April 2008

MANAGEMENT OF CHRONIC COUGH

HUEH 2011

TERRY FLOTTE, MD

Primary source:Murray and Nadel’sTextbook of Respiratory Medicine 2010

December 2010

ORIGIN OF COUGH REFLEX

• Irritant receptors of the airways via Cranial Nerve 10– Larynx

– Trachea

– Bronchi

• Rarely, referred from external ear due to Vagus innervation– foreign body in external auditory meatus

COMMON DIFFERENTIAL OF COUGH

• Upper airway

– Post-nasal drainage• Viral URI

• Allergic rhinitis

• Sinusitis

– Gastro-esophageal Reflux Disease

– Direct aspiration

• Lower airway

– Infectious• Pneumonia (bacterial, viral, mycoplasma, chlamydia)

• Bronchiolitis (RSV, metapneumovirus)

• Influenza, parainfluenza, Adeno, measles

• TB

• Pertussis

• HIV

– Environmental irritant

• Wood-burning

• Other environmental

– Asthma

– Aspirated foreign body

– Cystic fibrosis or immune defects

– Tumors and malformations

December 2010

MAJOR POINTS FROM HISTORY AND PHYSICAL

• Acute vs. chronic

– Acute: pneumonia, URI, other infections

• Upper vs. lower origin

– Upper: sinusitis, allergy,viral URI, GERD, aspiration

• Systemically ill vs. not systemically ill

– Systemic: TB, HIV, immune defects and CF

• Digital clubbing indicates chronic hypoxemia

December 2010

CASE

• 3 year old child with fever, tachypnea, cough progressing over last 4 days

• Exam RR60, T40.3C, Pulse ox 94%

• Crackles over right axilla, increased whispered pectorloqy, bronchial breath sounds

December 2010

MANAGEMENT OF ACUTELOWER RESPIRATORY TRACT

INFECTION

• Rule-out and treat malnutrition

• Evaluate for signs of sepsis or acute decompensation– In this case, stabilize, give first dose IM and ship to hospital

• Oral therapy with TMP/sulfa or amoxicillin

• Parenteral therapy with Amp/Pen and Gentamicin or Ceftriaxone

CHRONIC COUGH• With Sputum

– Chronic irritants (COPD in adults)

– TB

– Immune Defect, CF, cilia defect

– Bronchiectasis due to any of above, long-term aspirated foreign body

– Untreated pneumonia with abscess

– Rarely asthma

• Without sputum

– Asthma

– Chronic irritants

– Recent foreign body

– TB

– Upper airway sources

December 2010

CASE

• 6 yo with 5 month history of cough, weight loss, some night sweats, swallowing sputum

• Few anterior crackles on exam, very thin

• Tests? Differential?

December 2010

RISK OF PULMONARY AND EXTRAPULMONARY DISEASE IN TB

BY AGERisk of Disease Following Primary Infection Comments

Age Disseminated TB or Meningitis

Pulmonary TB

No Disease

<1 year 10-20% 30-40% 50% High morbidity

1-2 years 2-5% 10-20% 75-80% High morbidity

2-5 years 0-5% 5% 95%

5-10 years <0.5% 2% 98% Safe School years

> 10 years <0.5% 10-20% 80-90% Effusions or adult type pulmonary disease

December 2010

DIAGNOSIS OF TB• Tuberlin Skin Test (PPD) reactivity

– False positives due to BCG (altered criteria)

– False negatives due to anergy

• Acid-fast stain and/or culture (very poor sensitivity, 10 to 15%– Sputum

– Gastric aspirates

• Clinical– Radiographic pattern (hilar adenopathy, disseminated pattern,

effusion)

– Chronic history with fever, cough, weight loss, night sweats

– Exposure history

– Risk factors: HIV, overcrowding, local prevalence

December 2010

TB PREVENTION

• Prophylaxis for children in home of TB-infected adult

• BCG

• ? New vaccines

December 2010

CASE

• 10 year old with history of recurrent cough, dyspnea while playing soccer (?futbol?), nocturnal cough during episodes of rhinorrhea

• Exam normal, no digital clubbing

• Differential diagnosis? Studies? Medication trial?

December 2010

CASE

• 7 year old presents with 3 month history of cough

• History of when it first began reveals sudden onset of severe cough, no rhinorrhea or other prodrome, no fever

• Exam reveals differential wheezing right>left

• Further questions?

• X-ray Exams? Differential?

Ou est l’arachide?

December 2010

SPECIAL CASES

• Recurrent pneumonias, X-ray proven (see following)

• Chronic cough with sputum production

– Chronic irritant

– Immune Defect

– TB

– Less common with asthma

• Digital clubbing

RISK FACTORS FOR PNEUMONIAMORBIDITY AND MORTALITY

(WHO-GAPP)

• Nutritional deficiency– Shortened breast-

feeding time

– Underweight

– Zinc deficiency

• Indoor air pollution– Wood-burning

– Tobacco smoke

– Urban air pollution

• Immunization status (measles, pertussis, Hib, Pneumococcus)

• Case Management– Prompt detection and

Antibiotic therapy

• HIV status

© 2002 Lippincott Williams & Wilkins, Inc. Published by Lippincott Williams & Wilkins, Inc. 3

Table 2Evaluation of children with recurrent pneumonia diagnosed by World Health Organization criteria.HEFFELFINGER, JAMES; DAVIS, TIMOTHY; GEBRIAN, BETTE; BORDEAU, ROYNELD; SCHWARTZ, BEN; DOWELL, SCOTT

Pediatric Infectious Disease Journal. 21(2):108-112, February 2002.

Table 2 . Clinical findings* Chest radiographs revealed infiltrates.NS, not significant.

December 2010

EVALUATION OF CHILDREN WITH RECURRENT PNEUMONIA IN HAITI

• Heffelfinger, et al., Peds Inf Dis Journal 2002

– Screened for TB, immune deficiency, HIV

– Most were sporadic

– Only association was with Asthma, but this was a minority of cases

CASE

• 8 year old with history of three distinct episodes of right upper lobe pneumonia

PULMONARY SEQUESTRATION

• One of several congenital malformations that can lead to recurrent pneumonia at a single location– Congenital cystic

adenomatoid malformations

– Bronchogenic cysts

• Abnormal blood supply and lacks normal bronchial connection