World Allergy Organization Cancun, Mexico 2011
Pediatric Cough
Pramod Kelkar, MDPast Chair, Cough Committee, American
Academy of Allergy, Asthma & ImmunologyFounder, National Cough Clinic
Private Practice:www.allergy-care.netwww.nationalcoughclinic.comMinneapolis, MN, USA
Disclosures
• None
ChrCough is a Multi-Disciplinary Symptom
Pediatrician
Allergy/Immunology
Pulmonary
Otolaryngology
Gastroenterology
Speech therapy
Behavior counseling
Psychiatrist
Etiology of Pediatric Chronic Cough
Cough in Children• Important protective defensive mechanism, necessary
for effective airway clearance
AND• Common symptom of respiratory disease• Most common symptom for visit to MD office in US
(3.4%)• Parental reporting of cough correlates poorly w/ objective
measures (frequency, duration, intensity) Chang , Arch Dis Child 2003
• Cough known to cause anxiety and depression in parents
Chang , Arch Dis Child 2003; Marchant, Chest 2008
History• Triggers: Talking, laughter, walking, running,
strong smells, perfumes• Timing: Daytime Vs nighttime• Relationship with meals• Preceding Events:
Viral URI, Recent Immigration from a developing country, foreign travel
• Cough triggered by swallowing: aspiration, tracheoesophageal fistula, laryngeal abnormalities
• Review of systems is very important
Analysis of cough sound
• Barking or brassy cough: Croup, tracheomalacia, habit cough
• Honking: Psychogenic• Paroxysmal with or without whoop:
pertussis and parapertussis• Staccato: Chlamydia in infants
Physical Examination
• Thick, yellow postnasal drip visible in oropharynx: think chronic sinusitis
• Look into ears to rule out wax impaction and other causes (Arnold’s Nerve)
• Look at nails for clubbing (CF, etc.)• Check for thyroid masses• Look for signs of atopy
Cough Reflex Sensitivity
• Can be modulated by disease or drugs• Heightened CRS can occur in post-viral
cough, asthma, GERD, ACE-inhibitor therapy
• CRS more common in women
Cough Receptor Hypersensitivity Syndrome is an important concept!
Good resource: www.coughjournal.com
Normal Cough
• Normal Children Cough• Healthy school-age children can have up to
34 cough episodes per day• Can at times appear prolonged or nocturnal• Recurrent viral URI may seem like persistent
cough• Post-infectious cough can last 10 days or
longer after a viral infection
Abnormal Cough
• Chronic cough- lasts > 4 to 8 weeks• Character/Quality of cough- spasmodic
(pertussis), barking/brassy (croup)• Wet or dry• Nocturnal- asthma, sinusitis• Age of the child- infants and young children
have anatomic abnormalities of respiratory and GI tract
Classification Of Cough in Children
Chang, Cough 2005
Abnormal chest exam/ XR
Dyspnea
Hemoptysis
Recurrent pneumonia
FTT
Swallowing problems
Dry
nl CXR
Wet > Dry
10-11 cough episodes/day
(range up to 34)
Specific Cough
• Associated with underlying respiratory or systemic disease
• Obvious symptoms or signs/physical examination, abnormal CXR, abnormal laboratory results
• Example- Bronchiectasis, Pertussis
Nonspecific cough
• Isolated cough as the sole symptom• Usually dry• In adults- UACS, Asthma, Eosinophilic
bronchitis, GERD• In children- UACS, Asthma and GERD
account for <10% of causes• Most common cause in children- Protracted
Bacterial Bronchitis
Protracted Bacterial Bronchitis
• Most common ( up to 40%) cause of nonspecific chronic wet cough in children
• Resolves with antibiotic therapy• Misdiagnosed or underdiagnosed• Bronchoscopy shows neutrophilic
inflammation• S. pneumoniae, H. influenzae, M. catarrhalis• Amoxicillin and clavulanate for two weeks
