Transcript Approach to Cough

It’s the simple things in life we forget
You hear her talkin’ but don’t hear what she said
Why do you make something so easy so complicated?
Searching for what’s right in front of your face..
- Simple Things by Usher
APPROACH TO COUGH
Jerry V. Pua MD
2nd year Resident
Objectives


To discuss etiology, differential diagnosis and work
up for children presenting with cough
To discuss approach, diagnosis, management,
recommendations and prevention of B. pertussis
infection
General Data

A.E.
6 month old, Female
Filipino, Catholic
Brgy. Batasan Hills, Quezon City

Consulted at ER last June 15, 2013


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
Informant: Grandmother
Reliability: 80%
Cough – 2 weeks duration
Chief Complaint
History of Present Illness
2 weeks
PTA
• Non productive cough
• No fever nor other associated
symptoms
• No consult done
• Persistence of recurring bouts of cough
• No other associated symptoms
• Consulted LHC – Carbocisteine and
5 days PTA Amoxicillin (40mkday)
History of Present Illness
• Persistence of continous non productive
cough followed by facial cyanosis
3 days PTA
Few hours
PTA
• Difficulty breathing – alar flaring,
tachypnea, ‘seesaw’ breathing
• Persistence of symptoms prompted
consult at Local Clinic
• A> Bronchopneumonia rule out Pertussis
• Advised consult at a tertiary institution
Review of Systems


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Decrease appetite
No failure to thrive,
feeding interruption
No skin lesions
No diaphoresis, no
fainting spells
No vomiting, no
diarrhea nor
constipation

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No pallor
No facial redness
during bouts of
cough
No convulsion
No limitation of
movements
No bleeding
manifestations
Family History
(+) cough
(+)
(+)
No heredo-familial disease on both sides of the family
Birth and Maternal History

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


Born to 39 year old G5P4 (4014) non smoker, non
alcoholic beverage drinker mother
No pre natal check up, denies maternal illness
Multivitamins, Ferrous Sulfate intake
Delivered Full term via NSD at home assisted by
traditional birth attendant
No feto-maternal complication during and after the
delivery
Immunization History

No immunization received
Nutritional History

Milk Formula – since birth
 No

milk formula intolerance
Complimentary feeding – 6 months old
 No
interrupted feeding
 No feeding problems
Growth and Development

Motor
 Head
control – 2 mos. rolls over – 4 mos. sits with support –
6 mos.

Language
 Imitates

Daily Living
 Put

sounds – 5mos
anything at the mouth – 4 mos.
Social/Adaptive
 Social
smile – 2 mos. plays with caregiver – 6 mos
Past Medical History




No routine check up
No previous hospitalization
No previous surgical intervention done.
No allergies
Physical Examination



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

Awake, irritable, in mild respiratory distress. Well
hydrated.
Weight: 6 kg (z score below 0 )
Height: 65 cm (z score 0 )
BP 80/50
HR 122
RR 38
T 37.1
Skin: Warm, Moist, No rashes or other dermatosis.
No cyanosis.
Physical Examination
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HEENT: Normocephalic. Aniceteric sclera; pink
palpebral conjunctivae; no eye discharge
(+) intermittent alar flaring. No nasal discharge nor
bleeding. No tragal tenderness, no aural discharge
Non hyperemic posterior pharyngeal wall, no exudates,
uvula midline
(+) cervical lympadenopathy, bilateral
Chest and Lungs: No chest deformity nor skin lesions at
the chest. Symmetrical chest expansion, (+) subcostal
and intercostals retractions (+) crackles on both lung
fields
Physical Examination
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
Heart: Adynamic precordium, Apex beat at 4th ICS
LMCL, normal rate regular rhythm, no murmur
Abdomen: Globular, No visible veins. Normoactive
bowel sounds. Soft, non tender, no organomegaly.
Genitalia: Grossly female
Extremities: No preferential movement. Pulses on all
extremities are full and equal. No clubbing,
cyanosis of fingers or toes. CRT <2 seconds. No
deformities.
Neurologic Examination
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Mental Status: Awake, irritable. GCS 15
Cranial Nerves: Intact
Motor: Good muscle tone, no fasciculation or
atrophy, no involuntary movement. MMT 5/5 on all
extremities. DTR’s 2++
Sensory: No deficit. No babinski or clonus.
Cerebellar: No nystagmus
Meningeal signs: No Kernig’s, No Brudzinski, No
nuchal rigidity
BRONCHOPNEUMONIA
RULE OUT PERTUSSIS
NO STUNTING NO WASTING
Admitting Impression
SYMPTOMS, SIGN, OR LABORATORY
FINDINGS PATHOGNOMONIC OF A
DISEASE
Approach to Diagnosis
COUGH



