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.

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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

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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: