* what to ask in chronic cough * what investigations you would send * characters of cough * specific cough pointers * undergraduate seminar in pediatrics

1. z
Approach to
chronic cough in
children
Fakhri Atheer
Child care block

2. z
objectives
▪ To revise the cough reflex mechanism
▪ To define some common terms regarding cough.
▪ To be able to take a proper history and interpret
examination findings in child with chronic cough.
▪ To be able to evaluate a child with chronic cough.

3. z
Cough mechanism I
▪ Each cough occurs through the stimulation of a
complex reflex arc
▪ This is initiated by the irritation of cough
receptors that exist not only in the epithelium of
the upper and lower
▪ respiratory tracts, but also in the pericardium,
oesophagus, diaphragm, stomach, and external
ear

4. z
Cough mechanism II
Three phases:
❖ Inspiratory phase: air inhalation lengthens the expiratory
muscles (favourable length-tension relationship).
❖ Compressive phase: contraction of expiratory muscles
against a closed glottis leads to an increase in
intrathoracic pressure.
❖ 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.

6. z
Definitions I
Chronic cough: - Daily cough lasting 4 weeks or
more.
Specific cough: - a chronic cough that is
ultimately attributable to an underlying physiologic
cause.
nonspecific cough: - a chronic cough that does
not have an identifiable cause, after a reasonable
evaluation.

7. z
Definitions II
Tic cough: - a diagnosis made after exclusion of
organic causes and the cough is suppressible,
distractible and suggestible. (previously known as
habitual cough)
Somatic cough: - a diagnosis made after
exclusion of organic and tic cough with positive
psychiatric criteria of somatic disorder. (previously
known as psychogenic cough)

8. z
Evaluation
1- History
2- physical examination
3- CXR
4- spirometry

9. z
History
▪ Wet or productive cough➔➔ Suppurative
lung diseases (protracted bacterial bronchitis,
chronic suppurative lung disease,
bronchiectasis), aspiration, abscess,
cavitation.
▪ Haemoptysis➔➔ Infection (e.g.,
tuberculosis), interstitial lung disease,
bronchiectasis, autoimmune lung disease.

10. Cough characteristic Suggested pathology
Barking or brassy cough Tracheomalacia, tic cough (if acute:
Croup)
Honking or goose-likecough
Tracheomalacia, tic cough (habit
cough), somatic cough disorder
(psychogenic cough)
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
Chronic wet or productive cough only in
the mornings
Suppurative lung diseases (e.g.,
bronchiectasis, cystic fibrosis)
Wet or productive cough Presence of endobronchial secretions

11. z
History
▪ Wheeze (at rest or on exertion)➔➔ Asthma
(if no other specific cough pointer present
other than spirometry, and dyspnoea that
responds to bronchodilators); Bronchiectasis,
eosinophilic disorders (if other specific cough
pointer(s) present)
▪ Dyspnea (at rest or on exertion)➔➔ Asthma
or any severe lung disease.

12. z
History
▪ Classically recognizable cough sounds➔➔ These
cough characteristics (e.g. barking, honking,
whooping) often suggest a specific cause of cough.
▪ Recurrent pneumonia➔➔ Immunodeficiency,
obstructed airways or any conditions causing
bronchiectasis.
▪ Onset after episode of chocking ➔➔ retained
foreign body

13. z
History
▪ Cough worsens when child is anxious or
attention is focused; improves with distraction
or suggestion; can be voluntarily suppressed
➔➔ Tic cough (habit cough)
▪ Child has disproportionate thoughts and
anxiety about the seriousness of
symptoms➔➔ Somatic cough disorder
(psychogenic cough).

14. z
History
▪ Feeding difficulties➔➔ Laryngeal or trachea
disorders, aspiration.
▪ Failure to thrive➔➔ Any severe lung disease, cystic
fibrosis, immunodeficiency, indolent infections (e.g.,
tuberculosis).
▪ Autoimmune disease➔➔ Interstitial lung disease.
▪ ACE inhibitor use➔➔ Known adverse effect of ACE
inhibitor.
▪ Chronic fever➔➔ Indolent infection with or without
immunodeficiency

15. z
Physical examination
▪ General (head to toe) examination.
▪ Chest examination.