Donnelly D, et al. Thorax 2007;62:80-4
GERD
• Far less common in children than adults• Aspiration with swallowing in the absence of
GERD may cause cough• Silent reflux often associated with asthma• A positive response to empiric therapy with
thickened feedings in infants and an acid-suppressive regimen suggests GERD
• Nonacid reflux detected by impedance measurement
Habit Cough Syndrome
• Dry, barking or honking• Absent at night, improves with distraction• Sounds very annoying but the child is
unperturbed (la belle indifference)• Very disturbing to parents, teachers,
caregivers• May start after a viral infection• Can be difficult to differentiate from a tic
disorder/Tourette’s syndrome
Treatment of Habit Cough
• Accurate diagnosis is important to avoid unnecessary exhaustive work-up
• Self hypnosis• Biofeedback• Breathing exercises/Speech therapy• Suggestion therapy• Lidocaine via nebulization
Upper Airway Cough Syndrome
• Old terminology was postnasal drip syndrome• Includes allergic and nonallergic rhinitis,
sinusitis, tonsillar hypertrophy causing tissue impingement on the epiglottis
• Limited CT sinus is helpful for sinusitis• Treat the cause• Older/first-generation antihistamines like
brompheniramine can be helpful
Asthma
• Accurate diagnosis is critical• Cough-variant asthma- over-diagnosed
or under-diagnosed?• A time-limited (4-6 weeks) empiric trial
of ICS +/- leukotriene modifiers• By itself, a response to ICS does not
confirm a diagnosis of asthma• Presence of multiple causes may delay
the response
Interesting Facts
• While children with asthma can present with chronic cough, most children with isolated cough do not have asthma
• Environmental Tobacco Smoke (ETS) exposure is associated with increased coughing illnesses and an imprtant contributing factor, ETS alone is not the sole etiology
Methacholine Challenge testIn a setting of adult chronic cough
patients:
• Positive predictive value:60-88%• Negative predictive value:100%
Chest 1999;116(2):279-84
Natural history of cough-variant asthma
• Not entirely clear due to lack of sufficient data
• In one 4-year retrospective study of 42 patients, 7 went into remission, and 13 developed classical asthma
Matsumoto H, et al. J Asthma. 2006;43(2): 131-5
Recurrent Cough• What is the likelihood of asthma in a
child presenting with recurrent cough• In a child with asthma, is cough severity
a reflection of asthma severity• Recurrent cough in the absence of
wheeze is generally not from asthma• Children with recurrent cough have an
increased cough receptor sensitivity to capsaicin
Treatment of recurrent cough
• Usually self-limiting• A short therapeutic trial with asthma
meds can be considered (4 weeks)• If a child doesn’t respond, then avoid
escalating treatments but rather take a step back to reassess
• Is the child any worse without the treatment
Cough in an asthmatic child• Cough in an asthmatic child is often due
to increased cough receptor sensitivity• Cough severity may not reflect asthma
severity• Cough should not be used as the major
indicator for the level of asthma treatment especially in an acute episode
• Complete absence of cough may not be essential for asthma control. Avoid overtreatment
General Principles in Management
• Clinical history and physical exam are used to guide testing
• Recommendations are based primarily on expert opinion, due to lack of controlled pediatric studies
• No evidence supporting the use of medications for symptomatic relief of acute or chronic cough in children; some data suggests potentially harmful effects
Are we missing pertussis?
