chronic cough in kids

1. By: Dr Hisham Alrabty
Pediatrics consultant and pulmonologist at TCH
Senior lecturer at pediatrics department Tripoli university
Hisham Alrabty 2019

2. Introduction.
Definition.
Types.
Pathophysiology.
Epidemiology.
Causes.
Clinical presentation.
Diagnostic approach.
Treatment.
Prognosis.
Hisham Alrabty 2019
Topics:

3. • It is common presenting symptoms in children .
• It is common in season of viral infections autumn and
winter.
• Two types dry and loose or productive in general.
• Healthy children may cough on a daily basis; one study
documented an average of 11 cough episodes every 24
hours.
• It could be the only presenting symptom of asthma.
• Cough is an important defensive reflex that is required to
maintain the health of the lungs.
• Children who do not cough effectively are at risk for
atelectasis, recurrent pneumonia, and chronic airways
disease from aspiration and retention of secretions.
Hisham Alrabty 2019
Introduction:

4. There is no consensus as to the length of time
in the definition of chronic cough in children.
The American College of Chest Physicians,
Thoracic Society of Australia and New Zealand,
and many studies have defined chronic cough
as one that lasts more than four weeks,
because most acute respiratory infections in
children resolve within this interval.
Hisham Alrabty 2019
Definition:

5. Upto onset or duration:
1. Acute lasts less than 4 weeks.
2. Chronic lasts more than 4 weeks.
Upto nature of cough:
1. Dry without phlegm.
2. Wet or productive with sputum.
Upto causes:
1. Specific with clear cause like asthma or GERD.
2. Nonspecific without clear cause.
Hisham Alrabty 2019
Types of cough:

6. Cough pathway:
 Each cough is elicited by the stimulation of the cough reflex arc.
 Cough receptors, which are afferent endings of the vagus
nerve (cranial nerve X), are scattered in the airway mucosa and
submucosa.
 Some of these receptors are mechanosensitive and some are
chemosensitive.
 Mechanoreceptors are sensitive to touch or displacement and
are located mainly in the proximal airway such as larynx and
trachea.
 Chemoreceptors are sensitive to acid, heat, and capsaicin
derivatives through the activation of type 1 vanilloid receptor
(TRPV1) and are located mainly in the distal airways.
Hisham Alrabty 2019
Pathophysiology:

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Mechanics of coughing:
three phases:
1. Inspiratory phase: air inhalation lengthens the expiratory
muscles (favorable length-tension relationship).
2. Compressive phase: contraction of expiratory muscles
against a closed glottis leads to an increase in intrathoracic
pressure.
3. Expiratory phase: opening of the glottis results in high
expiratory flow and audible coughs.
During this phase, the airway undergoes dynamic
compression and the expulsion of air facilitates airway debris
and secretions clearance.
Pathophysiology:

9. Hisham Alrabty 2019

10. chronic cough appears to be common, with
an estimated prevalence of 5 to 7 percent in
preschoolers, and 12 to 15 percent in older
children Cough is more common among
boys than girls up to 11 years of age and may
be less common in developing countries
than in affluent countries.
Hisham Alrabty 2019
Epidemiology:

11. 1. Infections: viral or bacterial.
2. Inflammatory: asthma.
3. Aspiration syndromes: GERD and tracheoesophygeal
fistula.
4. Allergic: allergic rhinitis.
5. Inherited diseases: CF or immunodeficiency.
6. Cardiac: CHD pulmonary edema.
7. Mechanical: FB aspiration.
8. Habitual.
9. Connective tissue diseases: may affect lungs like SLE.
10. Medicines: captopril.
11. Nonspecific in 10-15% of children.
Hisham Alrabty 2019
Causes of chronic cough:

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13. History:
1. Fever: means infection.
2. With or without sputum.
3. Diurnal variation.
4. Family history of allergy or any inherited diseases like CF.
5. Is it seasonal ?
6. Is there any weight loss or FTT?
7. Night sweating.
8. Any Dysmorphic features.
9. Runny nose and or sneezing.
10. History of wheeze or chocking or chronic vomiting.
11. Interrupted feeding or cyanosis (CHD).
12. Skin manifestations pointing to connective tissue diseases or eczema.
13. Any joint involvement .
14. Chronic diarrhea pointing to CF.
Hisham Alrabty 2019
Clinical presentation:

14. On Examination:
1. Vital signs.
2. Growth parameters.
3. Signs of rep.distress.
4. Dysmorphic features.
5. Cyanosis.
6. Chest deformities.
7. ENT examination.
8. Heart murmurs.
9. Organomegaly.
10. Joint swelling.
11. Skin rash.
12. Nail clubbing.
13. Lymph nodes enlargement.
14. Tuberculin scar.
Hisham Alrabty 2019
Clinical presentation:

15. CBC : eosinophilia or neutrophilia.
Inflammatory reactants: nonspecific.
CXR: recurrent pneumonia.
Skin prick test or specific IGE.
24 PH monitoring or imepdiance study.
HRCT chest for bronchiectasis.
 sweat test.
PFT spirometry.
C.T.diseases assay.
Immunoassay.
Bronchoscopy rigid or flexible: FB aspiration.
Hisham Alrabty 2019
Diagnostic approach:

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17. Treat the cause simply cough will be soothed:
1. Inhaled steroids and bronchodilators for asthma.
2. Steroid nasal spray and antihistamines for AR.
3. Antibiotics for bacterial infections.
4. Enzymes replacement and good hydration for CF.
5. Immunoglobins for immunodeficiency.
6. Bronchoscopy FB removal.
7. antiTB for TB.
8. Mucolytics and chest physiotherapy for bronchiectasis.
9. Positioning and AR milk for GERD.
10. Surgery for tracheoesophygeal fistula.
11. Anticough medicines ???????
Hisham Alrabty 2019
Treatment:

18. WHO recommendation is:
All anticough medicines whether cough suppressants
or Mucolytics or decongestives are completely
forbidden to be given to children aging less than 6
years old.
Good hydration and treating the cause are only
recommended treatments for cough in children as
proved by many studies being done internationally.
Hisham Alrabty 2019
Anticough medicines:

19. Cause dependent ranging from
excellent as in asthma and recurrent
tonsillitis to lethal like severe
immunodeficiency.
Hisham Alrabty 2019
Prognosis:

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