Definition

Cough is a reflex response of the respiratory tract to

stimulation of irritant or cough receptors in the airway mucosa

Short inspiration followed by forced expiration

through partially closed glottis.

Cough is caused by 1) airway inflammation and

production of excessive mucus. 2) spasm of bronchial smooth muscles 3) direct stimulation of cough receptors.

Cough reflex
Receptors: nose, PNS, pharynx, larynx, trachea, bronchi, pleura

Centre
medulla

Effectors: diaphragmatic , intercostal , laryngeal

Based on the history

Type
Wet Asthma, Bronchitis, Bronchiectasis(CF, Kartegeners,following measles, pertusis),FB,Pneumonia, Lung abscess,CHF.

Dry URT : tonsillitis, pharyngitis, asthma

Based on History :
Type of cough:

Wet cough : <5 yrs post tussive vomiting , mucus in the stool. Cough with copious expectoration: brochiectasis ( often secondary to ciliary dyskinesia syndrome kartegener, cystic fibrosis) pulmonary suppuration. Pneumonia : esp in older children . young infants : cough may be absent. Paroxysmal and resemble that of pertusis : staph, ureaplasma urealyticum, CMV, PCP, School going adolescent children : mycoplasma ( paroxysm occuring over periods of weeks to months) .

Based on History
Duration
Acute: Aspiration,URTI, Croup, bronchiolitis, Chronic :Asthma, postnasal drip, FB,chr infection(immunodef.)

Persistent cough :

Asthma Chronic sinusitis Hypersensitivity of cough receptors after infection. GERD FB aspiration Bronchitis, tracheitis due to chronic infection.[ recurrent bronchitis with productive cough hyperimmnoglobulin E job syndrome). Interstitial pneumonitis. Bronchiectasis , CF Recurrent aspiration due to pharyngeal incompetence, TEF, Extrinsic compression of the tracheobronchial tree- vascular ring, neoplasm, LN, lung cyst Habit cough Exposure to Irritant

Based on History
Diurnal variation
More in the night Asthma, bronchitis, GERD, postnasal drip More in the morning Bronchiectasis, bronchitis, cystic fibrosis

Based on History
Postural change:

cough which is more on lying down : Asthma,irritative airway, post nasal drip,GERD, brochiectasis

Onset
Sudden Eg: FB aspiration, Pul Embolism

Insidious
asthma , infection,

Characteristics
Loose (discontinuos ) productive cough : bronchitis, asthmatic

bronchitis, brochiectasis , cystic fibrosis Brassy : tracheitis, habit cough , laryngotracheitis, tracheomalacia, epiglottitis With stridor: laryngeal obstruction , pertusis Paroxysmal (with or without gagging): pertusis syndrome, cystic fibrosis , foreign body ,staphylococcal infection. Staccato : Chlamydia pneumonia. (usually 1st 6 months of life; prolonged afebrile illness w/ congestion, tachypnea, rales, hyperinflated lungs w/ diffuse infiltrates, peripheral eosinophilia, +/preceding conjunctivitis) .Musical term - bursts of short , brassy cough. Nocturnal cough : upper or lower respiratory tract allergic reaction , sinusitis. Most severe on awaking in the morning : bronchiectasis, chronic bronchitis, cystic fibrosis.

Characteristics
With vigorous exercise: exercise induced asthma,

cystic fibrosis , bronchiectasis . Disappears with sleep: habit cough, mild hypersecretory states as in cystic fibrosis ,asthma . Tight(wheeze): reactive airways.

Cough in the first month of life

Cough in neonate is always abnormal and cause of concern.

It is a reflection of disease , usually of some severity . Although it is common for newborn infants to sneeze , it is abnormal to cough. The cough reflex is not well developed early in life and is totally absent in premature babies. Aspiration ( swallowing dysfunction, GERD, TEF) Respiratory infections bronchiolitis is more common Lung, airway, vascular malformations Cystic fibrosis, dyskinesia of cilia. Heart failure- less common

Cough in school age children and adolescent

Most common : asthma Postnasal drip due to sinusitis Habit cough /cough tic syndrome- dry, vibratory ,

throaty, barking/honking type. Severity mild throat clearing to uncontrollable violent cough associated with vomiting and exhaustion . Presence of other somatic symptoms- abdominal pain , headaches. Family history of somatisation. Treatment : shift the focus of attention to everyday concerns and away from the symptoms, self hypnosis , family therapy, wrapping the child in tight fitting sheet rarely works.