16. z
Finding interpretation
Dysmorphism anatomic abnormalities, or swallowing
dysfunction with aspiration.
Eczema atopic disease
swollen nasal turbinate, nasal obstruction, nasal
polyps
allergic disease
lymphadenopathy immunodeficiency, malignancy, or chronic
infection.
Tympanic membrane scarring or otorrhea possibility of primary ciliary dyskinesia.
Objects or disease in the ear canal Otogenic cough reflex (rare)
Hoarseness aspiration or vocal cord dysfunction.
Tonsillar hypertrophy or pharyngeal
cobblestoning
Allergic disease

17. z
Finding interpretation
Abnormal heart location Primary ciliary dyskinesia (50%)
Abnormal heart sounds or pulses CHD causing airway compression, pulmonary
oedema, or arrhythmia.
Abnormal liver size or texture Chronic liver disease due to CF
Splenomegaly CF, malignancy hemoglobinopathy
Rectal prolapse Cystic fibrosis
Edema cardiac disease.
Cyanosis or digital clubbing bronchiectasis or interstitial lung disease

18. z
Physical examination
Inspection
▪ Pectus exacavatum➔➔ associated with
tracheomalacia
▪ Harrison sulci, retraction, hyper-inflation➔➔
usually Obstructive diseases.
▪ Chest wall anomalies (e.g. kyphoscoliosis)➔➔
poor cough clearance and bronchiectasis.

19. z
Physical examination
Auscultation
▪ unilateral wheeze➔➔ Inhaled FB
▪ Polyphonic wheeze ➔➔ typical of asthma.
But may be bronchiolitis obliterans or
bronchiectasis.
▪ Monophonic wheeze➔➔ FB, Malacia
and/or stenosis of large airway

20. z
Chest radiograph
▪ Hyperinflation:- unilateral ➔➔ FB
bilateral➔➔ Asthma
▪ peribronchial accentuation: - Asthma
protracted bacterial bronchitis & primary
ciliary dyskinesia.
▪ Right middle lobe changes: - asthma.

21. z
▪ Linear atelectasis, dilated, and thickened
airways (i.e., tram-tracking or parallel lines,
ring shadows on cross section):
bronchiectasis.
▪ Lung or lobar collapse: - FB, mucous plug or
mass.

25. z
spirometry
When appropriate for the child's age (>3 years
in a pediatric lab and >6 years in other labs)

26. z
So what do we need to say it’s
asthma??
▪ Dry paroxysmal cough triggered by cold, dust,
allergens ore exercise
▪ Wheeze
▪ A history of eczema or bronchiolitis.
▪ Family history of atopy
▪ recurrent right middle lobe atelectasis
▪ airflow limitation on spirometry, which reverses to
treatment with bronchodilators

27. z
Wet/productive chronic cough??
▪ Give amoxicillin-clavulanate AB as it mostly PBB in
otherwise well child.
▪ If no response consider: - foreign body inhalation
- recurrent aspiration
- CF
- primary ciliary dyskinesia

28. z
When to suspect Foreign body
inhalation?
▪ age <5 years.
▪ cough began suddenly after an episode of choking.
▪ wheezing (particularly if monophonic).
▪ Halitosis
▪ unilateral hyperinflation in CXR
▪ Bronchoscopy is the definitive diagnosis and management.

29. Cough is dry and non-productive, and chest
radiograph and spirometry are normal……..
Non-specific cough

30. How to manage non-specific cough??
- Watchful waiting➔ the condition usually is post-viral
cough and resolve after 2-4 wks.
- Medication trial:-
1- it still may be cough-dominant asthma so it worth a trial of
bronchodilators.
2- a trial of antacids because GERD is a well identifiable cause
although rare.
3- No trial of anti-tussive is recommended

31. z
Additional investigations may be used
▪ Flexible bronchoscopy.
▪ Esophageal pH monitoring.
▪ Sinus imaging.
▪ Chest CT scans.
▪ Tests for tuberculosis.
▪ Allergy tests.