Most common symptom presenting to medical
practitioners
Cough is a forced expulsive maneuver, usually
against a closed glottis
Sound of a cough is due to vibration of larger
airways and laryngeal structures during turbulent
flow in expiration
Cough quality in children: a comparison of subjective vs. bronchoscopic findings
Anne Bernadette Chang, et. al
Dept of Paediatrics & Child Health, University of Queensland
Dept Respiratory Medicine, Royal Children's Hospital, Brisbane
COUGH

Estimating the duration of cough is the first step in
narrowing the list of possible diagnoses
THE DIAGNOSIS AND TREATMENT OF COUGH
RICHARDS. IRWIN, M.D.,AND J. MARK MADISON, M.D.
The New England Journal of Medicine
Types of Cough (Duration)




Acute Cough -- a recent onset of cough lasting <3 weeks
Subacute Cough (Prolonged acute cough) -- cough slowly
resolving over a 3–8-week period
Chronic Cough -- A cough lasting >8 weeks
Recurrent Cough -- cough without a cold is taken as
repeated (>2/year) cough episodes, apart from those
associated with colds, that each last more than 7–14 days
Recommendations for the assessment and management of cough in children
M D Shields, A Bush, M L Everard, S McKenzie, R Primhak, on behalf of the
British Thoracic Society Cough Guideline Group
ACUTE COUGH


Cough lasting for a maximum of 3 weeks
Common caused: URTI, acute bronchitis or
tracheobronchitis (bacterial or viral)
 Such
infections is usually self limited and subsides within one
to two weeks along the clearing of the infection

No targets or reliable measures to predict the duration
of cough at its onset, also to predict which will persist into
sub acute or chronic cough
COUGH MANAGEMENT: A Practical Approach
F. De Blasio, et. al
COUGH MANAGEMENT: A Practical Approach
F. De Blasio, et. al
COUGH MANAGEMENT: A Practical Approach
F. De Blasio, et. al
Types of Cough (Causes)



Specific Cough -- one in which there is a clearly
identifiable cause
Non specific isolated Cough -- typically have a persistent
dry cough, no other respiratory symptoms, well with no
signs of chronic lung disease and have a normal chest
radiograph
Post viral Cough -- cough originally starting with an upper
respiratory tract infection but lasting <3 weeks
Recommendations for the assessment and management of cough in children
M D Shields, A Bush, M L Everard, S McKenzie, R Primhak, on behalf of the
British Thoracic Society Cough Guideline Group
Types of Cough (Quality)

Classic Recognizable Cough
 Certain
cough characteristics classically taught to point
to specific etiologies


Dry Cough
Wet Cough
Cough in children: definitions and clinical evaluation
Position statement of the Thoracic Society of Australia and New Zealand
Salient Features
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
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


6 months old
2 weeks history of cough
No fever
Cyanosis at bouts of
cough
Difficulty of breathing
Siblings with cough
No immunization received




In mild respiratory
distress
Intermittent alar
flaring
Intercostal and
subcostal retractions
Crackles on both lung
fields
Course at the Ward
Patient: A.E.
6 months old, Female
Working Impression:
Bronchopneumonia
Rule out Pertussis
1st Hospital Day
Diagnostics
Arterial Blood Gas
pH
7.24
pCO2
pO2 179
O2sat
HCO3 11.1
BE
CBC w/ PC
Hgb
37.7
WBC
35.5
Lympho 79
26
99
- 14.7
Hct
0.42
Seg
21
Platelet 647
Case Definitions: Pertussis (WHO)

Cough lasting at least 2 wk with at least 1 of the
following symptoms:
 paroxysms
of coughing
 inspiratory whooping
 posttussive vomiting (ie, vomiting immediately after
coughing)


