week 4

Pediatrics 13: 6-year-old female with chronic cough User: Daniela Fernandez Email: [email protected] Date: August 5, 2021 12:49AM

Learning Objectives

Upon completion of the case, the student should be able to:

Perform an age-appropriate history and physical examination for a child with chronic cough. Generate an age-appropriate differential diagnosis for a child with chronic cough. Describe the epidemiology, pathophysiology, clinical findings, and management of important causes of chronic cough. Describe physical exam maneuvers included in a complete pulmonary examination and discuss the significance of abnormal findings. Summarize the epidemiology, risk factors, and diagnosis of tuberculosis in children. Summarize current guidelines for the diagnosis, classification of severity, and management of asthma. Discuss clinical findings and management of allergic rhinitis. Discuss the association between environmental allergies and asthma. Discuss how spirometry is used to measure lung function. Identify a child in acute respiratory distress.

Knowledge

Differential of Pediatric Cough

Descriptor Possible Etiology

Dry environmental irritant

asthma

Wet/productive lower-respiratory infection

Barking

croup

subglottic disease

foreign body

Brassy or honking habit cough

tracheitis

Paroxysmal

pertussis

chlamydia

mycoplasma

foreign body

Worse at night

asthma

sinusitis

allergic or vasomotor rhinitis (postnasal drip)

Disappears at night habit cough

Associated with gagging or choking gastroesophageal reflux disease

Clarifying Terminology

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Wheezing Most clinicians use "wheeze" to mean a high-pitched whistling sound associated with airway narrowing. "Wheezing" can mean many different things to parents, including wheezing, stridor, or anything that causes noisy breathing —including simple congestion. It is important to clearly define what a patient or parent means by the term "wheezing" when they use it.

Shortness of Breath "Difficulty breathing," "difficulty keeping up with playmates," or "chest tightness" are examples of how children and/or parents may describe what clinicians term "shortness of breath." A sensation of shortness of breath would likely suggest an inflammatory cause of a cough, the most common condition being asthma. Less likely causes include congestive heart failure (e.g., cardiomyopathy).

Pulmonary Tuberculosis in Children

Transmission

In the U.S., most children are infected by Mycobacterium tuberculosis in the home by someone close to them, but outbreaks in daycare centers and schools do occur.

The case rates for all ages are highest in urban, low-income areas and in foreign-born children, among whom more than two-thirds of reported cases in the U.S. now occur. A diagnosis of tuberculosis in a young child is a public health sentinel event usually representing recent transmission.

Signs and Symptoms

The signs and symptoms of primary pulmonary tuberculosis (due to M. tuberculosis) in most children are few to none, often in sharp contrast to their degree of radiographic changes.

More than 50% of infants and children with radiographically evident disease have no physical findings and are discovered only by contact tracing. Hilar adenopathy is the most common radiographic abnormality. Infants and toddlers are more likely to experience symptoms such as nonproductive cough, mild dyspnea, or wheezing due to bronchial compression by enlarged regional lymph nodes. Infants may present with failure to thrive. Severe cough and sputum production, together with systemic complaints (such as fever, night sweats, and anorexia) usually signify extrapulmonary dissemination.

Lung Findings

All lobar segments of the lung are at equal risk of initial infection. Two or more primary foci are present in 25% of cases. The hallmark of tuberculosis in the lung is a primary complex (relatively large size of the hilar lymphadenopathy compared with the relatively small size of the initial lung focus). The common sequence is hilar adenopathy, focal hyperinflation, and then atelectasis, with minimal evidence of the primary lung focus itself. Small local pleural effusions are common. The chest x-ray findings may be confused with foreign body obstruction. Small local pleural effusions are common; large effusions are rarely seen in children under 6 years.

Diagnosis

The Mantoux skin test (formerly called a "PPD" but now more correctly referred to as a "TST," which stands for "tuberculin skin test") is a practical tool for diagnosing TB infections in asymptomatic children. Blood based testing with Interferon-Gamma Release Assays (IGRAs) such as QuantiFERON-TB Gold may be considered in children 5 years and older. In children who have received the BCG (Bacille Calmette-Guerin) vaccine the IGRA test is preferred because there is a lower risk of a false positive test due to the vaccine.

