Cough in the Pediatric Population
INTRODUCTION
Cough is the most common presenting symptom to general practitioners and persistent cough is one of the most common problems referred to pediatricians and respiratory physicians. Although most of these consultations are likely for acute cough (cough lasting less than 2 weeks), a significant number of consults are for chronic cough. This article concentrates on chronic cough defined as cough present for more than 4 weeks.1
PREVALENCE
According to data published, prevalence of chronic cough in primary school-aged children (6-12 years) is 5% to 10 %. 2 The prevalence is supposed to be higher in preschool-aged children. Studies have revealed that the majority of children with chronic cough seen in clinics are young (median age 2 to 3 years). 3, 4
BURDEN OF ILLNESS
Chronic cough is associated with significant morbidity in children and their parents. The use of over-the-counter (OTC) cough medications is indicative of burden of cough. Furthermore, people report increased frequency of medical visits for cough before they visit a specialist. A study was done to evaluate the frequency of prior medical consultations for coughing over last one year. It reported that more than 80% of children had 5 or more doctor visits and 53% had more than 10 visits before children first presented to a pediatrician. 5
PATHOPHYSIOLOGY
There is evidence that age has direct correlation with physiologic domains involved and that consequently influence clinical manifestation where cough is a dominant feature. These physiologic domains are as follows:
1. Cough-specific physiology:
Cough-specific physiologic differences include age and gender-related variations in cough sensitivi...
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...Spirometry, if required
4 Children should be further investigated and should be referred to a pulmonologist if
Specific cough pointers are present, other than asthma (see Box 1)
Cough has not resolved with treatment trials
Assessment by an otolaryngologist should be considered when there are coexistent symptoms or signs that suggest an upper airway cause for a child's cough or if a foreign body is suspected. These include presence of stridor, snoring, obstructive sleep symptoms, laryngeal disorders causing aspiration (eg, laryngeal cleft), and persistent rhinitis/rhinosinusitis symptoms.
5. “A wait and see approach” is advised for children with nonspecific cough as medications are generally not efficacious for nonspecific cough. If medications are trialed, a reassessment is recommended in couple of weeks, which is the time to response for most medication.
Based on the subjective symptoms, it appears this patient has bronchitis, a type of chronic obstructive pulmonary disease, which is a respiratory disorder. The care plan will focus on intervention to prevent the disease from re-occurring and causing chronic bronchitis. Further assessment will be needed to obtain a baseline, so when the care plan is implemented, then it can be evaluated to measure positive outcome and where alteration will be need in the plan for a great outcome in the patient’s health.
Croup: Croup is another common airway inflammation caused by virus that can affect the trachea, larynx and possibility the bronchi (Murray, Sidani, & Zoorob, 2011) thus causing infection in the upper respiratory tract. Murray et al. describes it as the most common illness in children under the age of 6 to 36 months and cause for cough mostly when a child cries; acute stridor and hoarseness in febrile children (Murray et al., 2011). It can be a life-threatening situation in the life of the young infant and the family. Croup symptoms exhibit as hoarseness, barking cough, inspiratory stridor, and respiratory distress. I chose this diagnosis as my first preference because when I read the mother’s subjective report it matches that of croup symptoms: a barking cough, no fever, severe at night and when the baby cries, fatigue due to excessiveness of the tears, pain due to inflames and swollen of the airway. Murray et al., led us to understand that the etiologies of this viral causing agent can be traced to the parainfluenza viruses, type 1. (2011). This virus is commonly spread through contact or droplet secretion.
My disease is Streptococcal pneumonia or pneumonia is caused by the pathogen Streptococcus pneumoniae. Streptococcus pneumoniae is present in human’s normal flora, which normally doesn’t cause any problems or diseases. Sometimes though when the numbers get too low it can cause diseases or upper respiratory tract problems or infections (Todar, 2008-2012). Pneumonia caused by this pathogen has four stages. The first one is where the lungs fill with fluid. The second stage causes neutrophils and red blood cells to come to the area which are attracted by the pathogen. The third stage has the neutrophils stuffed into the alveoli in the lungs causing little bacteria to be left over. The fourth stage of this disease the remaining residue in the lungs are take out by the macrophages. Aside from these steps pneumonia follows, if the disease should persist further, it can get into the blood causing a systemic reaction resulting in the whole body being affected (Ballough). Some signs and symptoms of this disease are, “fever, malaise, cough, pleuritic chest pain, purulent or blood-tinged sputum” (Henry, 2013). Streptococcal pneumonia is spread through person-to-person contact through aerosol droplets affecting the respiratory tract causing it to get into the human body (Henry, 2013).
During a physical examination, a specialist may hear a heart murmur which will prompt a referral to a pediatric cardiologist for an analysis. Diagnostic testing will vary by the child’s age, clinical condition, and institutional preferences. Such test may incorporate a chest X-ray, electrocardiogram, echocardiography and cardiac catheterization. A chest X-ray uses unseen X-ray beams to cr...
Haas, D. F. (1990). The Chronic Bronchitis And EMPHYSEMA. New York,NY: John Wiley and Sons, Inc.
Imagine a young child competing with his or her fellow classmates during recess and immediately losing the ability to breathe normally. He or she stops in the middle of the competition and falls to the ground while holding his or her chest trying to find air. When you are young, being able to keep up with your peers during recess and sporting events is very important, however, having asthma restricts this. Asthma has a significant impact on childhood development and the diagnosis of asthma for children 18 years and younger has dramatically increased over the years. Asthma is known as a “chronic inflammation of the small and large airways” with “evident bronchial hyper-responsiveness, airflow obstruction, and in some patients, sub-basement fibrosis and over-secretion of mucus” (Toole, 2013). The constant recreation of the lung walls can even occur in young children and “lead to permanent lung damages and reduced lung function” (Toole, 2013). While one of the factors is genetics, many of the following can be prevented or managed. Obesity, exposure to secondhand smoke, and hospitalization with pneumonia in the early years of life have all been suggested to increase children’s risk of developing asthma.
