Dr. H. I. Boediman, Boediman, Sp.A(K) Sp.

A(K)
Born: Ambarawa, Ambarawa, October 11, 1943 Education: Ed i 1. Faculty of medicine University of Indonesia, 1967 2 2. Medical Post Graduate (Pediatrics), (Pediatrics) Faculty of Medicine Universitas Indonesia, 1972 3. Pediatric Pulmonology gy Subspecialty, p y Faculty y of Medicine Universitas Indonesia, 1987 R Recent position i i : Staf S f member b of f Di Division i i of f Respirology R i l Lecturer on Pediatric Pulmonology and Respirology, Dept of Child Health, Faculty of Medicine University of Indonesia

I Boediman B di YAPNAS SUDDHAPRANA JAKARTA

Cough
Cough: daily phenomenon, the most

common clinical symptom y p Cough & cold medication the most OTC drugs the most cost expenses, compared with ith ache h & pain i drugs d

Cough

Defense f mechanism h of f respiratory tract clears the airway from:

Respiratory tract reflex

Inhaled I h l d foreign f i materials t i l Large g amount of mucus Abnormal substances

.
Widdicombe J. Cough. Blackwell publishing 2004; 17 23 17-23 McCool FD.Chest 2006;129:48S-53S.

Cough
Different from other respiratory tract

(sneeze, hiccup) p) reflex ( Not stereotype in pattern Can be produced, produced and prevented voluntarily Voiceprint

Widdicombe J. Cough. Blackwell publishing 2004; 17-23

 time: 2 weeks; 3 weeks; 8 weeks; 12 weeks

acute sub acute

Definition
chronic

IDAI: BKB

: <2 weeks or < 3 weeks : 24 weeks or 38 weeks : >4 weeks or >8 weeks

chronic: >2 weeks AND/OR

t week, d ARI in i children, hild resolve l in i 1st k 94% i in 2nd Not a final diagnosis, leading to a group of

recurrent: 3 episodes in 3 months

disease with the same manifestations

P t h i l Patophysiology
Receptor Afferent nerve Cough control center Efferent nerve Respiratory muscles

Involves variety of complex reflexes It has a reflex arc that consist of:

Widdicombe J. Cough. Blackwell publishing 2004; 17-23

Cough model reflex

Voluntarycontrol ofcough Sensationof irritation

Cerebralcortex Placeboeffect

Coughcontrol centre +ve

Exogenous opioids ve

Exogenousopioids

Respiratoryareaofbrainstem

Vagus nerve

Airwayirritation

Respiratorymuscles COUGH Widdicombe J. Cough. Blackwell publishing 2004; 20

Cough g Reflex Arc

Receptor
Larynx Trachea Bronchus h Ear Gastric Nose Sinusparanasal Pharynx Pericardium diaphragm Vagal lnerve

Afferent
Vagal nerve branch

Coughcenter

Efferent

Efector
Muscle,

Larynx,trachea, andbronchus Distributedevenly inmedullanearby therespiratory p y center: Underthehigher controlcenter

Trigeminalnerve
Glossopharyngeal

Phrenicus nerve, Intercostal & lumbaris

Trigeminal,Facial, Hippoglosus nerve,etc

Diaphragm; Intercostal, Abdominal&lumbal muscles

Respiratorytractmuscles Musclesinvolvein respiration

nerve Phrenicus nerve

ChangAB.Cough2005;7:115.