A TST test is considered positive if it is: > 5 mm in high-risk children, > 10 mm in moderate-risk children and > 15 mm in low-risk children. See the following link for more detail on categories of risk: https://www.cdc.gov/tb/publications/factsheets/testing/skintestresults.htm. In symptomatic children, a culture of the M. tuberculosis organism should be obtained from a sputum sample, or from a first morning gastric aspirate in young children.

Common Terms for Physical Findings

Allergic shiners: Darkening of the lower eyelids as a result of venous stasis Allergic salute: A gesture that involves pushing the nose upward and backward with the hand to relieve nasal itching and obstruction. Over time, this may result in the development of a transverse nasal crease. Dennie-Morgan lines: Infraorbital creases that appear due to intermittent edema caused by allergies. Clubbing: Change in the appearance of the fingers so that the distal phalanx is rounded and bulbous and the angle between the nail plate and the nail fold is increased past 180 degrees. This phenomenon is suggestive of chronic hypoxia.

Asthma

Asthma is a chronic disorder of the airways that involves a complex interaction of airflow obstruction, bronchial hyper-

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responsiveness, and underlying inflammation. It is the most common chronic disease in children in developed countries. Epidemiologic risk factors include sex (males have higher prevalence), race/ethnicity (higher among non-Hispanic Black children), and socioeconomic status (higher among children whose family income is below the federal poverty level). Diagnosis requires:

Symptoms of recurrent airway obstruction by history and exam Demonstration that airway obstruction is at least partially reversible Exclusion of other causes of obstruction

Asthma Severity and Control

The NIH asthma classification system provides a broadly accepted and consistent definition of asthma, allowing for improved communication regarding its diagnosis and management among health care providers caring for patients with this chronic condition. During a patient's initial presentation, the emphasis is on assessment of asthma severity, as a guide to starting therapy. Once treatment is initiated, the emphasis changes to assessment of asthma control, as a guide to maintaining or adjusting therapy. Assessment of severity and control varies with the age of the patient and relies primarily on consideration of asthma-related impairment:

Frequency of daytime symptoms Frequency of nighttime awakenings related to asthma Interference with activity Pulmonary function (if available) Use of short-acting beta2-agonist medications (SABA) (if patient is already using medications)

A primary goal in classifying severity is to determine whether a patient's asthma is intermittent or persistent. Asthma severity classification based on history of impairment in a school-age child:

History Classification Treatment

Daytime sx ≤ 2 days/week Intermittent Quick relief (SABA) as needed

Nighttime awakening < 2 times/month Intermittent Quick relief (SABA) as needed

No interference with activity Intermittent Quick relief (SABA) as needed

More frequent symptoms, more interference with activity Persistent Daily controller + quick relief as needed

Persistent asthma is further classified as mild, moderate, or severe. See the NHLBI Quick Guide for additional details.

Anti-Inflammatory Therapy for Persistent Asthma

All patients with persistent asthma should receive daily prophylaxis with anti-inflammatory therapy such as inhaled corticosteroids. These medications are intended to prevent asthma exacerbations, thereby reducing the need for systemic steroids. The steroid medications most commonly prescribed include beclomethasone, fluticasone, and budesonide. Dose and Frequency

The micrograms of steroid medication per puff vary with each type of steroid inhaler and must be considered when prescribing. Inhaled steroids require several weeks of daily use before the beneficial effects are realized. Children with only seasonal symptomatology may require daily use of anti-inflammatory medications, starting several weeks before the expected antigen exposure.

Side Effects

Children with asthma are often undertreated, based on the misconception by parents and clinicians that long-term treatment with inhaled corticosteroids is deleterious. Side effects are rare, but can occur, especially when high doses are used. Children receiving long-term therapy should be routinely monitored for elevation in blood pressure, serum blood sugar, growth delay, and cataract development.

Clinical Skills

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Acute versus Chronic Cough

Acute Chronic

Duration < 4 weeks > 4 weeks

Etiologies Acute symptoms are most commonly due to an infectious cause (viral upper respiratory infection or viral or bacterial pneumonia) or a clear precipitating event (e.g., trauma or choking).

Children can have 5 to 8 upper respiratory infections a year, and the cough can last on average for up to 3 weeks with 10% lasting up to 25 days.