Clinical case: a case that meets the clinical definition, but is not
laboratoryconfirmed
Laboratory-confirmed case: a case that meets the clinical case
definition and is laboratory-confirmed
Clinical Definitions of Pertussis: Summary of a Global Pertussis Initiative
Roundtable Meeting, February 2011
Clinical Definitions: Pertussis (CDC)

Cough illness lasting ≥ 2 weeks with 1 of the
following without apparent cause:
 Paroxysms
of coughing
 Inspiratory “whoop”
 Posttussive vomiting


Probable case: symptoms, absence of laboratory confirmation and
epidemiologic linkage to a laboratory-confirmed case of pertussis
Confirmed case: symptoms + > 1 following – PCR positive for pertussis or
contact with laboratory-confirmed case of pertussis
Clinical Definitions of Pertussis: Summary of a Global Pertussis Initiative
Roundtable Meeting, February 2011
Diagnostics

Common laboratory diagnostic methods:
 Culture
– gold standard
 Direct antigen detection PCR
 Direct fluorescent antibody (DFA) testing
 Serologic demonstration enzyme-linked immunosorbent
assay (ELISA) or Western blot with various B. pertussis
antigens and agglutination
 Measuring
an increase in titers between acute and
convalescence phase serum specimens or high single serum
antibody values
Defining Pertussis Epidemiology
Clinical, Microbiologic and Serologic Perspectives
James D. Cherry, MD, et al Pediatr Infect Dis J 2005
Diagnostics: Serologic Testing


Proper performance of culture, PCR and ELISA to measure
increases or decreases in IgG and IgA antibody titers to
Pertussis Toxin in paired serum samples, the sensitivity and
specificity of the laboratory diagnosis of B. pertussis
infection
The greatest sensitivity is obtained when culture, PCR and
serologic testing are all performed on individuals with
cough illness
Defining Pertussis Epidemiology
Clinical, Microbiologic and Serologic Perspectives
James D. Cherry, MD, et al Pediatr Infect Dis J 2005
Pertussis PCR

Key factors for the successful application of PCR in
the diagnosis of infection by Bordetella spp.:
 Sample
collection and processing
 DNA purification
 Primer selection
 Amplification conditions

PCR as a diagnostic tool has the advantage of a
much higher sensitivity compared with conventional
culture
Defining Pertussis Epidemiology
Clinical, Microbiologic and Serologic Perspectives
James D. Cherry, MD, et al Pediatr Infect Dis J 2005
Pertussis: PCR



A 2.6-fold increase in detection of B. pertussis using PCR
compared with culture
PCR results were compared with serologic diagnosis;
PCR had a sensitivity of 61% and a specificity of 88%
Patients with symptoms meeting the CDC clinical case
definition for pertussis and who had a specimen positive
by PCR or DFA were considered to have true B. pertussis
infections
Defining Pertussis Epidemiology
Clinical, Microbiologic and Serologic Perspectives
James D. Cherry, MD, et al Pediatr Infect Dis J 2005
2nd Hospital Day
Diagnostic
Referred to Infection Control Committee
Blood CS
Nasopharyngeal Pertussis PCR
2D Echo with PAP
Complete Blood Counts
Hemoglobin
Hematocrit
WBC Count
Diff. Count
Segmenter
Lymphocytes
Monocytes
Platelet
06/15/13
137.7
0.42
35.5
06/16/13
125.1
0.38
27.5
06/17/13
126.2
0.38
25.9
06/18/13
131.4
0.40
19.2
06/20/13
140.3
0.43
16.8
21
79
14
72
10
523
16
65
15
537
21
62
14
539
31
63
06
465
647
Diagnotics: Complete Blood Count
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
A total count of ≥ 20,000 WBCs/mm3 with ≥
10,000 lymphocytes/mm3 in a young infant with
coryza, cough, apnea or other respiratory distress
is indicative of B. pertussis infection
A total count of ≥ 30,000 WBCs/mm3 is cause for
concern and the rapidity of the WBC count rise is
also an important indicator of worsening condition
Pertussis in Young Infants – Guidance for Clinicians
James D. Cherry MD, et. al. May 2010
Microbiology

