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

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

3. 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

4. SCOPE OF THE PROBLEM Faniran 1999

5. SCOPE OF THE PROBLEM Marchant 2008

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

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

8. PATHOPHYSIOLOGY Three phases to cough - Inspiratory - Compressive - Expiratory

9. WHAT’S NORMAL? “Expected cough” - Presence of cough in situations where cough is the norm Healthy children cough 10-11 times/day 35-40% of children still cough 10 days after onset of a common cold Children have acute URI 5-8 times/year

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

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

12. 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

13. ETIOLOGY Expected cough Nonspecific cough Specific cough

14. 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%

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

16. 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

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

18. QUALITY OF COUGH Not useful in adult cough Brassy cough - 0.57 sensitivity, 0.81 specificity for tracheomalacia Spasmodic/paroxysmal Wet/moist cough ( = “productive”) - Most children do not expectorate sputum - 0.75 sensitivity, 0.79 specificity

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

20. 4 YEAR OLD BOY WITH CHRONIC COUGH

21. 3 YEAR OLD GIRL WITH CHRONIC COUGH

25. TREATMENT OF CHRONIC COUGH

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

27. 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

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

29. 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 10-21 days Sx/signs suggest specific cough

30. 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

31. 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

32. Thank you!