RECURRENT CHRONIC COUGH

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, cant sleep well, disturbing the child growth and developmental

Cough Mechanism
Inhalating some air (200-3500 mL)
Inspiration phase

Closing of glottis
Compression phase

Increasing of intrapulmonary pressure (50-100 mmHg)

The glottis opened suddenly

Expiration of some air

Expiration phase

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

4. 5. 6.

Predisposition Factor
Group of age is predisposition factor of Recurrent Chronic Cough a) 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) 2) 3) 4) 5) 6) 7) 8) Patients medical record Past illness History Medication that has been received Patients growth and development Body weight that decrease simultaneously Decreasing acitivity 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. Coughs 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
Its important to know when cough appear : 1) Paroxysm : pertussis, corpus alienum, fibrosis cyst, chlamydial infection, mycoplasm 2) Nocturnal : sinusitis, upper respiratory tract allergy, asthma 3) Morning : bronchitis, fibrosis cyst, bronchiectasis 4) 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 bronchitis 2) Purulent : suppurative disease (bacterial infection, fibrosis cyst) 3) Bloody : corpus alienum, bronchiectasis, fibrosis cyst 4) Stinky : anaerobic infection, bronchiectasis

Physical Examinations
Examine : 1) Nutrition 2) Upper respiratory tract disorder 3) Chests 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 Grams 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) Others 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 dont 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 didnt need some specific therapy or any laboratories tests, etc. If the cough getting longer without any serious pathological findings, its 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.