Approach to Cough

1. It’s the simple things in life we forget You hear her talkin’ but don’t hear what she said Why do you make something so easy so complicated? Searching for what’s right in front of your face.. - Simple Things by Usher Approach to Cough Jerry V. Pua MD 2nd year Resident

2. Objectives • To discuss etiology, differential diagnosis and work up for children presenting with cough • To discuss approach, diagnosis, management, recommendations and prevention of B. pertussis infection

3. General Data • A.E. • 6 month old, Female • Filipino, Catholic • Brgy. Batasan Hills, Quezon City • Consulted at ER last June 15, 2013 • Informant: Grandmother • Reliability: 80%

4. Cough – 2 weeks duration Chief Complaint

5. History of Present Illness

6. History of Present Illness

7. Review of Systems • Decrease appetite • No failure to thrive, feeding interruption • No skin lesions • No diaphoresis, no fainting spells • No vomiting, no diarrhea nor constipation • No pallor • No facial redness during bouts of cough • No convulsion • No limitation of movements • No bleeding manifestations

8. Family History (+) (+) cough (+) No heredo-familial disease on both sides of the family

9. Birth and Maternal History • Born to 39 year old G5P4 (4014) non smoker, non alcoholic beverage drinker mother • No pre natal check up, denies maternal illness • Multivitamins, Ferrous Sulfate intake • Delivered Full term via NSD at home assisted by traditional birth attendant • No feto-maternal complication during and after the delivery

10. Immunization History • No immunization received

11. Nutritional History • Milk Formula – since birth • No milk formula intolerance • Complimentary feeding – 6 months old • No interrupted feeding • No feeding problems

12. Growth and Development • Motor • Head control – 2 mos. rolls over – 4 mos. sits with support – 6 mos. • Language • Imitates sounds – 5mos • Daily Living • Put anything at the mouth – 4 mos. • Social/Adaptive • Social smile – 2 mos. plays with caregiver – 6 mos

13. Past Medical History • No routine check up • No previous hospitalization • No previous surgical intervention done. • No allergies

14. Physical Examination • Awake, irritable, in mild respiratory distress. Well hydrated. • Weight: 6 kg (z score below 0 ) • Height: 65 cm (z score 0 ) • BP 80/50 HR 122 • RR 38 T 37.1 • Skin: Warm, Moist, No rashes or other dermatosis. No cyanosis.

15. Physical Examination • HEENT: Normocephalic. Aniceteric sclera; pink palpebral conjunctivae; no eye discharge • (+) intermittent alar flaring. No nasal discharge nor bleeding. No tragal tenderness, no aural discharge • Non hyperemic posterior pharyngeal wall, no exudates, uvula midline • (+) cervical lympadenopathy, bilateral • Chest and Lungs: No chest deformity nor skin lesions at the chest. Symmetrical chest expansion, (+) subcostal and intercostals retractions (+) crackles on both lung fields

16. Physical Examination • Heart: Adynamicprecordium, Apex beat at 4th ICS LMCL, normal rate regular rhythm, no murmur • Abdomen: Globular, No visible veins. Normoactive bowel sounds. Soft, non tender, no organomegaly. • Genitalia: Grossly female • Extremities: No preferential movement. Pulses on all extremities are full and equal. No clubbing, cyanosis of fingers or toes. CRT <2 seconds. No deformities.

17. Neurologic Examination • Mental Status: Awake, irritable. GCS 15 • Cranial Nerves: Intact • Motor: Good muscle tone, no fasciculation or atrophy, no involuntary movement. MMT 5/5 on all extremities. DTR’s 2++ • Sensory: No deficit. No babinski or clonus. • Cerebellar: No nystagmus • Meningeal signs: No Kernig’s, No Brudzinski, No nuchal rigidity

18. BronchopneumoniaRule out PertussisNo stunting no wasting Admitting Impression

19. Symptoms, sign, or laboratory findings pathognomonic of a disease Approach to Diagnosis

20. COUGH • Most common symptom presenting to medical practitioners • Cough is a forced expulsive maneuver, usually against a closed glottis • Sound of a cough is due to vibration of larger airways and laryngeal structures during turbulent flow in expiration Cough quality in children: a comparison of subjective vs. bronchoscopic findings Anne Bernadette Chang, et. al Dept of Paediatrics & Child Health, University of Queensland Dept Respiratory Medicine, Royal Children's Hospital, Brisbane