• 75 adults, cough for more than 14 days• Pertussis diagnosis based on culture and PT
or FHA titer• 21% of adults had evidence of B. pertussis
infection• Clinical features and routine lab tests were of
limited value in making the diagnosis
JAMA 1995;273:1044-1046
Pertussis: Laboratory Diagnosis
• Leukocytosis with absolute lymphocytosis• (Posterior) Nasopharyngeal swab and
aspirate• DFA testing: quick results but unreliable• PCR: results in 48 h, false positives possible• Culture of swab: takes 7 days for results• Negative culture does not rule it out!• Serology: IgG and IgA to fimbria, pertussis
toxin and filamentous hemagglutinin (not standardized)
• Blood cultures: not useful
Pertussis
When to suspect & Whom to treat? • Suspect and treat if a clear cut history of
exposure • Suspect and treat if cough and vomiting (?)• Erythromycin is the drug of choice; however,
unless administered early, it does not alter the course of the disease
NEJM 2000;343(23):1715-1721JAMA 1995;273:1044-1046
Foreign Body Aspiration
• Onset after an episode of choking, or sudden onset while eating or playing
• Toddler age range• Parents may have forgotten about
aspiration episode
Algorithm for evaluating chronic cough in children (modified from Chang 2006)
CXR, spirometry abnormal?
Sx and signs of respiratory disease?
Is cough characteristic?
NON-SPECIFIC COUGH
1. Watch, wait, review • Usually post-infectious2. Evaluate• Tobacco smoke• Environmental exposures• Child’s activity• Parent concerns, expectations3. Treat obvious illness
Yes
No
No
No
EVALUATE FOR SPECIFIC COUGH
Discuss options with parents
Review in 1-2 wk
Sx and signs suggestspecific cough
Resolving, resolved Persistent cough
Watch, wait, reviewTrial of therapy
Dry cough: ICS 4-8 wk
Wet cough: Antibiotic 10-21 d
Yes
SPECIFIC COUGH
Bronchiectasis or recurrent pneumonia
Aspiration
Chronic or less common infections
Interstitial lung disease
Airway abnormality
Other less common pulmonary conditions
Cardiac disease
Assess risk factors for:
Reversible airwayobstruction?
Yes
No
ASTHMA
Confirm with 4-8 wk trial of medication
Investigations as outlinedOr
Consider referral to allergy or pulmonary
specialist
Algorithm for evaluating chronic cough in children (modified from Chang 2006)
OTC Cough and Cold Medications in Children
• Ten percent of U.S. children were taking OTC CCM/week.
• Approved for adults, testing for efficacy and safety in children not adequate.
• Adverse events documented; rare deaths.• 2007 AAP position statement questioning efficacy
and safety <6 years.• 2008 FDA Public Health Advisory OTC CCM.• 2009 FDA recommended avoiding in <2 years.• 2010 Consumer Health Product Association avoid <4
years.• March 2011 FDA--removal of 500 unapproved Rx
cough, cold and allergy meds.
Can asthma be a possibility if a pre-and post-bronchodilator spirometryis completely normal?
(A)Yes(B) No
Methacholine Challenge test and allergy skin test correlative study in the diagnosis of
asthma
• N= 175• Allergy skin tests are simple, safe,
inexpensive and reliable and there was an excellent correlation between these two tests
• More studies needed to clarify this further
Graif Y, Yigla M, Tov N, et al Chest 2002 Sep;122(3):821-5
Chronic cough completelyRelieved by a course of Prednisone.
Is this diagnostic of asthma?
Chronic cough relieved by prednisone
Possibilities:
(1) Allergic rhinitis
(2) Asthma
(3) Eosinophilic bronchitis
(4) Others
Eosinophilic bronchitis
Asthma Eosinophilic bronchitis
• Sputum eosinophilia• Airway
hyperresponsiveness
• Treatment is inhaled or oral steroids
• Sputum eosinophilia• No airway
hyperresponsiveness
• Treatment is inhaled or oral steroids
• Natural history unclear
Am J Respir Crit Care Med 1999;160:406-410
Causes of cough: single or multiple?
