1) The document provides guidelines for managing chronic wet cough in children. 2) It recommends that children with chronic wet cough unrelated to underlying disease receive 2 weeks of antibiotics targeted to common respiratory bacteria. 3) For children whose cough resolves with antibiotics, a diagnosis of protracted bacterial bronchitis (PBB) is recommended. Children with lower airway bacteria confirmation can be said to have microbiologically-based PBB.

1. ‫الرحيم‬ ‫الرحمن‬ ‫هللا‬ ‫بسم‬

2. MANAGEMENT OF CHRONIC
WET COUGH IN CHIDERN
Ahmad Abu-Naglah
Prof of chest diseases
Al Azhar university

3. Cough is one of the most common symptoms for
which patients seek medical attention from
primary care physicians and pulmonologists

4. In children, it is the second symptom of
respiratory disease after runny nose, with 46-
56% representation depending on the age of the
child.

5. Types of cough
• Acute cough – lasting for less than four weeks
• Chronic cough – lasting for more than four
weeks

6. • This definition is used by most guidelines,
because most acute respiratory infections in
children resolve within this interval, and
evaluation at four weeks permits relatively
early diagnosis of serious underlying illnesses.

7. Specific cough
• Specific cough refers to a chronic cough that is
ultimately attributable to an underlying
abnormality or disease, which is usually, but
not always, of pulmonary origin (sometimes
termed, "specific cough pointers")

8. Nonspecific cough
• A chronic cough that does not have an
identifiable cause, after a reasonable
evaluation.
• A chronic cough is more likely to be
nonspecific if it is dry and there are no
abnormalities identified on initial evaluation
(ie, no "specific cough pointers“)

9. Causes of chronic cough in children
• Persistent respiratory infection including post
viral cough, chronic bronchitis, bronchiectasis,
cystic fibrosis, pertussis and tuberculosis
• Passive exposure to cigarette smoke
• Asthma
• Recurrent aspiration
• congenital abnormality

10. Causes of chronic cough in children
• Habit cough
• Upper airway cough syndrome
• Gastro-oesophageal reflux
• Cardiac causes e.g. congestive heart failure,
congenital heart disease
• Medication e.g. rarely ACE inhibitors

11. • Acute and sub-acute cough in children is
usually due to a viral respiratory tract infection
that will spontaneously resolve within one to
three weeks in 90% of children

12. Red flags in children who cough
• Neonatal onset of cough
• Cough during feeding
• Sudden onset of cough or a history of choking
that may suggest foreign body inhalation
• Chronic, wet cough with sputum production
• Continuous, unremitting or worsening cough

13. Red flags in children who cough
• Presence of associated features such as
shortness of breath, hypoxia or cyanosis, rapid
breathing, stridor, night sweats, weight loss or
haemoptysis
• Signs of chronic lung disease e.g. chest wall
deformity, digital clubbing, poor growth
• Parental concern that persists despite
reassurance

15. What is the wet cough
• Young children do not usually expectorate.
• The term wet cough is used instead, and this
is defined by its loose, self-propagating sound.
• When children can expectorate, the term
productive cough is preferred.

16. A chronic wet cough signifies the presence of
airway secretions , and in most cases airway
infection, and should not be ignored in children

17. Early diagnosis and management of chronic
productive cough were likely important for
future lung health.

18. Extended List of Cough Pointers

19. Systemic
• Cardiac abnormalities
• Digital clubbing
• Failure to thrive
• Medications or drugs associated with chronic
cough (angiotensin converting enzyme inhibitor
illicit drug use)
• Neurodevelopmental abnormality
• Fever

20. Systemic
• Immunodeficiency (primary or secondary)
• Feeding difficulties
• History of contacts (e g, TB)

21. Pulmonary
• Chest pain
• Hemoptysis
• Abnormal cough characteristics (brassy, plastic
bronchitis, paroxysmal with/ without posttussive
vomiting, staccato, cough from birth)
• Recurrent pneumonia
• Hypoxia/cyanosis

22. pulmonary
• Dyspnea at rest or tachypnea
• Chest wall deformity
• Auscultatory findings (e g, stridor, wheeze)
• Chest radiograph abnormalities
• Pulmonary function test abnormalities

23. PBB

24. PBB
The criteria in the original description of PBB
were as follows:
(1) presence of chronic wet cough
(2) response (cough resolution) to antibiotics
(amoxicillin-clavulanate) within 2 weeks of use

25. (3) lower airway infection defined as the
presence of respiratory pathogens at a density
equal to or more than 10000 CFUs/mL BAL, in
the absence of evidence of infection with
Bordetella pertussis, Mycoplasma pneumoniae,
or chlamydia infection (according to polymerase
chain reaction and/or serologic testing).

26. Respiratory pathogens
PBB is caused by typical respiratory pathogens,
such as H. influenzae Streptococcus
pneumoniae, and Moraxella catarrhalis

31. Extended PBB
Cough only resolves after an extended course
(four weeks) of antibiotics

32. Recurrent PBB
A child has more than three episodes per year

33. Management of Children With Chronic Wet
Cough and Protracted Bacterial Bronchitis
CHEST Guideline and Expert Panel Report
Anne B. Chang, MBBS, PhD, MPH; John J. Oppenheimer, MD; Miles M. Weinberger,
MD, FCCP; Bruce K. Rubin, MD; Cameron C. Grant, MBChB, PhD; Kelly Weir, BSpThy,
MSpPath, PhD, CPSP; and Richard S. Irwin, MD, Master FCCP; on behalf of the CHEST
Expert Cough Panel
CHEST 2017; 151(4):884-890

34. First state
• For children aged less than 14 years with
chronic (> 4 weeks’ duration) wet or
productive cough unrelated to an underlying
disease and without any specific cough
pointers (e g, coughing with feeding, digital
clubbing

35. Recommendation
• Children is recommended to receive 2 weeks
of antibiotics targeted to common respiratory
bacteria (Streptococcus pneumoniae,
Haemophilus influenzae, Moraxella
catarrhalis) and local antibiotic sensitivities

36. Second state
• The patients whose cough resolves within 2
weeks of treatment with antibiotics targeted
to local antibiotic sensitivities
• The diagnosis of protracted bacterial
bronchitis (PBB) is recommended (Grade 1C).

37. Third state
• For children with PBB with lower airway
(bronchoalveolar lavage or sputum)
confirmation of clinically important density of
respiratory bacteria

38. Recommendation
• The term ‘microbiologically-based-PBB’ (or
PBB micro) be used to differentiate it from
clinically based- PBB (PBB without lower
airway bacteria confirmation) Is
recommended (Grade 1C) .

39. Fourth state
• When the wet cough persists after 2 weeks of
appropriate antibiotics
• Treatment with an additional 2 weeks of the
appropriate antibiotic(s) is recommended

40. Fifth state
• When the wet cough persists after 4 weeks of
appropriate antibiotics
• Further investigations (e g, flexible
bronchoscopy with quantitative cultures and
sensitivities with or without chest computed
tomography) is suggested.

41. Sixth state
• For children with chronic wet or productive
cough unrelated to an underlying disease and
with specific cough pointers (e g, coughing
with feeding, digital clubbing )

42. Recommendation
• Further investigations (e g, flexible
bronchoscopy and/or chest computed
tomography, assessment for aspiration and/or
evaluation of immunologic competency)
should be undertaken to assess for an
underlying disease.

43. THANK YOU