Izyan Nadhirah

14923308
What is cough??
Definition
 Cough: a forceful expiration that can
clear the airways of debris and secretions.
 Chronic cough: daily cough lasting
longer than 3 weeks
 Chronic cough is one that has persisted
for more than 8wks (British Thoracic
Society 2008 guideline for the assessment
and management of children with chronic
cough).
Hx
 Type of cough
 Initiation, duration
 Triggers
 Changes
 Exacerbation and Relieving factors
 Associated symptoms
 Impact on child’s activity level
 History of sick contact
 Family Hx
 Upper airway
disease

• Chronic
sinusitis
• Tonsillitis
• Pertussis

Lower airway
disease Lung parenchymal
disease
• Congenital
Central causes abnormalities • Infection
• Asthma (pneumonia
• Psychogenic and empyema)
cough. • Infection
• Tourette • Foreign body
disease: with a • Bronchiectasis
tic involving • Cystic fibrosis
throat
clearing or
cough.
Investigations
 Physical examination
 FBC
 CXR
 Lung function testing
 Pulse oximetry
 ABG
 Sputum/Bronchoalveolar lavage (C&S)
 Bronchoscopy
ASTHMA
Asthma
 Chronic
 Reversible
 Bronchoconstriction, mucosal oedema,
airway inflammation
 ->Airway remodelling -> irreversible
structural changes -> loss of pulmonary
function
 Malaysia: 5.8% (6-7 y.o), 8.9% (13-14y.o)
 Clinical presentation
 Dry, non-productive cough
 Wheeze
 Chest tightness
 Reduced effort tolerance
 Hyperinflated chest
 Harrison’s sulci
 Eczema/dry skin
 Hypertrophied turbinates
 Diurnal variation: worst at night/early
morning
 Vary over time & in intensity
 Triggers : viral infection, allergens – dust,
weather, laughter, exercise, irritants –
smoke/fumes
Level of Control Treatment Action
Controlled Maintain and find
lowest controlling step
Partly controlled Consider stepping up
to gain control
Uncontrolled Step up until
controlled
Exacerbation Treat as exacerbation
PERTUSSIS
 Pertussis
 Whooping cough
 Bordetella pertussis
 Highly contagious, endemic
 1 and 10 years old.
 Toxins mediate localized and systemic
effects
catarrhal paroxysmal convalescent
stage (1-2w) stage (2-4w) stage (>4w)
Clinical presentation
 Coryza and low grade-fever (1st week)
 Paroxysmal/spasmodic cough followed by
inspiratory whoop (worse at night)
 Infants: apnoea
 Vomiting
Investigations
 Pernasal swab
 PCR
 Serology: anti-pertussis IgG
 FBC (WCC>15)
 CXR: perihilar infiltrates +/- segmental
lung atelectasis
 Eyes: subconjunctival haemorrhages
Management
 VACCINATION :DTaP (age 2months,
3months, 5months)
 Antibiotics Erythromycin for 14 days (or
clarithromycin for 7 days) to reduce
infectivity
PNEUMONIA
Pneumonia
 Infection of the lower respiratory tract
 airways and parenchyma with
consolidation of the alveolar spaces.
 Lobar pneumonia
 Atypical pneumonia
 Bronchopneumonia
Clinical presentation
Abrupt onset of illness
Followed by sustained fever (>38.5)
and shaking chills
Wet cough with purulent sputum
Pleuritic chest pain
Shortness of breath
Tachypnoea
< 2 months age: > 60 /min
2- 12 months age > 50 /min

12 months – 5 years age > 40 /min

Age Pathogens
Newborns Group B streptococcus,
Escherichia coli,
Klebsiella species,
Enterobacteriaceae

Infants 1- 3 months Chlamydia trachomatis

Preschool age Streptococcus pneumoniae,
Haemophilus influenzae type b,
Staphylococcal aureus

Less common: Group A

Streptococcus,
Moraxella catarrhalis, Pseudomonas
aeruginosa

School age Mycoplasma pneumoniae, Chlamydia

pneumoniae

Majority of lower respiratory tract infections are viral in origin,

e.g. Respiratory syncytial virus, Influenza A or B, Adenovirus, Parainfluenza virus.
Investigation
1. Clinical History and Examination
2. Laboratory Investigations
1. Sputum for Gram stain, culture & S
2. Blood for culture & S
3. Serology
4. WCC and differential, inflammatory
markers, e.g., CRP, ESR; U & E and LFTs
5. Fluid sample (if empyema)
3. Radiology – CXR
Inspection
 Increased respiratory rate (tachypnoea)
 (Tachycardia)
Palpation
 Reduced chest expansion
Percussion
 Dullness
Auscultation
 Bronchial breathing, crepitations
 Pleural rub
Optochin disk
Criteria for hospitalization
 Children aged 3 months and below,
whatever the severity of pneumonia.
 Fever >38.5 ⁰C
 Refusal to feed and vomiting
 Fast breathing with or without cyanosis
 Associated systemic manifestation
 Failure of previous antibiotic therapy
 Recurrent pneumonia
 Severe underlying disorder, e.g.
Immunodeficiency
Pathogens Antibiotics
Streptococcus pneumonia Penicillin, cephalosporins
Group A Streptococcus

Haemophilus influenzae type b Ampicillin, chloramphenicol,

cephalosporins

Staphylococcus aureus Cloxacillin

Mycoplasma pneumoniae Macrolides, e.g. erythromycin,
Chlamydia pneumoniae azithromycin
Bordetella pertussis
 Inpatient management
First line Beta-lactams: Benzylpenicillin,
amoxycillin, ampicillin,
amoxycillin-clavulanate
Second line Cephalosporins: Cefotaxime,
cefuroxime, ceftazidime

