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Clinical Practice Guideline on

CHRONIC COUGH

Ma. Quinna B. Boyles

COUGH

Is an explosive expiration that provides a normal protective mechanism for clearing the tracheobronchial tree of secretions and foreign materials.

MECHANISM
Coughing
Intiated either voluntary or reflexively by both Efferent and afferent pathways

Start with a deep inspiration, glottic closure, relaxation diaphragm

Marked positive intrathoracic pressure Glottis open, there is a rapid flow rates

Shearing force develop

one of the most common complaints for w/c the patient seek medical attention.

Important factor in the spreading of infection, a symptoms of underlying dse or a distressing problem itself.

2 Categories

1. ACUTE lasting less than 3 wks.

2. CHONIC lasting 3 wks or more.

Proper management is to identify the underlying disorder.


Thorough history and physical examination to help determine the most likely etiology. Include: Neonatal History Feeding History History of Foreign body aspiration Family History of TB Immunization Status (BCG, DPT) Medication given, noting the dosage, duration of treatment, degree of compliance and response.

Diagnostic Algorithm for Chronic Cough


Chronic cough (>3 wks) Do Hx and PE
No Signs and sx suggestive of Pulmonary problems No Signs and sx Suggestive of GERD Signs and sx Suggestive of PND

Yes
Request chest X-ray

Is the chest x-ray Normal?

No

Pneumonia, TB,CHF, Bronchiectasis, Recurrent Aspiration, Foreign Body

Clinical Issues
1. Is the chest x-ray normal? If normal further work up for possible etiology. In children, asthma, PNDS and GERD are the most common cause of chronic cough. Two local studies showed that asthma and PNDS from sinusitis or allergic rhinitis were common etiology of chronic cough

In foreign studies, aberrant innominate artery, GERD, and coughvariant asathma were common in children 0-18 months old, sinusitis and cva in 1.5 -6years old, and cva, psychogenic cough and sinusitis in children 6 yrs 16 yrs

Wheezing, or Chest tightness Breathlessness Gurgly chest

Possible asthma

Assd w/ any or all of the ff? Exercise, nocturnal occurrence Episodic/seasonal occurrence Personal or family history of Atopy, recognizable triggers

No

Expiratory Stridor?

n o

Consider Other Diagnosis

Probable asthma No Peak flow Meter Available/ Feasible? yes Normal or N Dec. predicted values o w/ >20% inc w/ inhaled SA B 2? Refer to Specialist for Confirmatory Test Therapeutic Trial Therapeutic trials w/ Inhaled/oral SA B 2 or Inhaled/oral SA B 2 and 5 days oral steroids n o

Patient Respond? Y e sTreat

Consider Other Diagnosis

asthma

Clinical Issue
2. Is wheezing present?

Asthma is the most common cause of persistent cough in children. In one study, it turned out that the most common cause of chronic cough on children was cough variant asthma, where it presented w/ persistent cough but without wheezing. 75%w/ chronic cough has c-v-asthma and 54% of these will develop into classical asthma

Associated with trigger factor

exercise Nocturnal occurence Seasonal and episodic attacts Personal and family hx of asthma

PROBABLE DIAGNOSIS OF ASTHMA

Is peak flow meter available and feasible?


Referral to an asthma specialist is imperative in the ff. situations: diagnosis of asthma needs to be confirmed by spirometry Peak flow measurements are normal in an asthma suspect(>80%) Peak flow measurements are below normal and responds to B2 agonist is equivocal (>20% inc. after B2 agonist) There is poor response to therapeutic trial

SPIROMETRY

Initial test for asthma suspects Is usually feasible in children from 5yrs old

PEAK FLOW METER


Measure peak expiratory flow rate (PEFR) which correlate well with FEV1 and offer an acceptable alternative to assess response to exercise challenge and peak flow variability. The predictive normal PEFR for Filipino Children bet. 6 -17 yo w/ the height of at least 100cm can be calculated using: Males: (Ht in cm-100) 5+175 Female: (Ht in cm-100) 5+170 When PEFR val. is abn or <80% of predicted, the change or inc in PEFR val. Is observed after B2 agonist. An inc of 20% will support a dx of asthma.

Is the PEFR normal or below predicted val and is there a >20% inc. in PEFR after inhaled B2 agonist ? In the asthma suspected whose baseline PEFR is normal or whose baseline is <80% of predicted val., a >20% inc. in PEFR after inhaled B2 agonist supports the diagnosis of asthma.

Therapeutic trial with B2 agonist with or without oral steroids


Peak flow meter is not available After administration of short acting inhaled or nebulized B2 agonist, improvement of expiratory airflow and relief of the sx seen w/n 5 min and peaks in 60 min. Oral form 30 min and peaks to 2-3hrs

Further ff-up meets asthma specialist consultation criteria?


