Differential diagnosis of cough in pediatric patients

Differential diagnosis of cough

1. Kharkiv National Medical University
Rector — professor Kapustnik V.A.
Department of Pediatrics 1 and Neonatology

Head of the department — professor Gonchar M.O.

Differential diagnostics of cough in
children

Dr. Oleksandr Onikiienko
DrMedSci Olga Logvinova

2. Learning aims

1. On the basis of history, clinical manifestations of the disease, laboratory
and instrumental tests learn how to diagnose cough in children.

2. Learn how to conduct differential diagnosis of cough in children.
3. To determine the etiological and pathogenetic factors of cough in children.
4. Formulate a diagnosis according to current classifications.

5. Make a plan for the examination and analyze the data of laboratory and
instrumental studies in the the case of acute and chronic cough in children.

6. Demonstrate mastery of the principles of treatment, rehabilitation and
prevention of disease that are associated with cough in children.

7. To conduct differential diagnosis of different types of cough in children.

8. Demonstrate mastery of moral and deontological principles of medical
specialist and principles of professional subordination in pediatrics

3. Layman Definitions

* to force air out of your lungs through your throat
with a short, loud sound

Cambridge dictionary

* is a sudden expulsion of air through the large
breathing passages that can help clear them of
fluids, irritants, foreign particles and microbes

Wikipedia

4. Why do we need to cough?

¢ Airway protection from irritation
FSI

+ Mucus clearance i
| Ke
+ Symptom of disease & Pr?

5. How do we cough?

Irritation Inspiration Compression Expulsion

Deep Inspiration>Closure of Glottis

=> Abdominal Contraction >Glottis Opens
—Forceful Abdominal Contraction > Expulsion
of Air / Mucus

Elsevier science, 2002

6. How do we cough?

Video from Hillrom Youtube account

https://www.youtube.com/watch?v=X6pnVMRbj4E

7. Fisher‘.

HEALTHCARE

100% Humidity 90% Humidity
for 15 minutes

Video from account

8. Intensity of cough

Cough classification

Acute cough
~~ Acute cough with delayed recovery A recent onset of cough lasting <3-4 weeks.
Recurrent acute cough Chronic cough
Persistent, non-remitting cough

A cough lasting >8 weeks.
Prolonged acute cough
Cough resolves over a 3-8-week period.

Duration (weeks)

Shields MD, Bush A, Everard ML, et al
Recommendations for the assessment and
management of cough in children

Thorax 2008;63:iii1-iii15.

9. Glossary

Recurrent cough

Arecurrent cough without a cold is taken as repeated (>2/year) cough episodes, apart
from those associated with head colds, that each last more than 7-14 days. If the
periods of resolution are short, frequently recurrent cough will be difficult to distinguish
from persistent chronic cough.

Postviral cough

Postviral cough is a cough originally starting with an upper respiratory tract infection
but lasting >3 weeks.

Specific cough

A specific cough is one in which there is a clearly identifiable cause.

Non-specific isolated cough

The term “non-specific isolated cough” has been used to describe children who typically
have a persistent dry cough, no other respiratory symptoms (isolated cough), are
otherwise well with no signs of chronic lung disease and have a normal chest
radiograph

10. The most common symptom in children

|

Acute cough

v Mostly infectious
(rhinitis, bronchitis,
pneumonia, pertussis)

v Viral illness (“cold”)

Y 90% resolve
spontaneously

Respiratory diseases

|

Chronic cough

Extrapulmonary problems

Congenital - Adenoiditis
anomalies - Sinusitis
- Cystic fibrosis - Gastroesophageal

Bronchial asthma reflux
Chronic bronchitis - Neurotic cough

Interstitial lung - Drug induced
diseases - Left ventricular
Neoplasm heart failure
- Mediastinal
tumors

*Allergy Asthma Proc 35:95-103, 2014; doi: 10.2500/aap.2014.35.37 11

11. Acute cough

TS

Common cold
Ml Bronchitis or bronchiolitis
D Asthma
O Whooping cough
@ Croup
E Influenza
E Pneumonia
D Foreign body
M Irritants (tobacco smoke)
Li

