1. Copyrights apply
COUGH
Dr.Khalid Hama salih
Ass.prof of Pediatrics
M.B.Ch. D. C.H F.I.B.M.S.ped
University of sulaimany
College of medicine
Pediatrics department
6. About 2.5L of air is inspired
Epiglottis closes, vocal cordsshut tightly to
entrap the air within the lung
Mechanism
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7. Abdominal muscles contract forcefully,
pushing against the diaphragm
Internal intercosatal muscles also contract forcefully
Pressurein the lungs rises to 100mmHg or more.
Markedly positive intrathoracic pressure causes
narrowing of the trachea
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8. The large pressure differential
between the airways and the
atmosphere coupled with tracheal
narrowing produces rapid flow
rates through the trachea.
Air is expelled at velocities ranging from
75 to 100 miles/hr.
Vocal cords and epiglottis suddenly open
widely .
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9. The shearing forces that develop aid in the elimination of
mucus and foreign materials
Cough is therefore PROTECTIVE
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13. Extrapulmonary causes
Causal role likely Risk factors or mechanisms Major evaluation method (in addition to clinical findings)
Cardiac* •May cause cough due to airway compression,
pulmonary edema, or arrhythmia
•ECG and other evaluation as indicated
Ear disease*
•Oto-respiratory reflex (Arnold reflex), in which
stimulation of the auricular branch of the vagus nerve
triggers cough
•Examination of the ear canal and removal of the
object, or treatment of disease that is triggering the
cough
Tic cough (habit cough) or somatic cough
disorder (psychogenic cough)*
•May be isolated, but more likely if other tics are
present
•Some children have generalized anxiety or
disproportionate anxiety about the seriousness of
their symptoms
•Suppressibility, distractibility, suggestibility,
variability, cough absent during sleep
•Response to behavioral therapy (eg, suggestion
therapy)
Δ
•Children with somatic cough disorder may require
referral to a psychologist and/or psychiatrist if
unresponsive to suggestion therapy
Medications*
•ACE inhibitors (common), any inhaled
medication, proton pump inhibitors, other drugs
(uncommon)
•Certain other medications (eg, cytotoxic drugs)
may be associated with interstitial lung disease
•Discontinuation of medication
•Evaluation for interstitial lung disease
Causal role unlikely
Esophageal disorders •Gastroesophageal reflux
•Esophageal pH monitoring or impedance
monitoring, with or without endoscopy
Upper airway pathology •Chronic sinusitis, obstructive sleep disorders
◊ •Evaluation guided by suspected disorder (CT,
polysomnography)
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15. Specific chronic cough "pointer" Possible major underlying etiology
History
Pulmonary symptoms
•Chronic wet or productive cough*
Suppurative lung diseases (bacterial bronchitis, chronic
suppurative lung disease, bronchiectasis), aspiration,
abscess, cavitations
•Hemoptysis
Infection (eg, tuberculosis), interstitial lung disease,
bronchiectasis, autoimmune lung disease
•Wheeze (at rest or on exertion)
Asthma (if no other specific cough pointer present other
than spirometry, and dyspnea that responds to
bronchodilators); bronchiectasis, eosinophilic disorders
(if other specific cough pointer present)
•Dyspnea (at rest or on exertion) Asthma or any severe lung disease
•Classically recognizable cough sounds
¶ These cough characteristics (eg, barking, honking,
whooping) often suggest a specific cause of cough
¶
•Recurrent pneumonia
Immunodeficiency, obstructed airways or any conditions
causing bronchiectasis
Specific pointer
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16. Timing and triggers
•Symptoms from neonatal period
Congenital abnormality related to airways, immune function, or causes with
predisposition to bronchiectasis (eg, primary ciliary dyskinesia)
•Onset after an episode of choking Inhaled retained foreign body
•Cough worsens when child is anxious or attention is focused and is
absent during sleep. Cough improves with distraction or suggestion
and can be voluntarily suppressed
Habit cough (tic cough)
•Child has disproportionate thoughts and anxiety about the seriousness of
symptoms
Somatic cough disorder (psychogenic cough)
Associated symptoms or conditions
•Cardiac disease
Primary cardiac disease causing cough, tracheomalacia or primary
ciliary dyskinesia
