COUGH, WHEEZES, AND SHORTNESS OF BREATH
From Sneezes and Wheezes: An Update on Asthma and Allergy presented by Health Partners Institute for Medical
Education of Minneapolis, MN
| ASTHMA: DIFFERENTIAL DIAGNOSIS AND MANAGEMENT IN CHILDREN —Warren E. Regelmann, MD,
FAAP, Associate Professor, Department of Pediatrics, University of Minnesota Medical School, Minneapolis
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| Diagnosis of asthma in children: made from clinical signs and symptoms and exclusion of other possible disorders;
points—allergy underlies persistent symptomatic asthma and remains key clinical clue to presence of disease; spirometry
unreliable in children <5 yr of age; no single laboratory test or set of tests diagnostic for asthma in children; clinical
signs and symptoms that improve with β2 agonist therapy include—cough with interruption of play; tachypnea; contraction
of sternocleidomastoid muscles during respiration (findings correlate well with increased negative pressures in
chest and airflow obstruction); awakening at night with cough, tachypnea, or accessory respiratory muscle use and retractions
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| Focused 2-wk recall: reliably assesses asthma activity in children; determines number of symptomatic days over 2 wk;
variables investigated during parent interview include number of—days child experienced wheezing, chest tightness,
or cough; days where asthma caused child to slow down or stop play activities; nights where asthma disturbed
child’s sleep; caveat—parents tend to underestimate severity of child’s asthma symptoms; appropriate questioning ensures
more accurate assessment of initial asthma severity and efficacy of therapy over time; risk for asthma exacerbation
requiring office visit ≤30 days after evaluation—≈3% for <1 symptom day/2 wk; 5% for 2 to 5 symptom days/2
wk; ≈8% for 6 to 10 symptom days/2 wk; ≈11% for >10 symptom days/2 wk; stepwise management program—uses
data derived from 2-wk recall to determine appropriate management
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| Pulmonary score (PS) system: calculated by combining scores for respiratory rate (determined by listening to
child’s chest sounds for ≥30 sec), wheezing, and accessory use of sternocleidomastoid muscles; data suggest—good
correlation between PS and peak expiratory flow rate (PEFR); PS good semiquantitative way of assessing airflow obstruction
and response to bronchodilation; value limited in young children by—use of peak flow analysis; inverse relationship
between upper limit of number of awake breaths/min and age
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| Environmental allergen control in childhood asthma
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 | Inner-city study program: investigated whether individualized environmental intervention can improve asthma-related
outcomes; environmental controls focused on sleeping area and included using—allergen-impermeable covers on
mattresses, box springs, and pillows; vacuum cleaners and air purifiers containing high energy particulate air (HEPA)
filters to clean bedroom of tobacco smoke or to protect sensitized child from cat, dog, or mold allergens; professional
pest control when sensitized child exposed to cockroach allergen; maximum number of days with symptoms over 2
wk decreased from—6 to 2.7 days in treated group; 6 to 3.5 days in control group; points—difference between 3.5
and 2.7 days statistically significant and persisted during 1-yr follow-up; results equaled those achieved with low
doses of inhaled corticosteroids
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| Early intervention with inhaled corticosteroids: asthma predictive index shows children with 4- to 6-fold increased
risk of developing asthma at ≤3 yr of age—experienced 4 wheezing episodes in prior year; have parental
history of asthma, personal history of atopic dermatitis, or experienced 2 of 3 disease characteristics, ie, allergic rhinitis,
eosinophilia, or wheezing without colds
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| Prevention of Early Asthma in Kids (PEAK) study: high-risk patients given placebo or 88 µg of fluticasone bid; inhaled
corticosteroids given continuously for 2 yr not shown to prevent asthma
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| Safety issues concerning use of inhaled corticosteroids in children: budesonide and fluticasone—ability of both drugs
to be metabolized during first pass through liver theoretically reduces risk for systemic side effects and enhances clinical
value in children; good epidemiologic data support viability of concept for budesonide and to lesser degree for
fluticasone; growth velocity—slowed during first 2 yr of cortico-steroid therapy; fluticasone data show catch-up
growth occurs ≤1 yr after termination of therapy
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| Data suggest: potential risks and lack of efficacy preclude giving steroids to patients classified as pre-asthmatic; benefits
outweigh risks of steroid therapy once child develops persistent asthma; children receiving inhaled corticosteroids require
monitoring of growth velocities and do well when therapy administered properly; intermittent therapy no better
than continuous therapy; avoiding secondhand smoke can reduce and may eliminate need for long-term inhaled therapy
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| Prognostic factors: wheezing and physician-diagnosed asthma during childhood increase risk for unremitting asthma
in puberty and adulthood; independent risk factors for asthma include obesity, active sinusitis, and skin sensitization
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| Differential diagnosis: includes—aspiration of secretions, food, fluid, or foreign bodies; cystic fibrosis; common-variety
immunodeficiency; laryngeal cleft; tracheobroncho-malacia; tracheoesophageal fistula; vascular rings and
slings; congenital cysts, papillomas, or hemangiomas; other congenital abnormalities
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| Gastroesophageal reflux disease (GERD): common in first year of life; incidence decreases by end of second year; role
