The unified Airway

1. A CPMC Regional CME Event The unified Airway - 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 Bronchiolitisobliterans Upper airway cough syndrome GER Endobronchial tuberculosis UACS 23% GERD 28% Asthma 13% Multiple etiologies 20% M. pneumoniae B. pertussis Aspiration Eosinophilic disorder Habit cough Asthma Uncertain cause Bronchiectasis Natural resolution Protracted bacterial bronchitis

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

22. 3 year old girl with chronic cough

23. 3 year old girl with chronic cough

24. 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? EVALUATE FOR SPECIFIC COUGH No CXR, spirometry abnormal? No Sx/signs suggest specific cough Characteristic quality? Review in 1-2 weeks No NON-SPECIFIC COUGH • Watch, wait, review • Evaluate • Tobacco smoke • Environmental exposures • Child’s activity • Parent concerns • Treat obvious illness Resolving, resolved Persistent Watch, wait, review Trial of therapy Dry—ICS 4 weeks Wet—Abx 10-21 days

30. algorithm for specific cough SPECIFIC COUGH Reversible airway obstruction or elevated eNO? Yes ASTHMA Confirm with 4 week medication trial 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!