Causes are many and can include infection, inflammation, and irritation, anatomic or psychogenic. Rarely the cough may be due to cardiac or gastrointestinal conditions.

The etiology is usually benign, resulting from a viral upper respiratory infection.

A viral upper respiratory infection can induce airway reactivity in a healthy host for weeks; cough may persist long after other symptoms have subsided.

Assessment of Respiratory Distress

For patients presenting with respiratory complaints, it is important to perform an early assessment of the child's level of respiratory distress.

Is the patient speaking in full sentences? Does she appear short of breath when she talks?

If yes, you would need to manage her symptoms first and obtain a more detailed history later.

Review of Systems Clues for a School-age Child with Cough

In a focused review of systems in a school-age child with cough, look for:

Finding Possible indication

Change in voice Dysphonia or hoarseness may suggest laryngeal irritation due to chronic rhinitis or gastroesophageal reflux.

Chest pain

Probe for evidence of gastrointestinal causes of cough, not cardiac conditions; true cardiac chest pain is rare in children.

Alternatively, you could also ask the patient if she "ever gets a bad taste in her mouth" or "if food ever comes back up."

While rare, congestive heart failure, most commonly due to infectious myocarditis, can present in school-age children with cough and wheezing and can easily be mistaken for a more common pulmonary condition, such as asthma or bronchitis.

Choking event

Although a foreign body aspiration is more likely in a toddler, otherwise healthy school-age children and adults are still at a small risk for aspiration pneumonia secondary to inadvertently choking on food.

Children with neurological impairment are at a significantly higher risk for aspiration, either from secretions ("above") or from refluxed gastric contents ("below").

Fever

Suggests an infectious etiology for cough, primarily pneumonia orupper respiratory infection.

Lobar pneumonia, particularly in the lower lobes, may also present with abdominal pain.

The presentation of bacterial pneumonia is usually acute, rather than chronic.

Headaches Frontal or orbital headaches may suggest a sinusitis, a common cause of persistent cough in children due to theassociated post-nasal drip, which is often worse at night when the child is supine.

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Sore throat

May suggest evidence of post-nasal drip and pharyngeal irritation due to allergies or sinusitis. (May be present in conjunction with nasal congestion, and/or a history of itchy, watery eyes.)

Significance of Findings on Lung Exam

Finding Significance

Tracheal deviation Tracheal deviation from midline may suggest a mediastinal mass, pneumothorax, or foreignbody aspiration.

Retractions

Caused by abnormal use of accessory muscles. Appears as inward movement of the soft tissues in the intercostal, supraclavicular, or subcostal spaces during inspiration. May be seen in severe obstructive airway disease in children, including asthma, bronchiolitis, and foreign body obstruction.

Use of accessory muscles of respiration

Inspiratory contraction of the sternocleidomastoid muscles at rest. This is a sign of significant respiratory distress.

Hyperinflated thorax Increased anteroposterior (AP) chest diameter, sometimes referred to as "barrel chest."This is suggestive of air-trapping due to chronic obstructive lung disease.

Increased I:E "I:E" refers to the ratio of time for full inspiration to time for full expiration (normally 1:1 or 1:2). In obstructive disorders, expiration is prolonged, and ratio is decreased.

Abnormal chest sounds on percussion

"Hyperresonance" may be heard when there is localized air trapping behind a mucus plug, foreign body, or mass. "Dullness" to chest percussion may be due to lobar consolidation (e.g.pneumonia or atelectasis) or pleural effusion.

Egophony This is when the patient is asked to say "ee" and the examiner hears "ay" through the stethoscope. The phenomenon is suggestive of a lobar consolidation (an airless lung).

Wheezing Wheezing is the sound of airflow through narrowed airways. It may be due to many different conditions, but one of the most common reasons for wheezing in children is asthma.

Describing Breath Sounds

The description of common breath sounds varies somewhat among practitioners and there is no universally agreed-upon definition. However, there are some areas of general agreement, as follows: Wheezing

The sound of airflow through narrowed airways and may be due to intraluminal obstruction (e.g., from edema, mucus, foreign object), bronchoconstriction or external compression (e.g., from lymphadenopathy, neoplasm). Wheezing from asthma or other obstructive processes such as bronchiolitis is associated with obstruction in multiple small or moderate-sized airways and results in continuous, musical, high-pitched, or polyphonic sounds that are generally heard during expiration and may be heard during inspiration.