Receptor

Distributed under/in the epithelium of

respiratory tract Types of receptors:

Rapid R pid adapting d ptin stretch st t h R Proximal respiratory tract is more s nsiti t sensitive to m mechanical h ni l stimulant stim l nt Distal respiratory tract is more ch m s nsitiv chemosensitive C-Fiber neurogenic inflammation
Widdicombe J. Cough. Blackwell publishing 2004; 17-23

Schematic diagram the potential roles C-Fibre & RAR

Cortex
General anaesthesia

SP/NKA

Brainstem
Centralsensitization

EAA

Respiratory muscles

Cough
Centralreflex

Cfiber Axonreflex f SP/NKA

Capsaicin Bradykinin Inflammation

Acetylcholine
Bronchospasm Mucussecretion Plasmaleakage

RAR

Breathing Obstruction Irritation

Widdicombe J.Cough.Blackwellpublishing2004;167

Stimuli to C-Fiber receptors & RARs

Cfibrereceptor Pulmonary Mechanical Inflation Foreign bodies Bronchial RARs
Inflation Foreign bodies Deflation Dust Mucus Foreign bodies Irritant gases I it t gases Irritant s s Irritant gases Cigarette smoke Cigarette smoke Capsaicin Capsaicin Volatile anesthetics Ac t lch lin Acetylcholine Ac t lch lin Acetylcholine Hi t i Histamine Histamine Histamine Serotonin Serotonin Serotonin Prostaglandins Prostaglandins Prostaglandins Bradykinin Bradykinin Bradykinin Substance P Substance P Anaphylaxis Microembolism Pulmonary congestion Microembolism Pulmonary y oedema At l t i Atelectasis Pulmonary congestion Bronchoconstriction Pneumonia Pulmonary oedema WiddicombeJG,EurRespirJ1995;8:1193

Ch i l Chemical

Mediators

Diseases

Does the stimulation on receptors always lead to cough?

The answer is NO!! Depends on the activation level that is caused by

the stimulation

Widdicombe J. Cough. Blackwell publishing 2004; 17-23

Role of Tachykinin in Cough

CFibre receptor Capsaicin Irritants,etc. RAR Mucus Mechanical
Epithelium

Tachykinins Peptidases
Tachykinin antagonists Antipeptidases Inhibit cough

Mucosa

CNS
Cough g

Excite cough

Widdicombe JG,Eur Respir J1995;8:1193

Cough Pattern
Depends on the location of the stimulated

receptor

In larynx expiration reflex More distal stimulation inspiration p phase as the beginning phase of the g cough

Mechanism of Cough
6.0 5.0 4.0 40 Air volume Flow rates

Sound 50 40 30 20 10 0 1 2

L/s

3.0 2.0 1.0 0.0

Subglottic pressure

Negative flow phase

Min flow phase

Positive flow phase

inspiratory phase

glottis closure

Expiratory phase (explosive)

Figure 1. Diagrammatic representation of the changes of the following variables during a representative cough: flow rate, volume, subglottic pressure, and sound level. McCoolFD.Chest2006;129:48S53S.

cmH2O

Cough g is the most common clinical manifestation

The most often etiology Infection of upper-respiratory tract and asthma inflammation process decrease the cough threshold Post nasal drip secretion and inflammation mediator stimulate the larynx GER: GER cough h as the th result lt of f receptor t activation in distal esophagus Bronchitis: excessive mucus secretion stimulate RAR

McCoolFD.Chest2006;129:48S53S.

Etiology

the most common in children: ARI, acute cough

diagnostic challenge: chronic recurrent cough singletwo or more etiologies nonsmoking adult: PND, asthma, GER many classification, no consensus, different

classification l ifi ti b base Children: many condition/diseases chronic cough; knowledge of cough mechanism, mechanism including cough receptors location

Cough in Children g Etiologies g

Infection
faringitis, laryngitis, otitis, croup, bronchitis, pneumonia

Allergy/inflammation
asthma, post viral cough, rhinosinusitis, eosinophilic bronchitis

Airway clearance
Aspiration (CP, vocal cord palsy, bulbar lesion, GERD, fistula T-E) Respiratory lesion: laryngo-tracheo-bronchomalacia; vascular ring

