Cough in children

Cough Definition
A critical reflex action, rapid expulsion of air from the
lungs, typically in order to clear the lung airways of
fluids, mucus, or the material. Also know as tussis.
-MedicineNet

Expel air from the lungs with a sudden sharp sound.

-Oxford dictionary
 Cough Introduction
Cough is the most common symptom of respiratory
disease for which parents seek medical attention in
young children.
The presence of cough indicate the entire spectrum
of cardiorespiratory childhood illness, ranging from a
symptom of common cold to a symptom of a severe
life-limiting disorder such as CF.
Most cough in children is acute and resolves
promptly.
 Pathophysiology - Cough Reflex
Bronchi and trachea are so sensitive to light touch
that slight amounts of foreign matter or other causes
of irritation initiate cough reflex
Larynx and carina are especially sensitive, and
terminal bronchioles and alveoli are sensitive to
corrosive chemical stimuli (sulfur dioxide or chloride
gas)
Afferent nerve impulses pass from the respiratory
passages (pulmonary irritant receptor) mainly
through the vagus nerves to the medulla of brain.
 Cough Reflex
Nucleus tractus solitarius

Vagus and
glossopharyngeal Vagus, phrenic and
nerves
spinal motor nerves

Pharynx, trachea(carina), Glottis, external intercostal,

bronchi and bronchioles diaphragm, major
inspiratory and expiratory
muscles
 Pathophysiology - Cough Reflex
An automatic sequence of events is triggered by the neuronal circuits
of the medulla, causing the following effect.

1. Up to 2.5 liters of air are rapidly inspired. (inspiratory)

2. Epiglottis closes and vocal cords shut tightly to entrap the air
within the lungs.
3. Abdominal muscles contract forcefully, pushing against the
diaphragm while other expiratory muscles (internal intercostal)
also contract forcefully. Pressure in the lungs rises rapidly to as
much as 100mmHg or more. (compressive)
4. Vocal cords and the epiglottis suddenly open widely, air under this
high pressure in the lungs explodes outwards (75-100 miles per
hour). The strong compression of lungs collapses the bronchi and
trachea by causing their noncartilagenous parts to invaginate
inward, so exploding air pass through bronchial and tracheal slits
and carries any foreign matter that is present in the bronchi or
trachea. (expiratory)
 Causes of cough in children
Croup
Infection of lower respiratory system
(bronchiolitis or RSV)
Asthma
Postnasal drip syndrome
Exposure to secondhand smoke
GERD
Blockage of airway by an inhaled object, such as
food or small toy
Emotional or psychological problems (dry cough)
 Types of cough
Acute less than 4 weeks
Infection (bacterial or viral, URTI and croup)
Nasal allergies
Blockage of airway by inhaled object
Bronchospasm
GERD

Chronic more than 4 weeks

Irritation of airway (secondhand smoke or pollution)
Increase in cough receptor sensitivity
Habit cough (common URTI)
Otogenic cough
 Types of cough
Wet cough Dry cough
Viral illness (common Viral illness (common
cold) cold)
Infection (pneumonia, Bronchospasm
bronchitis, sinusitis) Allergies
Chronic lung disease ACE inhibitors (Captopril)
(COPD) Dust, fumes and
chemical
GERD
Asthma
Postnasal drip
Blockage of airway by
Smoking inhaled object
 Types of cough
Classical recognizable cough in children
Cough characteristic Associated illness type
Barking or brassy cough (dry, Croup, tracheomalacia, habit
harsh, sound of barking seal) cough

Honking (goose, dry, harsh) Psychogenic

Paroxysmal (with or without Pertussis and paratussis
whooping) (sudden severe attack)

Staccato (inspiration between each Chlamydia trachomatis in

single cough) infants
Cough productive of casts Plastic bronchitis
 References
Guyton and Hall textbook of medical
physiology
Practical pediatrics 7th edition
www.webmd.com
www.medicinenet.com
 APPROACH FOR HISTORY