Rhonchi

Like wheezing, rhonchi are also continuous rather than discontinuous sounds and tend to be low-pitched and polyphonic and may occur during either inspiration and/or expiration; they are typically thought to be due to mucus/secretions in the airways.

Crackles

These are discontinuous sounds and are characterized as either fine or coarse. They are typically inspiratory and are generally associated with alveolar or small airway conditions such as pneumonia, pulmonary edema, and bronchiolitis, or with interstitial lung disease.

Stridor

A high-pitched, hoarse noise that is the result of a partial obstruction of the extrathoracic airways such as the larynx or trachea. Typically inspiratory, but may be biphasic. Stridor in children is most often due to croup, inhaled foreign body with partial obstruction, and laryngomalacia.

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Management

Types of Asthma Therapy

Quick-relief medications (short-acting beta2-agonists or SABAs) relax airway muscles to provide fast relief of symptoms. They do not provide long-term asthma control. If quick relief medications are used more than two days/week (except as needed for exercise-induced asthma), the patient may need to start or increase long-term control medications. Long-term control medications (such as inhaled corticosteroids, which reduce inflammation) prevent symptoms. These are taken daily and do not provide quick relief of acute symptoms. Reference: NHLBI Asthma Care Quick Reference

Metered-Dose Inhalers and Spacers

Metered-dose inhalers (MDIs) are portable, lightweight, and inexpensive. The disadvantages are the high speed of medication delivery (upward of 400 miles/hour, leading to impaction of almost 99% of the medication on the back of the throat) and the need to coordinate a breath with medication delivery. Using a spacer device (seen here with a mask attachment for infants and small children that allows for a tight seal around the nose and mouth) is the preferred way to use an MDI and optimizes drug delivery. A spacer should be used in all children (and many adults).

Because the medication is suspended within the spacer device, it may be inhaled either through the mouth as a single breath or with multiple tidal breaths with equal effect. When used for inhaled corticosteroids, spacers also have the added benefit of preventing side effects such as dysphonia and oral thrush.

See a patient handout on using an MDI.

Asthma Action Plan

One of the mainstays of asthma management is to educate parents and children about their asthma, and to provide them with tools to manage their asthma effectively. An "asthma action plan" provides practical and easy-to-follow instructions, based on:

Daily symptoms and/or Peak flow readings

The plan also communicates these individualized instructions clearly to the school or daycare provider. It may be helpful to encourage parents to think of managing asthma as a "team sport."

Monitoring Peak Expiratory Flow

Peak expiratory flow (PEF) provides a simple, objective, and reproducible measure of the existence and severity of airflow obstruction. PEF monitoring can be used for:

Short-term monitoring Managing exacerbations at home and in the emergency department Daily long-term monitoring of asthma-particularly in moderate to severe asthma

When used in these ways, the patient's measured personal best is the most appropriate reference value. Personal Best

The child's personal best can be determined by averaging their PEF values for 14 consecutive days during a period of good control. See a table used to predict a child's personal best PEF based on height. PEF is designed as an ongoing tool for monitoring asthma and is not appropriate for use in diagnosis. Formal pulmonary function tests are necessary for this purpose. Peak flow monitoring may be difficult for young children. Many clinicians rely primarily on patients' report of symptoms as a measure of asthma control.

Aeroallergens and Asthma

Patients with asthma often have inhalational allergies as a common trigger for their asthma. The most common indoor aeroallergens that are responsible for sensitizing susceptible people include:

House dust mites

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Animal dander Cockroaches

Common outdoor aeroallergens include fungi and some grass and ragweed pollens. The approach to treatment of allergies in children varies somewhat among doctors and from one area of the country to the other. Exposure Avoidance

Reducing exposure to known outdoor and indoor allergens—such as cigarette smoke or wood smoke from a stove—is a good choice. In an individual who already demonstrates sensitivity to some environmental allergens, the risk of becoming sensitized to other environmental allergens is greater. The decision to recommend changes to the indoor environment (e.g., removing carpets or pets) should be individualized. The expense and effort involved in implementing indoor environmental allergen controls may be greater than any potential benefit. Medication

Medications are frequently included in the management of environmental allergies. Typical options include oral antihistamines, leukotriene receptor antagonists, and topical nasal steroids.

