Define respiratory rate for tachypnea in neonates 1 year old

tachypnea in children: >60 for 50 for 2-12m, >40 for >1 yr

JC121 (Paediatrics) - Cough in children Flashcards by Max Kam

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

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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

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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

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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

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Causes of cough in early childhood

Aspiration

Asthma (>2 years old)

Infections:
 Viral
 Tuberculosis
 Mycoplasma
 Fungal

Bronchiectasis:
 Immunodeficiency
 Cystic fibrosis
 Post-infectious

Sinusitis

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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*

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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)

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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

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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)

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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

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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

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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

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Child presents with cough and nasal discharge, sore throat and fever

Most likely Dx

Acute upper respiratory tract infection

Most likely viral infection

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Child presents with hoarseness, acute cough, high fever, and stridor

Most likely ddx

 Viral croup
 Recurrent spasmodic croup
 Bacterial tracheitis

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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)

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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

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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)

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Clinical features of acute URTI in children

 Coryzal symptoms (common cold: cough, nasal discharge)
 Sore throat
 Fever

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Clinical presentation of acute airway obstruction in children e.g. croup, epiglottitis

 Stridor (upper airway obstruction)
 ‘Barking’/ brassy/ ‘croupy cough’
 Hoarseness
 +/- fever

Clinical features of LRTI in children

 Fever
 Tachypnea
 Respiratory distress with increased work of breathing
 (Productive cough)
 Chest signs (crepitations/ wheeze/ rhonchi)

Clinical features of chronic respiratory disorder in children

 Failure to thrive
 Finger clubbing
 Chest deformity
 Features of atopy

First-line investigations for acute cough in children

Not needed in most children with simple URTI

CXR - indications:

LRTI
Relentless progressive cough past 2 weeks
Hemoptysis

Microbiological workup:

CBC and differentials (bacterial pneumonia)
Nasopharyngeal aspirates for common viruses, Mycoplasma
Sputum for Gram stain and culture
Blood culture e.g. pneumococcus

Definition of pediatric (<15yrs) chronic cough

American College of Chest Physician Guideline:
daily cough lasting for > 4 weeks

British Thoracic Society
Cough lasting >8 weeks
Recognizes a ‘grey’ area of ‘subacute cough’ between 2-8 weeks

Outline history taking for chronic cough in children

HPI:

Onset of cough: e.g. from neonatal period or later
Start of cough: after choking? with URTI?
Quality of cough
Trigger of cough: Exercise/ cold air, nocturnal, feeding

Ddx underlying cause:

Feeding difficulties
Chest pain-related
Neurodevelopmental abnormality (cerebral palsy)
Recurrent pneumonia

Ddx causes of chronic cough depending on onset and start/ first episode

``` Neonatal onset  Aspiration (tracheoesophageal fistula)  Congenital malformation  Cystic fibrosis (inherited)  Primary ciliary dyskinesia (inherited) ``` With choking: inhaled foreign body With URTI: Post-viral cough

Ddx causes of chronic cough by quality of cough ***

Dry cough: Mycoplasma, asthma, viral infection Dry/ repetitive/ disappears with sleep/ Honking cough: Psychogenic/ habit cough Productive (Moist/ wet) - Chronic suppurative lung disease/ pneumonia Hemoptysis/ blood-stained: TB, Bronchiectasis, AV malformation, Pneumonia, Excoriated airway Paroxysmal spasmodic cough: Pertussis, Parapertussis, Mycoplasma, Viral Barking/ brassy cough: Croup, Tracheomalacia, Habit cough Staccato cough: Chlamydia

Ddx dry vs productive chronic cough in children

Dry:  Mycoplasma (1st week)  Asthma  Viral (e.g. coronavirus) Productive:  Chronic suppurative lung disease (e.g. bronchiectasis)  Pneumonia

Ddx hemoptysis/ blood stained chronic cough in children

```  TB (in adolescents)  Bronchiectasis  AV malformation (in younger children)  Pneumonia  Excoriated airway ```

Ddx Paroxysmal spasmodic chronic cough in children

 Pertussis, parapertussis  Mycoplasma  Virus

Ddx causes of chronic cough due to trigger by exercise, cold air, nocturnal, feeding

Exercise, cold air = Asthma/ reactive airway Nocturnal (2-3am, early morning)  Upper/ lower respiratory allergy  Sinusitis Feeding = Recurrent aspiration

