RECURRENT CHRONICCOUGH

Tutor :

Dr. Leopold Simanjuntak, Sp.A

Presented by :Deanno Willio Saputra, S. Ked.

(0361050128)

Preface

Cough is not a disease, but it is a clinical manifestation of many respiratory tract disease

Cough is a natural defence mechanism of respiratory tract primitive protection reflex

That can happen if the cough receptor stimulated by abundant tracheobronchial secretion or corpus alienum that enter the respiratory tract

Cough receptor End of vagal nerve among the ciliated epithelial cells.

Pharynx, bronchiolus, nose, paranasal sinuses, auditory meatus & tymphanic membrane, pleura, gaster, pericardium, and

diaphragm

Cough stimulator :

1. Cold air

2. Corpus alienum, ex : dust

3. Inflammatory/oedema of respiratory tract musosal

4. Pressure to the respiratory tract, ex : by tumour

5. Mucus at the respiratory tract

6. Contraction of the respiratory tract

If the cough get prolonged or recurrent in a spesific period, there can make some complications, can’t sleep well, disturbing the child growth and developmental

Cough Mechanism

Inhalating some air (200-3500 mL)

Closing of glottis

Increasing of intrapulmonary pressure (50-100 mmHg)

The glottis opened suddenly

Expiration of some air

Inspirationphase

Compressionphase

Expirationphase

Cough Mechanism

Recurrent Chronic Cough

Prolonged cough and/or recurrently.

Kongres Nasional Ilmu Kesehatan Anak (KONIKA) V in Medan, 1981 :

Recurrent Chronic Cough cough that caused by many etiologies and happen for 2 weeks and/or recurrent at least 3 episodes in 3 months with or without other respiratory or non respiratory symptoms

Etiology

1. Bronchitis

· Infection : - Virus

- Bacteria

· Allergy : Asthma

· Chemical : milk aspiration, gastric content, smoke inhalation

· According to upper respiratory tract chronic infection

2. Suppurative pulmonary disease

· Fibrosis

· Bronchiectasis

· Atelectasis with secondary infection

· Other cysts and infected congenital disorder, abscess, inhalation pneumonia and corpus alienum

Etiology

3. Focal lesion of larynx, trachea, or bronchus

· Corpus alienum

· Tumour, cyst, or glands in mediastinum or lungs

· Stenosis, cyst, or haemangioma from larynx or trachea

4. Tuberculosis

5. Psychogenic cough

6. Post Nasal Drip

In Indonesia, we should thinks to three possible cause; Primary Tuberculosis, allergic cough, and cough caused by congenital heart diasese

Predisposition Factor

Group of age is predisposition factor of Recurrent Chronic Cougha) Baby age (until 1 year old) :

· Congenital disorders· Congenital and neonatal infection· Aspiration· Fibrosis Cyst

 b) Preschool Age (1- 5 years old) :

· Recurrent viral bronchitis and allergic/asthmatic bronchitis are 2 main etiology

· Bacterial Infection, mycoplasm.· Bronchitis that connect with upper respiratory tract infection : sinobronchitis· Reactive disease : asthma· Suppurative lung disease· Productive cough without remission· Aspiration of corpus alienum

Predisposition Factor

c) School age (5 15 years old) :· Recurrent viral bronchitis· Asthma.· Iritative· Mycoplasm pneumonia· Psychogenic cough (tic cough). Usually heard loud, like goose (honking) and sounds false to get an attention. Children coughs if stressed and cough gone when sleeping· Postnasal drip. Cough caused by stimulation of secret flow from nasopharynx downward

 d) Common at all group of ages :

· Recurrent viral bronchitis· Asthma· Pertussis

Anamnesis

Things that we should got in anamnesis :

1) Patients medical record

2) Past illness

3) History

4) Medication that has been received

5) Patients growth and development

6) Body weight that decrease simultaneously

7) Decreasing acitivity

8) Prolonged febrile

Anamnesis

About the cough :

1) Since when; in a year, how many times the patient get cough.

2) Cough period : continuously, in certain times, daytime, night, morning.

3) Precipitating factors : fasting, dust, exercise, smoking (active/passive).

4) Cough pitch : hoarse, loud, dry, wet, barking, with wheezing, vomiting.

5) If excreting sputum : clear, yellowish, green, bloody.

 

Cough’s type according to the pathology :

1) Productive : bronchitis, bronchiectasis, fibrosis cyst.

2) Dry/high pitch : URTI, tracheitis, psychogenic

3) Barking : laryngitis (croup).

4) Cough with wheezing : asthma, bronchitis, asthmatic, corpus alienum.

5) Cough stridor : larynx obstruction, subglottis, trachea.

Anamnesis

It’s important to know when cough appear :1) Paroxysm : pertussis, corpus alienum, fibrosis cyst, chlamydial infection,

mycoplasm2) Nocturnal : sinusitis, upper respiratory tract allergy, asthma3) Morning : bronchitis, fibrosis cyst, bronchiectasis4) After exercise : reactive respiratory tract (asthma), fibrosis cyst,

bronchiectasis.5) Gone when sleep : psychogenic (habit cough)6) When eat/drink : tracheoesofageal fistulae, gastroesofageal reflux

If excreting sputum :1) Clear mucoid : commonly caused by allergy, asthma, asthmatic bronchitis2) Purulent : suppurative disease (bacterial infection, fibrosis cyst)3) Bloody : corpus alienum, bronchiectasis, fibrosis cyst4) Stinky : anaerobic infection, bronchiectasis

Physical Examinations

Examine :

1) Nutrition

2) Upper respiratory tract disorder

3) Chest’s shape

Barrel-shaped go to asthma, bronchiectasis

4) Respiratory rate : commonly increase

5) Auscultation :

· Difuse expiratory wheezing characterized to asthma

· Local wheezing : consider corpus alienum or narrow respiratory tract caused by external pressure, for example glandular enlargement

· Low breathing sound similiar with local wheezing

Finger clubbing can be found in suppurative lung disease : such like fibrosis cyst,

bronchiectasis

Supportive Examinations

1) Radiology Examinations

- Chest radiology

- Paranasal sinuses

- Barium meal (tracheoesofageal fistule suspicious), etc.

2) Sputum

Gram’s stain, Ziehl-Nielsen, culture if needed.

3) Hematology

- Neutrophilia : bacterial infection

- Limphositosis : pertussis

- Limphositopenia : viral infection, immunodeficiency.

- Eosinophilia : allergy, helminthiasis, chlamydia pneumonia.

Supportive Examinations

4) Bronchoscopy and bronchography

5) Other’s test

- Mantoux Test/PPD (specific process), sweat test (fibrotic cyst), Immunoglobulin IgE (allergy), IgA, IgG, IgM (immunodeficiency), serological test for mycoplasma and if needed, lung biopsy can be done to

identifying the bacteria

- Lung functional test to estimate any respiratory tract obstruction, by measuring FEV-1 and PEFR (Peak Expiratory Flow Rate). But, this test

is difficult to do in children

- In allergy suspicious or allergy in family history, IgE test should done and can be continue with Prick test

Therapy

Management of Recurrent Chronic Cough commonly consist of causative, symptomatic, and rehabilitation therapy

Antibiotics in causative therapy only given to the true infection cases. For example, to patient with Pertussis can be given eritromycin with dose 30-50

mg/kg/day. In Tuberculosis case, can be given a specific treatment

Therapy

Symptomatics therapy commonly consist of drugs below :

1. Expectorant

Increasing respiratory tract secretion

Guaphenesis, gliseryl guaiacolate, ipecac, ammonium carbonate, ammonium chloride, potassium iodide, sodium citrate

2. Antitussive

Depressing cough reflex (central & perifer) at cough receptor

Dextrometorphan hidrobromide (non-narcotic antitussive)

Codein phosphate (narcotic antitussive).

Therapy

3. Mucolytic

Decreasing mucous viscosity so can be excreted easily

Bromhexin, asetyl cysteine

4. Antihistamine

Antitussive groups

Diphenhidramine

5. Bronchodilator

Teophiline derivate & simpathomimethics drug (adrenergik)

Teophiline increasing CAMP concentration (smooth muscle relaxan), blocking phosphodiesterase.

Simpathomimetics drug caused bronchodilatation by stimulating beta-2 adrenergics receptor

Salbutamol, Terbutalin, Metaproterenol

Therapy

Some preventive procedure :

Reducing possibility to get persistent respiratory tract infection

Flatter the parents to smoking outside

Avoiding contact with potential allergens and other pollutant inside or outside the house.

Children with gastroesofageal reflux better don’t eat/drink abundant and after that, keep the body position erect for a few hours

Physiotherapy can be done. In a patient with lot of mucous secretion in the respiratory tract, postural drainage and chest slaps, breathing regularly and diathermy is helpful. This is the most important treatment in suppurative lung disease

Summary

Cough as a nonspecific manifestation of many patophysiology of respiratory tract is the most common complain in children

r

Cough in children commonly is acute and self limiting

Commonly caused by upper respiratory tract virus and didn’t need some specific therapy or any laboratories tests, etc.

If the cough getting longer without any serious pathological findings, it’s commonly caused by bronchiale asthma or recurrent viral bronchitis

Complete anamnesis and physical examination plays an important role in diagnostics

Literature

1. Lubis Helmi M. Batuk Kronik dan Berulang (BKB) pada Anak. Downloaded from : library.usu.ac.id/download/fk/anak-helmi.pdf

2. Tjandra Yoga Aditama. Patofisiologi Batuk. Cermin Dunia Kedokteran No. 84, 1993. Downloaded from : http://www.kalbe.co.id/files/cdk/files/05PtofisiologiBatuk084.pdf/05PatofisiologiBatuk084.html

3. Sidharta Herman. Simposium Satelit : Batuk kronik pada anak. Downloaded from :

www-portalkalbe-files-cdk-files-43_BatukKronikpadaAnak81 _pdf

4. Tim Pendidikan Kedokteran Berkelanjutan IKA FK UI - RSCM. Strategi Pendekatan Klinis Secara Profesional Batuk pada Anak. PKB IKA FK UI – RSCM. Jakarta. 2006.

5. Rahjoe, N. Batuk kronik dan berulang pada anak. Batuk kronik, penanggulangan secara rasional. FK UI. Jakarta. 1985.

6. Wahab AS, Utomo. Batuk kronik pada anak. MDK 6(11), 1987, 640

- Thank You -

• EIC (exercise induced cough) dapat berlanjut menjadi EIA.

• Hidden Asma.. Yaitu asma yang tidak disertai dengan wheezing, disebabkan bronchokonstiksi yang tidak lebih dari 50% dan umumnya disertai dengan batuk yang terus-menerus.