LUQMAN HAKIM BIN ROZLAN

BMS 14091336
 History taking
Patients age
Duration : days, months, years;
(acute <3weeks, chronic >8 weeks)
Frequency : continuously/intermittent
Character : wet or dry cough
barking and whopping cough
Timing : worse at night
Severity : hospitalization, ED visit, missed school
days
 Sputum
- Clear mucoid sputum: allergic
reaction/asthma
- Cloudy(purulent) sputum: respiratory tract
infection, increased cellularity from asthma
- Very purulent sputum: bronchiectasis
- Malodorous expectoration: anaerobic
infection
- Purulent, rarely foul smelling: cystic fibrosis
- Sputum with blood: hemoptysis
 Presence of pre-existing disease:
allergic rhinitis
bronchial asthma
Feeding history for infant :coughing or choking
family history of asthma, atophy, immune
defficiency, cystic fibrosis
Environment : exposure to smoke, pets
Travel history : tuberculosis
APPROACH (PHYSICAL EXAMINATION)
General Examination: Vitals:
- mental state - BP
- pallor - Respiratory rate
- cyanosis - Pulse rate
- clubbing - Temperature
- generalized
lymphadenopathy Movement of accessory
muscles of respiration
Examination of neck
 APPROACH (PHYSICAL EXAMINATION)
RESPIRATORY SYSTEM PALPATION
- Position of trachea
- Expansion of the chest
INSPECTION
- Apex beat
- Nasal flare
- Shape and symmetry of the chest
wall PERCUSSION
- Respiratory rate - age > 3
- Degree of effort
- Use of accessory muscles of AUSCULTATION
respiration
- Movements of the chest - vesicular/bronchial sound
- Audible breath sound - air entry quality
- grunting - symmetry air entry on both side
- stridor - prolonged expiration phase
- wheezing - abnormal sound
 APPROACH (INVESTIGATION)

FBC Pulmonary Function

Imaging: Testing:
- Chest X-ray - Peak Expiratory Flow
Rate (PEFR)
- CT Scan
- Ultrasonography Endoscopic Evaluation of
the Airway
Measures of Respiratory - Bronchoscopy
Gas Exchange:
- Arterial blood gas Examination of Sputum
- Pulse oximetry
- Transcutaneous
electrodes
 Asthma

Lim Yen Xin

BMS14091381
 Most common chronic respiratory disorder in
childhood, affecting 15-20% of children.
Important cause of absence from school
,restricted activity and anxiety for the child
and family.
There are two types of wheezing:
a)Transient early wheezing
b)Persistent and recurrent wheezing
 Transient early Persistent and
wheezing recurrent wheezing

Episodic nature, triggered Presence of IgE to common

by viruses inhalant allergens (dust mites,
Decreased lung function pollens or pets)
from birth ,from small
airway diameter

Family history of Not a risk factor Positive family history

atopy Maternal smoking during Strongly associated with
or after pregnancy and other atopic diseases
prematurity (eczema,rhinoconjunctivitis
and food allergy)
Resolves by 5 years of Persistent symptoms and
age,presumbly from the decreased lung function
increase in airway size
 Causes of childhood wheeze
Transient early wheezing
Atopic asthma (IgE-mediated)
Non-atopic asthma
Recurrent aspiration of feeds
Inhaled foreign body
Cystic fibrosis
Recurrent anaphylaxis in a child with food
allergies
Congenital abnormality of lung,airway or heart
Idiopathic
 Pathophysiology of asthma
Up to 40% of all children are atopic.
Presence of one allergic condition increases
the risk of another
Majority of asthma exacerbations are
triggered by rhinovirus infection.
Genetic predisposition ,atopy and
environmental triggers(cold
air,allergens,smoking)
 Pathophysiology
Bronchial inflammation

Bronchial hyperresponsiveness

Airway narrowing

Symptoms
(wheeze,cough,breathlessness,chest
tightness)
 Key features
Symptoms worse at night & early morning
Triggers (e.g. exercise, pets, dust, cold air,
emotions, laughter)
Interval symtoms, i.e. symptoms between
acute exacerbations
Personal/family history of atopic disease
Positive response to asthma therapy
 Clinical features
Asthma should be suspected in any child with
wheezing on more than one occasion
Acute :
Wheeze & tachypnoea (poor guide to severity)
Increasing tachycardia (better guide to severity)
Use of accessory muscles & chest recession (better
guide to severity)
Presence of marked pulsus paradoxus (unreliable,
moderate to severe asthma)
Breathlessness interferes with talking (severe)
Cyanosis, fatigue, drowsiness (late signs)
 Chronic :
Hyperinflation of chest
Generalised polyphonic expiratory wheeze &
prolonged expiratory phase
Harrison sulci
Wet cough/sputum production
Finger clubbing chronic
Poor growth infection
 Management
Aim of management is to allow the child to live
as normal a life as possible by controlling
symptoms and preventing exacerbations,
optimising pulmonary function , while
minimising treatment and side effects.
Stepwise approach to treatment of chronic asthma
Bronchiolitis

By: Lim Ee Vern

Bronchiolitis and Pneumonia
 Definition: A disease of small bronchioles with increased mucus
production, occasionally bronchospasm, sometime leading to airway
obstruction.
Commonly caused by a viral lower respiratory tract infection.
Primary cause(80%) --> Respiratory Syncytial Virus(RSV)
Remainder are human metapneumovirus, parainfluenza virus, rhinovirus,
adenovirus, influenza virus, Mycoplasma pneumoniae
Most commonly seen in infants and young children, 90% are aged 1-9
months.
 Clinical features
RSV incubate for 4-6 days

