1. Childhood cough A forced expulsive manoeuvre against a closed glottis by a child Dr Steve Wadams Consultant Paediatrician steve.wadams@poole.nhs.uk

3. Aim to cover Acute vs Chronic cough Targeted history and examination Red flags in red Investigations/referral/treatment Old, new and recycled thoughts on cough Occasional personal practice points in red italics

4. Why concentrate on cough? Common reported Annoying Anxiety provoking Lots of remedies on sale Wide differential of causes BTS guidance in 2008 by whom? to whom? in whom? Why?

5. Cough timelines Often difficult to establish start Recurrent (>2 episodes, unrelated to URTI in a year) Acute 8 weeks I often draw disease progression with parents

6. An acute cough timeline

7. Acute cough (< 3 weeks) Feature Snotty Barking cough Tachypnoea, resp distress, fever or focal signs Paroxysmal/spasmodic Sudden onset Season Other features (suggesting chronicity) Diagnosis URTI Croup/tracheitis Pneumonia/Bronchiolitis/As thma Pertussis Foreign body Allergic rhinitis Underlying chest disease etc

8. URTI 7-10 per year normal, often seasonal Resolve in between No abx, No linctus, ?salbutamol inhaler Education on cough durations 25% remain at 2 weeks, 10% at 4 weeks The cough should be resolving!!! If handing out salbutamol inhaler ensure max use 10 puffs 4 hourly (or less?)

9. Pertussis Role for a macrolide abx early on Whoop in older children only Variable onset of cough, role of mobile video?

11. Allergic seasonal cough Trial of nasal steroids or antihistamines reasonable

12. The CxR in acute cough Fever/ Tachypnoea with nil else (esp toddler) or > 5 days Unusual high fever with bronchiolitis Relentless progressive Foreign body (mention on the form!) Suspect an acute on chronic presentation I do not perform a CxR to confirm diagnosis, but to make a diagnosis

13. Refer Progressively worsening and serious cough Evolving sick child Foreign body Haemoptysis (rare) Instinct/other pathology concerns Review your decision/ arm parents with useful observations to make

14. Prolonged acute/subacute cough (3-8 weeks) Grey area Still likely viral and pertussis aetiology Role for watchful waiting Actively follow up View as chronic cough if not abating Increasing role for CxR Consider measuring the child at this early stage to establish a baseline

15. Chronic cough Includes recurrent frequent cough (>2 URTI free episodes 7-14 days apart in a year) Stratify into normal child, specific cough and non specific isolated cough It would not have been unreasonable to have referred by this stage

16. Sadly it is not this simple

17. Detailed history Often easier stated than to do! Never unreasonable to re clarify!

18. How and when did the cough start? Acute/sudden Post URTI initially Neonatal onset FB? Post infective (e.g. viral) Congenital malformation (e.g. CCAM) Primary Ciliary dysknesia In utero lung infection CF (rare nowadays)

19. What is the cough quality? Wet Paroxysmal Bizarre/dry/nil nocte Barking/dry Haemoptysis (rare) Secretions Pertussis/parapertussis Habit/psychogenic Tracheal/Glottic ( e.g. malacia) FB, CF, TB, Bronchiectasis, Tumour (all rare)

20. Is the cough an isolated symptom? Associated ill health, recurrent pneumonia Associated SOB Wheeze present Immune deficiency, cilia disorders, bacterial bronchitis, FB Interstitial lung disease Asthma, FB, aspiration, malacia, interstitial lung disease, neonatal CLD

21. What triggers/exacerbates the cough? Exercise, cold air Lying down Feeding ?Attention Asthma Postnasal drip, gastro- oesophageal reflux, PBB Aspiration ?Psychogenic

22. Other history of note Feature FH atopy DH Relentless and progressive Consequence Asthma more likely ACE inhibitor cough Lobar collapse, TB, tumour

23. Examination Clubbed Chest shape Asymmetric signs Ask child to cough Measure and plot height and weight ENT Skin

24. Investigations CxR useful to order at time of referral Consider spirometry Consider sputum sample (cough swab?) Consider aeroallergen testing (RAST or SPT) Consider pH probe/Barium swallow??? I prefer the CxR only

25. Treatment options Underlying diagnosis if specific cough otherwise…… Reduce/stop cigarette exposure Asthma therapy trial 8 weeks Watch and wait still Allergic rhinitis treatment?? GORD??? I am always interested in response to PO steroids (be generous)?

26. A recycled diagnosis – Protracted Bacterial Bronchitis (PBB) Conducting airways disease – a biofilm disease Role for temporary viral mediated cilia dysfunction? Mainly children <6 years with persistent wet cough resolving briefly with antibiotics Mimics asthma interval symptoms “60 a day smoker cough”

27. Management dilemma After referral please Attempt an induced sputum sample Unequivocal response to prolonged abx course ?how long ( 2 weeks to resolution, then some more 6-8 weeks) Cross over with asthma? Concerns about abx over use.

28. A few sounds to finish off. http://children.webmd.com/pertussis- whooping-cough-10/coughing-sounds http://children.webmd.com/pertussis- whooping-cough-10/coughing-sounds

29. Other resources/references http://www.brit- thoracic.org.uk/Portals/0/Guidelines/Cough/Guidelines/cough_in_children.pdf http://www.brit- thoracic.org.uk/Portals/0/Guidelines/Cough/Guidelines/cough_in_children.pdf http://www.patient.co.uk/doctor/Chronic-Cough-in-Children.htm http://www.bmj.com/content/344/bmj.e1177 http://n3.learning.bmj.com/learning/module-intro/.html?moduleId=10032122 http://healthguides.mapofmedicine.com/choices/map/cough_in_children1.html http://adc.bmj.com/content/98/1/72.abstract Protracted bacterial bronchitis http://adc.bmj.com/content/98/1/72.abstract

33. Questions