Common Respiratory Problems for the Pediatric Provider. Conflict of Interest. Goals and Objectives. Normal Airway Clearance. Mucociliary Transport

Transcription

1 Common Respiratory Problems for the Pediatric Provider.Chronic Cough Conflict of Interest I have actual or potential conflicts of interest pertaining to this talk or topic Jane B. Taylor, MD, MSCR Assistant Professor of Pediatrics, UMKC Children s Mercy Hospital and Clinics CAPS Conference 9/18/15 The Children's Mercy Hospital, Goals and Objectives Definition of chronic cough Identify most common causes of chronic cough in 3 different pediatric age groups Familiarize yourself with the initial steps in evaluation/management and when to refer THE NATURAL PROGRESSION OF CHRONIC COUGH FOR THE PCP 3 4 Normal Airway Clearance Respiratory zone Chemical absorption Alveolar macrophages Conducting airways Mucociliary Airflow Cephalad airflow bias Cough Mucociliary Transport Gel Layer (high viscosity and elasticity) Sol Layer (low viscosity and elasticity) Rapid movement in extension to propel material in gel phase Slow return in flexion to starting position, traveling through sol phase Most effective in small airways due to large cross-sectional area 5 6 1

2 Cephalad Airflow Bias Decreased airway diameter during exhalation results in increased flow velocity Increased airflow velocity shears secretions and drives material in direction of flow Present in large and small airways but is the primary mechanism of transport in smaller airways 3-Phase process Inspiratory Compressive Expiratory Cough Deep inspiration Glottic closure Muscle contraction Glottic opening Debris clearance Dynamic airway compression Shearing forces at airway wall Cough Cough most effective in clearing large airways Mucociliary escalator moves airway lumen material from smaller peripheral airways to larger central airways where cough expels them Control Center (tractus solitaris & respiratory control center) Laryngeal and vagus nerves Chemo- and Mecha- Receptors (rapidly adapting, slowly adapting, C-fibers): nasopharynx, larynx, lower airways, interstitium, diaphragm, and esophagus Effectors (nasopharyngeal, laryngeal, accessory, intercostal, diaphragm, abdominal) Laryngeal, vagus, intercostals, phrenic, and other nerves 10 How Common is Cough? Healthy children cough up to 11 times per day airway protection rmal airway clearance Impaired cough ted in Neuromuscular disorders Chest wall deformities Cerebal Palsy / CNS disorders Pain (splinting / sedation) Epidemiology Cough PubMed 41, 635 articles ( ) 200 review articles and policy statements 2,200 articles in 2014 Chronic Cough PubMed 7,512 articles 465 articles in 2014 Chronic Cough in Children PubMed - 1,523 articles 84 articles in 2013 (81 in 2014)

3 Findings? Incidence and Prevalence 35% of parents at PCP reported their child coughing in previous month 5-10% of preschool and up to 15% of school aged children with chronic cough 80% of children with > 5 office visits exclusively for cough Scope 6.7% of all pediatric office visits (16 million) due to cough 10-38% of Pediatric Pulmology referrals 13 Impact Physiologic Quality of life Sleep for children and parents School performance Disrupted play Anxiety and stress Ecomic $2 billion spent on OTC cough medicines annually Office visits and referrals Lost time from work and school What is Chronic Cough? Definition Cough > 4 weeks duration for US, Australian/New Zealand pediatricians > 8 weeks for British Thoracic Society > 8 weeks for adult care providers > 3 weeks for Belgian providers Different Types of Cough Acute Normal Cough Protracted Cough Cough of < 3 weeks duration Majority are viral related Consider indications of foreign body, severe lower respiratory tract infection, exacerbation of chronic disease Testing t indicated unless there are concerns as above Specific therapy t indicated Cough of 4-8 weeks duration Majority are post infectious Any findings (history or physical examination) suggestive of other etiologies warrant evaluation as per chronic cough algorithm 3

4 Chronic Cough Cough of > 4 weeks duration with signs or symptoms indicative of specific diagsis or > 8 weeks duration without signs or symptoms indicative or specific diagsis Non-specific isolated chronic cough Age Related Causes of Chronic Cough Causes Preschool School Teens + Airway infection Airway amalies (tracheobronchomalacia) Foreign body PBB (Protracted Bacterial Bronchitis) ++ +/- - Upper airway syndrome (sinusitis/pnd) GERD Asthma Eosiphilic inflammation Vocal Cord Dysfunction (VCD) Somatic Cough Syndrome and tic cough Adapted from Kantar et al. Early Hum Devel Workup: Start with History Cough Age at onset Duration Severity Wet/moist/productive vs. Dry Diurnal variability Specific ise Triggers Exacerbating and ameliorating factors AFB event Recurrent emesis/gagging/choking Infectious contacts Smoke exposure Immunization status Other organ system pathology (ENT, cardiac, immune, neurodevelopmental, etc.) Medications 21 Symptoms and Exam Symptoms Fever URI Dysphagia Allergies Sputum production Wheeze Dyspnea Chest pain Hemoptysis Examination Tachypnea Hypoxemia ENT Chest deformities Breath sounds (wheezes, crackles, fixed rhonchi) FTT Clubbing Recurrent or chronic CXR abrmality Initial Testing Screening tests for chronic cough in children should include CXR Spirometry if old eugh Sweat test Tuberculin Skin Test May include if clinically indicated Pertussis titers Mycoplasma titers Basic immuworkup: IgG, IgM, IgA, tetnus/hib/s.pneumo titers Diagstic Algorithm Cough > 4 weeks with Indicators of Specific Cough? CXR and Spirometry rmal Diagstic Cough? Specific Testing Cough Type Barking or brassy Honking Paroxysmal Staccato Productive of casts Wet/moist Diagstic Cough Underlying Disease Croup, malacia, habit Habit/tic/psychogenic Pertussis Chlamydia Plastic or cast bronchitis Suppurative lung disease 24 4