Early phase: dry cough + rhinorrhea

Progress over 3-7 days

Noisy, raspy breathing, audible wheezing

Usually accompanied by low grade fever by irritability

Reason of admission: usually due to increasing dyspnea

 Laboratory and Imaging Studies
Routine lab tests are not required.
Pulse oximetry: monitor arterial oxygen saturation
PCR or ELISA: from nasopharyngeal secretion, to confirm
the infection
Chest X-ray: unnecessary in straightforward case,
often show signs of lung hyperinflation

Supportive
Humidified oxygen via nasal cannula(concentration determined by pulse
oximetry)
Fluids: IV or NG tube
Assisted ventilation: CPAP or full ventilation, required in small quantity of infants
admitted
Infection control measures: RSV highly contagious, good hygiene to prevent cross-
infection to other infants
 Differential diagnosis
Asthma (differentiate by age of presentation, presence of fever,
personal or family history of asthma)
Bronchiolitis Asthma
First year of life Older children with previous
wheezing episode
Fever No fever, unless respiratory
tract infection is the trigger for
asthma exacerbation

Cardiogenic asthma (wheezing with pulmonary congestion

secondary to left heart failure)
Cystic fibrosis
Foreign body aspiration
Pneumonia
 Prognosis
Most infants recover within 2 weeks
About half will have recurrent wheeze and cough
Rarely, illness result in permanent damage to the
airway (bronchiolitis obliterans)

Prevention
Monthly IM injection to palivizumab (RSV-specific monoclonal
antibody)
Limited use because it is costly and multiple injection needed
Pneumonia
Definition: Pneumonia is an infection of lower respiratory tract that
involves the airway and parenchyma with consolidation of the alveolar
spaces.
Mechanism
Pneumonia frequently starts as an upper respiratory
tract infection that moves into the lower respiratory
tract.
It is pneumonitis (lung inflammation) combined with
consolidation (liquid in spaces normally inflated with
air).

(A) Bronchopneumonia with localized pattern

(B) Lobar pneumonia with a diffuse pattern within the
lung lobe
(C) Interstitial pneumonia is typically diffuse and
bilateral
 Incidence peaks in infancy and old ages
Major cause of childhood mortality in resource poor
countries.
Viruses cause more common in young children, bacteria more
common cause in older children.
Pathogens vary according to age:
 Clinical features
Upper respiratory tract
infection Examination

Best clinical sign of pneumonia is increased

Commonest presenting symptoms:
respiratory rate
Fever
(can be missed if not measure in a febrile child
Difficulty in breathing
Silent pneumonia)

Tachypnea, nasal flaring, chest indrawing

Other symptoms: End inspiratory coarse crackles over affected
Cough area
Lethargy Oxygen saturation may decrease
Poor feeding
unwell child Classic sign often absent in young children:
1) Consolidation with dullness on percussion
2) Decreased breathe sounds
Bacterial infection 3) Bronchial breathing over affected area
Localized chest , abdominal or
neck pain is feature of pleural
irritation
 Laboratory and Imaging Studies
In younger children, nasopharyngeal aspirate useful to
identify viral cause. FBC and acute phase reactants unhelpful
in differentiating viral and bacterial cause.
Chest X-ray may confirm the diagnosis, with the exception of
classic lobar pneumonia characteristic of Strep pneumoniae
(cant differentiate between viral and bacterial)
Pneumonia associated with pleural effusion cause blunting of
costophrenic angle, some develop to empyema.
Ultrasound can distinguish between parapneumonic effusion
and empyema (different echogenicity)
 Management
Supportive and specific depends on the degree of illness. Most cases can be
managed at home.
Indication for admission: oxygen saturation<93%, severe tachypnea, apnea,
and not feeding.
Oxygen hypoxia
Analgesic pain
Antipyretic, sponging fever
Intravenous fluid correct dehydration and salt imbalance
Antibiotic according to childs age, severity, chest x-ray appearance.
Parapneumonic effusion antibiotics
Empyema drainage of collection (chest drain with or without fibrinolytic
agent in intrapleural space to break down septation/ surgical decortication)
Newborn Broad spectrum IV antibiotics
Infants Oral amoxicillin
Infants (complicated) Broad spectrum eg co-amoxiclav
>5 years old Amoxicillin or
oral macrolide(erythromycin)
 Prognosis
Follow up not required for children with simple consolidation
who recover clinically.
Repeat CXR after 4-6 weeks for cases of lobar collapse,
atelectasis, empyema.

Prevention
Annual influenza vaccine recommended for children over 6
months age.
Vaccination of H.influenzae typeb and S.pneumoniae greatly
reduce the incidence of pneumonia.