•Neurologic and developmental abnormalities Aspiration
•Feeding difficulties Laryngeal or trachea disorders, aspiration
•Failure to thrive
Any severe lung disease, cystic fibrosis, immunodeficiency, indolent
infections (eg, tuberculosis)
•Exposure to tuberculosis, pertussis, and/or sick animals and travel
history
Tuberculosis and other mycobacterium, pertussis, parasites
(eg, Toxocara),
•History of deep infections ± immunodeficiency (primary or
secondary to cancer treatment or medications)
Opportunistic infections (eg, fungal)
•Autoimmune disease Interstitial lung disease
•Angiotensin-converting enzyme inhibitor use Known adverse effect of angiotensin-converting enzyme inhibitor
•Chronic fever Indolent infection with or without immunodeficiency
Specific pointer
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17. Examination
Digital clubbing Bronchiectasis or interstitial lung disease
Chest wall abnormality Any lung disease, neuromuscular disease
Wheezing or crepitations
Any lung disease; in particular, asthma,
bronchiolitis obliterans, bronchiectasis (from any
cause), bronchopulmonary dysplasia, heart failure,
immunodeficiency and aspiration
Hypoxia Any lung disease
Routine investigations/tests
Abnormal chest radiography Any lung disease
Abnormal spirometry Obstructive or restrictive lung/chest wall diseases
Specific pointer
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17
18. Classically recognizable cough sounds in children
Cough characteristic Suggested underlying pathology[1,2]
Barking or brassy cough
Tracheomalacia, tic cough/somatic cough disorder*,
croup (if acute)
Honking or "goose-like" cough Tracheomalacia, tic cough/somatic cough disorder*
Paroxysmal cough (with or without inspiratory
whoop)
Pertussis and parapertussis
Staccato cough Chlamydia in infants
Cough productive of casts
Plastic bronchitis and conditions associated with
mucous plugs such as ABPA
Chronic wet or productive cough only in the
mornings
Suppurative lung diseases (eg, bronchiectasis, cystic
fibrosis)
Wet or productive cough Presence of endobronchial secretions
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19. Copyrights apply
Red flag symptoms
Systemic symptoms: Fever
Historty of chocking
Cough since birth
Cyanosis or hypoxia on pulse oximetry
Stridor
Respiratory distress
Toxic appearance
Abnormal lung examination
History of contact with TB and/or HIV
20. Clinical point
Close history taking and physical examination are
sufficient to diagnose the cause of an acute cough without
red flag symptoms! In chronic cough and cough with red
flag symptoms,investigation , cxr and pulmonary function
testing should be considered at an early stage
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21. CAUTION
Coughreceptors maynot be involved inthe earlystages of pneumonia
• Hencecough maybe alate feature of pneumonia- Fever with tachypnea
+/- retractionsis diagnostic of pneumonia
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23. Diagnostics
An acute cough is often a clinical diagnosis (diagnostic tests are not routinely indicated in
this case).
Patients with chronic cough and/or red flag symptoms require further assessment.
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24. laboratory tests
Complete blood count : indicated in patients with chronic cough/red flag symptoms
If an infective etiology (e.g., neutrophilic leukocytosis in pneumonia, lymphocytosis in TB) or allergic etiology
(e.g., eosinophilia in asthma)
Tuberculin skin test and IGRA : patients with suspected TB
Sputum examination &Sputum culture ,for acid-fast bacilli : suspected bacterial pneumonia, TB
Bronchoalveolarlavage,gastric lavage
Blood culture: suspected pneumonia
Arterial blood gas analysis: patients with dyspnea and those with suspected life-threatening causes of acute cough
Imaging
Chest x-ray Suspected pneumonia
cough with abnormal physical examination findings ,Red flag symptoms
X-ray of paranasal sinuses: patients with suspected sinusitis
Chest CT scan Suspected bronchiectasis (diagnostic test)
Bronchoscopy
Foreign body aspiration
Suspected tracheoesophageal fistula
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25. Specific test:
Spirometry: indicated to differentiate between obstructive lung disease
(e.g., asthma) and restrictive lung disease (e.g., interstitial lung disease)
Bronchial challenge test (methacholine challenge test; bronchodilator reversibility test): to
differentiate asthma from other obstructive lung disease.
