12-Feb-16

DIAGNOSTIC APPROACH OF
COUGH IN CHILDREN

Respirology Working Group

Indonesian Pediatrics Society
Courtesy of UKK Respirologi PP IDAI

Children adults miniature

12-Feb-16

Children is not small adults

Same etiology, different impact - respiratory viral infection
adult, mild disease: common cold
children, life threatening: croup, bronchiolitis

Same symptom, lead to different disease;

chronic cough in adult, think TB
chronic & recurrent cough in children, think asthma

Pediatric patient spectrum

Cut off point ???

Pediatric patient

Adult
patient
Typical

Clinical
The younger the less specific
presentation
the more difficult diagnosis
Classic
The older getting closer to
pattern
typical adult patient
neonate

underfive

adolescense

12-Feb-16

Medical management (tatakelola)

Diagnosis
Anamnesis: history
of symptomatology

Treatment
Symptomatic
treatment
Pathophysiology

Physical
examination:
symptomatology
Supp examination:
pathophysiology,
pathology, adapt
response, insults

Pathology
Adaptive
response

Etiologic
treatment

Time related cough

Acute
cough

Short time stimulation

Chronic
cough

Continous stimulation

Recurrent Repeated episodic

stimulation
cough

12-Feb-16

Chronic cough
2 or 3 or 4 or 8 or 12 weeks ?
acute
sub acute
chronic

:
:
:

Aust & NZ TS :
ACCP (US)
:
NGC (Findland) :
BTS (British)
:
ERS (Europe) :

<2 weeks or < 3 weeks

2-4 weeks or 3-8 weeks
>4 weeks or >8 weeks
chronic > 2 weeks
chronic > 4 weeks
chronic > 6 weeks
chronic > 8 weeks
chronic > 8 weeks

Cough classification
Indonesian Pediatric Society (IPS) - IDAI Chronic Recurrent
Cough (CRC) - BKB
oChronic : >2 weeks AND/OR
oRecurrent : >3 episodes in 3 months

ARI in children, 75% resolve in 1st week, 94% resolve in 2nd

week
An entry (symptomatology), NOT a diagnosis, leading to a
group of disease with the same manifestation

12-Feb-16

Important points
Knowledge of cough mechanism & location of cough receptor
A child is not a small adult; difference in :
growth and development
disease pattern and symptoms
Etiology
Age difference
Cough could be :
a protective mechanism
warning sign of disease
detrimental symptoms when persist and excessive

Etiology - diagnosis

the most common in children, acute cough: ARI

diagnostic challenge: chronic recurrent cough
single two or more etiologies
non smoking adult: PND, asthma, GERD
(CHEST 1999; 116:279284)

many classification, no consensus, different classification

base
Children: many conditions /diseases chronic cough; need
knowledge of cough mechanism, including cough receptors
location

12-Feb-16

Diagnostic approach
ACCP (American College of Chest Physician): children = adults
(previously, not anymore)
Knowledge of cough mechanism and receptor location! causes
identification >90%; treatment - same success
Pediatrician: different, child # small adult G&D process, disease
pattern, disease symptom
thats why : different diagnosis & treatment
Children: congenital, aspiration, neurological abnormality

Diagnostic approach - 2
No accepted general consensus of diagnostic approach of
cough in children
Classic medical approach:
ohistory,
ophysical examination,
osupporting examination

most common etiology: ARI, self limiting, no need further

diagnostic approach

12-Feb-16

Diagnostic evaluation
history :
o age
o cough type, duration
o influence factors : time of day (night, early morning), exercise, posture, food,
eating / drinking, cold
o sputum character
o associated symptoms : pain (chest, throat) dyspnea, hoarseness, rhinorrhea,
wheezing

physical examination : watch (hear & see) the cough type when patient
coughing
supporting examination: imaging, spirometry, respiratory endoscopy

Anamnesis
Age of onset
Cough characteristic: productive/dry, single/serial
Time: nocturnal, night waking
Additional symptoms : fever, wheezing, dyspnea
Pattern: ever before? same pattern?
Trigger factors
Influencing factors: worsening, relieving
Treatment : what treatment, the response
Growth and development disorder

12-Feb-16

Anamnesis
How & when did the cough start?
What is the nature and quality of the cough?
Is the cough an isolated symptom?
What triggers the cough?
Family history of resp symptoms, disorders & allergy?
Medications, the effect?
Disappear when asleep, or worsen at night?
Exposure to ETS?
Choking episode?

Cough pattern

12-Feb-16

Dry & wet cough

Non-productive

Productive

Increased cough
receptor sensitivity
Inflammation
Surfactant
abnormalities
Epithelial damage
Environmental
tobacco smoke

Mucus collection
Inflammation
Suppuration
Impaired mucociliary
clearance
Airway caliber
Impaired respiratory
muscle strength

Cough characteristic
Productive cough only heard from the examination
Choking cough, no inspiration stimulation from the larynx
Barking cough, dry Croup, acute tracheitis
Whooping cough, continuing cough without any inspiration on it
pertussis
Honking cough
Spasmodic / spastic irritative sticky mucous
Staccato cough

