Transcript Cough Diagnosis & Treatment

World Allergy Organization
Cancun, Mexico 2011
Pediatric Cough
Pramod Kelkar, MD
Past Chair, Cough Committee, American
Academy of Allergy, Asthma & Immunology
Founder, National Cough Clinic
Private Practice:
www.allergy-care.net
www.nationalcoughclinic.com
Minneapolis, MN, USA
Disclosures
• None
ChrCough is a Multi-Disciplinary Symptom
 Pediatrician
 Allergy/Immunology
 Pulmonary
 Otolaryngology
 Gastroenterology
 Speech therapy
 Behavior counseling
 Psychiatrist
Etiology of Pediatric Chronic Cough
Cough in Children
• Important protective defensive mechanism, necessary
for effective airway clearance
AND
• Common symptom of respiratory disease
• Most common symptom for visit to MD office in US
(3.4%)
• Parental reporting of cough correlates poorly w/ objective
measures (frequency, duration, intensity) Chang , Arch Dis Child 2003
• Cough known to cause anxiety and depression in
parents
Chang , Arch Dis Child 2003; Marchant, Chest 2008
History
• Triggers: Talking, laughter, walking, running,
strong smells, perfumes
• Timing: Daytime Vs nighttime
• Relationship with meals
• Preceding Events:
Viral URI, Recent Immigration from a
developing country, foreign travel
• Cough triggered by swallowing: aspiration,
tracheoesophageal fistula, laryngeal
abnormalities
• Review of systems is very important
Analysis of cough sound
• Barking or brassy cough: Croup,
tracheomalacia, habit cough
• Honking: Psychogenic
• Paroxysmal with or without whoop:
pertussis and parapertussis
• Staccato: Chlamydia in infants
Physical Examination
• Thick, yellow postnasal drip visible in
oropharynx: think chronic sinusitis
• Look into ears to rule out wax impaction
and other causes (Arnold’s Nerve)
• Look at nails for clubbing (CF, etc.)
• Check for thyroid masses
• Look for signs of atopy
Cough Reflex Sensitivity
• Can be modulated by disease or drugs
• Heightened CRS can occur in post-viral
cough, asthma, GERD, ACE-inhibitor
therapy
• CRS more common in women
Cough Receptor Hypersensitivity
Syndrome is an important concept!
Good resource: www.coughjournal.com
Normal Cough
• Normal Children Cough
• Healthy school-age children can have up to
34 cough episodes per day
• Can at times appear prolonged or nocturnal
• Recurrent viral URI may seem like persistent
cough
• Post-infectious cough can last 10 days or
longer after a viral infection
Abnormal Cough
• Chronic cough- lasts > 4 to 8 weeks
• Character/Quality of cough- spasmodic
(pertussis), barking/brassy (croup)
• Wet or dry
• Nocturnal- asthma, sinusitis
• Age of the child- infants and young children
have anatomic abnormalities of respiratory
and GI tract
Classification Of Cough in Children
Dry
nl CXR
10-11 cough
episodes/day
Abnormal chest exam/
XR
(range up to 34)
Dyspnea
Hemoptysis
Recurrent pneumonia
Wet > Dry
Chang, Cough 2005
FTT
Swallowing problems
Specific Cough
• Associated with underlying respiratory
or systemic disease
• Obvious symptoms or signs/physical
examination, abnormal CXR, abnormal
laboratory results
• Example- Bronchiectasis, Pertussis
Nonspecific cough
• Isolated cough as the sole symptom
• Usually dry
• In adults- UACS, Asthma, Eosinophilic
bronchitis, GERD
• In children- UACS, Asthma and GERD
account for <10% of causes
• Most common cause in children- Protracted
Bacterial Bronchitis
Protracted Bacterial Bronchitis
• Most common ( up to 40%) cause of
nonspecific chronic wet cough in children
• Resolves with antibiotic therapy
• Misdiagnosed or underdiagnosed
• Bronchoscopy shows neutrophilic
inflammation
• S. pneumoniae, H. influenzae, M. catarrhalis
• Amoxicillin and clavulanate for two weeks
Donnelly D, et al. Thorax 2007;62:80-4
GERD
• Far less common in children than adults
• Aspiration with swallowing in the absence of
GERD may cause cough
• Silent reflux often associated with asthma
• A positive response to empiric therapy with
