Clinical Question of the Week
January 16, 2015
MY NAILS ARE UGLY AND DISCOLORED, IT MUST BE FUNGUS!
January 30, 2015
Show all

CHRONIC COUGH: ITS CHALLENGES IN CHILDREN AND ADULTS

Susan SymingtonWritten by: Susan Symington DFAAPA, MPAS, PA-C

Chronic cough can be a challenging condition to treat in both children and adults. There are differences in the definition, differential diagnosis, and treatment for both children and adults. In children there is not a clear definition for chronic cough. The American College of Chest Physicians and the Thoracic Society of Australia and New Zealand both agree that a chronic cough in children is any cough that lasts longer than 4 weeks. However, The British Thoracic Society defines a chronic cough in children is a cough that lasts longer than 8 weeks but anything that lasts longer than 3 weeks and is “ relentlessly progressive”. Anyone who has treated a child with chronic cough knows the burden that this places on the child, parents, caregivers, and teachers and other children at school. It is important to determine the etiology of the cough in order to treat the chronic cough accurately. The following are possible causes for chronic cough in a child: congenital anomalies, infection, asthma, allergic or non-allergic (vasomotor) rhinitis – post nasal drip, aspiration, and habitual cough. The treatment depends on what the etiology is determined to be. In adults, chronic cough is defined as a cough lasting longer than eight weeks. Forty percent of all patients seen in an outpatient pulmonary practice account for chronic cough. Chronic cough is more common in adult women. The following conditions are part of the differential diagnosis in adult patients with cough: Medications (ACE Inhibitors), Upper airway (post nasal drip, post infectious causes, Vocal Cord Dysfunction), GERD, Asthma, and Non-asthmatic eosinophilic bronchitis.

Working in allergy one of the most challenging diseases to treat is vocal cord dysfunction (VCD). Vocal Cord Dysfunction ( VCD) is a partial airway obstruction caused by paradoxical adduction ( medial movement) of the vocal cords. It is usually associated with inspiration and can be associated with asthma. It is often misdiagnosed as asthma and may co-exist with asthma. Symptoms of VCD are as follows:
• Coughing
• Wheezing ( upper airway, stridor)
• Chest tightness anterior upper chest
• Hoarseness
• Sensation of Choking
• Dizziness
• Anxiety
• Sighing
• Frequent clearing of the throat
• Sensation of not being able to get air in

Triggers of VCD are similar to triggers in asthma and include, post nasal drip, post nasal drip, history of recent upper respiratory infection, talking or singing, exercise, gastroesophageal reflux disease and neurological causes. Unlike asthma, VCD rarely occurs at night and usually is worse during the day. When diagnosing VCD, it is important to go with what you have and not with what you don’t have as you could have one or more of the presenting symptoms as written above. Another key finding with VCD is that it does not respond to oral corticosteroids so if the patient has been on oral corticosteroids and is still having severe symptoms it is more likely to be VCD than asthma. One way to determine if a patient has VCD is to have the patient perform a pulmonary function test in the office and if there is a flattening of the inspiratory loop, this can clue the clinician into the diagnosis. The ultimate determining factor is through nasolaryngoscopy but the patient has to be having symptoms at the time of the procedure. It can be difficult to reproduce on direct visualization. Treatment for VCD involves exercises to help relax the vocal cords. These exercises can be provided in the office or through a speech pathologist.

Chronic cough is a challenging condition that presents often in the clinical setting. Determining the cause for the cough can help in treatment. In both children and adults this can be debilitating and days of work, school and day care can be missed until the etiology is diagnosed and the underlying caused is treated appropriately.