The unified Airway
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Transcript of The unified Airway
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THE UNIFIED AIRWAY A CPMC Regional CME Event
- An Integrated Approach
Saturday October 1, 2011
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PEDIATRIC ENT: CHRONIC COUGH IN CHILDREN
Theresa Kim, MD
San Francisco Otolaryngology Medical Group
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SCOPE OF THE PROBLEM
• Most common complaint for which patients seek medical attention
• Major contributor to parental stress- Adults with chronic cough
experience more depression and anxiety
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SCOPE OF THE PROBLEM
Cough ever Persistent cough0%
5%
10%
15%
20%
25%
30%
5-7 year old (Aus-tralia)8-11 year old (Aus-tralia)8-11 year old (Nigeria)
Faniran 1999
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SCOPE OF THE PROBLEM
<5 5-10 10-15 15-20 >20
0%5%
10%15%20%25%30%35%
Number of doctor visits in last 12 months
% of children
Marchant 2008
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OUTLINE OF DISCUSSION
• Pathophysiology• Causes of chronic cough in children• Treatment• Diagnostic algorithm
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PATHOPHYSIOLOGY
• Two types of cough- Laryngeal
(“cough reflex”)
- Tracheobronchial (can be volitional)
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PATHOPHYSIOLOGY
• Three phases to cough- Inspiratory- Compressive- Expiratory
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WHAT’S NORMAL?
• “Expected cough”- Presence of cough in situations where
cough is the norm• Healthy children cough 10-11
times/day• 35-40% of children still cough 10 days
after onset of a common cold• Children have acute URI 5-8 times/year
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DEFINING COUGH
• Timeframe- Acute vs. chronic
• Etiology- Specific vs. nonspecific
• Quality of cough- Moist vs. dry, brassy, staccato
• Age of child
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TIMEFRAME
Acute cough< 2 weeks
Subacute cough2-4 weeks
Chronic cough>4 weeks
(3-12 weeks)
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ETIOLOGY
• Nonspecific- Defined as cough in the absence of signs
and symptoms of pulmonary or cardiac disease
• Specific- Anatomic abnormalities- Cardiac disease- Lung disease- Immune dysfunction
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ETIOLOGY
Expected cough Nonspecific
cough
Specificcough
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NONSPECIFIC COUGH
0% 10% 20% 30% 40% 50%43%
22%6%6%
4%1%
4%6%
1%2%
1%3%3%
1%Causes of chronic cough
Protracted bacterial bronchitisNatural resolution
BronchiectasisUncertain cause
AsthmaHabit cough
Eosinophilic disorderAspiration
B. pertussisM. pneumoniae
Endobronchial tuberculosisGER
Upper airway cough syndromeBronchiolitis obliterans
UACS 23%GERD 28%Asthma 13%Multiple etiologies 20%
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PROTRACTED BACTERIAL BRONCHITIS
• Chronic wet cough• Positive BAL fluid culture• Resolution with antibiotics
• Often misdiagnosed as asthma• S. pneumoniae, H. influenzae, M.
catarrhalis
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OTHER CAUSES OF CHRONIC COUGH
• Asthma- Cough with air flow obstruction- Uncommon cause of nonspecific cough in
children• GERD
- Reflux is the norm in infants- Association with cough is controversial
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HABIT COUGH
• Also known as psychogenic cough• Harsh, dry, repetitive cough• Significant improvement with
distraction, absence when asleep
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QUALITY OF COUGH
• Not useful in adult cough• Brassy cough
- 0.57 sensitivity, 0.81 specificity for tracheomalacia
• Spasmodic/paroxysmal• Wet/moist cough ( = “productive”)
- Most children do not expectorate sputum- 0.75 sensitivity, 0.79 specificity
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AGE OF CHILD
• Congenital anatomic abnormalities• Aspiration more common in younger
children- Must ask parents about possible aspiration
events
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4 YEAR OLD BOY WITH CHRONIC COUGH
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3 YEAR OLD GIRL WITH CHRONIC COUGH
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3 YEAR OLD GIRL WITH CHRONIC COUGH
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3 YEAR OLD GIRL WITH CHRONIC COUGH
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3 YEAR OLD GIRL WITH CHRONIC COUGH
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TREATMENT OF CHRONIC COUGH
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TREATMENT
• OTC cough medications- No benefit
• Asthma medications- No benefit for nonspecific cough
• Antihistamines- No benefit
• GERD medications- Inconclusive evidence
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TREATMENT
• Antimicrobials- No effect in viral URI- Modest benefit in cough with nasal discharge
• Other remedies- Steam, vitamin C, zinc, Echinacea little benefit- Honey (0.5-2 teaspoons) helpful for reducing
nocturnal cough and improving sleep quality of parents and children
• Placebo- 85% response
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DIAGNOSIS OF CHRONIC COUGH
• All children with chronic cough should have- Spirometry- CXR
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ALGORITHM FOR CHRONIC COUGHSx/signs of respiratory disease?
CXR, spirometry abnormal?
Characteristic quality?
1. Watch, wait, review2. Evaluate
Tobacco smoke Environmental
exposures Child’s activity Parent concerns
3.Treat obvious illness
NON-SPECIFIC COUGH
No
No
No
EVALUATE FOR SPECIFIC COUGH
Review in 1-2 weeks
Resolving, resolved
Persistent
Trial of therapy
Watch, wait, review
Dry—ICS 4 weeks
Wet—Abx 10-21 days
Sx/signs suggestspecific cough
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ALGORITHM FOR SPECIFIC COUGH
SPECIFIC COUGHReversible airway
obstruction orelevated eNO?
ASTHMAConfirm with 4 week
medication trial
Yes
No
BronchiectasisRecurrent pneumonia
Chronic infectionInterstitial lung disease
Airway abnormalityOther pulmonary disease
Cardiac disease
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PEARLS
• Causes of chronic cough are different than adults- Chronic wet cough...protracted bacterial
bronchitis- GERD, asthma and UACS are less common
• Empiric treatment is not recommended• Always remember to think about
aspiration in children younger than 5 years
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Thank you!