Pediatrics 13: 6-year-old female with chronic cough

User: Maryam Fadah

Email: 201315184@uaeu.ac.ae
Date: March 8, 2020 9:00PM

Learning Objectives

Upon completion of the case, the student should be able to:

Perform an age-appropriate history and physical examination for a child with chronic cough.
Generate an age appropriate differential diagnosis for a child with chronic cough.
Describe the epidemiology, pathophysiology, clinical findings, and management of important causes of chronic cough.
Describe physical exam maneuvers included in a complete pulmonary examination and discuss the significance of abnormal
findings.
Summarize the epidemiology, risk factors, and diagnosis of tuberculosis in children.
Summarize current guidelines for the diagnosis, classification of severity, and management of asthma.
Discuss clinical findings and management of allergic rhinitis.
Discuss the association between environmental allergies and asthma.

Knowledge

Differentiating descriptors of cough

Descriptor Possible etiology

environmental irritant
Dry
asthma

Wet/productive lower-respiratory infection

croup

Barking subglottic disease

foreign body

habit cough
Brassy or honking
tracheitis

pertussis

chlamydia
Paroxysmal
mycoplasma

foreign body

asthma

Worse at night sinusitis

allergic or vasomotor rhinitis (postnasal drip)

Disappears at night habit cough

Associated with gagging or choking gastroesophageal reflux disease

Clarifying terminology

Wheezing

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 Most physicians use "wheeze" to mean a high-pitched whistling sound associated with airway narrowing.
"Wheezing" can mean many different things to parents, including wheezing, stridor, or anything that causes noisy breathing-
including simple congestion.
It is important to clearly define what a patient or parent means by the term "wheezing" when they use it.

Shortness of Breath

"Difficulty breathing," "difficulty keeping up with playmates," or "chest tightness" are examples of how children and/or
parents may describe what physicians term "shortness of breath."
A sensation of shortness of breath would likely suggest an inflammatory cause of a cough, the most common condition
being asthma. Less likely causes include congestive heart failure, e.g., cardiomyopathy).

Pulmonary Tuberculosis in Children

Transmission

In the U.S., most children are infected by Mycobacterium tuberculosis in the home by someone close to them, but outbreaks in
daycare centers and schools do occur.

The case rates for all ages are highest in urban, low-income areas and in foreign-born children, among whom more than
two-thirds of reported cases in the U.S. now occur.
A diagnosis of tuberculosis in a young child is a public health sentinel event usually representing recent transmission.

Signs and Symptoms

The signs and symptoms of primary pulmonary tuberculosis (due to M. tuberculosis) in most children are few to none, often in
sharp contrast to their degree of radiographic changes.

More than 50% of infants and children with radiographically evident disease have no physical findings and are discovered
only by contact tracing. Hilar adenopathy is the most common radiographic abnormality.
Infants and toddlers are more likely to experience symptoms such as nonproductive cough, mild dyspnea or wheezing due
to bronchial compression by enlarged regional lymph nodes.
Infants may present with failure to thrive.
Severe cough and sputum production, together with systemic complaints (such as fever, night sweats and anorexia) usually
signify intrapulmonary dissemination.

Lung Findings

All lobar segments of the lung are at equal risk of initial infection.
Two or more primary foci are present in 25% of cases.
The hallmark of tuberculosis in the lung is a primary complex (relatively large size of the hilar lymphadenopathy compared
with the relatively small size of the initial lung focus).
The common sequence is hilar adenopathy, focal hyperinflation and then atelectasis, with minimal evidence of the primary
lung focus itself.
Small local pleural effusions are common.
The chest x-ray findings may be confused with foreign body obstruction.
Small local pleural effusions are common; large effusions are rarely seen in children under 6 years.