Antihistamines (H1 antagonists) are safe and effective for controlling the symptoms of sneezing, nasal pruritus and rhinorrhea, particularly associated with intermittent or short-term seasonal allergies. Newer antihistamines are available that are significantly less sedating than the earlier antihistamines. Leukotriene receptor antagonists may be useful in the treatment of both asthma and allergic rhinitis. Topical nasal steroids are the most effective pharmacologic agents for the treatment of allergic rhinitis, but may not be indicated for short-term symptoms of seasonal allergies.

Examples of Control Measures for Environmental Allergies

Animal Dander

Remove pets with fur or hair from the home, or, at a minimum, keep animals out of the patient's bedroom and carpeted rooms within the home. House Dust Mites

Encase mattresses and pillows in an allergen-impermeable cover. Wash non-encased pillows, sheets, blankets and any special stuffed animal weekly in water hotter than 130 F (54.5 C). Remove all other stuffed animals from the child's bed. Placing toys weekly in the dryer or freezer may help. Remove carpet from the child's bedroom, if possible, and damp mop wood or vinyl floor weekly. If not possible, vacuum the child's bedroom carpet twice per week with the child out of the room. Reduce humidity to < 60% (ideally 30%–50%). Eliminate any cockroaches. Use poison bait or traps to control pests (chemical sprays may irritate asthma). Do not allow food in patient's bedroom. Do not leave food or garbage exposed.

Indoor Mold

Fix all leaks and eliminate water sources associated with moldy growth. Clean moldy surfaces. The child should avoid damp rooms such as basements. Dehumidify the basement to below 60% humidity, if possible.

Outdoor Mold

Try to keep windows closed; stay indoors when pollen and mold spore counts are highest (midday and afternoon), if possible.

Smoke, Strong Odors, and Sprays

Do not allow smoking in the child's home, family vehicle, daycare center, or school. Avoid strong odors, perfume and sprays whenever possible.

Studies

About Spirometry

How Does Spirometry Work?

Spirometry measures "active" lung volume (i.e., air volumes that a patient actively blows into the spirometer while the rate of air flow is simultaneously measured). To obtain a volume-time spirogram, a child first breathes quietly ("tidal breaths") into the spirometer to determine tidal volume (Vt = amount of air inhaled during a breath). A slow and a forced vital capacity (SVC and FVC) breath is then performed to determine the maximum amount of air that can be inspired (TLC = total lung capacity) and then released when exhaling. Next, a forced exhalation is performed to determine the rate of airflow during exhalation, which rises quickly to its maximum

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value immediately after exhalation is initiated. As the lung volume decreases, the intrathoracic airways narrow, airway resistance increases, and the rate of air flow progressively falls. The standard time for exhalation is six seconds. The volume exhaled in one second (FEV1 = forced expiratory volume in one second) is obtained during this maneuver.

Requirements for Testing

Because it is essential to obtain maximal efforts to differentiate restrictive from obstructive disease, PFTs are performed in children who can accomplish a coordinated, forced expiratory maneuver (generally, children older than 5 years).

Measuring Reversibility

Measurements are obtained before and after bronchodilator use in order to determine the amount of reversible airway disease that is present.

Findings in Obstructive Lung Disease

Obstructive lung disease (e.g., asthma and cystic fibrosis) is characterized by a reduction in air flow and trapping of air inside the thorax behind tight, plugged airways, which lowers the FEV1. Because the FEV1 is more reduced than the forced vital capacity (FVC), obstruction results in a low FEV1/FVC ratio, the FEV1 (%), which produces the scalloped shape on the exhalation limb of the flow-volume curve.

References

Chang AB, Glomb WB. Guidelines for evaluating chronic cough in pediatrics: ACCP evidence-based clinical practice guidelines. Chest. 2006;129(1 Suppl):260S-283S. doi:10.1378/chest.129.1_suppl.260S

Kliegman, RM, Stanton BF, St Geme JW, Schor, NF. Nelson's Textbook of Pediatrics. 20th ed. Philadelphia, PA: Elsevier, 2016:11095- 1115.

Traisman ES. Clinical Evaluation of Chronic Cough in Children. Pediatr Ann. 2015;44(8):303-307. doi:10.3928/00904481-20150812-03

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