Lung poison
smoking, particulate matter, gaseous biomass combustion

Primary lung disease

ILD, PH, bronchiolitis obliterans

N Non respiratory i t
GER without aspiration, psychogenic, habitual

Etiology According to Age

Infants Congenital
Tracheomalacia Vascular ring

Under Five Aspiration

Post infectious
Asthma Tuberculosis Pertussis OMC GER Bronchiectasis

Adolescence Asthma Smoking

Infection:
Pertussis, RSV, Chlamydia Chlamydia, adenovirus

Postnasal drip Post infectious

Infection Tuberculosis OMC Bronchiectasis Psychogenic T Tumor

Asthma Aspiration GER S ki Smoking

h effectiveness ff d d on Cough depends

The ability of generating high velocities of the air

steam

Dispersion of liquid mucus into the air stream (misty flow) Increase the waves of mucus Vibration of the bronchus wall
The physical property of the mucus

McCoolFD.Chest2006;129:48S53S.

Cough Ineffectiveness
Altered cough mechanism Altered mucus rheology

McCoolFD.Chest2006;129:48S53S.

Diagnostic Approach
ACCP: child = adult Knowledge of cough mechanism and receptor

location! a causes identification >90%, treatment same success Pediatrician: different, child # small adult a G&D process, disease pattern, disease symptom thats why: different etiology & management Child: congenital, aspiration, neurological abnormality

Diagnostic Approach
approach of cough in children Classical medical approach:
history, physical examination, supporting s pp tin examination x min ti n

p g g No accepted general consensus of diagnostic

most common etiology: ARI, self limiting, no need

further diagnostic approach

Practical Approach
Practical approach, approach 2 groups of chronic cough: specific cough & non specific cough non specific p cough: g isolated, , apparently pp y healthy y specific cough: significant underlying cause Specific cough: presence of specific clues as sign of underlying disease
deJongste,Thorax,2003 ChangAB,Cough,2003

Differential Diagnosis g
Group 1: healthy Recrt acute bronchitis Post infectious cough Pertussis & Tussis like Asthma Post nasal drip GER Psychogenic Group 2: sick Chronic lung disease Recurrent aspiration Foreign bodies Bronchiectasis Immune deficiency Primary ciliary dyskinesia Respiratory lesion Tracheomalacia Tuberculosis Tumor, , cyst, y , sequestration q Neurological lesion
deJongste,Thorax,2003

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
ChangAB,Cough,2003

Anamnesis
Onset age Acute or chronic Cough characteristic: productive/dry, single/serial Time: nocturnal nocturnal, night waking Additional symptoms: fever, wheezing, dyspnea Pattern: ever before? same pattern? Trigger factors, choking episode, after meal Influencing factors factors: worsen, relieving Treatment: what, response G&D disorder, ,Q QoL

Anamnesis
Onset age: neonate Congenital malformations Swallowing problemchronic aspiration Anatomic lesion along the respiratory tract (cyst, tracheomalacia Mucociliary M ili clearance l impairment i i t Neuromuscular problem (delayed development, dysmorphic syndrome, syndrome CP Passive smoking

Physical Examination

G&D evaluation Nutritional state Clubbing g fingers g Sinusitis sign; cobblestone, PND, pain Allergic signs: geographic tongue, allergic

Tracheal deviation Thorax: p. p carinatum carinatum, p. p excavatum; ronchy, ronchy

shi s Dennie shiners, D i crease s

wheezing, hypersonor Ear: serumen, foreign bodies

Supporting Examination
Chest X ray Tuberculin skin test Spirometry, provocation test Otoscopy Ot s p SPN X ray, CT scan pH pH-metry metry for GER Barium meal: swallowing problem, related to

feeding, stridor, wheezing Ig G,A,M,E: recurrent otitis, bronchiectasis, productive, non responsive to AB Bronchoscopy: congenital, congenital foreign bodies

R i Ch ll Respiratory Challenge
adult person inhale 15.000-25.000 15 000 25 000 l of air everyday (restexercise) the air is usually not in ideal condition (the humidity, the temperature, & the content) foreign antigenic material (incl (incl micro org): up to 1010 particles/day alveolar region respiratory system must have a defense mechanism to overcome such a huge challenge

