APPROACH TO
CHRONIC COUGH
Definitions :
Cough is a protective reflex aimed at
maintaining a clear airway
Chronic cough is defined as cough of
more than four weeks duration
Receptor Effector
Nerve Nerve
Nose and sinuses Trigeminal
Expiratory muscles
Posterior pharynx Phrenic Spinal motor
Pericardium
Diaphragm Medullary cough Diaphragm
center
Phrenic
Trachea
Bronchi Glosso Pharyngeal
Esophagus Larynx
Trachea
Pleura Vagus Bronchi
Ear canals
Ear drums Vagus
Stomach
CAUSES
Aspiration syndromes
Birth defects
Compressive / Cardiac
Defects of mucous clearance
Environmental lung disease
Foreign bodies / Functional
Granulomatous diseases
Hyper reactive airways
Infections / Infiltrations
Aspiration syndromes
Common Rare
G E Reflux H-shaped T E F
Strictures
Cleft palate
Palato pharyngeal
Mental
incontinence
retardation Neuromuscular
Epilepsy incoordination
Birth defects
Less Common
Congenital Lobar Emphysema
Cystic Adenomatoid Malformation
Sequestration
Compressive / Cardiac
Common
Nodes
L-R shunts
Left sided failure
Rare
Tumors
Cysts
Aberrant vessels
Defects of mucous clearance
Cystic fibrosis
Ciliary dyskinesias
( RARE )
Environmental lung disease
Extrinsic allergic
alveolitis
Eosinophilia
(PIE )
Foreign bodies/Functional
Foreign body
inhalation
Functional / Habit
cough
Granulomatous diseases
Sarcoidosis
Wegener’s
( Rare )
Hyper reactive airways
Asthma
WALRI
Post - nasal drip
Infections/Infiltrations
Chronic:
Mycobacteria
Mycoplasma
Chlamydia Hemosiderosis
Pertussis Histiocytosis
COMMON CAUSES
Infant: Aspiration, birth defects, cardiac
defects
Toddler: Hyper-reactive airways, infection,
foreign body
Schooler / Adolescent: Hyper-reactive
airways, infections, functional
EVALUATION
RED FLAGS
Respiratory distress
Known foreign body
Cardiac failure
Infant
RED FLAGS
Complications of severe cough
Cough syncope
Air-leak syndrome
pneumothorax
pneumomediastinum
subcutaneous emphysema
superior vena - caval syndrome
EVALUATION
Ask:
1. Duration
2. Age at onset
3. Periodicity
4. Nature
5. Aggravated by
6. Relieved by
7. Associations
DURATION
As a general rule, cough less than 2-
3 weeks is referred to as short
duration cough
cough lasting greater than 4 weeks
is designated as chronic cough.
PERIODICITY
Recurrent cough is characterized by
period of normalcy between episodes
and thus indicates a dynamic
pathology e.g. asthma
Persistent symptoms usually indicate a
fixed pathology e.g. foreign body,
pressing nodes or tumors
NATURE OF COUGH
Infants and young children usually do
not expectorate
In older children, presence of copious
purulent sputum suggests suppurative
lung disease
NATURE OF COUGH
Hemoptysis is rare in children and
when present should raise the suspicion
of Bronchiectasis or hemosiderosis
Tuberculosis is not a common cause of
Hemoptysis in the pediatric population
AGGRAVATING FACTORS
Feeds :- aspiration
Time of the day :- hyper-reactive airways
(nocturnal)
Posture :- aspiration, post-nasal drip
Triggers :- hyper-reactive airways
Exercise :- hyper-reactive airways
RELIEVING FACTORS
Relieved by
Sleep: functional
Bronchodilators: hyper-reactive
airway disease
ASSOCIATED FEATURES
Allergic diathesis and markers (Hyper-
reactive airways)
Choking (aspiration)
Snoring/mouth breathing (adenoids)
Multiple multifocal infections
(immunodeficiencies)
Consanguinity (Autosomal recessive disorders)
Drugs (ACE inhibitors)
LOOK
1. Quality
2. Respiratory distress
3. Failure to thrive