5 Cough > 4 weeks with Specific Cough Indicators Specific Testing Specific Cough Indicators or Abrmal CXR or Spirometry Persistent Non-specific Cough CXR and Spirometry Reversible Airway Obstruction Referral Empiric Therapy Diagstic Cough Dx & Tx Asthma Comprehensive Assessment (suggest Pulmology referral) dry Asthma wet PBB Reassure & Reassess Specific Cough Atypical Infection & Recurrent Pneumonia Bronchiectasis GERD & Aspiration Congenital Amalies Other Resolution = Success 2 Week Reassessment resolving TB Fungus Mycoplasma Pertussis Chlamydia CF PCD Immune Deficiency PBB AFB GERD Laryngeal Cleft Neurodevelopmental TEF Cystic Amaly Malacia Vascular Ring ILD Cardiac Tumors UACS/sinusitis Habit/tic Persistent = Referral Discharge Chronic Cough Pneumonic I Am Coughing Green And Copious Sputum Habitually Infection Asthma Cystic fibrosis GERD & Aspiration Airway amalies Ciliary dyskinesia Sinusitis & UACS Habit cough References Chang AB, Robertson CF, Van Asperen PP, et al. A Multicenter study on chronic cough in children. CHEST 2012; 142(4):943. Morice AH. The diagsis and management of chronic cough. Eur Respir J 2004; 481. Chang AB, Glomb WB. Guidelines for evaluating chronic cough in pediatrics: ACCP evidence-based clinical practice guidelines. CHEST 2006; 129:260S. Landau. Acute and chronic cough. Paed Respir Rev 2006; 7S:S64. Gupta A, McKean M, Chang AB. Management of chronic n-specific cough in childhood: an evidence-based review. Arch Dis Child Educ Pract Ed 2007; 92:ep33. Shields MD, Bush A, Everard ML, et al. Recommendations for the assessment and management of cough in children. Thorax 2008; 63 Suppl III:iii15. Chang AB, Redding GJ, Everard ML. Chronic wet cough: protracted bronchitis, chronic suppurative lung disease, and bronchiectasis. Pediatr Pulmol 2008; 43:519. Chang AB. Cough. Pediatr Clin N Am 2009; 56:19. Massie J. Cough in children: when does it matter. Paed Respir Rev 2006; 7:9. Wubbel C, Faro A. Chronic cough in children. Pediatr Case Rev 2003; 3:95. Hart MA, Kercsmar CM. Chronic cough in children: a systematic approach. J Respir Dis for Pediatr 2001; 3:155. Asilsoy S, Bayram E, Agin H, Apa H, Can D, Gulle S, Altiz S. Evaluation of chronic cough in children. CHEST 2008; 134:1122. Chung KF, Pavord ID. Prevalence, pathogenesis, and causes of chronic cough. Lancet 2008; 371:1364. Daigle KL, Cloutier MM. Evaluation and management of chronic cough in children. Clin Pulm Med 2000; 7:134. Blumberg MZ. J Respir Dis for Pediatr 2001:3:80. Urbach AH, Bloom MD, Mendelsohn MJ, McIntire SC, Gartner CG, Zitelli BJ. What s behind that chronic cough? Cont Pediatr 1993; September: 106. Kamei. Chronic cough in children. Pediatr Clin N Am 1991; 38:593. Shields MD, Doherty GM. Chronic cough in children. Paed Respir Rev 2013; 14:100. Kantar A, Bernardini R, Paravati, et al. Chronic cough in preschool children. Early Hum Dev 2013; 89:S19. Chang AB, Robertson CF, Van Asperen PP, et al. A cough algorhithm for chronic cough in children: a multicenter, randomized controlled study. Pediatrics 2013; 131:e576. Kaslovsky R, Sadof M. Chronic cough in children; a primary care and subspecialty collaborative approach. Ped in Rev 2013; 34(11):498. Castro Wagner JB, Pine HS. Chronic cough in children. Pediatr Clini N Am 2013; 60:951. Kantar H, Bernardini R, Francesco P, Domenico M, Oliviero S. Chronic Cough in Preschool Children. Early Hum Dev DOI: /j.earlhumdev Verhagen LM, De Groot R. Recurrent, protracted and persistent lower respiratory tract infection: A neglected clinical entity. J of Infection. 2015; 71: S Bertigan AE, Murad MH, Pringsheim T, Feinstein A, Chang AB et al. Somatic Couth Syndrome (Previously Referred to as Psychogenic Cough) and Tic Cough (Previously Referred to as Habit Couth) in Adults and Children (CHEST guideline and Expert Panel Report). CHEST. 2015; 148(1):

6 Questions? and Thank you for coming! 31 6