Diagnosis

The Mantoux skin test (formerly called a "PPD" but now more correctly referred to as a "TST," which stands for "tuberculin skin
test") is a practical tool for diagnosing TB infections in asymptomatic children. Blood based testing with Interferon-Gamma Release
Assays (IGRAs) such as QuantiFERON-TB Gold may be considered in children 5 years and older. In children who have received the
BCG (Bacille Calmette-Guerin) vaccine the IGRA test is preferred because there is a lower risk of a false positive test due to the
vaccine.

A TST test is considered positive if it is: > 5 mm in high-risk children, > 10 mm in moderate-risk children and > 15 mm in
low-risk children. See the following link for more detail on categories of risk:
https://www.cdc.gov/tb/publications/factsheets/testing/skintestresults.htm.
In symptomatic children, a culture of the M. tuberculosis organism should be obtained from a sputum sample, or from a first
morning gastric aspirate in young children.

Common Terms for Physical Findings

Allergic shiners: Darkening of the lower eyelids as a result of venous stasis

Allergic salute : A gesture that involves pushing the nose upward and backward with the hand to relieve nasal itching and
obstruction. Over time, this may result in the development of a transverse nasal crease.

Dennie-Morgan lines : Infraorbital creases that appear due to intermittent edema caused by allergies.

Clubbing: Change in the appearance of the fingers so that the distal phalanx is rounded and bulbous and the angle between the
nail plate and the nail fold is increased past 180 degrees. This phenomenon is suggestive of chronic hypoxia.

Asthma

Asthma is a chronic disorder of the airways that involves a complex interaction of airflow obstruction, bronchial
hyperresponsiveness and underlying inflammation.

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 It is the most common chronic disease in children in developed countries. Epidemiologic risk factors include gender (males have
higher prevalence), race/ethnicity (non-hispanic black children), and socioeconomic status (higher among children whose family
income is below the federal poverty level)

Diagnosis requires:

Symptoms of recurrent airway obstruction by history and exam

Demonstration that airway obstruction is at least partially reversible
Exclusion of other causes of obstruction

Asthma severity and control

The NIH asthma classification system provides a broadly accepted and consistent definition of asthma, allowing for improved
communication regarding its diagnosis and management among health care providers caring for patients with this chronic
condition.

During a patient's initial presentation, the emphasis is on assessment of asthma severity, as a guide to starting therapy.

Once treatment is initiated, the emphasis changes to assessment of asthma control, as a guide to maintaining or adjusting
therapy.

Assessment of severity and control varies with the age of the patient and relies primarily on consideration of asthma-related
impairment:

Frequency of daytime symptoms

Frequency of nighttime awakenings related to asthma
Interference with activity
Pulmonary function (if available)
Use of short-acting beta2-agonist medications (SABA) (if patient is already using medications)

A primary goal in classifying severity is to determine whether a patient's asthma is intermittent or persistent.

Asthma severity classification based on history of impairment in a school-age child:

History Classification Treatment

Daytime sx Intermittent Quick relief (SABA) as needed

Nighttime awakening <2/month Intermittent Quick relief (SABA) as needed

No interferene with activity Intermittent Quick relief (SABA) as needed

More frequent symptoms, more interference with activity Persistent Daily controller + quick relief as needed

Persistent asthma is further classified as mild, moderate, or severe. See the NHLBI Quick Guide for additional details.

Anti-inflammatory therapy for persistent asthma

All patients with persistent asthma should receive daily prophylaxis with anti-inflammatory therapy such as inhaled
corticosteroids. These medications are intended to prevent asthma exacerbations, thereby reducing the need for systemic
steroids.

The steroid medications most commonly prescribed include Beclomethasone, Fluticasone and Budesonide.

Dose and Frequency

The micrograms of steroid medication per puff vary with each type of steroid inhaler and must be considered when
prescribing.
Inhaled steroids require several weeks of daily use before the beneficial effects are realized.
Children with only seasonal symptomatology may require daily use of anti-inflammatory medications, starting several weeks
before the expected antigen exposure.