GERD

https://www.ncbi.nlm.nih.gov/core/lw/2.0/html/tileshop_p
mc/tileshop pmc_inline.html?title=Click%20on%20image%
20to%20z00m&p=PMC3&id=3056681 315fig1.jpg

12. Summary of guidelines for acute cough

History and clinical

examination
I
(Coryza/fever} (Acute onset/ {Allergic solute, {lll health,
choking) ‘clearing throat chest shape abnormal,
‘cough) finger clubbing)
1 + Y +
Acute Inhaled Seasonal Fi
5 A = irst presentation
respiratory foreign allergic Pelican
infection body rhinits
+ Y +
Bronchoscopy See specific Investigations
guidelines for see tables 3,4 Further
treatment ——— a
diagnostics
Poda Simple head cold Reassure
upper respiratory *| Croup syndrome,
tract a A
bacterial tracheitis
See specific
guidelines for
treatment
Predominantly Bronchiolitis
lower respiratory }—+ asthma
infection pneumonia

Shields MD, Bush A, Everard ML, et al
Recommendations for the assessment and
management of cough in children

Thorax 2008;63:1111-11115.

13. Simplified guide for prolonged cough

Specific pointers identified Yes, chest x ray „| Be one Inhaled FB,
in history and examination ung bronchoscopy
episode
Ne]
No-other than features of: TB,
« Post infectious Progressive expanding or
cough m cough, compressing
e Pertussis like +/- weight loss intrathoracic
illness lesion
y
Further period observation P
iS ae complete No, chest x ray „| Features chronic Further
resolution lung disease diagnostics
Yes
y
Cough resolved Shields MD, Bush A, Everard ML, et al

Recommendations for the assessment and
management of cough in children
Thorax 2008;63:1111-11115.

14. DDx to chronic cough

Specific pointers identified 5
ton history, enaminaton, cas | — Er Wer aid, Aa
xray, spirometry (> 5 years) ma
No |_ (Clearing root, Post nasal drip/
Olergi sk] allecgic hi
Isolated cough
herwise well
hote Persistent endobronchial
infection
| OMer/productve + CF
cough) «FCO
ls ho cough trly + PBB
troublesome? a)
foster DR or
ie PER meng
No Yes | (Choking with foods, Recurrent
chest ao Foods) expiration
Reassure, Til enti
observe, asıhna
followup medication | fórosyor _| Tracheo/bronchomalacia,
borking cough] airways compression
Cough bizare, mm =
No response, Yes | dsappsars when asleep, —{ Psychogenic coug
“lo bel iniference™
Stop anti. Stop ant.
‘asthma asthma L (Ory cough, breathless Intestiiol
medication medication restive spromany] lung disease
Consider further | [ Restor antcasihma
investigations, and | | medication only if | | rcoressive cough,
followup cough relapses | Mao vs) 18

Shields MD, Bush A, Everard ML, et al
Recommendations for the assessment and
management of cough in children

Thorax 2008;63:1111-11115.

15. Acute laryngitis (J04)

Usually lasts for 3-7 days y
Etiology

A

z
EN

Infectious:

+ Viruse:
measles, chicken pox. Coxaci
with impaired immunity.

Streptococcus pneumoniae, H.influenzae and Moraxella catarrhalis,

rhinovirus, parainfluenza, coronavirus, adenovirus, influenza virus,
us and HIV can be potential causes among people

+ Fungal: histoplasma, blastomycetes, candida, cryptococci and coccidioids

Laryngitis caused by fungal infection is also common but often remains undiagnosed.
his usually occurs as a secondary use of inhaled corticosteroids or recent use of

Non-infectious

Vocal cords trauma,

Allergic,

Gastroesophageal reflux disease,

Inhaled corticosteroids,

Pollution,

Smoking, heat or chemical burns of the larynx.