21. COUGH • Estimating the duration of cough is the first step in narrowing the list of possible diagnoses THE DIAGNOSIS AND TREATMENT OF COUGH RICHARDS. IRWIN, M.D.,AND J. MARK MADISON, M.D. The New England Journal of Medicine

22. Types of Cough (Duration) • Acute Cough -- a recent onset of cough lasting <3 weeks • Subacute Cough (Prolonged acute cough) -- cough slowly resolving over a 3–8-week period • Chronic Cough -- A cough lasting >8 weeks • Recurrent Cough -- cough without a cold is taken as repeated (>2/year) cough episodes, apart from those associated with colds, that each last more than 7–14 days Recommendations for the assessment and management of cough in children M D Shields, A Bush, M L Everard, S McKenzie, R Primhak, on behalf of the British Thoracic Society Cough Guideline Group

23. ACUTE COUGH • Cough lasting for a maximum of 3 weeks • Common caused: URTI, acute bronchitis or tracheobronchitis (bacterial or viral) • Such infections is usually self limited and subsides within one to two weeks along the clearing of the infection • No targets or reliable measures to predict the duration of cough at its onset, also to predict which will persist into sub acute or chronic cough COUGH MANAGEMENT: A Practical Approach F. De Blasio, et. al

24. COUGH MANAGEMENT: A Practical Approach F. De Blasio, et. al

25. COUGH MANAGEMENT: A Practical Approach F. De Blasio, et. al

26. Types of Cough (Causes) • Specific Cough -- one in which there is a clearly identifiable cause • Non specific isolated Cough -- typically have a persistent dry cough, no other respiratory symptoms, well with no signs of chronic lung disease and have a normal chest radiograph • Post viral Cough -- cough originally starting with an upper respiratory tract infection but lasting <3 weeks Recommendations for the assessment and management of cough in children M D Shields, A Bush, M L Everard, S McKenzie, R Primhak, on behalf of the British Thoracic Society Cough Guideline Group

27. Types of Cough (Quality) • Classic Recognizable Cough • Certain cough characteristics classically taught to point to specific etiologies • Dry Cough • Wet Cough Cough in children: definitions and clinical evaluation Position statement of the Thoracic Society of Australia and New Zealand

28. Salient Features • 6 months old • 2 weeks history of cough • No fever • Cyanosis at bouts of cough • Difficulty of breathing • Siblings with cough • No immunization received • In mild respiratory distress • Intermittent alar flaring • Intercostal and subcostal retractions • Crackles on both lung fields

29. Course at the Ward Patient: A.E. 6 months old, Female Working Impression: Bronchopneumonia Rule out Pertussis

30. 1st Hospital Day

31. Case Definitions: Pertussis (WHO) • Cough lasting at least 2 wk with at least 1 of the following symptoms: • paroxysms of coughing • inspiratory whooping • posttussive vomiting (ie, vomiting immediately after coughing) • Clinical case: a case that meets the clinical definition, but is not laboratoryconfirmed • Laboratory-confirmed case: a case that meets the clinical case definition and is laboratory-confirmed Clinical Definitions of Pertussis: Summary of a Global Pertussis Initiative Roundtable Meeting, February 2011

32. Clinical Definitions: Pertussis (CDC) • Cough illness lasting ≥ 2 weeks with 1 of the following without apparent cause: • Paroxysms of coughing • Inspiratory “whoop” • Posttussive vomiting • Probable case: symptoms,absence of laboratory confirmation and epidemiologic linkage to a laboratory-confirmed case of pertussis • Confirmed case: symptoms + > 1 following – PCR positive for pertussis or contact with laboratory-confirmed case of pertussis Clinical Definitions of Pertussis: Summary of a Global Pertussis Initiative Roundtable Meeting, February 2011

33. Diagnostics • Common laboratory diagnostic methods: • Culture – gold standard • Direct antigen detection PCR • Direct fluorescent antibody (DFA) testing • Serologic demonstration enzyme-linked immunosorbent assay (ELISA) or Western blot with various B. pertussis antigens and agglutination • Measuring an increase in titers between acute and convalescence phase serum specimens or high single serum antibody values Defining Pertussis Epidemiology Clinical, Microbiologic and Serologic Perspectives James D. Cherry, MD, et al Pediatr Infect Dis J 2005