Side Effects

Children with asthma are often undertreated, based on the misconception by parents and physicians that long-term
treatment with inhaled corticosteroids is deleterious.
Side effects are rare, but can occur, especially when high doses are used.
Children receiving long-term therapy should be routinely monitored for elevation in blood pressure, serum blood sugar,
growth delay, and cataract development.

Clinical Skills

Assessment of Respiratory Distress

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 For patients presenting with respiratory complaints, it is important to perform an early assessment of the child's level of
respiratory distress.

Is the patient speaking in full sentences?

Does she appear short of breath when she talks?

If yes, you would need to manage her symptoms first and obtain a more detailed history later.

Review of systems clues for a school-aged child with cough

In a focused review of systems in a school-aged child with cough, look for:

Finding Possible indication

Change in
Dysphonia or hoarseness may suggest laryngeal irritation due to chronic rhinitis or gastroesophageal reflux.
voice

Probe for evidence of gastrointestinal causes of cough, not cardiac conditions; true cardiac chest pain is rare in
children.

Alternatively, you could also ask the patient if she "ever gets a bad taste in her mouth" or "if food ever comes
Chest pain back up."

While rare, congestive heart failure, most commonly due to infectious myocarditis, can present in school-aged
children with cough and wheezing and can easily be mistaken for a more common pulmonary condition, such as
asthma or bronchitis.

Although a foreign body aspiration is more likely in a toddler, otherwise healthy school-aged children and adults
Choking are still at a small risk for aspiration pneumonia secondary to inadvertently choking on food.
event Children with neurological impairment are at a significantly higher risk for aspiration, either from secretions
("above") or from refluxed gastric contents ("below").

Suggests an infectious etiology for cough, primarily pneumonia and sinusitis.

Lobar pneumonia, particularly in the lower quadrants, may also present with abdominal pain mimicking
Fever
appendicitis.

The presentation of bacterial pneumonia is usually acute, rather than chronic.

Frontal or orbital headaches may suggest a sinusitis, a common cause of persistent cough in children due to the
Headaches
associated post-nasal drip, which is often worse at night when the child is supine.

Sore May suggest evidence of post-nasal drip and pharyngeal irritation due to allergies or sinusitis. (May be present
throat in conjunction with nasal congestion, and/or a history of itchy, watery eyes.)

Significance of Findings on Lung Exam

Finding Significance

Tracheal deviation from midline may suggest a mediastinal mass, pneumothorax, or foreign
Tracheal deviation
body aspiration.

Caused by abnormal use of accessory muscles.

Appears as inward movement of the soft tissues in the intercostal, supraclavicular, or

Retractions subcostal spaces during inspiration.

May be seen in severe obstructive airway disease in children, including asthma, bronchiolitis,
and foreign body obstruction.

Use of accessory muscles of Inspiratory contraction of the sternocleidomastoid muscles at rest.

respiration This is a sign of significant respiratory distress.

Increased anteroposterior (AP) chest diameter, sometimes referred to as "barrel chest."

Hyperinflated thorax
This is suggestive of air-trapping due to chronic lung disease.

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 "I:E" refers to the ratio of time for full inspiration to time for full expiration (normally 1:1 or
Increased I:E 1:2).

In obstructive disorders, expiration is prolonged, and ratio is decreased.

"Hyperresonance" may be heard when there is localized air trapping behind a mucus plug,
Abnormal chest sounds on foreign body or mass.
percussion "Dullness" of breath sounds may be due to lobar consolidation from pneumonia or
atelectasis.

This is when the patient is asked to say "ee" and the examiner hears "ay" through the
Egophony stethoscope).

The phenomenon is suggestive of a lobar consolidation (an airless lung).

Wheezing is the sound of airflow through narrowed airways.

Wheezing It may be due to many different conditions, but one of the most common reasons for
wheezing in children is asthma.