, ECG, and ECHO: patients with cough due to suspected heart disease
Endoscopy, 24-hour esophageal pH monitoring and/or barium swallow: patients with chronic
cough suspected to be due to GERD/TEF.
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26. Acute cough management
Nonpharmacological
treatment
HoneyWorld Health Organization (WHO) and American
Academy of Pediatrics (AAP) suggest it as a potential
treatment for URI in young children who are older than one
year. The American College of Chest Physicians suggests
that honey is more effective than placebo for cough
Maintaining adequate hydration may help to
thin secretions and soothe the respiratory
mucosa
lozenges, The AAP suggests that cough lozenges or
hard candy may be used to coat the irritated throat
for children older than six years.
warm fluids have a soothing effect on the
respiratory mucosa, increase the blood flow of
nasal mucus, and loosen respiratory secretions,
making them easier to remove
Menthol may help thin mucus and
loosen phlegm.
glucocorticoid therapy administer
aerosolized bronchodilators and
N-acetylcysteine
hydration
lozenges
honey
Warm fluid
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27. Post-infectious cough
Often resolves spontaneously (no treatment needed)
Cough interfering with sleep/daily activities:
antitussives,inhaled bronchodilators, oral/inhaled
corticosteroids
Subacute
cough
Suspected infection : early administration of
antibiotics
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28. Management of chronic cough
Chronic cough
Nonspecific cough
wait, reassess, and review
Medication trials if suspect
asthma is reasonable to perform
an empiric trial of
bronchodilators (short-acting
beta2-agonists) or low-dose
inhaled corticosteroids
Gastroesophageal reflux disease
(GERD) is probably an unusual
cause of chronic
cough medications such as a
proton pump inhibitor (PPI)
Specific cough — Treatment
of children with a specific
cough is directed at the
suspected cause It is important
to reassess the child
periodically to determine
whether treatment has been
optimized and to confirm the
diagnosis..
key principles are:
1. ●Targeted treatment for the
suspected or confirmed cause of
the cough, as determined by a
systematic evaluation
2. ●Identifying and mitigating
exacerbation factors, such as
exposure to environmental
tobacco smoke
3. ●Defining and discussing the
expectations of, and the effect of
the cough on, the child and
parent parent.
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29. four different categories of drugs
They are:
1.Cough suppressants (dextromethorphan)
2.Cough expectorants (guaifenesin)
3.Decongestants (pseudoephedrine and phenylephrine)
4.Certain antihistamines (suchas brompheniramine, chlorp
heniramine maleate,and diphenhydramine
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30. The American College of Chest Physicians guidelines do not recommend
cold and cough medications for children younger than age 15.
For children younger than 15 years of age, they suggest that an anti-
inflammatory medication like ibuprofen or naproxen may be helpful with a
cough.
An anti-histamine such as diphenhydramine. A decongestant may help
with post-nasal drip .
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31. The AAP recommends against codeine and dextromethorphan-containing
medications for the treatment of cough associated with viral respiratory
infections because there are no well-controlled studies demonstrating
efficacy and safety.
The US Food and Drug Administration recommends against codeine- or
hydrocodone-containing prescription cough and cold medicines in children
and adolescents younger than 18 years .
The European Medicines Agency recommends against codeine to treat cough
and cold in children younger than 12 years and in children between 12 and
18 years who have breathing problems (eg, asthma)
The WHO guidelines recommend against the use of codeine preparations for
cough in children but suggest that dextromethorphan may be warranted in the
unusual circumstance when severe prolonged coughing interferes with feeding
or sleeping.
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32. What is bad for ?complications
syncope
Vomiting
Headache&
Dizzness
Sleep&classroom
disruption
Loss of
bladder
control
(urinary
incontinence)
Fractured
ribs
Complications
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34. n contrast, the prevalence of cough without
colds increased with age from 34% in 1-
year-olds to 55% in children aged 14–17.
Night cough was reported for 25% (25–
26%) of children. It increased slightly from
23% in1yera Cough is common during
childhood. It leads to many medical
consultations, affects quality of life and
places a considerable burden on children,
families and society [1]. Cough is a non-
specific symptom of various diseases
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