Chronic Cough in Children Fiona Kritzinger Chest and Allergy Centre - - PowerPoint PPT Presentation

Chronic Cough in Children

Fiona Kritzinger

Chest and Allergy Centre Christiaan Barnard Memorial Hospital

“My daughter had a cold last week and she was better after a few days. Two nights ago she had a fever and started coughing quite a lot. Last night she had another fever and coughed the whole night. We are all exhausted today. I am dreading another coughing night. Do I call and make an appointment? Can we come after I pick her up from school?”

Children cough!

• Very common presenting symptom
• Usually acute viral respiratory tract

infection

• Prospective studies: 50% well at 10

days; 75% at 14 days; 90% at 21 days

• Even healthy children can cough

most days 1

• 1. Munyard. Arch Dis Child 1996

When do we call it chronic ? Defined as > 4 weeks by most studies and guidelines

1-3

Except the British Irritating Distressing to parents Poor quality of life Can indicate serious underlying disease Why is it important?

1.

• Chang. Chest 2012

2.

• Chang. Pediatrics 2013

3.

• Chang. Chest 2016

Importance of paediatric cough guidelines

Etiology in children differs 1 Paediatric-specific guidelines published in 2013 2 Better clinical outcomes 3

1.

• Marchant. Chest 2006

2.

• Chang. Paediatrics 2013

3.

• Chang. Chest 2016

Specific cough pointer or abnormal spirometry or abnormal CXR Reversible airway obstruction Asthma

Appropriate treatment If poor response reevaluate risks

NO Bronchiectasis Recurrent Pneumonia Aspiration Chronic or less common infections Interstitial Lung disease Airway abnormalities Other uncommon pulmonary disorders Cardiac disease

Cystic Fibrosis Primary Ciliary Dyskinesia Immunodeficiency Congenital lung lesion Missed foreign body TEF/H-fistula Laryngeal abnormalities Neurological abnormalities Neuromuscular disease GERD Sweat test Cilia biopsy Immune work up HRCT chest Flexible bronchoscopy Contrast swallow Contrast swallow Videofluroscopy pH monitoring Milk scan Salivagram Bronchoscopy TB Non TB Mycobacterial infections Mycoses Parasites Tuberculin test Bronchoscopy & Lavage HRCT chest

YES

Rheumatic diseases Bone marrow or solid organ transplantation Cytotoxic drugs Radiation Autoimmune screen HRCT Chest Bronchoscopy and lavage Lung Biopsy Laryngotracheo- malacia Tracheal stenosis Extrinsic compression e.g. vascular rings Intrinsic lesions e.g. tumors Bronchoscopy CT Chest +-MRI chest Primary and secondary pulmonary tumours Pulmonary hypertension Pulmonary edema Cardiology referral ECHO Cardiac Catheterization

Assess risk factors for

Consider early referral to paediatric pulmonologist

Diagnostic approach

Identify Cough phenotype

Specific vs non- specific

History

Examination

Special investigations

History

• Cough specifics

– Age and onset – Nature – Timing and triggers – Associated symptoms

• Birth history, prematurity
• Atopy/allergy
• Past episodes of

pneumonia

– Focal/diffuse

• Family history
• Exposure to allergen,

irritant, infection, medication

• Response to treatment

Diagnostic approach

Identify Cough phenotype

Examination

Respiratory Exclude underlying disease Special investigations Spirometry CXR

Cough Pointers

Chang Chest 2006; Chang Ped Pulmonol 1999

Specific cough pointer or abnormal spirometry or abnormal CXR?

Reversible airway obstruction ?

Asthma

Appropriate treatment If poor response reevaluate risks NO

REFER

NO

Isolated non-specific cough Daily wet cough only? Protracted Bacterial bronchitis

Treat with antibiotics for two weeks If incomplete response REFER NO YES YES YES

Recognition of Chronic wet cough

• Up to 65% of referred population
• Two most common conditions: Protracted bacterial

bronchitis (41%) and CT scan proven bronchiectasis (9%)1

• Untreated Protracted Bacterial bronchitis can lead to

bronchiectasis 2,3

• 1. Chang. Chest 2012
• 2. Craven. Arch Dis Child 2013
• 3. Chang. Paediatr Respir Rev.

