THE UNIFIED AIRWAY A CPMC Regional CME Event - An Integrated Approach Saturday October 1, 2011

PEDIATRIC ENT: CHRONIC COUGH IN CHILDREN Theresa Kim, MD San Francisco Otolaryngology Medical Group

SCOPE OF THE PROBLEM Most common complaint for which patients seek medical attention Major contributor to parental stress - Adults with chronic cough experience more depression and anxiety

SCOPE OF THE PROBLEM Faniran 1999

SCOPE OF THE PROBLEM Marchant 2008

OUTLINE OF DISCUSSION Pathophysiology Causes of chronic cough in children Treatment Diagnostic algorithm

PATHOPHYSIOLOGY Two types of cough - Laryngeal (“cough reflex”) - Tracheobronchial (can be volitional)

PATHOPHYSIOLOGY Three phases to cough - Inspiratory - Compressive - Expiratory

WHAT’S NORMAL? “Expected cough” - Presence of cough in situations where cough is the norm Healthy children cough times/day 35-40% of children still cough 10 days after onset of a common cold Children have acute URI 5-8 times/year

DEFINING COUGH Timeframe - Acute vs. chronic Etiology - Specific vs. nonspecific Quality of cough - Moist vs. dry, brassy, staccato Age of child

TIMEFRAME Acute cough < 2 weeks Subacute cough 2-4 weeks Chronic cough >4 weeks (3-12 weeks)

ETIOLOGY Nonspecific - Defined as cough in the absence of signs and symptoms of pulmonary or cardiac disease Specific - Anatomic abnormalities - Cardiac disease - Lung disease - Immune dysfunction

ETIOLOGY Expected cough Nonspecific cough Specific cough

NONSPECIFIC COUGH Protracted bacterial bronchitis Natural resolution Bronchiectasis Uncertain cause Asthma Habit cough Eosinophilic disorder Aspiration B. pertussis M. pneumoniae Endobronchial tuberculosis GER Upper airway cough syndrome Bronchiolitis obliterans UACS 23% GERD 28% Asthma 13% Multiple etiologies 20%

PROTRACTED BACTERIAL BRONCHITIS Chronic wet cough Positive BAL fluid culture Resolution with antibiotics Often misdiagnosed as asthma S. pneumoniae, H. influenzae, M. catarrhalis

OTHER CAUSES OF CHRONIC COUGH Asthma - Cough with air flow obstruction - Uncommon cause of nonspecific cough in children GERD - Reflux is the norm in infants - Association with cough is controversial

HABIT COUGH Also known as psychogenic cough Harsh, dry, repetitive cough Significant improvement with distraction, absence when asleep

QUALITY OF COUGH Not useful in adult cough Brassy cough sensitivity, 0.81 specificity for tracheomalacia Spasmodic/paroxysmal Wet/moist cough ( = “productive”) - Most children do not expectorate sputum sensitivity, 0.79 specificity

AGE OF CHILD Congenital anatomic abnormalities Aspiration more common in younger children - Must ask parents about possible aspiration events

4 YEAR OLD BOY WITH CHRONIC COUGH

3 YEAR OLD GIRL WITH CHRONIC COUGH

TREATMENT OF CHRONIC COUGH

TREATMENT OTC cough medications - No benefit Asthma medications - No benefit for nonspecific cough Antihistamines - No benefit GERD medications - Inconclusive evidence

TREATMENT Antimicrobials - No effect in viral URI - Modest benefit in cough with nasal discharge Other remedies - Steam, vitamin C, zinc, Echinacea little benefit - Honey (0.5-2 teaspoons) helpful for reducing nocturnal cough and improving sleep quality of parents and children Placebo - 85% response

DIAGNOSIS OF CHRONIC COUGH All children with chronic cough should have - Spirometry - CXR

ALGORITHM FOR CHRONIC COUGH Sx/signs of respiratory disease? CXR, spirometry abnormal? Characteristic quality? 1.Watch, wait, review 2.Evaluate  Tobacco smoke  Environmental exposures  Child’s activity  Parent concerns 3.Treat obvious illness NON-SPECIFIC COUGH No EVALUATE FOR SPECIFIC COUGH Review in 1-2 weeks Resolving, resolvedPersistent Trial of therapyWatch, wait, review Dry—ICS 4 weeksWet—Abx days Sx/signs suggest specific cough

ALGORITHM FOR SPECIFIC COUGH SPECIFIC COUGH Reversible airway obstruction or elevated eNO? ASTHMA Confirm with 4 week medication trial Yes No Bronchiectasis Recurrent pneumonia Chronic infection Interstitial lung disease Airway abnormality Other pulmonary disease Cardiac disease

PEARLS Causes of chronic cough are different than adults - Chronic wet cough...protracted bacterial bronchitis - GERD, asthma and UACS are less common Empiric treatment is not recommended Always remember to think about aspiration in children younger than 5 years

Thank you!