4. Malabsorption
5. Clubbing
6. Murmurs
7. Neuromuscular/anatomic defects
8. Pressure effects (hernia / prolapse)
1. QUALITY
Whoop: Pertussis, adenovirus
Honking: laryngeal pathology
Dry barking / Brassy: pharyngeal
pathology, habit
Feeble: neuro -muscular disease
Moist rattly / Productive: suppurative
lung disease
2. RESPIRATORY DISTRESS
Stridor/grunt/wheeze localizes anatomical
level
Stridor suggests upper airway obstruction
If the voice is hoarse it signifies a glottic or
supra-glottic problem
A grunt indicates alveolar disease and
wheeze is typical of airway disease
3. Failure to thrive -Severe asthma,
suppurative disease
4. Malabsorption / malnutrition -chronic
disorders, cystic fibrosis
5. Clubbing - suppurative disorders
6. Murmurs - cardiac lesions
7. Neuro –muscular / anatomical defects -
aspiration
8. Pressure effects-hernia, prolapse -
consequence of violent or chronic cough
PERFORM
X-ray chest
RADIOLOGICAL
EVALUATION
OF
CHRONIC COUGH
NORMAL / SEEMINGLY
NORMAL X-RAY
Asthma
Post-nasal drip
Aspiration
Vascular compression
Habit
Foreign body
Drugs
PERSISTENT PATCH AT THE
SAME SPOT
TB
Congenital anomaly
Foreign body
MULTIFOCAL LESIONS OVER
TIME
Aspirations
Asthma
Mucociliary / immune defects
Cardiac disorders
DIFFUSE INTERSTITIAL LACY
PATTERN
Infections
Interstitial lung disease
FOCAL OR MASS LESION
Nodes
Tumors
Cysts
PRACTICAL APPROACH TO
CHRONIC COUGH
1. Snoring/ Mouth Breathing
2. Persistent Spasmodic
3. Recurrent, nocturnal, Seasonal, related
to feeding
4. Infants
5. Murmurs
6. Multiple multifocal Infections
Snoring / Mouth Breathing
X-ray Paranasal Sinuses and lateral Neck
Sinusitis
Adenoids
Antibiotics
Consider Surgery
Persistent Spasmodic
CBC / Chest X-ray
Endo-bronchial TB
Pertussis
Foreign body
No response
Bronchoscopy
Recurrent, nocturnal, Seasonal,
related to feeding
Spirometry / Barium studies
Asthma
Aspiration syndromes
Eosinophilia
Bronchodilator/ appropriate Management
No response / surgical causes
Infants
X-ray chest
Ba. Swallow / HRCT
Angiography
Aspiration syndromes
Congenital Anomalies
Sequestrations
Appropriate medical / surgical management
Murmurs
X-ray Chest / 2D-ECHO
Congenital Heart
Disease
Anti failure Therapy/ Surgical Management
Multiple multifocal Infections/F.T.T./
Malabsorption /Clubbing
X-ray chest / HRCT
CF / immuno - deficiency work Up
Suppurative lung
disease
Medical / surgical Management
Genetic counseling
CASE - 1
Anxious Parents bring a school going
child to you
He had a respiratory infection a few
weeks ago
Of late his cough has worsened
He is not without a honking cough for
a single minute
CASE - 1
His cough disrupts your conversation
but when asked to open his mouth or
breath deep his cough lessens
Uniquely there is no cough when he is
asleep and it is much lesser when
distracted (e.g. when reading a book
or watching T V )
Step 1 - Evaluation and treatment
Step 2 - Treat PND, antihistamine/decongestant
Step 3 - Treatment for asthma, bronchodilators for
2 weeks
Step 4 -Treatment of GER for 2 weeks
Step 5 - Chest X-Ray, Mantoux, sinus CT,
pulmonary function test, Ba. swallow
Step 6 - Refer to pulmonologist
American Academy of Allergy, Asthma and Immunology
In conclusion
Suspect congenital lung conditions in infants
with chronic cough
Asthma / Cough-variant asthma are the most
common cause of chronic cough in children
followed by postnasal drip and GERD
The best way to approach cough is, find the
cause and treat it!
THANK YOU