Ddx chronic cough with feeding difficulties in children

 Serious systemic illness (including pulmonary)  Aspiration Neurodevelopmental abnormality (cerebral palsy)

Ddx chronic cough with chest pain in children

 Arrhythmia  Asthma, increased respiratory distress (parenchymal disease)

Ddx recurrent pneumonia in children

 Immunodeficiency  Congenital lung abnormalities  H-type tracheoesophageal fistula

Outline P/E for chronic cough in children ***

Growth: Failure to thrive Respiratory distress: Hypoxia/ cyanosis Finger clubbing: chronic suppurative lung diseases Upper respiratory tract: Sinusitis, allergic rhinitis - Sinusitis: facial tenderness, persistent purulent nasal discharge - Allergic sinusitis: nasal obstruction/ discharge Lower respiratory tract: Chronic lung disease - Chest wall deformities: Harrison sulcus, Pectus carinatum, Barrel chest - Hyperresonance - Creptitation and breath sounds Cardiac: Murmur, heart failure Skin: Eczema

Causes of non-specific chronic cough in children (dry cough in absence of an identifiable respiratory disease of known etiology) Management of non-specific cough

Causes:  Post-viral  Another episode of acute infection  Others: foreign body, asthma, GERD (reflux) etc. Evaluation: conservative, non-interventional  Avoid Tobacco smoke, other pollutants  Child’s activity and thriving

First-line investigations for chronic cough in child

- Workup bronchiectasis, TB, Primary immunodeficiency, Chronic pneumonia, structural lesions in bronchi List: - CXR - Spirometry tests: obstructive or restrictive pattern - CBC with differentials (immunodeficiencies, infections) Microbiological workup: - Test for TB (Mantoux test or purified protein derivative test or interferon-based test - Sputum/ gastric aspirate for AFB stain and culture, TB PCR, routine culture and CST Radiological: - HRCT/ MRI DDx: - Cilia study for primary ciliary dyskinesia - 24h esophageal pH study - Reflux - VFSS - aspiration - Bronchoscopy - intraluminal lesions

Treatment for viral URTI

most viral infection, including: bronchitis, viral pneumonia - No specific antivirals - Supportive Influenza: - Antivirals available: oseltamivir, zanamivir

Treatment of CAP in children

Community acquired pneumonia  Streptococcus pneumoniae  Haemophilus influenzae  Moraxella catarrhalis Augmentin

Treatment of atypical pneumonia in children

Commonly Mycoplasma pneumoniae, others: Legionella and Chlamydia  Quinolone  Doxycycline (avoid in <8yo because permanent teeth discoloration)  Clarithromycin (macrolide resistance 30%)

Treatment of pseudomonas and S. aureus respiratory infection in children

Pseudomonas  Extended-spectrum penicillins (e.g. piperacillin- tazobactam)  3rd/ 4th generation cephalosporins (e.g. ceftazidime)  Carbapenems (e.g. meropenem)  Aminoglycosides (e.g. amikacin)  Fluoroquinolones (e.g. levofloxacin) = only oral available Staphylococcus aureus: Vancomycin

Symptomatic treatment options for cough in children

Antihistamine: diphenhydramine, Chlorpheniramine Antipyretic, analgesic: paracetamol, ibuprofen Antitussives/Cough suppressants: Codeine, Dextromethorphan, Hydrocodone Expectorant: Guaifenesin Nasal decongestants: Ephedrine, Phenylephrine, Pseudoephedrine, Phenylpropanolamine Cough relief: - Oral hydration with warm liquid - Honey in water

Which symptomatic relief agents are not recommended for treating cough in children

Antihistamines: no effect, not recommended Expectorants, mucolytics: No recommendation for expectorants, limited recommendation for mucolytics Cough suppressants: Definitely NOT recommend codeine or hydrocodone-containing cough suppressants

Codeine - Reasons for contraindicated use in children - S/E

``` Codeine: - Narcotic with addictive potential - Dose-related toxicity:  Respiratory depression  Narcosis, somnolence  Ataxia  Miosis  Vomiting, rash  Swelling  Itching ```

Dextromethorphan - Reasons for contraindicated use in children - S/E

Nonaddictive but abused by teenagers Dose-related S/E:  Ingesting huge doses = bizarre behaviour  CNS depression

Honey as cough relief for children - Recommendation on use - Contraindications

Recommendation: Modest beneficial effect on nocturnal cough (more effective than placebo or diphenhydramine) Contraindication: risk of botulism (food poisoning)