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 ? Why is it important? Defined as > 4 weeks by Irritating most studies and guidelines Distressing to parents 1-3 Poor quality of life Except the British Can indicate serious underlying disease 1. Chang. Chest 2012 2. Chang. Pediatrics 2013 3. Chang. Chest 2016

Importance of paediatric cough guidelines Etiology in children differs 1 Specific cough pointer or abnormal spirometry or abnormal CXR Reversible airway obstruction Consider early referral to paediatric pulmonologist Asthma YES� Paediatric-specific guidelines NO Assess risk factors for Appropriate treatment If poor response reevaluate risks published in 2013 2 Bronchiectasis Chronic or less Other Cardiac Interstitial Airway Recurrent common Aspiration uncommon disease Lung disease abnormalities Pneumonia infections pulmonary disorders Better clinical outcomes 3 Cystic Fibrosis Pulmonary Laryngeal Rheumatic Laryngotracheo- Primary Ciliary TB hypertension malacia abnormalities diseases Dyskinesia Non TB Pulmonary Tracheal Neurological Bone marrow or Primary and Immunodeficiency Mycobacterial edema stenosis abnormalities solid organ secondary Congenital lung infections Extrinsic Neuromuscular transplantation pulmonary Mycoses lesion compression disease Cytotoxic drugs tumours Cardiology Missed foreign body Parasites e.g. vascular GERD Radiation referral TEF/H-fistula rings ECHO Intrinsic lesions Cardiac e.g. tumors Tuberculin test Autoimmune Catheterization Contrast swallow Sweat test Bronchoscopy & screen Videofluroscopy Cilia biopsy Lavage HRCT Chest pH monitoring Bronchoscopy Immune work up HRCT chest Bronchoscopy Milk scan CT Chest HRCT chest and lavage Salivagram +-MRI chest Flexible Lung Biopsy Bronchoscopy bronchoscopy Contrast swallow 1. Marchant. Chest 2006 2. Chang. Paediatrics 2013 3. Chang. Chest 2016

Diagnostic approach Examination Special History investigations Identify Cough phenotype Specific vs non- specific

History • Cough specifics • Past episodes of pneumonia – Age and onset – Focal/diffuse – Nature – Timing and triggers • Family history – Associated symptoms • Exposure to allergen, • Birth history, prematurity irritant, infection, • Atopy/allergy medication • Response to treatment

Diagnostic approach Examination Special investigations Respiratory Spirometry Exclude underlying CXR disease Identify Cough phenotype

Cough Pointers Chang Chest 2006; Chang Ped Pulmonol 1999

Isolated Specific cough pointer or abnormal spirometry or abnormal CXR? NO non-specific cough YES Reversible airway obstruction ? Daily wet cough only? YES NO YES NO Protracted Bacterial bronchitis Asthma Treat with antibiotics for two Appropriate treatment weeks If poor response If incomplete response reevaluate risks REFER REFER

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

Isolated Specific cough pointer or abnormal spirometry or abnormal CXR? NO non-specific cough YES Reversible airway obstruction ? Daily wet cough only? YES NO YES NO Protracted Bacterial bronchitis Asthma Treat with antibiotics for two Appropriate treatment weeks If poor response If incomplete response reevaluate risks REFER REFER

Isolated non-specific cough • Usually post infectious cough or prolonged acute bronchitis • Exclude ear problems • Cough Hypersensitivity Syndrome (Habit cough) • Exposure to irritant • Rare: Foreign body, Asthma, GERD

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 (5 th %) and height 1.38 (10 th %) • 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 of aspiration • Not every wheeze is asthma • Refer children with the recurrent pneumonia or prolonged wet cough

drkritzinger@chestandallergy.co.za