Third line Carbapenem: Imipenam

Other agents Aminoglycosides: Gentamicin,

amikacin
• Fluids
• Oxygen
• Temperature control (Antipyretics)
• Chest drain
Outpatient
 Mild pneumonia
 Rapid breathing but there is no chest
indrawing.
 Oral antibiotics
 Educate parents/caregivers about
management of fever, preventing
dehydration and identifying signs of
deterioration.
 Return in two days for reassessment, or
earlier if the condition is getting worse.
Pulmonary TB
 MTB complex (M. tuberculosis or M. bovis)
 Pulmonary and/or extrapulmonary
 World Health Organisation (WHO)
estimates for 2016 are that 1 million
children (<15 years) currently suffer from
TB worldwide, and that more than
210,000 die each year.
Clinical features
 Fever of unknown origin
 Productive cough
 Haemoptysis
 Weight loss
 Night sweats
 Respiratory distress.
 Failure to thrive
 Extrapulmonary disease: prolonged fever, apathy, weight loss,
enlarged lymph nodes (cervical, supraclavicular, axillary),
headache, vomiting, increasing drowsiness, infants may stop
vocalising. Swellings and loss of function may suggest bone,
joint or spinal TB.
 Hypersensitivity reactions: erythema nodosum and pleural
effusions
 Investigations:
 +ve Mantoux test (>10 mm induration at 72 hours; tuberculin strength of 10
IU PPD).
 CXR:
- Enlarged hilar Iymph nodes +/- localised obstructive emphysema
- Persistent segmental collapse consolidation not responding to
conventional antibiotics.
- Pleural effusion.
- Calcification in Iymph nodes - usually develops > 6 mths after infection.

 Laboratory tests :
- Presence of AFB on smears of clinical specimens
- Positive histopathology or cytopathology on tissue specimens
- Gastric lavage/aspiration (infants and young children)
Clinical manifestation
Latent tuberculosis Asymptomatic
TST positive
Normal CXR,
No signs or symptoms of illness.

Tuberculosis disease clinical signs and symptoms

Abnormal CXR.
Primary pulmonary tuberculosis Asymptomatic
TST positive
Minimal abnormalities on CXR
(Ghon complex.)
Lymphadenopathy-> low-grade
fever, erythema nodosum
Progressive primary disease Primary pneumonia that develops shortly
after initial infection.
Progression to pulmonary disease,
disseminated miliary disease,
or CNS granulomas to meningitis occurs
most commonly in the first year of life.
 Treatment
 6 month regimen (pulmonary tuberculosis and
non-severe extrapulmonary tuberculosis)
Intensive Phase (2 months) Maintenance Phase (4 months)
Daily Isoniazid, Rifampicin and Isoniazid and rifampicin
Pyrazinamide
A 4th drug (Ethambutol) is added
when initial drug resistance may be
present or for extensive disease eg.
miliary TB or where prevalence of
HIV is high.
Prevention
 BCG (at birth)
 7 years old (if no scar)
 Cystic Fibrosis

 Autosomal recessive
 Incidence of CF is approximately 1 in 3200
whites, 1 in 15,000 African Americans, and 1 in
31,000 persons of Asian heritage.
 Defect in the CFTR (cystic fibrosis
transmembrane regulator) gene
CFTR Gene mutation (Chromosome 7)

Cl- Channel defect

Defective epithelial ion transport

Airway surface liquid dehydration

Defective mucociliary clearance

Bacterial colonization

Neutrophilic inflammation

Panbronchiectasis
Respiratory symptoms
  Productive cough
 Sputum -  volume,  purulence, 
viscidity
  SOB
  Wheeze
  Haemoptysis
 Nasal/ sinus symptoms
 Duration of onset – few days- couple
of weeks
A/w
 Stool type (e.g. fatty, oily, pale) and
frequency.
 Weight loss or poor weight gain.
 Neonatal period: meconium ileus.
 Children:
 malabsorption;
 failure to thrive;
 recurrent chest infection.
General Inspection
 BMI, Delayed puberty
 Clubbing, Cyanosis
Chest
 Hyperinflation,  Portacath
 Crepitations, Wheeze
Abdomen
  Hepatosplenomegaly
Investigations
 Sweat test showing increased chloride
levels (>60mmol/L).
 Lung function test: obstructive pattern with
decreased FVC and increased lung
volumes.
 CXR
 Chest physiotherapy
 Antibiotic therapy
 Inhaled/ Nebulized bronchodilators
Bronchiectasis
 Abnormal irreversible
dilatation of the
bronchi
 a vicious circle of
transmural infection
Causes
 Infections
 Congenital conditions
 Obstruction
 Ciliary abnormalities
 Rheumatic conditions
Clinical presentation
• Wet, productive cough
• Sputum may be mucoid ,mucopurulent
thick or viscous
• Dyspnoea and wheezing
• Pleuritic chest pain
Management
 Surgical resection
 Reference
 Guidelines for Evaluating Chronic Cough in Pediatrics: ACCP
Evidence-Based Clinical Practice Guidelines
http://journal.chestnet.org/article/S0012-3692(15)52858-4/pdf
 Clinical practice guidelines: Approach to cough in children:
The official statement endorsed by the Saudi Pediatric
Pulmonology Association (SPPA)
https://www.sciencedirect.com/science/article/pii/S2352646715
000344#tbl1

 CPG Malaysia for Management of Childhood Asthma 2014

 Paediatric Protocols for Malaysian Hospitals 3rd Edition
 Nelson Essential of Paediatrics