Cough – Chronic

Cough – Chronic: Excerpt from In A Page: Pediatric Signs and Symptoms

In adults, “chronic” is often defined as more than 3 months of coughing in 2 years, but chronic cough is not as well defined in children. In general, for children, cough of more than 3–4 weeks’ duration will be brought to the attention of caregivers as “chronic,” as is a cough with every URI (more properly defined as recurrent).

Differential Diagnosis

• Lower airway disease
  –Asthma
       –Inflammatory triad of edema, mucus, and bronchospasm, characterized by reversibility with asthma drugs
  –The most common triggers for asthma are viral disease, irritants (e.g., ETS), allergic disease, and GER
  –Airway infections: Bronchiolitis, caused by RSV in babies, may cause chronic cough from persistent inflammatory change and debris; bronchitis is more common in older children and may be secondary to smoking or ETS exposure
  –Foreign body: Associated with endobronchial infection and damage
  –Cystic fibrosis: The most common life-threatening inherited illness of whites, is associated with production of chronically infected sputum
  –Bronchiectasis: Chronic infection and damage to the airway; may be secondary to another disease (e.g., TB or CF)
  –Structural abnormalities: PCD, TEF, or cleft, rings, slings

• Upper airway disease
  –Infectious diseases: Chronic sinusitis, tonsillitis, laryngitis, including that secondary to GER (although acute disorders, the inflammation from URI may be associated with a chronic cough if frequent enough)
• Parenchymal and pleural disease
  –Infectious disease accounts almost exclusively for all parenchymal and pleural causes of cough (e.g., pneumonia and empyema)
  • CNS causes
    –CNS causes of cough include “habit cough” (or psychogenic cough), Tourette disease associated “cough tic” or throat clearing, VCD
    –Irritation of a branch of cranial nerve ten in the external auditory canal can trigger chronic cough

  Workup and Diagnosis

  • History
    –Cough lasting longer than 2–6 weeks suggests either a predisposing factor (e.g., bronchomalacia) or an ongoing trigger (e.g., asthma)
    –An acute lung or airway injury (i.e., infection or FB) suggests a mechanism for chronic cough
    –An insidious onset is more consistent with a chronic underlying condition (i.e., CF, TB, GER)
    –Seasonal change suggests allergic disease
    –Night cough suggests GER
    –A positive response to asthma therapy suggests asthma
    –Antibiotic responsiveness suggests chronic infection (i.e., CF, bronchiectasis, sinusitis)
    –Distractability suggests habit cough, as may a lack of coughing while asleep
    –Is the cough productive? Culture sputum and consider asthma, bronchiectasis, smoking, or CF
  • Physical exam: Loud, “brassy,” vibrato, honking quality suggests tracheomalacia; high-pitched stridor suggests a fixed tracheal obstruction (ring, sling, FB, subglottic stenosis); violent paroxysms with an inspiratory whoop suggest pertussis syndrome
  • Studies: Chest films often not diagnostic; PFT to diagnose asthma or large airway obstruction; bronchoscopy and lavage to diagnose malacia, infection, FB, VCD
  • Exercise testing may provoke symptoms of EIA or VCD

  Treatment

  • Treatment is often empiric and based on history
  • An empiric “diagnostic trial” of medication may treat asthma, GER, or bacterial infections. Treatment of “habit component” may help with other chronic conditions (e.g., postinfectious bronchitis)
  • Speech therapy is helpful for VCD or habit cough (i.e., using cold water “hard swallow,” benzocaine throat lozenges, breathing exercises)
  • Serious psychiatric disease may be associated with VCD, but referral to mental health specialist is rarely needed
  • Other treatments first require accurate diagnosis (e.g., TB, CF, FB)
    
  • Cough suppression may be of use at night to achieve sleep, but is generally avoided

Book Source Details

• Book Title: In A Page: Pediatric Signs and Symptoms
• Author(s): Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
• Year of Publication: 2007
• Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: In A Page: Pediatric Signs and Symptoms Authors: Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-4051-0427-9

 » Next page: COUGH (Differential Diagnosis in Primary Care)

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