thickened feedings in infants and an acidsuppressive regimen suggests GERD
• Nonacid reflux detected by impedance
measurement
Habit Cough Syndrome
• Dry, barking or honking
• Absent at night, improves with distraction
• Sounds very annoying but the child is
unperturbed (la belle indifference)
• Very disturbing to parents, teachers,
caregivers
• May start after a viral infection
• Can be difficult to differentiate from a tic
disorder/Tourette’s syndrome
Treatment of Habit Cough
• Accurate diagnosis is important to avoid
unnecessary exhaustive work-up
• Self hypnosis
• Biofeedback
• Breathing exercises/Speech therapy
• Suggestion therapy
• Lidocaine via nebulization
Upper Airway Cough Syndrome
• Old terminology was postnasal drip syndrome
• Includes allergic and nonallergic rhinitis,
sinusitis, tonsillar hypertrophy causing tissue
impingement on the epiglottis
• Limited CT sinus is helpful for sinusitis
• Treat the cause
• Older/first-generation antihistamines like
brompheniramine can be helpful
Asthma
• Accurate diagnosis is critical
• Cough-variant asthma- over-diagnosed
or under-diagnosed?
• A time-limited (4-6 weeks) empiric trial
of ICS +/- leukotriene modifiers
• By itself, a response to ICS does not
confirm a diagnosis of asthma
• Presence of multiple causes may delay
the response
Interesting Facts
• While children with asthma can present
with chronic cough, most children with
isolated cough do not have asthma
• Environmental Tobacco Smoke (ETS)
exposure is associated with increased
coughing illnesses and an imprtant
contributing factor, ETS alone is not the
sole etiology
Methacholine Challenge test
In a setting of adult chronic cough
patients:
• Positive predictive value:60-88%
• Negative predictive value:100%
Chest 1999;116(2):279-84
Natural history of coughvariant asthma
• Not entirely clear due to lack of
sufficient data
• In one 4-year retrospective study of 42
patients, 7 went into remission, and 13
developed classical asthma
Matsumoto H, et al. J Asthma.
2006;43(2): 131-5
Recurrent Cough
• What is the likelihood of asthma in a
child presenting with recurrent cough
• In a child with asthma, is cough severity
a reflection of asthma severity
• Recurrent cough in the absence of
wheeze is generally not from asthma
• Children with recurrent cough have an
increased cough receptor sensitivity to
capsaicin
Treatment of recurrent cough
• Usually self-limiting
• A short therapeutic trial with asthma
meds can be considered (4 weeks)
• If a child doesn’t respond, then avoid
escalating treatments but rather take a
step back to reassess
• Is the child any worse without the
treatment
Cough in an asthmatic child
• Cough in an asthmatic child is often due
to increased cough receptor sensitivity
• Cough severity may not reflect asthma
severity
• Cough should not be used as the major
indicator for the level of asthma
treatment especially in an acute episode
• Complete absence of cough may not be
essential for asthma control. Avoid
overtreatment
General Principles in
Management
• Clinical history and physical exam are used to
guide testing
• Recommendations are based primarily on
expert opinion, due to lack of controlled
pediatric studies
• No evidence supporting the use of
medications for symptomatic relief of acute or
chronic cough in children; some data
suggests potentially harmful effects
Are we missing pertussis?
• 75 adults, cough for more than 14 days
• Pertussis diagnosis based on culture and PT
or FHA titer
• 21% of adults had evidence of B. pertussis
infection
• Clinical features and routine lab tests were of
limited value in making the diagnosis
JAMA 1995;273:1044-1046
Pertussis: Laboratory Diagnosis
• Leukocytosis with absolute lymphocytosis
• (Posterior) Nasopharyngeal swab and
aspirate
• DFA testing: quick results but unreliable
• PCR: results in 48 h, false positives possible
• Culture of swab: takes 7 days for results
• Negative culture does not rule it out!
• Serology: IgG and IgA to fimbria, pertussis
toxin and filamentous hemagglutinin (not
standardized)
• Blood cultures: not useful
Pertussis
When to suspect & Whom to treat?
• Suspect and treat if a clear cut history of
exposure
• Suspect and treat if cough and vomiting (?)
• Erythromycin is the drug of choice; however,
unless administered early, it does not alter
the course of the disease
NEJM 2000;343(23):1715-1721
JAMA 1995;273:1044-1046
Foreign Body Aspiration
• Onset after an episode of choking, or
sudden onset while eating or playing
• Toddler age range
• Parents may have forgotten about
aspiration episode
Algorithm for evaluating chronic cough in children
(modified from Chang 2006)
Sx and signs of
respiratory disease?
Yes
No
CXR, spirometry abnormal?
EVALUATE FOR
SPECIFIC COUGH
Yes
No
Is cough characteristic?
Sx and signs suggest
specific cough
No
NON-SPECIFIC COUGH
1. Watch, wait, review
•Usually post-infectious
2. Evaluate
•Tobacco smoke
•Environmental exposures
•Child’s activity
•Parent concerns, expectations
3. Treat obvious illness
Review in 1-2 wk
Resolving, resolved
Persistent cough
Discuss options with parents
Trial of therapy
Dry cough:
ICS 4-8 wk
Watch, wait, review
Wet cough:
Antibiotic 10-21 d
Algorithm for evaluating chronic cough in children
(modified from Chang 2006)
SPECIFIC COUGH
ASTHMA
Confirm with 4-8 wk
trial of medication
Yes
Reversible airway
obstruction?
No
Assess risk factors for:
Bronchiectasis or recurrent
pneumonia
Aspiration
Chronic or less common infections
Interstitial lung disease
Airway abnormality
Other less common pulmonary
conditions
Cardiac disease
Investigations as outlined
Or
Consider referral to
allergy or pulmonary
specialist
OTC Cough and Cold Medications
in Children
• Ten percent of U.S. children were taking OTC
CCM/week.
• Approved for adults, testing for efficacy and safety in
children not adequate.
• Adverse events documented; rare deaths.
• 2007 AAP position statement questioning efficacy
and safety <6 years.
• 2008 FDA Public Health Advisory OTC CCM.
• 2009 FDA recommended avoiding in <2 years.
• 2010 Consumer Health Product Association avoid <4
years.
• March 2011 FDA--removal of 500 unapproved Rx
cough, cold and allergy meds.
Can asthma be a possibility if a preand post-bronchodilator spirometry
is completely normal?
(A)Yes
(B) No
Methacholine Challenge test and allergy
skin test correlative study in the diagnosis
of asthma
• N= 175
• Allergy skin tests are simple, safe,
inexpensive and reliable and there was an
excellent correlation between these two tests
• More studies needed to clarify this further
Graif Y, Yigla M, Tov N, et al Chest 2002 Sep;122(3):821-5
Chronic cough completely
Relieved by a course of
Prednisone.
Is this diagnostic of asthma?
Chronic cough relieved by
prednisone
Possibilities:
(1) Allergic rhinitis
(2) Asthma
(3) Eosinophilic bronchitis
(4) Others
Eosinophilic bronchitis
Asthma
Eosinophilic
bronchitis
• Sputum eosinophilia
• Sputum eosinophilia
• Airway
• No airway
hyperresponsiveness
hyperresponsiveness
• Treatment is inhaled or • Treatment is inhaled or
oral steroids
oral steroids
• Natural history unclear
Am J Respir Crit Care Med 1999;160:406-410
Causes of cough:
single or multiple?