Describing Breath Sounds

The description of common breath sounds varies somewhat among practitioners and there is no universally agreed-upon
definition. However, there are some areas of general agreement, as follows:

Wheezing

The sound of airflow through narrowed airways and may be due to intraluminal obstruction (e.g., from edema, mucus,
foreign object) or external compression (e.g., from lymphadenopathy, neoplasm).
Wheezing from asthma or other obstructive processes such as bronchiolitis is associated with obstruction in multiple small
or moderate-sized airways and results in continuous, musical, high-pitched, or polyphonic sounds that are generally heard
during expiration and may be heard during inspiration.

Rhonchi

Like wheezing, rhonchi are also continuous rather than discontinuous sounds and tend to be low-pitched and polyphonic and
may occur during either inspiration and/or expiration; they are typically thought to be due to mucus/secretions in the
airways.

Crackles

These are discontinuous sounds and are characterized as either fine or coarse.
They are typically inspiratory and are generally associated with alveolar or small airway conditions such as pneumonia,
pulmonary edema and bronchitis, or with interstitial disease.

Stridor

A high-pitched inspiratory noise that is the result of a partial obstruction of the extrathoracic airways such as the larynx or
trachea.
Stridor in children is most often seen in croup, inhaled foreign body with partial obstruction, and laryngomalacia.

Management

Types of asthma therapy

Quick-relief medications (short-acting beta2-agonists or SABAs) relax airway muscles to provide fast relief of symptoms. They do
not provide long-term asthma control. If quick relief medications are used >2 days/week (except as needed for exercise-induced
asthma), the patient may need to start or increase long-term control medications.

Long-term control medications (such as inhaled corticosteroids, which reduce inflammation) prevent symptoms. These are taken
daily and do not provide quick relief of acute symptoms.

Reference: NHLBI Asthma Care Quick Reference

Metered-dose inhalers and spacers

Metered-dose inhalers (MDIs) are portable, lightweight, and inexpensive.

The disadvantages are the high speed of medication delivery (upward of 400 miles/hour, leading to impaction of almost 99% of
the medication on the back of the throat) and the need to coordinate a breath with medication delivery.

Using a spacer device (seen here with a mask attachment for infants and small children that allows for a tight seal around the
nose and mouth) is the preferred way to use an MDI and optimizes drug delivery. A spacer should be used in all children (and
many adults).
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 Because the medication is suspended within the spacer device, it may be inhaled either through the mouth as a single
breath or with multiple tidal breaths with equal effect.
When used for inhaled corticosteroids, spacers also have the added benefit of preventing side effects such as dysphonia and
oral thrush.

Link to a patient handout on using an MDI.

Asthma action plan

One of the mainstays of asthma management is to educate parents and children about their asthma, and to provide them with
tools to manage their asthma effectively.

An "Asthma Action Plan" provides practical and easy-to-follow instructions, based on:

Daily symptoms and/or

Peak flow readings

The plan also communicates these individualized instructions clearly to the school or daycare provider. It may be helpful to
encourage parents to think of managing asthma as a "team sport."

Monitoring peak expiratory flow

Peak expiratory flow (PEF) provides a simple, objective and reproducible measure of the existence and severity of air flow
obstruction.

PEF monitoring can be used for:

Short-term monitoring
Managing exacerbations at home and in the emergency department
Daily long-term monitoring of asthma-particularly in moderate to severe asthma

When used in these ways, the patient's measured personal best is the most appropriate reference value.

Personal Best

The child's personal best can be determined by averaging their PEF values for 14 consecutive days during a period of good
control. See a table used to predict a child's personal best PEF based on height.

PEF is designed as an ongoing tool for monitoring asthma and is not appropriate for use in diagnosis. Formal pulmonary function
tests are necessary for this purpose.

Peak flow monitoring may be difficult for young children. Many clinicians rely primarily on patients' report of symptoms as a
measure of asthma control.