Physiologic or Pathologic?
Cough, part of respiratory defense mechanism in synergy with mucociliary clearance (MC) normally, respiratory tract produce secretion up

to 30 ml (adult) entrapment of ff foreign material, l b brought h b by M MC, swallowed

Physiologic or Pathologic?
Cough does not always mean abnormal or

clinically significant healthy h lth child hild (no ( respiratory i t infection i f ti or other th disease): cough 10 times/day (up to 34x) in 24 hours considered: normal or expected usually y not become m a complain, mp , not aware, , not a problem

Ph i l i or Pathologic? P h l i Physiologic
Cough will be generated if the receptor(s) is

stimulated respiratory secretion of MC large enough stimulates cough receptor, expels it out inhaled food or other foreign g material cough g out Cough: prevent aspiration useful physiologic mechanism h i i ah in healthy l h person

Ph i l i or Pathologic? P h l i Physiologic
in pathologic patholo ic condition e.g. e respiratory

infection larger & frequent secretion cough frequency & intensity will in healthy children, ARI 6-8 times/year in healthyphysiologic condition: mucociliary clearance in diseasepathologic condition: cough

Ph i l i or Pathologic? P h l i Physiologic
Cough will be generated if the receptor(s) is

stimulated any disease/disorder in respiratory system will stimulate cough receptor Chronic stimulationchronic cough g Recurrent stimulationrecurrent cough Nonrespiratory p y disorder also can cause cough: g GERD, CHD

Ph i l i or Pathologic P th l i ? Physiologic
cough
h i l i physiologic th l i pathologic

Pathologic: intensity, intensity frequency, frequency cough characteristic,sputumcharacteristic Coughwithoutreceptorstimulation: psychogenic,habitualcough

Ad t fC h Advantages of Cough
p g is very y useful medical aspect, cough
very important respiratory defense mechanism very important in respiratory clearance,

especially when MC is disturbed by disease important role of cough: neuromuscular di disease, t tracheobronchomalacia h b h l i without cough reflex: aspiration serious problems drown problems, drown in our secretion

Ad t fC h Advantages of Cough
other function: ALARM give us warning that something is wrong almost all respiratory disorder and some

nonrespiratory disorder: cough symptoms one of the most important cause of cough in children: hild SMOKING Parents awarepathologic search medical advice without cough symptoms: delayed diagnosis, advance disease

Di d t fC h Disadvantages of Cough
medical impact of cough is very vast the most chief complaint reasons:
disturbed di t b d f feeling li fatigue worry that something wrong Sleepless

musculoskeletal aching hoarseness urinary incontinence

Disadvantages of Cough
other medical impact of cough: effective mode of infection transmission Tuberculosis Morbilli Rubella respiratory infection: Influenza Pertussis

Disadvantages of Cough
impact of continuous cough could be annoyed disturbed respiration disturbed social activity decrease quality l of life l rigorous cough: intrathoracal pressure: 300 mm Hg air flow speed: 500 mph ~ 85% sound speed energy: up to 25 joule p of rigorous g cough g can cause complications p to impact almost all organ systems

Do We Have to Relieve Cough?

Cough respiratory defense mechanism Infection transmission facility Etiology gy of f cough? g irritant, , infection f Severe cough serious complication

The Using of Cough Drugs

Explanation for the patients Find the etiology OTC

The Using of Cough Drugs

Antitussive Mucoactive Expectorant Mucolytic y kinetic Surfactant preparation Mucokinetic Mucoregulator

Side Effects
Too much drugs Too T much h doses d Long-term

Side Effects
Narcotic antitussive moist skin, confuse,

seizure, pin point pupil seizure pupil, etc etc. Acetaminophen diarrhea, lose of appetite, nausea, etc. Salicylic hearing disorder, seizure, diarrhea, etc.

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