Blood Culture and Sensitivity:
 No

growth for 5 days of incubation
Nasopharyngeal Bordetella pertussis
Polymerase Chain Reaction
 POSITIVE
for Bordetella pertussis DNA
PERTUSSIS
BRONCHOPNEUMONIA
NO STUNTING NO WASTING
Final Diagnosis
Pertussis



Acute respiratory infection caused by Bordetella
pertussis
‘intense cough’
Extremely contagious -- attack rates as high as
100% in susceptible individuals exposed to aerosol
droplets at close range
Bordetella pertussis


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
Tiny, fastidious, gram-negative coccobacilli that
colonize only ciliated epithelium
Expresses pertussis toxin (PT), the major virulence
protein
After aerosol acquisition, pertussis organism attaches
to ciliated respiratory epithelial cells
Tracheal cytotoxin, adenylate cyclase, and PT appear
to inhibit clearance of organisms
 Responsible
for the local epithelial damage
Epidemiology

Worldwide, pertussis is a significant cause of
infectious mortality
 20
to 40 million cases
 200,000 to 400,000 death per years
 Most of cases and deaths occur in infancy
WHO. Pertussis vaccines. Wkly Epidemiol Rec. 1999;74:137–143
Epidemiology

Philippine Pediatric Society Registry
 99

out of 1935660 cases
Philippine Children’s Medical Center
 32
cases: Total probable and confirmed pertussis cases
admitted from JANUARY-JUNE 2013
Source of Infection



Rate of subclinical infection is as high as 80%
Coughing adolescents and adults -- major reservoir
for B. pertussis -- usual sources of infection for infants
and children
Household contact with infected adolescent and
adults – major source of pertussis infection in not fully
immunized infants
Infant Pertussis and Household Transmission n Korea.
The Korean Academy of Medical Sciences.
Mode of Transmission
Stages of Pertussis Infection
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
Catarrhal stage (1-2 wk) begins insidiously after an incubation
period (3-12 days)
Paroxysmal stage (2-6 wk) onset marks by coughing
 Cough begins as a dry, intermittent, irritative hack and
evolves into the inexorable paroxysms
 Post-tussive emesis is common, and exhaustion is universal.
Convalescent stage (≥2 wk), the number, severity, and
duration of cough episodes diminishes
Stages of Pertussis Infection
Pertussis in Young Infants


Catarrhal stage -- characterized by excessive sneezing or
“throat clearing” -- adherence of organism in the ciliated
epithelium throughout the respiratory tract – tissue necrosis,
production of mucus, and inflammatory cell response
Paroxysmal stage – atypical




Acute life-threatening episode is common
Spells of cough leading to cyanosis or bradycardia and limpness as
well as apnea
Post-tussive vomiting is common
“whoop cough” is rarely present in very young infant
Review: Age-Specific Presentation and Burden of Pertussis by Sarah Long M.D.
1st - 2nd Hospital Day
Management
Isolation
D5LR (mild)
O2 at 10Lpm
Medications:
Ampicillin (100)
Erythromycin (40) ---- Azithromycin (10)
Salbutamol nebulization every 4 hours
NPO
Goals of hospitalization
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Assess progression of disease and likelihood of lifethreatening events at peak of disease
Prevent or treat complications
Educate parents in the natural history of the disease
and in care that will be given at home
Goals of therapy
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Limit the number of paroxysms
Observe the severity of the cough
Provide assistance when necessary
Maximize nutrition, rest, and recovery without
sequelae
Medications
Age
Primary Agents
Alternate Agents
Azithromycin
Erythromycin
Clarithro
TMP-SMZ
<1 mo
10 mg/kg/day in a
single dose for 5 days
(Infantile hypertrophic
pyloric stenosis)
40-50 mg/kg/day in 4
divided doses for 14
days
Not
recommended
(safety data
unavailable)
Contraindicated for
infants aged <2 mo (risk
for kernicterus)
1-5 mo
10 mg/kg/day in a
single dose for 5 days
40-50 mg/kg/day in 4
divided doses for 14
days
15 mg/kg/d
in 2 divided
doses for 7
days
Contraindicated at age
<2 mo
For infants aged ≥2 mo:
TMP 8mg/kg/day plus
SMZ 40 mg/kg/day in
2 divided doses for 14
days
Infants
aged
≥6 mo
and
child
10 mg/kg in a single
dose on day 1
(maximum 500 mg),
then 5 mg/kg/day
(maximum 250 mg) on
days 2-5
40-50 mg/kg/day
(maximum 2 g/day) in
4 divided doses for 14
days
15 mg/kg/d
in 2 divided
doses
(maximum
1 g/day) for
7 days
TMP 8 mg/kg/day plus
SMZ 40 mg/kg/day in
2 divided doses for 14
days
Pertussis Complications in Young Infants