34. Diagnostics: Serologic Testing • Proper performance of culture, PCR and ELISA to measure increases or decreases in IgG and IgA antibody titers to Pertussis Toxin in paired serum samples, the sensitivity and specificity of the laboratory diagnosis of B. pertussis infection • The greatest sensitivity is obtained when culture, PCR and serologic testing are all performed on individuals with cough illness Defining Pertussis Epidemiology Clinical, Microbiologic and Serologic Perspectives James D. Cherry, MD, et al Pediatr Infect Dis J 2005

35. Pertussis PCR • Key factors for the successful application of PCR in the diagnosis of infection by Bordetella spp.: • Sample collection and processing • DNA purification • Primer selection • Amplification conditions • PCR as a diagnostic tool has the advantage of a much higher sensitivity compared with conventional culture Defining Pertussis Epidemiology Clinical, Microbiologic and Serologic Perspectives James D. Cherry, MD, et al Pediatr Infect Dis J 2005

36. Pertussis: PCR • A 2.6-fold increase in detection of B. pertussis using PCR compared with culture • PCR results were compared with serologic diagnosis; PCR had a sensitivity of 61% and a specificity of 88% • Patients with symptoms meeting the CDC clinical case definition for pertussis and who had a specimen positive by PCR or DFA were considered to have true B. pertussis infections Defining Pertussis Epidemiology Clinical, Microbiologic and Serologic Perspectives James D. Cherry, MD, et al Pediatr Infect Dis J 2005

37. 2nd Hospital Day

38. Complete Blood Counts

39. Diagnotics: Complete Blood Count • A total count of ≥ 20,000 WBCs/mm3 with ≥ 10,000 lymphocytes/mm3 in a young infant with coryza, cough, apnea or other respiratory distress is indicative of B. pertussis infection • A total count of ≥ 30,000 WBCs/mm3 is cause for concern and the rapidity of the WBC count rise is also an important indicator of worsening condition Pertussis in Young Infants – Guidance for Clinicians James D. Cherry MD, et. al. May 2010

40. Microbiology • Blood Culture and Sensitivity: • No growth for 5 days of incubation • Nasopharyngeal Bordetella pertussis Polymerase Chain Reaction • POSITIVE for Bordetella pertussis DNA

41. PertussisBronchopneumoniano stunting no wasting Final Diagnosis

42. Pertussis • Acute respiratory infection caused by Bordetella pertussis • ‘intense cough’ • Extremely contagious -- attack rates as high as 100% in susceptible individuals exposed to aerosol droplets at close range

43. Bordetella pertussis • Tiny, fastidious, gram-negative coccobacilli that colonize only ciliated epithelium • Expresses pertussis toxin (PT), the major virulence protein • After aerosol acquisition, pertussis organism attaches to ciliated respiratory epithelial cells • Tracheal cytotoxin, adenylate cyclase, and PT appear to inhibit clearance of organisms • Responsible for the local epithelial damage

44. Epidemiology • Worldwide, pertussis is a significant cause of infectious mortality • 20 to 40 million cases • 200,000 to 400,000 death per years • Most of cases and deaths occur in infancy WHO. Pertussis vaccines. Wkly Epidemiol Rec. 1999;74:137–143

45. Epidemiology • Philippine Pediatric Society Registry • 99 out of 1935660 cases • Philippine Children’s Medical Center • 32 cases: Total probable and confirmed pertussis cases admitted from JANUARY-JUNE 2013

46. Source of Infection • Rate of subclinical infection is as high as 80% • Coughing adolescents and adults -- major reservoir for B. pertussis-- usual sources of infection for infants and children • Household contact with infected adolescent and adults – major source of pertussis infection in not fully immunized infants Infant Pertussis and Household Transmission n Korea. The Korean Academy of Medical Sciences.

47. Mode of Transmission

48. Stages of Pertussis Infection • Catarrhal stage (1-2 wk) begins insidiously after an incubation period (3-12 days) • Paroxysmal stage (2-6 wk) onset marks by coughing • Cough begins as a dry, intermittent, irritative hack and evolves into the inexorable paroxysms • Post-tussive emesis is common, and exhaustion is universal. • Convalescent stage (≥2 wk), the number, severity, and duration of cough episodes diminishes

49. Stages of Pertussis Infection