In addition, rhii is patients are more likely to develop laryngitis

NSBI, 2019 Acute Laryngitis hups://www.ncbi.nlm.nih.gov/book/NBK534871/

16. Acute laryngitis (J04)

More common in children over 3 years

Pathophysiology +

Infectious form: inflammation of the larynx
leads to increased swelling of the vocal
cords, which negatively affects the
vibration. As the swelling progresses, the
threshold level of voice increases.
Generation of adequate phonation is
difficult, and the patient has wheezing.
Could be aphonia.

Acute trauma occurs after excessive crying
or singing. This causes damage to the outer
layer of the vocal fold. However, repeated
episodes can cause fibrosis and scarring at
a later stage.

Larynx inflammation (laryngoscopy)

\

2
a
oS

NSBI, 2019 Acute Laryngitis hups/wwsw.ncbi.nim.nih,gov/books/NBK534871/

17. Acute laryngitis (J04)

Presentation:

1. Initial symptoms: fever, cough, sore throat, and
rhinorrhea, which occur rapidly and exacerbate
within two to three days.

2. Changing the quality of the voice, in the later
stages, there may be complete loss of voice
(aphonia).

3. Discomfort and sore throat, especially after

talking.

. Dysphagia, odinophagia

. Dry annoying cough that worsens at night.

Common symptoms of throat dryness, malaise Barkling cough

and fever.

sap

5 Children’s Coughs - Spot The Difference
https://www.child-matters.co.uk/2018/09/21/childrens-coughs/

18. Acute laryngitis (J04)

Diagnostics

1. Clinical examination (usually sufficient for the diagnosis)
2. Visualization:

fiberoptic laryngoscopy Y = 7

indirect laryngoscopy

stroboscopy

19. Acute laryngitis (J04)

Treatment

Voice rest

Inhalations with saline

Nutrition Modification: Avoiding reflux by limiting

caffeinated beverages, spicy foods, fatty foods,

chocolate, and mint. Another important lifestyle

modification is to avoid late meals. The patient should

eat at least 3 hours before bedtime. The patient should

drink plenty of water.

Medications

1. Bacterial laryngitis - antibiotics: amoxicillin 80-90mg / kg,
amoxicillin clavulanate 40-60 mg / kg

2. Fungal laryngitis - fluticonazole 4-5mg / kg

3. GERD - H2 blockers of histamine receptors / proton pump blockers

20. Etiology

Pathogenesis

Presentation

Croup (laryngotracheobronchitis) J05

Viral disease in children from 6 months to 3 years

Commonly - parainfluenza
Seasonal :late autumn-winter-early spring

Inflammation and narrowing of the larynx, trachea, bronchi and

bronchi

Obstruction is caused by swelling and hypersecretion may
increase respiratory efforts

y
Typical “barking” cough, rough voice and
scream
Inspiratory stridor (squeaking while
inhaling)
An inspiratory stridor of mild to moderate
severity occurs during anxiety
Severe - at rest

Wheezing occurs when bronchioles are
affected

21. Croup (laryngotracheobronchitis) J05

Treatrment
Mild disease

No inspiratory stridor
No retractions

y

Sufficient rehydration Symptoms observation (absence of worsening)
0 | RR and Sp02 monitoring

22. Croup (laryngotracheobronchitis) J05

Symptoms associated with poor outcome

Inspiratory stridor Retraction
Paradoxical respiration

Nasal flaring
Cyanosis

23. Croup (laryngotracheobronchitis) J05 Qu=

Treatment

Moderate disease

Inspiratory stridor on exertion

Hospitalization for y . Dexamethasone
medical observation Rehydration 0,6 mg/kg once

Oral: solution for injection
dissolved in 10% dextrose

ss 5e

IM if child vomits

24. Treatment

E Severe form
e

Treatment of wheezing
Salbutamol/albuterol 2-3 puffs each
20-30 minutes

Qu=

25. Treatment

E Severe form
e

o Oxygen support when SABA are not
effective

26. Acute bronchitis J20

Bronchitis is a pepito infection with inflammation of the trachea, bronchi and bronchioles
lasting less than 2 weeks y
Etiology

ACUTE BRONCHITIS IS CAUSED PRIMARILY BY VIRUS (APPROXIMATELY 90%):
Adenovirus
Influenza
Parainfluenza
Respiratory syncytial virus
Rhinovirus and others.

