Recurrent & Persistent Coughs

Cough can be classified as either recurrent or persistent and lasting 4 – 6 weeks. [highlight] Cough further info: [/highlight]

[tabs style=”default” title=”Recurrent cough”]

[tab title=”Consultation “]

  • History – Severity of cough, timeline, missing school, wheeze, [highlight] atopic features… [/highlight] upper airways symptoms, snoring.  Ensure no serious [highlight] respiratory symptoms… [/highlight]. Whilst taking a history, undress the top half to watch the [highlight] breathing… [/highlight]
  • Examination – Assess growth and respiratory examination, including ENT. Child with frequent URTIs may have sinus/middle ear disease, nasal discharge. Large tonsils will increase night time coughing.
  • Management
    • [highlight] NPA [/highlight] if concerned about pertussis/atypical RTI or current viral URTI
    • Education and review if diagnosis is recurrent viral illnesses.
    • Consider trial of ventolin via spacer. see wheezy illness section
    • If unwell consider CXR and referral.

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[tab title=” Wheezy illnesses “]

  • Infant with Bronchiolitis – Wheezy respiratory illnesses common in infants. Current guidelines do not support the use of steroids or ventolin. There is little benefit to CXR. However trial of ventolin may have some use after around 10 – 11 months of age. Management is supportive, education and clearing nasal secretions with saline. [highlight] NPA [/highlight] for resp viral cause is useful as help confirm diagnosis and prevent further unnecessary testing.
  • Wheeze associated with viral URTIs – this is the most common cause of recurrent coughing. It can occur in up to 30% of toddlers and small children. The primary difference between this and a formal diagnosis of asthma is atopy – however the diagnosis is not essential as the management is similar.
  • Asthma will be more likely if the toddler has history of eczema and perhaps some non viral triggers, such as dust mite, animal dander, weather changes or pollen. Suspect if features of allergic rhinitis. More likely older children

Evidence based management – Trial of ventolin in room to assess response.  3- 5 Puffs via small vol spacer ± [highlight] mask… [/highlight]

Further tips

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  • Review to assess response and answer questions. Print off handout  
  • Prednisolone is not particulalry useful in viral induced wheeze, but has its place in asthma.
  • Antibiotics, Antihistamines, Vaporisers have no role in helping wheezy respiratory illnesses
  • If significantly short of breath then use ventolin repeatedly and organise transfer to hospital
  • CXR is of little benefit in wheezy resp illnesses. Usually show some perihilar changes that will not change management.

[/tab] [tab title=”Upper airways”]

  • Some children will have recurrent upper airways coughing due to cough receptor hypersensitivity to viruses.
  • They maybe well and healthy during the day with slight cough – more productive at night, or have concurrent URTI
  • No history of wheezing or family history of asthma.
  • Examination reveals healthy child with adequate growth, no respiratory findings. ENT examination may reveal large tonsils or adenoids.

Evidence based management –

  • Education about recurrent viral URTIs. This can be difficult as parents feel something should be ‘done’ or a medicine prescribed. There is no evidence that prednisolone/antihistamines/asthma treatment/antibiotics help. The effectiveness of cough mixture is equivalent to giving any liquid.
  • If large tonsils and history of disordered breathing with night time coughing consider ENT appt
  • Purulent nasal discharge and productive cough for several weeks on a recurrent basis consider course of augmentin (45mg/kg/day) – see below protracted bronchitis
  • See persistent cough if concern about serious cause

[/tab] [tab title=”Aspiration Syndromes”]

  • Some infants and toddlers will aspirate with GORD
  • Usually other GORD symptoms to help with diagnosis and more common in those with underlying neurological problems such as cerebral palsy
  • Difficult to diagnose – and so treat with PPI and assess response.

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[tabs style=”default” title=”Persistent Cough”] [tab title=”Consultation”]

Initial Short consultation – It is impossible to properly assess a child in a short consultation. If 15mins only then simply establish rapport, brief examination and consider simple test such as [highlight] NPA [/highlight] for viral/pertussis PCR, or trial of ventolin, or if justified a CXR – then review for a longer appointment to further evaluate clinically.