• Multiple causes were found in more than 60% when a large number of diagnostic tests are performed (US experience)
• Multiple causes were found in <26% when investigations were tailored to presenting features (European experience)
Reasons for misdiagnosis of chronic cough
• Failure to consider common extrapulmonary causes
• Insufficient dose of medication or duration of therapy
GERD/Laryngopharyngeal Reflux
Ear, Nose, Throat J 2002;82 (9 Suppl 2): 10-13
Pseudosulcus vocalis
Posterior commissure hypertrophy
Vocal fold edema
Ventricular obliteration
Risks of proton-pump inhibitor therapy
• Community-acquired pneumonia• Calcium malabsorption and hip fractures • Vitamin B-12 malabsorption
(assess vitamin B-12 levels in patients on long-term PPI
• Community-acquired C diff. infection• Atrophic gastritis (PPI+ H. pylori)Dose and duration- dependent!
Bradford GS, Taylor CT. Omeprazole and vitamin B-12 deficiency. Ann Pharmacother 1999, 33: 641-643
Yang YX, et al. Long-term PPI therapy and risk of hip fracture JAMA. 2006 Dec 27;296(24):2947-53
What is the clinical utility of flexible bronchoscopy
• Adds little to the diagnosis of chronic cough in the context of normal CXR or CT
• Useful to detect and assess endobronchial lesions (tumors, foreign bodies): very rare
• Always get a Chest CT before bronchoscopy
• If you are checking a Chest CT: include neck (speaker’s experience)
Barnes TW, et al. Chest 2004;126:268-272
Psychogenic (Habit) cough
• True incidence unknown• Overdiagnosed by physicians • Diagnosis of exclusion• Patient education is the key
Ramanuja S, Kelkar P. Ann Allergy Asthma Immunol. 2009 Feb;102(2):91-5; quiz 95-7, 115.
Refractory Idiopathic CoughRule out all the possible causes firstVery challenging to treatExperimental therapies:Lidocaine nebulization, Water and salt irrigations
of nose and sinus, Neurontin, Pamelor, Xanax, Baclofen, speech therapy evaluation and breathing exercises
Patient and family education and counselling
Am J Respir Crit Care Med 1995;152:2068-75
Zebras to watch for
• “Clinically silent” suppurative airway disease• Congestive heart failure• Cancer: bronchogenic, esophageal, metastasis• Cystic fibrosis• Interstitial lung disease• Foreign bodies• Pneumonia, Recurrent aspiration, pharyngeal dysf.• Sarcoidosis
Chest 1995;108(4):991-7
Zebras to watch for cont…
• Pressure from an intrathoracic mass• Primary ciliary dyskinesia (infertility)• Lingual thyroid (hypothyroidism)• Sleep apnea• Vocal cord dysfunction• Pulmonary tuberculosis• BronchiectasisAnn Med 1989;21(6):425-7Otolaryngol Head Neck Surg 2001;125:433-4J Allergy Clin Immunol 2001;108(1):143
Take Home Points
• Individualize the treatment• Flow diagrams/ Suggested reading
(1) Ramanuja S, Kelkar P. Ann Allergy Asthma Immunol. 2009 Feb;102(2):91-5; quiz 95-7, 115.
(2) Rank MA, Kelkar PS, Oppenheimer JJ. Ann Allergy Asthma Immunol. 2007;98:305-313
(3) Morice AH. ERJ 2004;24:481-492 (European)
(4) Irwin RS, et al. Chest 2006;129 (American)
(4) Morice AH, McGarvey L, Pavord I. Thorax 2006; 61:suppl 1 (British)
Bibliography continued…
• Ramanuja V, Kelkar P. Pediatric Cough. Annals of Allergy Asthma and Immunology 2010;105(1):3-8
• Goldsobel A, Chipps B. Cough in the pediatric population. The Journal of Pediatrics 2010;156(3): 352-358
• Chang AB. Cough guidelines for children : can its use improve outcomes. Chest 2008;134:1111-1112
Thank you!
Pramod Kelkar, MDPast- Chair, Cough Committee, American Academy of
Allergy, Asthma & ImmunologyFounder, National Cough Clinic
Private Practice:www.allergy-care.netwww.nationalcoughclinic.comMinneapolis, MN, USA
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