Referral must be considered once patient is diagnosed to have persistent asthma. Patient was labeled to have such if: > than 1 attact per wk nocturnal sx of > than twice a month

PEFR of < than 80% of predicted PEFR variability of >than 20% FEV1 of < than 80% of predicted

Emphasize asthma education Aviodance of asthma triggers Peak flow monitoring Keep a diary of sx Proper and prompt use of medication Prompt management of acute exacerbations at home or school Using asthma action plan

Treat asthma

On further ff-up meets criteria for Persistent asthma

N o

Emphasize Asthma education

yes

Refer to Asthma Specialist

Consider other diagnosis

Expiratory Stridor?

yes Pulmonary Consult for Bronchoscopy

Collapsed Trachea on Expiration?

no

Vascular ring

yes Refer to Pediatric cardiologist

tracheomalacia

Is there expiratory stridor? Stridor may be produced by aspiration symdrome or by any anatomical or dynamic problem of the airways Predisposition to recurrent respiratory infections

Tracheomalacia A congenital condition characterized by floppiness or weakness of the wall of the airway, presents as expiratory stridor Noise produced during expiration because most trachea is intrathoracically located Usually resolved w/n 18-24 mos

Refer to Pediatric Cardiologist

Post nasal Drainage/ Nasal Obstruction? yes Presence of Mucopurulent discharge yes Consider sinusitis

Therapeutic Trial of antibiotics yes Consider other Diagnosis/ Suspect Complication/ Comorbid condition

Patients Responds?

no

Sinusitis

Refer to Appropriate specialist

Postnasal Drip Syndrome presenting as Chronic Cough


Most common cause of chronic cough in adult and children Considered when a patient complain of something dripping down their throat Upon PE on nasopharynx and oropharynx reveals mucoid or mucupurulent secretions

Consider Sinusitis

Inflammation of perinasal sinuses with concomitant inflammation of the nasal passages Causes: allergies, non-allergic rhinitis, bacterial and viral infections, anatomic abnormality Important to diagnose bacterial sinusitis treatment lead to rapid recovery

Therapeutic Trials with Antibiotics


Bacterial sinusitis most common pathogens are S. pneumonia, H. influenza and M.

catarrhalis

Choice of antibiotics should be considered with these organism susceptability

Nasal pruritus Or sneezing Or family hx


yes Consider Allergic rhinitis

no

Consider Non-allergic rhinitis

Refer to otorhinolaryngologist

Therapeutic trial w/ antihistamines, Steroids, decongestants singly or In combination based on px classification Consider severe AR & other Rhinitidis Otitis media, adenoidal hypertropy

no Patient responds? yes Probable Allergic rhinitis yes Further ff up Meets allergy Consultation criteria

Refer to Appropriate specialist

no

Px family multidiscipli Nary health care Provider ff up

Refer to allergologist immunologist

Consider Allergic Rhinitis


Symptomatic disorder of the nose induced by IgE mediated inflammation after allergen exposure of the membrane lining of the nose.

Criteria:
Positive identification of allergen Establishment of a causal relationship between exposure to the antigen and occurrence of the symptoms Positive identification of immunologic mechanism

PE patient had:
Facial pallor and mouth breathing Pale bluish gray edematous nasal mucosa Watery nasal secretions Clear to mucoid post-nasal drip Cobblestoning of posterior pharyngeal wall

Classifications
Intermittent Symptoms
< 4 days per week or < 4 weeks

Persistent Symptoms
> 4 days per week and > 4 weeks

Mild
Normal Sleep Normal daily activities Normal work and school No troublesome symptoms

Moderate to Severe
Abnormal sleep Impairment of daily activities Problems caused at work Troublesome symptoms

Therapeutic Trial based on Patient Classification


Oral antihistamines dec. symptoms of allergy Nasal antihistamines decrease congestion but cause sedation Nasal corticosteroids antiinflam agent w/ effects on sneezing, pruritus rhinorrhea and nasal blockage

Nasal Chromones mast cell stabilizer Oral decongestants and antihistamines Antileukotrienes anti-inflam acting on the lipooxygenase pathway

Consultation with an allergist/immunologist


Prolonged duration of rhinitis symptoms Identification of allergic or other triggering factors Possible immunotherapy Patient requiring systemic corticosteroids Patient quality of life is significantly affected

Consider non-allergic rhinitis


Condition with prominent nasal congestion but lacks the criteria for diagnosis for allergic rhinitis
Infectios rhinitis Idiopathic rhinitis Food induced Mucosal Abnormalities

Regurgitaion/ Dyspeptic sx?

Vomiting/

no

Consider Psychogenic cough

Consider GERD

Refer for counseling

Therapeutic trial w/ H2 RA/PPI Lifestyle/dietary Modification (2 wks course)

Patient Responds? yes Probable GERD

no

Refer to Pediatric Gastroenterologist

Continue treatment Co-manage w/ Gastroenterologist

Consider GERD
10% - 20% of patient with chronic cough have GERD 40% - 50% of patient with chronic cough have a silent GER

Signs and Symptoms of GERD

Recurrent vomiting in an infant Recurrent vomiting with poor weight gain Recurrent vomiting and irritability Heartburn Esophagitis Dysphagia Recurrent pneumonia Upper airway symptoms

Therapeutic Trial with Acid Suppressant


Omeprazole

GI referral for diagnosis and monitoring


Endoscopy and biopsy
Direct visualization of esophageal mucosa and biopsy of esophageal epithelium

24 hr Esophageal pH monitoring
Helps confirm presents of GERD without evidence of mucosal damage on endoscopy

Psychogenic Cough
Diagnosis of exclusion Manifestation of more severe psychological problem Relatively common in pediatric age group Diagnosis 3-10% in children with cough of unknown etiology Refer for councelling