Chronic Cough

Case

The mother of a 9 year old boy brings her son to the office because of a cough that has persisted for a month. The child has no fever, no respiratory distress, and appears to engage in normal activities. The school is concerned about the child's cough and will not allow him back to school until the problem resolves. How would you evaluate this boy?

A chronic cough is defined as a cough that persists for more than 3-4 weeks. In most instances the process is self limited.

Infants with chronic cough

  1. Infection
    1. RSV
    2. Pertussis
    3. Chlamydia
    4. Tuberculosis
  2. Gastroesophogeal reflux-aspiration or vagal response. May have chemical or inflammatory reaction.
  3. Reactive airway disease-associated with smoke exposure, URIs, cold air, family history of atopy
  4. Cystic fibrosis
  5. Congenital anomalies
    1. Vascular rings
    2. TEF
    3. Sequestration of the lung
Toddler and Pre-school Age
  1. Recurrent URIs. Children may have up to 10 viral URIs during a year and overlaps may appear to be "chronic". This is pertinent in daycare attendees.
  2. Reactive airway disease
  3. Foreign body aspiration
  4. GER
  5. Pollutant exposure
  6. TB
  7. Suppurative Lung Disease- often will be growing poorly and cough productive
    1. CF
    2. bronchiectasis
School Age Children
  1. Sinusitis
  2. RAD
  3. Smoking
  4. Psychogenic- usually the cough is bizarre sounding( honking, barking, croupy). The child is often not disturbed by the cough although others around are. Often disappears when asleep. 
  5. Suppurative lung disease
Important questions to cover in history
  1. Past medical history including illnesses, hospitalizations, infections
  2. Environmental exposures - pets, dust, house dust mites, smoke
  3. Allergic history and family history of atopy
  4. Birth history
  5. Any history of choking?
  6. Type of cough
  7. production of sputum
  8. Travel and TB exposure
  9. Medications taking
  10. Relationship of cough to exercise and cold weather
  11. Time of day when is worse?
    1. RAD usually worse at night
    2. GER usually worse at night
    3. Post nasal drip usually causes cough in the AM when arising and at bedtime
  12. Other symptoms including fever, SOB, conjunctivitis, nasal symptoms, chest pain
Physical Exam
  1. Growth
  2. Respiratory rate
  3. Cardiac Exam
  4. Clubbing and Cyanosis
  5. Chest exam
  6. Evidence of atopic disease
Diagnosis- Most often chronic coughs are caused by self-limited common processes. 
  1. Chest xray
  2. Sweat Chloride if indicated by history and exam. 
  3. GER evaluation
  4. PPD
  5. Evaluation for foreign body if history consistent with the possibility
  6. Trial of bronchodilators and course of oral steroids
  7. Skin testing
Management
  1. Treat reactive airway disease including oral steroids
  2. Treat cough equivalent asthma with beta-agonists prior to activities
  3. Environmental evaluation and elimination of exposures
  4. Treat GER
  5. Patients with psychogenic cough need to be counseled on managing the problem
  6. Treat sinusitis with antibiotics
  7. Nasal saline followed by topical nasal steroids 
  8. May use narcotic cough medications to break the cycle of irritation leading to cough and leading to more irritation. Be careful in young children
References
  1. What's behind that chronic cough? Contemporary Pediatrics. September 1993
  2. Chronic Cough in Children. JAMA. Nov.11, 1992. pg 2572
  3. Irwin R.S., Madison  JM Diagnosis and Treatment of Cough. NEJM Dec. 7, 2000
  4. Weinberger M, Abu-Hasan M. Pseudo Astham: When Cough, Wheezing, and Dyspnea Are Not Asthma.  Pediatarics October 2007 page 855