Life-threatening complications are most common in
infants younger than 3 months
Respiratory tract complications: apnea, bacterial
pneumonia, and pulmonary hypertension
 Secondary
bacterial pneumonia – leading identified
cause of pertussis-related infection
Review: Age-Specific Presentation and Burden of Pertussis by Sarah Long M.D.
Pertussis Complications in Young Infants

Respiratory Failure with Pertussis may stem from
complications of Pneumonia, Pulmonary
Hypertension, and Apnea
 Apnea
– due to failure of self-rescue breathing at the
end of a paroxysm of coughing or profound vagal
stimulation
 Infants intubated due to respiratory failure secondary
to apnea have better prognosis than those intubated
due to pneumonia or pulmonary hypertension
Review: Age-Specific Presentation and Burden of Pertussis by Sarah Long M.D.
Pertussis Complications in Young Infants


Severe Bordetella pertussis consist of constellation
of bronchopneumonia, extreme leukocytosis,
refractory hypoxemia, and pulmonary hypertension
White blood cell counts >100 000 in the setting of
B. pertussis pneumonia associated with increase
mortality
Pertussis Pneumonia, Hypoxemia, Hyperleukocytosis, and Pulmonary Hypertension:
Improvement in Oxygenation After a Double Volume Exchange Transfusion
Michael J. Romano, et. al. Pediatrics 2004
Pertussis: Proposed Pathologic Course
Infection of tracheal epithelium with
Bordetella pertussis
Ciliostasis, epithelial damage and compromised mucociliary clearance
Pulmonary Infection
apnea
Necrotizing bronchopneumonia
hypoxemia
ARDS
Pulmonary vasoconstriction
Toxin mediated
leukocytosis
Increase whole blood mass
Increase vascular resistance
PULMONARY HYPERTENSION
Cardiac Failure and Shock
Pathology and Pathogenesis of Fatal
Bordetella pertussis Infection in Infants
Christopher D. Paddock, et. al.
3rd -5th Hospital Day



The rest of hospital stay patient completed her
antibiotics.
O2 supplementation was titrated down and
eventually discontinued.
Patient discharged well and stable.
Indications for ICU referral






Infants less than or equal 3 months old with clinical
deterioration
White Cell Count more than or equal to 30, 000 or
rapidly rising in count (>10,000 in 6 hours)
Respiratory failure or frequent apnea
Progressive pneumonic changes in CXR
Persistent tachycardia/ cardiovascular instability
Neurological symptoms including seizure
South Thames Retrieval Service Guideline
ICU care



Apnea, pneumonia, and seizures are the most
common presenting symptoms requiring ICU care
Leukocytes aggregate within the pulmonary
circulation and form a mechanical obstruction to
transpulmonary blood flow with the result being
severe hypoxemia and pulmonary hypertension
Cardiac failure associated with critical pertussis is
likely right sided heart failure secondary to the
pulmonary hypertension
Double Volume Exchange Transfusion



Multiple authors have reported double volume
exchange transfusion as an effective therapy for the
pulmonary hypertension, and secondarily the
hypoxemia and cardiac failure
Technique of double volume exchange utilized is the
same as performed for the newborn with
hyperbilirubinemia
Hypomagnesemia and especially hypocalcemia may
occur thus recommended routine calcium
supplementation
Chen H, Lee M, Tsao L. Exchange Transfusion Using Peripheral Vessels Is Safe and Effective in
Newborn Infants. Pediatrics 2008
Indications for DVET



White cell count more than or equal to 30,000 and
rapidly rising count
White cell count more than or equal to 30, 000
with pneumonia or hemodynamic instability
White cell count more than or equal 50,000
South Thames Retrieval Service Guideline
Studies shows…