Rarely, a secondary Bacterial infection occurs, this occurs in
secondhand smokers
children with immune deficiency
with genetic predisposition (cystic fibrosis)
with allergy / asthma
primary ciliary dyskinesia
GERD and others

27. Acute bronchitis J20

Presentation:

Sore throat
+ Coryza
+ Subfebrile body temperature
+ Weakness
+ Muscle pain
+ Cough (often dry) for 7-10 days.
In some cases wheezing

Treatment:

1. Ensuring adequate oxygenation

2. Bed rest

3. When T is higher than 38.0 - paracetamol 10-15 mg/kg; ibuprofen 5-10 mg/kg (Q6H)
4. Adequate rehydration

5. Avoid irritation / smoke

infection or if the cough is damp and lasts
80-90 mg / kg / day; amoxicillin clavulanate

If there is a suspicion of a secondary bacte
longer than 2-4 weeks, antibiotics (amoxi
45-60mg / kg / day) may be prescribed

28. Acute bronchiolitis J 21

The disease usually begins with rhinitis and progresses rapidly enough to the lower
respiratory tract, with tachypnea, wheezing, involvement of the accessory muscles in
the act of breathing and nasal flarii ty

ESTA
Laos

Etiology Viral ( RSV (75%), rhinovirus (39%), metapneumovirus (3%), adenovirus, influenza (10%),
parainfluenza (1%) coronavirus (2%)

Small airways acute inflammation associated with hypersecretion, swelling and
epithelial necrosis

The disease begins with a presentation ofupper respiratory viral infection (rhinorrhea,
cough), followed by shortness of breath and wheezing. Body temperature is often

Symptoms subfeb The course of bronchiolitis is very dynamic, apnea can occur rapidly
(especially in premature babies) and progress to respiratory distress syndrome.
Workup

Pulse oximetry, virologic studies, radiological examination, CBC and ABG

29. Acute bronchiolitis J 21

pone,
q

Rie,
ERIC ay,
ES

SS

Y
1908

Outpatient:

Monitoring compliance
with parents

Treatment (AAP-2014; NICE-2016; PREDICT-2017)

smeting

parents
Frequent feeding with
small portions

30. SA
to

CH
ES

Acute bronchiolitis J 21

aa Treatment (AAP-2014; NICE-2016; PREDICT-2017)

Outpatient:

0,9 % NaCl nasal
flushing and nasal
aspiration (when
issues with feeding)

Oxygen therapy at home. Oxygen therapy
can be given through the nasal cannulas, if
there is no viscous secretion, with a flow
rate of 2.51 / min. The American Academy of
Pediatrics and the European Respiratory
Society allow home oxygen therapy through
oxygen concentrators in children> 2 months,
with adequate nutritional support and
hydration, with no cyanosis and expected to
be satisfactory treatment compliance.

Viruses that cause
bronchlolltis are highly
virulent. Therefore,
frequent hand washing
with soap before and after
Infant treatment or contact
with objects such as toys
Is the most Important step
In prevention of the
disease spreading

31. Ai Acute bronchiolitis J 21

= Treatment (AAP-2014; NICE-2016; PREDICT-2017)
Inpatient:

Nebulized hypertonic
solution (3% NaCl)

= a ge
et

Oral Feeding. LE

In case of inefficiency, feeding
through a tube.

In extremely severe condition -
IV rehydration of 2.5% glucose
and 0.45% saline solution and
potassium subsidy

32. Ai Acute bronchiolitis J 21

N Treatment (AAP-2014; NICE-2016; PREDICT-2017)
Inpatient:

If the baby is> 6 months old and there
is a family history of asthma or child
presents with wheezing it is possible

Curre)
er | to perform a salbutamol (2.5 mg via
E a] oF = nebulizer) test once with a follow-up
yi LE response. If no response - further
st Y & u administration of salbutamol is not
indicated.

Routine use of antibiotics in children with acute bronchiolitis is
not indicated unless a co-bacterial infection is diagnosed and

suspected
No data available on routine nebulizing therapy with saline,

adrenaline, caffeine, aminophylline