Other points in the HOPI

Onset : sudden onset foreign body , pulmonary
embolism History of fb : sudden onset of cough with breathlessness, children with rec or persistent pul suppuration. Cough associated with eating/ drinking : GERD, aspiration, TEF. Follows exercise reactive airway disease. Hoarsness : laryngeal involvement . croup. Animal exposure : chlamydia psittaci(birds), yersinia pestis( rodents), francisella tularensis (rabbits) , q fever (sheep, cattle), hantavirus (rodents ), histoplasmosis (pigeons).

Other points in HOPI

Stridor:
Harsh , vibratory , high pitched, shrill, crowing noise caused by obstructed air flow Inspiratory :upper airway obstruction Expiratory : lower airway obstruction below the level of larynx . Biphasic due to mid tracheal disorder, Laryngotracheobronchitis, tracheitis. expiratory effort through partially closed glottis to increase end expiratory pressure to prevent collapse of alveoli during expiration)

Expiratory grunting: pneumonia. (Grunting : when infant makes

Wheeze : bronchiolitis, asthma Breathlessness: Cardiac cause. Fever: low grade : consider viral cause

high grade : pneumonia

Chest pain: uncommon and can occur due to Headache or facial pain : sinusitis H/o malabsorption : cystic fibrosis

pleurisy, pericarditis,

Other points in HOPI

Heart burn: postprandial, bedtime, common in

infants and neonates. Hemoptysis: uncommon. bronchiestasis, lung abscess, resolving lobar pneumonia, pul hemosiderosis(IDA), pul edema, mitral stenosis, tubercular cavity, bleeding disorder. Bright red color following bout of cough Presence of feeding difficulty, presence of cyanosis suggestive of life threatening respiratory disorder that requires immediate hospitalisation.

Other points in history:

Family history : tb, astma, hay fever, unsatisfactory

living cond over crowding, parental smoking, polltion, -increased incidence of resp inf, n bronchospasm.history of allergy rhinitis, asthma.eczema, urticaria. H/o cystic fibrosis. Vaccination status

Sputum
Clear mucoid - - allergic reaction, asthmatic bronchitis, Purulent sputum respiratory tract infection , increased

cellularity (eosinophilia ) due to asthma. Very purulent bronchiectasis Foul smelling sputum : anaerobic infection. Greenish color: pseudomonas 3 layered sputum : bronchiectasis. Microscopic examination sputum : Sputum that contain alveolar macrophages reflect lower respiratory tract process. Eosinophilia: asthma, asthmatic bronchitis, hypersensitivity reaction. PMN cells : infection.

Physical examination
General examination :

Look for allergic shiners, nasal crease, hypertrophy of turbinates, polyps, enlarged tonsils. Clubbing : bronchiectasis
Temperature

<38.5 viral infection > 38.5 bacterial infection .

Respiratory system
RR : Fast breathing : Birth-2 months: >60/min 2 12 months:> 50/min 1yr -5 yr: >40/min Tracheal deviation FB, mediastinal mass, Pl effusion, Pneumothorax.
Subcostal retractions: Lower respiratory tract infection Suprasternal retraction : upper airway obstruction.

Creps: coarse crackles pneumonia, bronchiectasis, cystic fibrosis, acute exacerbation of asthma
Wheeze : asthma ,bronchiolitis.

Other points in examination

Erythema nodosum, phlyctenular conjunctivitis tb.
Pertusis subconjuctival hge, facial puffiness,

suffusion of eyes, subcutaneous emphysema . Mediastinal mass : - facial plethora, , brassy cough, hoarsness, stridor, dysphagia.

 Auscultation of RS :

Discontinuos sounds : crackles: predominantly during inspiration . Opening of previously closed air spaces. fine high pitched , low amplitude , short duration coarse low pitched , high amplitude , long duration . Continuos sounds: musical sound due to turbulent flow of air through narrowed airways. wheeze high pitched rhonchi low pitched

Indicators of serious chronic lower respiraory tract disease in children

Persistent fever Failure to thrive Persistent tachypnea and labored ventilation. Chronic purulent sputum Persistent hyperinflation Clubbing of digits Cyanosis and hypercarbia, hypoxia Refractory infiltrates on CXR Persistent pulmonary function abnormalities Family history of heritable lung disease.

Investgations
CBC
Chest Xray Pulmonary function test

Sweat test

Case 1
3 year old girl presents with 1 month of history of

cough which was insidious in onset , gradually progressive, productive type, sputum is white in color , non foul smelling, present more in the night , associated with fever which is low grade and continuous .
Probable diagnosis :
Infection lower RT Asthma

Case 2
12 year old boy presents with 5 days history of cough associated with difficulty in breathing . Cough is dry type, present more in the night. H/o dust allergy .

Probable diagnosis : URT infection , Reactive airway disease.

Ref : Mehraban singh clinical methods Nelson Practical guide to pediatric respiratory dis by daniel and david, jaypee publications. Mosby illustrated paediatrics