Appearance of respiratory symptoms paralleled the
rise in leukocyte count
Temporal relationship between the initiation of
exchange transfusion and improvement in
oxygenation
Pertussis Pneumonia, Hypoxemia, Hyperleukocytosis, and Pulmonary Hypertension:
Improvement in Oxygenation After a Double Volume Exchange Transfusion
Michael J. Romano, et. al. Pediatrics 2004
Pertussis Pneumonia, Hypoxemia, Hyperleukocytosis, and Pulmonary Hypertension:
Improvement in Oxygenation After a Double Volume Exchange Transfusion
Michael J. Romano, et. al. Pediatrics 2004
Criteria for Hospital Discharge





Over a 48-hr period disease severity is
unchanged or diminished
No intervention is required during paroxysms
Nutrition is adequate
No complication has occurred
Parents are adequately prepared for care at home
Prevention: Vaccination


Efficacy of the vaccine in reducing disease severity
was 48% among children vaccinated with 3 doses
of whole-cell (67%) or acellular (32%)
Pertussis vaccination substantially decrease the
severity of breakthrough disease in vaccinated
children (3 doses) compared to unvaccinated
children
 Unvaccinated
children twice likely to have severe
disease than vaccinated children
Effects of Pertussis vaccination on Disease: Vaccine Efficacy in Reducing Clinical Severity
Preziosi, Marie-Pierre, et.al. Clinical Infectious Disease 2003
Prevention: Vaccination

DTaP (Diphtheria, tetenus toxoid and acellular
Pertussis)
 contain
inactivated PT and 2 or more other
bacterial components (FHA, Pn, and Fim 2 and 3)

4 doses during the 1st 2 years of life
 2,4,6

and 15-18 months
5th dose of DTaP recommended for children
at 4-6 yr of age
Prevention: Vaccination

Tdap (Tetanus toxoid, reduced diphtheria
toxoid, and acellular pertussis vaccine,
adsorbed)
 Preferred
age for Tdap vaccination is 11-12 yr
 Pregnant adolescents who are in their 2nd or 3rd
trimester
 All adolescents 11-18 yr of age who received Td,
but not Tdap, should receive a single dose of Tdap
to provide protection against pertussis
Vaccination of women during pregnancy
and newborns


Timing of maternal Tdap immunization is important
– administered during the third trimester to have
maternal pertussis antigen-specific IgG levels at
their peak
Immunization with DTaP or aP vaccines is not
recommended in newborns -- controversial
Pertussis re-emergence in the post-vaccination era
Chiappini et al. BioMedCentral Infectious Disease 2013
Cocooning strategy

Providing indirect protection to infants who are too
young to be immunized or protected by vaccine
through immunization of their parents and other
family members, caregivers and close contacts
Pertussis re-emergence in the post-vaccination era
Chiappini et al. BioMedCentral Infectious Disease 2013
Vaccination of preschool and adolescent


Contributes to increase herd immunity
Reduce transmission of pertussis to susceptible
population
 Reduce
reservoir of pertussis within population and
indirectly prevent pertussis case in infants and young
children
Pertussis re-emergence in the post-vaccination era
Chiappini et al. BioMedCentral Infectious Disease 2013
Immunization of health-care workers


Pertussis among health-care personnel has been
reported to be 1.7 times higher than the general
population
Health-care personnel who have direct contact with
patients should receive single dose of TdaP as soon
as feasible, if they have not previously received
TdaP
Pertussis re-emergence in the post-vaccination era
Chiappini et al. BioMedCentral Infectious Disease 2013
Updates
Patient follow up at OPD – well, active
 Received her first dose of DPT, OPV, and
Hepatitis B
 Relatives were educated regarding the
importance of immunization as well as proper
hygiene to stop the vicious cycle of transmission

Summary




A case of 6 month old unimmunized infant who
presented with subacute cough with paroxysms, who
after a nasopharyngeal swab PCR was confirmed
with Bordetella pertussis
Started on Azithromycin per orem and eventually
discharged well and stable
Recommendations for management of pertussis
Emphasized the importance of immunization on
preventing vicious transmission cycle
THANK YOU!!!