• Multiple causes were found in more
than 60% when a large number of
diagnostic tests are performed (US
experience)
• Multiple causes were found in <26%
when investigations were tailored to
presenting features (European
experience)
Reasons for misdiagnosis of
chronic cough
• Failure to consider common
extrapulmonary causes
• Insufficient dose of medication or
duration of therapy
GERD/Laryngopharyngeal Reflux
Vocal fold edema
Pseudosulcus vocalis
Ventricular obliteration
Posterior commissure hypertrophy
Ear, Nose, Throat J 2002;82 (9 Suppl 2): 10-13
Risks of proton-pump inhibitor therapy
• Community-acquired pneumonia
• Calcium malabsorption and hip fractures
• Vitamin B-12 malabsorption
(assess vitamin B-12 levels in patients on
long-term PPI
• Community-acquired C diff. infection
• Atrophic gastritis (PPI+ H. pylori)
Dose and duration- dependent!
Bradford GS, Taylor CT. Omeprazole and vitamin B-12 deficiency. Ann
Pharmacother 1999, 33: 641-643
Yang YX, et al. Long-term PPI therapy and risk of hip fracture JAMA. 2006
Dec 27;296(24):2947-53
What is the clinical utility of
flexible bronchoscopy
• Adds little to the diagnosis of chronic
cough in the context of normal CXR or CT
• Useful to detect and assess endobronchial
lesions (tumors, foreign bodies): very rare
• Always get a Chest CT before
bronchoscopy
• If you are checking a Chest CT: include
neck (speaker’s experience)
Barnes TW, et al. Chest 2004;126:268-272
Psychogenic (Habit) cough
•
•
•
•
True incidence unknown
Overdiagnosed by physicians
Diagnosis of exclusion
Patient education is the key
Ramanuja S, Kelkar P. Ann Allergy Asthma
Immunol. 2009 Feb;102(2):91-5; quiz 95-7,
115.
Refractory Idiopathic Cough
Rule out all the possible causes first
Very challenging to treat
Experimental therapies:
Lidocaine nebulization, Water and salt irrigations
of nose and sinus, Neurontin, Pamelor, Xanax,
Baclofen, speech therapy evaluation and
breathing exercises
Patient and family education and counselling
Am J Respir Crit Care Med 1995;152:2068-75
Zebras to watch for
•
•
•
•
•
•
•
•
“Clinically silent” suppurative airway disease
Congestive heart failure
Cancer: bronchogenic, esophageal, metastasis
Cystic fibrosis
Interstitial lung disease
Foreign bodies
Pneumonia, Recurrent aspiration, pharyngeal dysf.
Sarcoidosis
Chest 1995;108(4):991-7
Zebras to watch for cont…
•
•
•
•
•
•
•
Pressure from an intrathoracic mass
Primary ciliary dyskinesia (infertility)
Lingual thyroid (hypothyroidism)
Sleep apnea
Vocal cord dysfunction
Pulmonary tuberculosis
Bronchiectasis
Ann Med 1989;21(6):425-7
Otolaryngol Head Neck Surg 2001;125:433-4
J Allergy Clin Immunol 2001;108(1):143
Take Home Points
• Individualize the treatment
• Flow diagrams/ Suggested reading
(1) Ramanuja S, Kelkar P. Ann Allergy Asthma
Immunol. 2009 Feb;102(2):91-5; quiz 95-7,
115.
(2) Rank MA, Kelkar PS, Oppenheimer JJ. Ann
Allergy Asthma Immunol. 2007;98:305-313
(3) Morice AH. ERJ 2004;24:481-492 (European)
(4) Irwin RS, et al. Chest 2006;129 (American)
(4) Morice AH, McGarvey L, Pavord I. Thorax
2006; 61:suppl 1 (British)
Bibliography continued…
• Ramanuja V, Kelkar P. Pediatric Cough.
Annals of Allergy Asthma and
Immunology 2010;105(1):3-8
• Goldsobel A, Chipps B. Cough in the
pediatric population. The Journal of
Pediatrics 2010;156(3): 352-358
• Chang AB. Cough guidelines for
children : can its use improve outcomes.
Chest 2008;134:1111-1112
Thank you!
Pramod Kelkar, MD
Past- Chair, Cough Committee, American Academy of
Allergy, Asthma & Immunology
Founder, National Cough Clinic
Private Practice:
www.allergy-care.net
www.nationalcoughclinic.com
Minneapolis, MN, USA