12-Feb-16

Physical examination
Growth & development evaluation
Nutritional state
Allergic signs: geographic tongue, allergic shiners, Dennie lines
(Dennie-Morgan folds)
Ear: cerumen, corpus alienum; nose & throat
Sinusitis sign: cobblestone, post nasal drip, pain
Tracheal deviation
Thorax: pectus carinatum, pectus excavatum, rales/crackles,
wheezing, hipersonor
Skin: atopic dermatitis
Clubbing fingers

Classification of pediatric cough

normal
or
expected
cough

non-specific
isolated
cough
specific
cough

Chang AB, Cough, Chest, 2006

BTS gln Management of cough in children, Thorax, 2008

10

12-Feb-16

Practical approach
Practical approach, 2 groups of chronic cough: specific cough & non
specific cough
non specific cough: isolated, apparently healthy
specific cough: significant underlying cause
Specific cough: presence of specific pointers (clues) as sign of
underlying disease

Specific cough pointers

neonate onset
G&D disorder
neuromuscular problem
stridor, wheezing
swallowing problem
recurrent pneumonia
chronic dyspnea

chronic sputum production

thorax deformity
clubbing finger
abnormal auscultation
hemoptysis

11

12-Feb-16

Differential diagnosis
Group 1: healthy
Recrt acute bronchitis
Post viral cough
Pertussis & Tussis like
Atypical pneumonia
Asthma
Rhino-sinusitis
GERD, LPR
Psychogenic

de Jongste, Thorax, 2003

Differential diagnosis
Group 1: healthy
Recrt acute bronchitis
Post viral cough
Pertussis & Tussis like
Asthma
Rhino-sinusitis
GERD, LPR
Psychogenic

de Jongste, Thorax, 2003

Group 2: sick
Chronic lung disease:
Recurrent aspiration
Corpus alienum
Bronchiectasis
Immune deficiency
Primary ciliary dyskinesia
Respiratory lesion:
Tracheomalacia
Tuberculosis
Tumor, cyst, sequestration
Neurological disorder: CP, ...

12

12-Feb-16

ACCP & BTS recommendation

Children with CC: careful & systematic evaluation
Children with CC should undergo, as a minimum, a CXR & spirometry
(if appropriate).
In children with specific cough, further investn may be warranted,
except when asthma is the etiologic factor.
Children with chronic productive purulent cough should be
investigated for bronchiectasis & to identify underlying causes such
as immune deficiency.
Cough in children, Med J Aust, 2006
ACCP gln Chronic cough in ped, Chest, 2006
BTS gln Management of cough in children, Thorax, 2008

Etiology according to age

Infants
Congenital
Airway malacia
Vascular ring
Infection:
Pertussis, RSV,
chlamydia,
adenovirus

Asthma
Aspiration
GERD
Passive smoking

Under five
Aspiration
Post infectious

Asthma
Passive smoking
Tuberculosis
Pertussis
Chronic Otitis M
GERD
Bronchiectasis

Adolescence

Asthma
Smoking
Postnasal drip
Post infectious
GERD
Infection
Tuberculosis
Chronic Otitis M
Bronchiectasis
Psychogenic
Tumor
Chow PY. Singapore Med J. 2004;45:462-9.

13

12-Feb-16

Supporting examination

Tuberculin skin test atau IGRA

Chest X-ray
Sinus paranasalis X-ray or CT-scan
Spirometry, lung function test
pH-metry for GERD
Barium meal: swallowing problem, related to feeding, stridor, wheezing
Eosinophil count
IgG, IgA, IgM, IgE: in recurrent otitis, bronchiectasis, productive cough, no
response to antibiotics
Respiratory endoscopy
o rhinopharyngolaryngoscopy: congenital, anomalies
o bronchoscopy: congenital, corpus alienum
Response to empirical treatment: bronchodilator, steroid, antibiotic

Supporting examination
X-ray
oThorax: AP, lateral, lateral decubitus
oThorax : inspiration and expiration phase
oSinus paranasalis
oIf necessary CT-scan and MRI
(These procedures will be discussed further by another speaker)

14

12-Feb-16

Plain sinus X-ray

Supporting examination
Blood examination

Routine peripheral blood examination

IgE : total and specific
IgG : total and subclass
Serology diagnostic: atypical agent, not TB.

Sputum direct, gastric lavage, induction :

Macroscopic
Microscopic : AFB, Eosinophil
Culture : Bacteria, M.tb, Fungus

Allergic skin prick test using several antigen

15

12-Feb-16

Supporting examination
Oesophageal pH-monitoring:
supporting procedure to detect
Gastroeosophageal Reflux
Fine needle aspiration biopsy (FNAB)
Cytology examinations
Different cells
Malignant cells

Nasal mucus membrane biopsy :

Mucociliary movement
Different types of cell

Skin prick test

16

12-Feb-16

Lung function test

Spirometry
Routine / standard test
Reversibility
Variability
Provocation test

Resp endoscopy
Bronchoscopy and laryngoscopy

Rigid bronchoscope
Fiberoptic bronchoscope
Detect abnormality
Provide specimen for examination :

Biopsy
BAL

17

12-Feb-16

Summary
Cough is a common presenting symptom in daily practice
There are a lot of diagnosis with cough as the main symptom
The majority of children with acute cough have a viral respiratory
infection
An attempt should be made to arrive at a specific clinical diagnosis

18

12-Feb-16

THE END

19