia nosisGroup 1: healthy Group 2: sick Recrt acute bronchitis Chronic lung disease

Post infectious coughPertussis & Tussis like

Recurrent aspirationForeign bodies

Asthma

Post nasal drip

Bronchiectasis

Immune deficiency

Psychogenic Respiratory lesion

Tuberculosis

umor, c st, se uestration

Neurological lesion

deJongste,Thorax,2003


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neonate onset

neuromuscular problem ,

swallowing problem

recurrent pneumonia chronic dyspnea

chronic sputum production

thorax deformity clubbing finger

hemoptysis ChangAB,Cough,2003


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Onset age: neonate

Congenital malformations Swallowing problemchronic aspiration

Anatomic lesion along the respiratory tract (cyst,tracheomalacia

ucoc ary c earance mpa rmen

Neuromuscular problem (delayed development,,

Passive smoking


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Nutritional state Clubbin fin ers Sinusitis sign; cobblestone, PND, pain

Allergic signs:geographic tongue, allergics ners, enn e crease Tracheal deviation

. , . ,wheezing, hypersonor

Ear: serumen, foreign bodies


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Chest X ray

Tuberculin skin test

Spirometry, provocation test

oscopy

SPN X ray, CT scan

- Barium meal: swallowing problem, related to

feeding, stridor, wheezing

Ig G,A,M,E: recurrent otitis, bronchiectasis,productive, non responsive to AB

ronc osco y: congen a , ore gn o es


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espiratory a engea u er on n a e . - . o a r

everyday (restexercise)

humidity, the temperature, & the content)

up to 1010 particles/day alveolar region

mechanism to overcome such a huge challenge


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Physiologic or Pathologic?

Cough, part of respiratory defense mechanism in synergy with mucociliary clearance (MC)

normally, respiratory tract produce secretion up

to 30 ml (adult) entrapment o oreign materia , roug t y MC,swallowed


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Physiologic or Pathologic? Cough does not always mean abnormal or

clinically significant

ea y c no resp ra ory n ec on or o erdisease): cough 10 times/day (up to 34x) in 24

h considered: normal or expected

usuall not become a com lain not aware not a

problem


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ysio ogic or at o ogic?

stimulated

stimulates cough receptor, expels it out

inhaled food or other forei n material cou hout

Cough: prevent aspiration useful physiologic

mec an sm n a ea t y person


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ysio ogic or at o ogic?. .

infection larger & frequent secretion

in healthy children, ARI 6-8 times/year

mucociliary clearance


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ys o og c or a o og c

p ys o og c pa o og c

, ,characteristic,sputumcharacteristic

psychogenic,habitualcough


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van ages o oug medical as ect, cough is ver useful

very important respiratory defense mechanism very important in respiratory clearance,

especially when MC is disturbed by disease

important role of cough: neuromuscularsease, rac eo ronc oma ac a

without cough reflex: aspiration serious ,


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van ages o oug other function: ALARM

give us warning that something is wrong almost all respiratory disorder and some

nonrespiratory disorder: cough symptoms

one of the most important cause of cough inc ren:

Parents awarepathologic search medical

without cough symptoms: delayed diagnosis,advance disease


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sa van ages o ougmedical impact of cough is very vast the most chief complaint reasons:

s ur e ee ng worry that something wrong

Sleepless musculoskeletal aching

hoarseness urinary incontinence


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other medical impact of cough: effectivemode of infection transmission

Tuberculosis

Morbilli

Rubella respiratory infection:

Influenza

Pertussis


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impact of continuous cough could be annoyed

disturbed respiration

disturbed social activity

decrease quality of life

intrathoracal pressure: 300 mm Hg

~

energy: up to 25 jouleim act of ri orous cou h can cause com lications to

almost all organ systems


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Do We Have to Relieve Cough?

Cough respiratory defense mechanismInfection transmission facility

Etiolo of cou h? irritant infectionSevere cough serious complication


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The Using of Cough Drugs

Explanation for the patientsFind the etiology

OTC


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The Using of Cough Drugs

Antitussive

Expectorant

Mucol tic kinetic Surfactant preparation

Mucokinetic

Mucoregulator


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Side Effects

Too much drugs oo muc oses

Long-term


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Side Effects

Narcotic antitussive moist skin, confuse,, , .

Acetaminophen diarrhea, lose of appetite,

nausea, etc. Salicylic hearing disorder, seizure, diarrhea,

etc.


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