Cough in the Pediatric Patient Flashcards
Pathophysiology of Cough
Cough is a protective mechanism required to maintain patency of the airway and clear retained secretions
Cough receptors are found along the surface of the pharynx, larynx, trachea, major bronchi middle ear, sinuses, pericardium and diaphragm
Cough is a brainstem reflex but is also under voluntary control
Cough receptors can become unresponsive to repeated stimulation
Cough Involves 3 Phases
Deep inspiration, compression and exhalation
During inspiration the airways open and lungs inflate
During compression the glottis closes and the abdominal and intercostal muscles contract increasing pressure in the lungs
Exhalation occurs when the glottis opens
In the pediatric patient a cough of more than 3 to 4 weeks is a chronic cough
Key parts of the history
Age of the child
Nature and timing of the cough
Time of year
Cough wet or dry
Cough after feeding in the newborn
May be overfeeding, GERD or TEF
If cough stops after decreasing volume of feedings, overfeeding is most likely cause
If cough worsens with feedings or is associated with vomiting, GERD is a likely
If cough worsens with feeding and no vomiting TEF should be considered
Both GERD and TEF can be associated with wheezing, cyanosis and tachypnea
Respiratory Rate as a Clue
Cough associated with tachypnea in the presence of elevated, normal or decreased body temperature requires sepsis to be considered
Cough associated with cyanosis that is relieved by O2 administration suggests a intrapulmonary process
Cough with cyanosis not relieved by O2 suggests congenital heart disease with R to L shunt
***** This finding with or without heart murmur REQUIRES a thorough cardiac evaluation
Cough in Infancy
Infectious causes must be considered
RSV infection-infants at higher risk include preterm infants, infants with cyanotic heart disease or immunodeficiency
A staccato cough in the first few months of life suggests infection with Chlamydia trachomatis pneumonia
Pertussis may cause spells with apnea
Causes of Cough in Infancy
Asthma – consider family history
Aspiration – ask about choking with feedings, rattly breathing after feedings
Congenital airway disease – laryngomalacia,
tracheomalacia, tracheoesophageal fistula, vascular compression of the airways
Cystic fibrosis (normal newborn screening does not completely exclude cystic fibrosis)
Infections – Chlamydia, pertussis, viruses, maternally transmitted tuberculosis
Other – environmental tobacco smoke, pollution, congenital heart disease, idiopathic hemosiderosis
A Cough in the Toddler
Asthma must be considered in this age group but because toddlers cannot perform spirometry it can be a difficult diagnosis
Bronchiectasis may be present if the toddler has CF, ciliary dyskinesia or immunodeficiency
The cough of bronchiectasis is described as wet
Chronic middle-ear disease, allergy and sinusitis can cause chronic cough
Causes of Cough in Toddlers and Early Childhood
Asthma (with or without wheezing)
Bronchiectasis – cystic fibrosis, ciliary dyskinesia,
immunodeficiency, postinfectious
Chronic middle ear disease, allergy, sinusitis
Foreign body in airways
Pulmonary hemosiderosis
Cough in an Adolescent
Asthma is a common cause of chronic cough
Tumors in the chest (rare) can cause chronic cough in this age group
Vocal cord dysfunction that is often associated with stress or exercise can mimic exercise induced asthma with sudden symptoms of inability to breathe
Causes of Cough in Adolescents
Asthma Bronchiectasis – postinfectious Ciliary dyskinesia Immunodeficiency Cystic fibrosis Infection: viral, Mycoplasma, fungal Middle ear disease Smoking Occupational exposure Psychogenic cough Sinusitis/postnasal drip Chest tumor
Focused History for Cough
Age of child Nature of cough Stridor or wheezing Timing and season Sputum, presence and character Exposure to infection Response to previous therapy Family history of atopy, asthma, eczema, cystic fibrosis
Focused Examination for Cough
Nutrition and growth
Upper respiratory tract – ears, nose, and sinuses
Chest – Anterior-posterior thoracic diameter, lung sounds, cardiac examination
Extremities – clubbing
Skin – eczema
Diagnosis of a Foreign Body
Flexible bronchoscopy can identify a foreign body but cannot be utilized for removal
Rigid bronchoscopy is required for removal so that the airway can be stabilized and instruments passed to use in the removal of the object
The entire tracheobronchial tree should then be examined to look for other foreign bodies