2011

Diagnostic criteria of PPB

• Chang. Ped Pulmonol 2016

Protracted bacterial bronchitis

• Etiology: Haemophilus influenza, Moraxella cattharalis,

Streptococcus pneumoniae

• Amoxycillin-clavulanic acid (90mg/kg/day) or Cefuroxime

(30mg/kg/day)

• 2 weeks
• Refer immediately if: 1

– Specific cough pointers present at time of diagnosis – Poor/incomplete response after 2 weeks – Recurrent episodes

• 1. Chang. Chest 2016

Specific cough pointer or abnormal spirometry or abnormal CXR?

Reversible airway obstruction ?

Asthma

Appropriate treatment If poor response reevaluate risks NO

REFER

NO

Isolated non-specific cough Daily wet cough only? Protracted Bacterial bronchitis

Treat with antibiotics for two weeks If incomplete response REFER NO YES YES YES

• Usually post infectious cough or prolonged acute

bronchitis

• Exclude ear problems
• Cough Hypersensitivity Syndrome (Habit cough)
• Exposure to irritant
• Rare: Foreign body, Asthma, GERD

Isolated non-specific cough

Post-Infectious Syndrome

• Viral & Atypical bacteria - Pertussis, Mycoplasma

and Chlamydia

• Natural resolution of the cough occur in almost all

children

• The median duration of cough was 118 days in the

pertussis positive group, 39 days in mycoplasma positive group and 70 days if neither positive 1,2

• 1. Harnden. BMJ 2006
• 2. Wang. Pediatric Infectious Disease Journal 2011

Pertussis

• More common than we think
• One third of children >5 years with prolonged acute

cough 1

• In infants and young children typical whooping

cough

• Adolescents may be less typical with only prolonged

cough

• 2. Chang Chest 2006

Pertussis

• Despite immunization, significant % of those with

chronic cough had positive serology

• After 4 weeks usually does not need macrolide

antibiotic, unless still PCR or culture positive

• Recommend booster vaccines for adolescents and

adults to prevent disease

• Reassurance and support

Habit cough

• Up to 10% of children and adolescents
• Very prominent during visit; Absent at night
• Rarely interrupts playing, eating or speech
• Distinctive cough: short, single dry coughs (tics) or

honking/barking after short inhalation

• Very loud and disruptive in class
• Normal examination, CXR and spirometry

Habit cough

• May lead to excessive school absence
• Usually begins during URTI and fails to resolve
• Often emotional or social stessors identified
• Challenge to convince parents
• REFER

11 year old girl: daily wet cough for 4 months

• Known asthmatic since age 8 years
• Gradual onset, partial response to short antibiotics (2

courses, less than 7 days) and steroids (7 courses, 7-10 days)

• Dust mite, grass and cat sensitization
• ICS/LABA for last 2 years
• Daily nasal steroid and oral anti-histamine for AR

• Weight 28kg (5th%) and height 1.38 (10th%)
• Cushinoid facies.
• Allergic facies. Facial and flexural Atopic

Dermatitis and Allergic rhinitis

• Hyperinflated
• Bilateral polyphonic expiratory wheezing

and coarse crackles

Pre and post spirometry

Bronchoscopy and BAL

• Neutrophilic inflammation
• Culture:

– Moraxella on right lung sample – Strep pneumo and Haemophilus on left lung sample. Sensitive organisms

Posterior coronal view

After 8 weeks of antibiotics

Points of interest

• Chronic productive/wet cough is not Asthma
• Untreated Protracted Bacterial Bronchitis can

lead to bronchiectasis

19 month old boy: dry cough for 5 months

• Known Long QT Syndrome
• Sudden onset cough and stridor;

diagnosed as Croup

• 2 weeks later re-admitted for ongoing

cough and wheeze

• Normal CXR

• 3 months later still coughing and associated

intermittent wheeze

• Started Budesonide 100mcg BD
• Bilateral wheezing but worse over left lung
• CXR normal

Points of interest

• Acute onset cough and stridor without

prodrome or fever is not Croup

• Normal CXR does not exclude a foreign body
• Refer any child with monophonic/unilateral

wheezing for bronchoscopy

4 year old girl: cough for 6 months

• Known long segment esophageal atresia without fistula

repair after birth

• Feeding difficulties since birth. Required gastrostomy.
• Gradual onset of wet cough
• Worse around feeding times
• 1 month later “Asthma attack”. Started on asthma

medication by GP

• 2 episodes of pneumonia since start of asthma medication
• Examination normal

Points of interest

• Coughing associated with feeding is suggestive
• f aspiration
• Not every wheeze is asthma
• Refer children with the recurrent pneumonia
• r prolonged wet cough

drkritzinger@chestandallergy.co.za