JC121 (Paediatrics) - Cough in children Flashcards
Physiology of cough reflex
Cough reflex protects the airway following inhalation of foreign material (food, secretions etc.):
Stimuli: Mechanical, chemical, thermal, inflammation
Cough receptors located within the epithelium of the pharynx, larynx, trachea, major bronchi become stimulated:
Local reaction:
Local mediators: histamine, prostaglandins, leukotrienes
Local bronchoconstriction
Afferent fibres from vagus nerve to cough centre in upper brainstem
Efferent fibres from vagus nerve and spinal cord to larynx, diaphragm, abdominal muscles cough
Respiratory and non-respiratory causes of cough
Respiratory Upper respiratory tract infection Postnasal drip syndrome (upper airway cough syndrome) Asthma Aspiration Pneumonia/pneumonitis Bronchiectasis
Non-respiratory Heart failure Gastroesophageal reflux ACE inhibitor (S/E) Psychogenic/habit cough
Outline history taking questions for cough
Patient background:
- Age: type of organism, respiratory problem
- Previous health: CAI or HAI
- Immune status: Opportunistic infections
- Neurological: aspiration pneumonia
- Atopy: asthma, post-nasal drip
- Living status: CAI from institutions
Cough characteristics: Dry vs productive, bloody or not, barking/ brassy/ wheezing/ paroxysmal
Duration of cough
Triggering factors
Associated constitutional symptoms
Causes of cough in infancy
Aspiration
Allergy: reactive airway (not dx asthma until 2 years old)
Infections: Chlamydia Pertussis Tuberculosis Post- respiratory syncytial virus
Structural Congenital malformation:
Laryngotracheomalacia/ bronchomalacia
Vascular compression (ring/ sling innominate artery)
Passive smoking
Congenital heart disease
Causes of cough in early childhood
Aspiration
Asthma (>2 years old)
Infections: Viral Tuberculosis Mycoplasma Fungal
Bronchiectasis:
Immunodeficiency
Cystic fibrosis
Post-infectious
Sinusitis
Causes of cough in late childhood/ adolescence
Aspiration
Asthma
Infections: Viral Tuberculosis Mycoplasma Fungal
Bronchiectasis:
Immunodeficiency
Cystic fibrosis
Post-infectious
Sinusitis*
Mediastinal tumor*
Active or passive smoking*
Psychogenic cough*
Types of productive cough
Mucus: Normally produced by goblet cells and submucosal glands, increase in volume during illness
Exudates: Protein-rich fluid leaked from capillaries in alveoli due to inflammatory response (usually due to infection)
Acute cough
Define time limit
Causes
= recent onset of cough lasting <3 weeks
Causes of acute cough: URTI: mostly viral infection LRTI: Viral or bacterial infection Exacerbation of pre-existing disease: - Asthma (acute attack) - Bronchiectasis (flare) - Upper airway cough syndrome
List viral and bacterial pathogens that cause acute cough
Viral:
Influenza, respiratory syncytial virus, parainfluenza, adenovirus, rhinovirus, human coronavirus, human metapneumovirus (hMPV), bocavirus
Bacterial: Streptococcus pneumoniae Haemophilus influenzae Moraxella catarrhalis Pseudomonas (if immunocompromised) Chlamydia (if neonate)
Outline P/E for acute cough
A. Vital signs, temperature (fever)
B. Respiratory distress: RR, use of accessory muscles, dyspnea, cyanosis
C. Chest exam: deformity, percussion, auscultation (wheeze, crepitations, rhonchi)
D. Associated finding:
Skin rash, eczema
Lymph nodes, tonsils
Rhinorrhea
Define respiratory rate for tachypnea in neonates < 2 months, 2-12 months and >1 year old
tachypnea in children:
>60 for <2m,
>50 for 2-12m,
>40 for >1 yr
Child presents with acute cough that worsens when laying down
The cough is triggered by pollen at certain seasons
Most likely dx
Post-nasal drip from allergic rhinitis
Child presents with cough and nasal discharge, sore throat and fever
Most likely Dx
Acute upper respiratory tract infection
Most likely viral infection
Child presents with hoarseness, acute cough, high fever, and stridor
Most likely ddx
Viral croup
Recurrent spasmodic croup
Bacterial tracheitis
Child presents with fever, tachypnea, increase work of breathing, productive cough and some wheezing
Most likely dx
Lower respiratory tract illness:
Acute bronchiolitis:
Typically RSV, hMPV
Present with wheezing due to inflammatory exudates in small airways
+/- crepitations
Pneumonia (viral, bacterial)
Asthma (should not present with crepitations, just wheeze)
Child with acute cough presents with finger clubbing, failure to thrive and some chest deformity
Most likely Dx
Acute exacerbation of a chronic respiratory disorder e.g. bronchiectasis
Clinical features of allergic rhinitis/ reactive airway/ asthma in a child
Seasonal and diurnal variation
Posture (more cough when lay down worsen postnasal drip)
Triggers (dust, pollutant, pollen etc.)
Association with rhinitis
‘Clearing of throat’ (postnasal drip)
Clinical features of acute URTI in children
Coryzal symptoms (common cold: cough, nasal discharge)
Sore throat
Fever