Aeroallergens and asthma

Patients with asthma often have inhalational allergies as a common trigger for their asthma.

The most common indoor aeroallergens that are responsible for sensitizing susceptible people include:

House dust mites

Animal dander
Cockroaches

Common outdoor aeroallergens include fungi and some grass and ragweed pollens.

The approach to treatment of allergies in children varies somewhat among doctors and from one area of the country to the other.

Exposure Avoidance

Reducing exposure to known outdoor and indoor allergens-such as cigarette smoke or wood smoke from a stove-is a good choice.
In an individual who already demonstrates sensitivity to some environmental allergens, the risk of becoming sensitized to other
environmental allergens is greater. The decision to recommend changes to the indoor environment (e.g. removing carpets or pets)
should be individualized. The expense and effort involved in implementing indoor environmental allergen controls may be greater
than any potential benefit.

Medication

Medications are frequently included in the management of environmental allergies.

Typical options include oral antihistamines, leukotriene receptor antagonists, and topical nasal steroids.

Antihistamines (H1 antagonists) are safe and effective for controlling the symptoms of sneezing, nasal pruritus and
rhinorrhea, particularly associated with intermittent or short-term seasonal allergies. Newer antihistamines are available
that are significantly less sedating than the earlier antihistamines.
Leukotriene receptor antagonists may be useful in the treatment of both asthma and allergic rhinitis.
Topical nasal steroids are the most effective pharmacologic agents for the treatment of allergic rhinitis, but may not be
indicated for short-term symptoms of seasonal allergies.

Studies
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 About spirometry

How Does Spirometry Work?

Spirometry measures "active" lung volume (i.e., air volumes that a patient actively blows into the spirometer while the rate of air
flow is simultaneously measured).

To obtain a volume-time spirogram, a child first breathes quietly ("tidal breaths") into the spirometer to determine tidal volume (Vt
= amount of air inhaled during a breath).

A slow and a forced vital capacity (SVC and FVC) breath is then performed to determine the maximum amount of air that can be
inspired (TLC = total lung capacity) and then released when exhaling.

Next, a forced exhalation is performed to determine the rate of air flow during exhalation, which rises quickly to its maximum
value immediately after exhalation is initiated.

As the lung volume decreases, the intrathoracic airways narrow, airway resistance increases, and the rate of air flow
progressively falls.
The standard time for exhalation is 6 seconds.
The volume exhaled in 1 second (FEV1 = forced expiratory volume in 1 second) is obtained during this maneuver.

Requirements for Testing

Because it is essential to obtain maximal efforts to differentiate restrictive from obstructive disease, PFTs are performed in
children who can accomplish a coordinated, forced expiratory maneuver (generally, children older than 5 years).

Measuring Reversibility

Measurements are obtained before and after bronchodilator use in order to determine the amount of reversible airway
disease that is present.

Findings in Obstructive Lung Disease

Obstructive lung disease (e.g., asthma and cystic fibrosis) is characterized by a reduction in air flow and trapping of air
inside the thorax behind tight, plugged airways, which lowers the FEV1.
Because the FEV1 is more reduced than the forced vital capacity (FVC), obstruction results in a low FEV1/FVC ratio, the FEV1
(%), which produces the scalloped shape on the exhalation limb of the flow-volume curve.

References

Guidelines for Evaluating Chronic Cough in Pediatrics ACCP Evidence-Based Clinical Practice Guidelines. CHEST. January 2006;129(no.
1) suppl. 260S-283S. doi: 10.1378/chest.129.1_suppl.260S

Kliegman, RM, Stanton BF, St Geme JW, Schor, NF. Nelson's Textbook of Pediatrics. 20th ed. Philadelphia, PA: Elsevier, 2016:11095-
1115.

Traisman ED. Clinical Evaluation of Chronic Cough in Children. Pediatric Annals. 2015: 44 (8); 303-307.

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