Chronic cough

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Chapter 10 CHRONIC COUGH

Theodore X. O’Connell

General Discussion

Chronic cough, defined as daily cough for more than 3 to 4 weeks, is a common symptom in childhood. One study found that healthy children (mean age, 10 years) have, on average, 10 cough episodes per 24 hours, mostly during the daytime. This number increases during respiratory infections, which may occur five to eight times per year in healthy children. Adding to the difficulty in treating cough, several studies have shown that the parental reporting of cough does not correlate well with the frequency, duration, or intensity of the actual cough.

In children, upper and lower respiratory tract infections, asthma, and gastroesophageal reflux disease (GERD) have been considered the most common causes of chronic cough. In older children, cough-variant asthma, sinusitis, and psychogenic cough increase in frequency. Sinusitis, tuberculosis, pertussis, and cystic fibrosis are other causes of chronic cough that should be considered. Foreign-body aspiration should be considered in younger children. Recurrent infections may indicate an underlying immunologic disorder. Rare causes that may present early in life include vascular rings, tracheoesophageal fistulas, and primary ciliary dyskinesia.

The 1998 American College of Chest Physicians guidelines advocate that “the approach to managing chronic cough in children is similar to the approach in adults.” However, a subsequent study found that protracted bacterial bronchitis was the most common diagnosis in children, in contrast to adults, in whom asthma, postnasal drip syndrome, and GERD are the most common diagnoses. In fact, these adult diagnoses were found to be relatively uncommon in children. Because some controversy exists regarding the best algorithmic approach to the child with chronic cough, we provide two algorithms (Figures 10-1 and 10-2). The history and physical examination should provide significant guidance when using these algorithms. At some points in the algorithms, an empiric trial of therapy may be considered before additional testing is performed.

Figure 10-1 Sequential approach to the evaluation of chronic cough in the immunocompetent adult.

(From Irwin RS, et al. Managing cough as a defense mechanism and as a symptom: a consensus panel report of the American College of Chest Physicians. Chest 1998;114(2 suppl managing):166S

Figure 10-2 Diagnostic algorithm for use in children with chronic cough.

(From de Jongste JC, Shields MD. Chronic cough in children. Thorax 2003;58:998–1003, with permission.)

Up to 10% of preschool and early school-aged children have chronic cough without wheeze at some time, and parental smoking is associated with an increased prevalence of chronic cough. Fortunately, chronic cough has a favorable prognosis, with improvement being the rule in the majority of children who have chronic cough. Nonetheless, chronic cough may be the result of a serious underlying lung condition. Warning signs for serious underlying lung disease include the following:

1. Neonatal onset of the cough, which may represent a congenital defect, a problem with ciliary function (such as cystic fibrosis or primary cilial abnormality), an anatomic lesion in the airways, or a chronic viral pneumonia acquired in utero or during the perinatal period

2. Chronic moist or purulent cough

3. Cough that began and persisted after a choking episode, which may be the result of foreign body aspiration

4. Cough that occurs during or after feeding, which suggests gastroesophageal reflux or aspiration during feeding

5. General ill health with failure to thrive

Medications Associated with Chronic Cough

• Angiotensin-converting enzyme (ACE) inhibitors

• β-blockers

Suggested Work-up

Chest radiographs	To evaluate for infiltrates, atelectasis, congenital abnormalities, radio-opaque foreign bodies, or cardiomegaly
Complete blood cell count (CBC)	To evaluate for infection or eosinophilia
Purified protein derivative (PPD)	To evaluate for tuberculosis, especially if risk factors for exposure are present

Additional Work-up

High-resolution chest CT	May reveal bronchiectasis that is not seen on plain radiography
Sputum gram stain, cultures, and serology (e.g., Bordetella pertussis, Chlamydia spp., cytomegalovirus)	To evaluate for infection, especially if there are fevers or purulent sputum
Adenosine 5’-monophosphate bronchial challenge	To differentiate asthma from other chronic pulmonary diseases of childhood
Immunoglobulins and subclasses	To evaluate for immunologic disease
Pulmonary function tests	To evaluate for reversible obstruction
Bronchoscopy	If there is suspicion of foreign-body aspiration or congenital anomalies. Also may provide specimens from the lower airways for culture and microscopy.
Barium swallow with 24-hour esophageal pH monitoring	If reflux is suspected. Alternatively, an empiric trial of therapy may be considered.
Sinus radiographs or computed tomography (CT) scan	If sinusitis is suspected. Alternatively, an empiric trial of therapy may be considered.
Chloride sweat test	Should be performed in children with chronic cough and failure to thrive and in any child with a chronic productive cough to evaluate for cystic fibrosis
Ciliary function studies	Performed at specialized centers to evaluate for primary ciliary dyskinesia
HIV test	If risk factors for HIV exposure are present