Management of Cough and Dyspnea

in Children Training

Module 1

Cough
Pathophysiology

Pediatric Respirology Working Group

Introduction (1)
Cough: daily phenomenon, universal experience
function:
respiratory defense mechanism
symptom alarm, something wrong
the most common clinical symptom, main chief complain
Chronic cough in children, many cases
Chronicity/recurrency: disturbing
child: activity, study , G&D, QoL
parents: worry, sleepy in the office

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Introduction (2)
Pattern of respiratory disease, children # adult
Same etiology, different impact - respiratory viral infection
adult, mild disease: common cold
children, life threatening: croup, bronchiolitis
Same disease, different main symptoms
adult TB, cough is prominent symptom
pediatric TB, cough is NOT main symptom
Same symptom, lead to different disease;
chronic cough in adult, think TB
chronic & recurrent cough in children, think asthma
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Definition of cough

a sudden explosive expiratory

maneuver that tends to clear
materials from the airways and
prevent aspiration of food or fluid

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 Physiologic or pathologic (1)
Cough, part of respiratory defense mechanism
In synergy with mucociliary clearence (MC)
Normally, respiratory tract produce secretion up to
30 mL (adult)
Entrapment of foreign material, brought by MC,
swallowed

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 Physiologic or pathologic
(2)
Cough does not always mean abnormal or clinically
significant
Healthy child : cough 10 times/day (up to 34x) in 24
hours
Considered: normal or expected
Usually not become a complain, not aware, not a
problem

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 Physiologic or pathologic
(3)
Cough will be generated if the receptor(s) is
stimulated
Respiratory secretion of MC large enough
stimulates cough receptor, expelled it out
Inhaled food or other foreign material cough out
Cough: prevent aspiration useful physiologic
mechanism in a healthy person

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 Physiologic or pathologic
(4)
In pathologic conditions eg respiratory infection
larger & frequent secretion cough frequency &
intensity will
In healthy children, ARI 6-8 times/year
In healthy physiologic condition: mucocilliary
clearance and cough
In disease pathologic condition: frequency and
intensity of cough increased

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Cough: friend or foe??
 Physiologic or pathologic
(5)
Cough will be generated if the receptor(s) is
stimulated
Any disease / disorder in respiratory system will
stimulate cough receptor
Chronic stimulation chronic cough
Recurrent stimulation recurrent cough
Non respiratory disorder also can cause cough:
GERD, CHD
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Physiologic or pathologic (6)
cough

physiologic pathologic

Pathologic: intensity, frequency, cough characteristic, sputum

characteristic
Cough without receptor stimulation: psychogenic, habitual cough

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Cough as friend (1)
Medical aspect, cough is very useful
A very important respiratory defense mechanism
Very important in respiratory clearance, especially when
MC is disturbed by disease
Important role of cough: neuromuscular disease, tracheo-
bronchomalacia
Without cough reflex: aspiration serious problems, drown
in our secretion

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Cough as friend (2)
Other function: ALARM
Give us warning that something is wrong
Almost all respiratory disorder and some non respiratory
disorder: cough symptoms
One of the most important cause of cough in children:
SMOKING
Parents aware pathologic search medical advice without
cough symptoms: delayed diagnosis, advance disease

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Cough as foe (1)
Medical impact of cough is very vast
The most frequent of chief complaint
Reasons:
disturbed feeling
worry that something wrong
fatigue
sleepless
musculoskeletal aching
hoarseness
urinary incontinence
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Cough as foe (2)

Other medical impact of cough: effective mode of infection

transmission

Tuberculosis
Morbili
Rubella
Respiratory infection:
Influenza
Pertussis

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Cough.
Different from the other respiratory tract reflexes
(sneeze, hiccup)
It can be produced and prevented voluntarily
Not stereotyped in pattern: voiceprint

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Cough

Involves variety of complex reflex

It has a reflex arc that consist of:
Receptor
Afferent nerve
Cough control center
Efferent nerve
Respiratory muscles
Widdicombe J. Cough. Blackwell publishing 2003 17-23
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Cough model reflex
Cerebral cortex
Voluntary control Placebo effect
of cough

Sensation of
irritation

Cough control Endogenous

centre opioids
+ve -ve Exogenous opioids

Respiratory area of brainstem

Vagus nerve

Airway irritation Respiratory muscles

COUGH
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Widdicombe J. Cough. Blackwell publishing 2003; 20
Cough Reflex Arc

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Chang AB. Cough 2003;7:1-15.
Receptor
Distributed under/in the epithelia of respiratory tract
Type of receptor:
Rapid adapting stretch R
Proximal respiratory tract is more sensitive to
mechanical stimuli
Distal respiratory tract is more chemosensitive
C-fibre neurogenic inflammation

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Widdicombe J. Cough. Blackwell publishing 2003; 17-23
Cough pattern
Depends on the location of the stimulated receptor
In larynx expiration reflex
More distal stimulation inspiration phase
as the beginning phase of the cough

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 How do we cough ?
inspiratory compressive expiratory
Inspiratory muscles contraction
Deep inspiration Glottic closure 0.2 Expiratory muscles
(150-200% tidal contraction
Contraction of
volume)
thoracic & abdminal Sudden glottic
Maximal dilation of muscles vs fixed opening
tracheo-bronchial tree diaphragm
Explosive release of
Intrathoracic intrathoracic air
pressure

Cloutier MM: Cough, in : Loughlin GM ed Resp dis in children, 1994

 Mechanism of Sound
cough
6.0 Air
volume
5.0 50

cmH2O
4.0 40
Flow rates
Subglottic 30
L/s

3.0
pressure
2.0 20

1.0 10
0.0 0
1 2 3
Negative Min flow positive
Flow phase phase Flow phase

Inspiratory glottis Expiratory phase

phase closure (explosive)

Figure 1. Diagrammatic representation of the changes of the following variable

a representative cough: flow rate, volume, subglottic pressure and sound level
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McCool FD. Chest 2006;129:48S-53S.
Cough Effectiveness Depend on

The ability to generate high velocities of the air

stream
Dispersion of liquid mucus into the air stream
(misty flow)
Increase the waves of mucus
Vibration of the bronchus wall
The physical property of the mucus

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McCool FD. Chest 2006;129:48S-53S.
Cough Ineffectiveness
Altered Cough mechanism
Altered mucus rheology

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McCool FD. Chest 2006;129:48S-53S.
Conclusion.
Cough, a symptom with many faces
respiratory protective mechanism
sign of disease(s)
disturbing if continuously or rigorously
Pathologic cough increase the intensity and frequency of cough
Pathologic cough pathologic changes in respiratory tract
Cough: a knife with two sides: a friend that could be a foe
Causal treatment

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Thank you.

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