Proper assessment – Whilst taking a history, if possible undress the top half to watch the [highlight] breathing… [/highlight]
History – think of pertussis, atypical RTI,  atopy, recurrent viruses, and upper airways symptoms such as snoring.  Assess severity by asking about school attendance, effect on exercise, sputum production, night time sleep disturbance. Ensure no serious [highlight] respiratory symptoms… [/highlight] that suggest bronchiectasis or congenital respiratory anomaly.
Examination- respiratory system and ENT.

  • Pertussis will have minimal examination findings.
  • Atypical RTI such as mycoplasma will have crepitations/wheeze focally and abnormal CXR (mycoplasma can do anything to CXR)
  • Atopic child may have allergic crease blocked nose and eczema.
  • Child with frequent URTIs/sinusitis will have chronic nasal discharge and may have middle ear disease.
  • Clubbing indicates suppurative lung disease.
  • Large tonsils irritate cough receptors and contribute to symptomatology
  • Toddler is at risk for foreign body ingestion, particularly aged 6months to 4 yrs.

Management – guided by above assessment

  • CXR if concerned about persistent cough caused by lower respiratory tract condition. Not necessary if concerned about pertussis or wheezy respiratory illness
  • [highlight] NPA [/highlight] – for pertussis/viral/mycoplasma – this is useful as may stop further unnecessary investigation
  • Further Ix – Respiratory function testing, [highlight] immunodeficiency screening [/highlight], Hr Res CT – under direction from specialist
  • Referral – resp paediatrician, or ENT (sinus disease)[/tab]

[tab title=”Pertussis Syndrome”]

  • Generally caused by pertussis but also mycoplasma can have a similar picture.
  • Whooping cough is currently common in school aged children
  • Presents as a well looking child generally older than 7 yrs with paroxysmal cough particularly at night – often post tussive vomiting
  • PCR  [highlight] NPA [/highlight] swab and treat with Clarithromycin 7.5mg/kg/dose bd for 7 days
  • Check rest of family – immunisation status and contact management
  • Antibiotics may not have any effect on the chronicity of the cough.
  • There is no role for any other medications such as ventolin/predmix/antihistamines/inhaled steroids[/tab]

[tab title=”Wheezy Illness”]

  • Wheeze generally causes recurrent cough. But the history may be unclear and often a wheezy illness such as wheeze associated with recurrent URTis or genuine asthma is the cause of persistent cough and should be considered in the differential. see section above
  • Evidence based management – Trial of ventolin in room to assess response.  3- 5 Puffs via small vol spacer ± [highlight] mask… [/highlight][/tab]

[tab title=”Protracted bronchitis”]

A cough that is productive and lasted for 4 – 6 weeks in a child, who is otherwise been well in the past and does not have the features of  pertussis may have protracted bacterial bronchitis. This condition will respond to a two week course of antibiotics, such as augmentin. In some cases it is worth adding a macrolide such as rulide to cover atypical RTI such as mycoplasma.

[/tab] [tab title=”Bronchiectasis”]

This involves dilatation and anatomical distortion of the bronchial tree, diagnosed on high resolution CT. It is the result of chronic suppurative lung disease due to

1. Chronic diseases such as Cystic fibrosis, Primary ciliary dyskinesia, Immunodeficiency.
2. Chronic atypical RTI – pertussis, measles, TB
3. Congenital Anatomical conditions – including right middle lobe syndrome

Hx – Chronic persistent  cough, with copious sputum production, poor weight gain, sometimes haemoptysis, and anorexia
Ex – Evidence of poor weight gain, sometimes clubbing, localised chest signs including crepitations and wheeze. In severe cases tachypnoea and dyspnoea
Ix – CXR will show some bronchial changes and possibly consolidation.

Further Ix – [highlight] sputum [/highlight] sample if possible, Lung function testing – specialist testing will include high resolution CT and sweat test and/or  [highlight] immunodeficiency screening [/highlight].[/tab] [tab title=”Other causes”]

1. Habit Cough – honking or throat clearing, will disappear during sleep and no other associated symptoms.  Settles after a while and no treatment except explanation is needed
2. Foreign body – will occur in toddler age group – 6 months to 4 yrs[/tab]

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