THE UNIFIED AIRWAY A CPMC Regional CME Event

- An Integrated Approach

Saturday October 1, 2011

PEDIATRIC ENT: CHRONIC COUGH IN CHILDREN

Theresa Kim, MD

San Francisco Otolaryngology Medical Group

SCOPE OF THE PROBLEM

• Most common complaint for which patients seek medical attention

• Major contributor to parental stress- Adults with chronic cough

experience more depression and anxiety

SCOPE OF THE PROBLEM

Cough ever Persistent cough0%

5%

10%

15%

20%

25%

30%

5-7 year old (Aus-tralia)8-11 year old (Aus-tralia)8-11 year old (Nigeria)

Faniran 1999

SCOPE OF THE PROBLEM

<5 5-10 10-15 15-20 >20

0%5%

10%15%20%25%30%35%

Number of doctor visits in last 12 months

% of children

Marchant 2008

OUTLINE OF DISCUSSION

• Pathophysiology• Causes of chronic cough in children• Treatment• Diagnostic algorithm

PATHOPHYSIOLOGY

• Two types of cough- Laryngeal

(“cough reflex”)

- Tracheobronchial (can be volitional)

PATHOPHYSIOLOGY

• Three phases to cough- Inspiratory- Compressive- Expiratory

WHAT’S NORMAL?

• “Expected cough”- Presence of cough in situations where

cough is the norm• Healthy children cough 10-11

times/day• 35-40% of children still cough 10 days

after onset of a common cold• Children have acute URI 5-8 times/year

DEFINING COUGH

• Timeframe- Acute vs. chronic

• Etiology- Specific vs. nonspecific

• Quality of cough- Moist vs. dry, brassy, staccato

• Age of child

TIMEFRAME

Acute cough< 2 weeks

Subacute cough2-4 weeks

Chronic cough>4 weeks

(3-12 weeks)

ETIOLOGY

• Nonspecific- Defined as cough in the absence of signs

and symptoms of pulmonary or cardiac disease

• Specific- Anatomic abnormalities- Cardiac disease- Lung disease- Immune dysfunction

ETIOLOGY

Expected cough Nonspecific

cough

Specificcough

NONSPECIFIC COUGH

0% 10% 20% 30% 40% 50%43%

22%6%6%

4%1%

4%6%

1%2%

1%3%3%

1%Causes of chronic cough

Protracted bacterial bronchitisNatural resolution

BronchiectasisUncertain cause

AsthmaHabit cough

Eosinophilic disorderAspiration

B. pertussisM. pneumoniae

Endobronchial tuberculosisGER

Upper airway cough syndromeBronchiolitis obliterans

UACS 23%GERD 28%Asthma 13%Multiple etiologies 20%

PROTRACTED BACTERIAL BRONCHITIS

• Chronic wet cough• Positive BAL fluid culture• Resolution with antibiotics

• Often misdiagnosed as asthma• S. pneumoniae, H. influenzae, M.

catarrhalis

OTHER CAUSES OF CHRONIC COUGH

• Asthma- Cough with air flow obstruction- Uncommon cause of nonspecific cough in

children• GERD

- Reflux is the norm in infants- Association with cough is controversial

HABIT COUGH

• Also known as psychogenic cough• Harsh, dry, repetitive cough• Significant improvement with

distraction, absence when asleep

QUALITY OF COUGH

• Not useful in adult cough• Brassy cough

- 0.57 sensitivity, 0.81 specificity for tracheomalacia

• Spasmodic/paroxysmal• Wet/moist cough ( = “productive”)

- Most children do not expectorate sputum- 0.75 sensitivity, 0.79 specificity

AGE OF CHILD

• Congenital anatomic abnormalities• Aspiration more common in younger

children- Must ask parents about possible aspiration

events

4 YEAR OLD BOY WITH CHRONIC COUGH

3 YEAR OLD GIRL WITH CHRONIC COUGH

3 YEAR OLD GIRL WITH CHRONIC COUGH

3 YEAR OLD GIRL WITH CHRONIC COUGH

3 YEAR OLD GIRL WITH CHRONIC COUGH

TREATMENT OF CHRONIC COUGH

TREATMENT

• OTC cough medications- No benefit

• Asthma medications- No benefit for nonspecific cough

• Antihistamines- No benefit

• GERD medications- Inconclusive evidence

TREATMENT

• Antimicrobials- No effect in viral URI- Modest benefit in cough with nasal discharge

• Other remedies- Steam, vitamin C, zinc, Echinacea little benefit- Honey (0.5-2 teaspoons) helpful for reducing

nocturnal cough and improving sleep quality of parents and children

• Placebo- 85% response

DIAGNOSIS OF CHRONIC COUGH

• All children with chronic cough should have- Spirometry- CXR

ALGORITHM FOR CHRONIC COUGHSx/signs of respiratory disease?

CXR, spirometry abnormal?

Characteristic quality?

1. Watch, wait, review2. Evaluate

Tobacco smoke Environmental

exposures Child’s activity Parent concerns

3.Treat obvious illness

NON-SPECIFIC COUGH

No

No

No

EVALUATE FOR SPECIFIC COUGH

Review in 1-2 weeks

Resolving, resolved

Persistent

Trial of therapy

Watch, wait, review

Dry—ICS 4 weeks

Wet—Abx 10-21 days

Sx/signs suggestspecific cough

ALGORITHM FOR SPECIFIC COUGH

SPECIFIC COUGHReversible airway

obstruction orelevated eNO?

ASTHMAConfirm with 4 week

medication trial

Yes

No

BronchiectasisRecurrent pneumonia

Chronic infectionInterstitial lung disease

Airway abnormalityOther pulmonary disease

Cardiac disease

PEARLS

• Causes of chronic cough are different than adults- Chronic wet cough...protracted bacterial

bronchitis- GERD, asthma and UACS are less common

• Empiric treatment is not recommended• Always remember to think about

aspiration in children younger than 5 years

Thank you!