Management of Chronic Cough in Children

Abnormality

Examples of etiology

Symptoms or signs

Auscultatory finding

Wheeze

Crepitations-any airway lesions (from secretions) or parenchymal disease such as interstitial disease

Cardiac abnormalities

Associated airway abnormalities, cardiac failure, arrhythmia

Chest pain

Arrhythmia, asthma

Chocked

Foreign body inhalation

Dyspnea or tachypnea

Any pulmonary airway or parenchymal disease

Chest wall deformity

Any pulmonary airway or parenchymal disease

Digital clubbing

Suppurative lung disease

Daily wet/ productive cough

Protracted bacterial bronchitis, suppurative lung disease, recurrent aspiration, atypical infections, TB, diffuse panbronchiolitis

Exertional dyspnea

Any airway or parenchymal disease

Facial pain/purulent nasal discharge

Chronic sinusitis, (protracted bacterial bronchitis), primary ciliary dyskinesia

Feeding difficulties

Any serious systemic including pulmonary illness, aspiration

Growth failure

Any serious systemic including pulmonary illness such as cystic fibrosis

Hoarse voice/stridor

Laryngeal cleft/problems, airway abnormalities

Hemoptysis

Suppurative lung disease, vascular abnormalities

Hypoxia/cyanosis

Any airway or parenchymal disease, cardiac disease

Neurodevelopmental abnormalities

Aspiration lung disease

Recurrent pneumonia

Immunodeficiency, atypical infections, suppurative lung disease, congenital lung abnormalities, trachea-esophageal H-type fistula

Recurrent infections

Immunodeficiency

Previous history of chronic lung disease, esophageal disease (neonatal lung disease, esophageal atresia)

Multiple causes (eg, second H-type fistula, bronchiectasis, aspiration, asthma)

Wheeze-monophonic

Large airway obstruction(eg, from froing body aspiration, malacia, and/or stenosis, vascular ring, lymphadenopathy, and mediastinal tumors)

Wheeze-polyphonic

Asthma, bronchiolitis obliterans, bronchiolitis

Tests

Chest radiograph (other than peribronchial changes or spirometry abnormalities) 

Any cardiopulmonary disease

Cause

Remarks

Asthma

- Cough is commonly associated with recurrent wheezing

- Asthma can be manifested only with cough and is then called cough-variant asthma or cough-dominant asthma.

- A therapeutic trial of prednisolone should be offered if diagnoses of cough-predominant asthma or eosinophilic bronchitis are being considered (15).

Cystic fibrosis

- Clubbing and failure to thrive.

- Universal newborn screening

- Diagnosis is by measurement of sweat chloride concentration and genetic identification (16).

Primary ciliary dyskinesia

- Chronic wet cough

- History of transient neonatal distress is common

- Begins in infancy and persists (17).

- Screening by measuring nitric oxide from nose

- Diagnosis by electron microscopy and high-speed video-microscopy analysis (18).

Bronchiectasis

- Bronchiectasis can occurs with cystic fibrosis, primary ciliary dyskinesia, and in some patients with protracted bacterial bronchitis Bronchiectasis unrelated to chronic lung disease is also seen (19).

-Diagnosis by radiology confirmed by computed tomography (20).

Pertussis (whooping cough)

- Frequent spasms of coughing followed by nausea or vomiting, cyanosis or apnea. like the barking cough

- No history DPT vaccination (21).

Tracheomalacia or trachea-broncho-malacia

- Occasionally cause chronic cough

- Barking quality

- But persists during sleep, unlike habit cough.

- Diagnosed only by bronchoscopy performed with light sedation so that dynamic movements can be visualized (22).

Protracted bacterial bronchitis (PBB)

Diagnosed clinically by:

1) Presence of continuous chronic (>4 weeks’ duration) wet or productive cough;

2) Absence of symptoms or signs (i.e. specific cough pointers) suggestive of other causes of wet or productive cough; and

3) Cough resolved following a 2–4-week course of an appropriate oral antibiotic.

 Diagnosed as PBB-micro by the contents of a broncho-alveolar lavage (23).

Habit cough (tic cough)

- Now labeled as somatic cough disorder (24).

- Diagnosis should only be made after an extensive evaluation (25). 

Postnasal drip syndrome/Upper airways cough syndrome (UACS)

UACS acting as a trigger for cough hypersensitivity although the mechanism remains obscure (26), (27).

Foreign body aspiration

- Causes localizing auscultatory findings.

- History of sudden shocking (28).

Medications and Adverse Events

As a side effect of

• Angiotensin converting inhibitors (ACEI) (29),
• Asthma medications immediately after inhalation (30).
• Psychostimulant medications (e.g. Dextro-amphetamine resulting in new onset tics) (31).

Cardiac causes

Associated with specific manifestations (cough pointers)

Immunodeficiency

Two or more of these warning signs should alert clinician to the possibility of primary immunodeficiency and merit further assessment (32) (Appendix)

 Gastro-esophageal reflux disease (GERD)

- GIT manifestations must be present

- (GERD is not commonly identified as the cause of pediatric chronic cough (33).

Otogenic etiology

Arnold's nerve reflex

Uncommon cause of chronic cough

-The ears should always be examined for the presence of any foreign material (34).