His positive result of nasopharyngeal aspirate for Respiratory Syncytial Virus (RSV) indicates that Liam has acute bronchiolitis, which is a viral infection (Glasper & Richardson, 2010). “Bronchiolitis is the most common reason for admission to hospital in the first 6 months of life. It describes a clinical syndrome of cough tachypnoea, feeding difficulties and respiratory crackles in chest auscultation” (Fitzgerald, 2011, p.160). Bronchiolitis can cause respiratory distress and desaturation (91% in the room air) due to airway blockage; therefore the infant appears to have nasal flaring, intercostal and subcostal retractions, and tachypnoea (54 breathes/min) during breathing (Glasper & Richardson, 2010). Tachycardia (152 beats/min) could occur due to hypoxemia and compensatory mechanism for low blood pressure (74/46mmHg) (Fitzgerald, 2011; Glasper & Richardson, 2010).
Silverman, Michael, ed. Childhood Asthma and Other Wheezing Disorders. 2nd ed. London: Arnold, 2002. Print.
Cough-induced asthma is one of the most difficult asthmas to diagnose. The doctor has to eliminate other possibilities, such as chronic bronchitis, post nasal drip due to hay fever, or sinus disease. In this case the coughing can occur alone, without other asthma-type symptoms being present. The coughing can happen at any time of day or night. If it happens at night it can disrupt sleep.
Friedman JF, Lee GM, Kleinman KP, Finkelstein JA. "Acute Care and Antibiotic Seeking for Upper Respiratory Tract Infections for Children in Day Care: Parental Knowledge and Day Care Center Policies." JAMA Pediatrics 157.4 (2003): 369-374. .
This generality of symptoms leads many primary care providers to not check for pertussis on a regular basis. Inconsistencies in screening can lead to a large number of cases being undiagnosed and untreated. In order for correct identification of pertussis, microbiological confirmation is needed. This correctly establishes the diagnosis of B. pertussis infection as well as identifies the diagnosis for public health surveillance and for outbreak investigations. Bacterial culture and polymerase chain reaction (PCR) are the most useful clinical tools for patients with a cough duration shorter than four weeks. If the cough has been longer than four weeks, serology is the test of choice (Cornia & Lipsky,
Chronic obstructive pulmonary disease (COPD) is preventable disease that has a detrimental effects on both the airway and lung parenchyma (Nazir & Erbland, 2009). COPD categorises emphysema and chronic bronchitis, both of which are characterised by a reduced maximum expiratory flow and slow but forced emptying of the lungs (Jeffery 1998). The disease has the one of the highest number of fatalities in the developed world due to the ever increasing amount of tobacco smokers and is associated with significant morbidity and mortality (Marx, Hockberger & Walls, 2014). Signs and symptoms that indicate the presence of the disease include a productive cough, wheezing, dyspnoea and predisposing risk factors (Edelman et al., 1992). The diagnosis of COPD is predominantly based on the results of a lung function assessment (Larsson, 2007). Chronic bronchitis is differentiated from emphysema by it's presentation of a productive cough present for a minimum of three months in two consecutive years that cannot be attributed to other pulmonary or cardiac causes (Marx, Hockberger & Walls, 2014) (Viegi et al., 2007). Whereas emphysema is defined pathologically as as the irreversible destruction without obvious fibrosis of the lung alveoli (Marx, Hockberger & Walls, 2014) (Veigi et al., 2007).It is common for emphysema and chronic bronchitis to be diagnosed concurrently owing to the similarities between the diseases (Marx, Hockberger & Walls, 2014).
Parker, Steve. "Chronic Pulmonary Diseases." The Human Body Book. New ed. New York: DK Pub., 2007.
The clinical manifestation one may see in patients with chronic bronchitis are chronic cough, weight loss, excessive sputum, and dyspnea. Chronic cough is from the body trying to expel the excessive mucus build up to return breathing back to normal. Dyspnea is from the thickening of the bronchial walls causing constriction, thereby altering the breathing pattern. This causes the body to use other surrounding muscles to help with breathing which can be exhausting. These patients ca...
Nursing Diagnosis I for Patient R.M. is ineffective airway clearance related to retained secretions. This is evidenced by a weak unproductive cough and by both objective and subjective data. Objective data includes diagnosis of pneumonia, functional decline, and dyspnea. Subjective data include the patient’s complaints of feeling short of breath, even with assistance with basic ADLs. This is a crucial nursing diagnosis as pneumonia is a serious condition that is the eighth leading cause of death in the United States and the number one cause of death from infectious diseases (Lemon, & Burke, 2011). It is vital to keep the airway clear of the mucus that may be produced from the inflammatory response of pneumonia. This care plan is increasingly important because of R.M.'s state of functional decline; he is unable to perform ADL and to elicit a strong cough by himself due to his slouched posture. Respiratory infections and in this case, pneumonia, will further impair the airway (Lemon, & Burke, 2011). Because of the combination of pneumonia and R.M's other diagnoses of lifelong asthma, it is imperative that the nursing care plan of ineffective airway clearance be carried out. The first goal of this care plan was to have the patient breathe deeply and cough to remove secretions. It is important that the nurse help the patient deep breathe in an upright position; this is the best position for chest expansion, which promotes expansion and ventilation of all lung fields (Sparks and Taylor, 2011). It is also important the nurse teach the patient an easily performed cough technique and help mobilize the patient with ADL's. This helps the patient learn to cough and clear their airways without fatigue (Sparks a...