in pediatric asthma unclear; generally, children unresponsive to asthma intervention evaluated for reflux; anecdotal
evidence suggests combination of proton pump inhibitor (PPI) and lifestyle changes helpful; in one study of asthmatics
with reflux confirmed by 24-hr pH probe, combination of PPI and short-acting bronchodilator did not alter respiratory
symptoms, lung function, or short-acting bronchodilator use
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| Vocal cord dysfunction (VCD): involves paradoxic adduction of vocal cords during inspiratory phase of respiratory cycle;
elicits inspiratory noise (stridor), not wheeze; alarming; patients can learn to control and resolve problem by biofeedback
training; exercise-induced asthma—common complaint in patients with VCD; diagnosis often based on self report (correlation
poor between self reporting and exercise testing); preliminary data show ipratropium bromide (Atrovent) controls
documented exercise-related VCD; disease—resolves by itself; severe symptoms prompt severe intervention; diagnosis
based on stridor and use of Machida scope
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| CHRONIC COUGH: A PATIENT-CENTERED APPROACH —Pramod Kelkar, MD, Chair, Cough Task Force, American
Academy of Allergy, Asthma, and Immunology, Co-chair, Minnesota Asthma Coalition, Metro Region, Partner, Allergy
and Asthma Care P.A., Maple Grove, MN
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| Cough: triggered by chemical, mechanical, and thermal stimuli; cold air common trigger; nonspecific triggers include
cigarette smoke, foreign body, dust, and talking; people seek treatment when cough affects quality of life
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| Chronic cough: multidisciplinary problem; management success rate high as long as physician diligent in effort to determine
specific cause; >1 physician visit may be necessary to successfully treat cough; classification systems based
on duration of cough suggest that—in adults, acute cough lasts <3 wk, subacute 3 to 8 wk, and chronic >8 wk; in children,
acute cough lasts <2 wk, subacute 2 to 4 wk, and chronic >4 wk; point—each classification category has specific
list of causes that helps narrow clinical focus
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| Patient history: look for possible cough triggers (eg, talking, laughter, walking, running, strong smells, and perfumes); determine
timing and character of cough (daytime or nighttime onset may be important; history of little help in making diagnosis
in adults); assess relationship with meals (important when dealing with reflux disease); document preceding events
(cough can persist for weeks after viral infection (postinfectious cough) or may represent worsening of baseline asthma);
check for recent immigration or foreign travel; analysis of cough sounds—may be meaningful in children (eg, data suggest
honking cough should raise concern about psychogenic cough); cough recordings of no value; systems review—key;
look for fevers, chills, night sweats, and weight loss; obtain chest x-ray
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| Physical examination: evaluate—throat (eg, thick, yellow postnasal drip suggestive of chronic sinusitis); ears (rule
out wax impaction as cause of chronic cough); nails for clubbing (indicative of cystic fibrosis); additional aspects—
palpate for thyroid masses that compress airway; look for atopy (swelling of inferior turbinate in cases of allergic rhinitis
can cause drainage in back of throat)
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| Causes of acute cough: common cold (most common); exacerbation of chronic obstructive pulmonary disease (COPD);
pertussis
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| Cough and bronchial hyperreactivity (BHR): independent physiologic responses that may coexist; inhibition
studies—differentiate between cough and BHR; lidocaine and oral codeine inhibit cough but not BHR; cromolyn and
atropine inhibit BHR but not cough
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| Increased cough receptor sensitivity: when asthma does not respond to prednisone—BHR may not be causing
cough; investigate other etiologic factors because it can take time for stimulated cough receptors to normalize, (eg, after viral
infection); increase in cough receptor sensitivity related to—foreign body; dust; cigarette smoke; airway deformation;
thick mucus; nicotine; histamine; bradykinin; prostaglandins; capsaicin—used instead of methacholine in Europe to trigger
cough in research studies; not approved by Food and Drug Administration (FDA); permits measurement of cough sensitivity
reflex
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| Basic steps for managing chronic cough: stop angiotensin-converting enzyme (ACE) inhibitor therapy for 1 mo
(if cough continues >1mo, reassess); stop smoking for ≥1 mo; obtain chest x-ray; perform spirometry
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| Pertussis: diagnosis difficult; data suggest—clinical features and laboratory diagnosis of limited value; diagnosis can
depend on physician’s judgment; antibiotic therapy—ideally administered ≤1 wk after onset of illness; if therapy postponed
until culture results obtained, frequency or duration of cough not reduced; laboratory diagnosis—culture provides
most accurate data; leukocytosis with absolute lymphocytosis suggestive of pertussis, but may be absent;
polymerase chain reaction (PCR) test good but can provide false-positive results; recommendation—treat patient if
cough lasting 2 wk and PCR positive for pertussis; factors of concern—exposure from family or school; vomiting with
cough
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| Chronic upper-airway cough syndrome, ie, postnasal drip syndrome (PNDS)-induced cough: treat—
allergic rhinitis with antihistamines, intranasal steroids, and allergy immunotherapy; nonallergic (vasomotor) rhinitis with
steroid nasal sprays, antihistamine nasal sprays, and saline irrigation; sinusitis with antibiotics; data suggest postnasal
drainage treatable with—older antihistamines, eg, dexbrompheniramine and pseudoephedrine (Drixoral), 0.06% ipratropium
nasal spray, saline irrigation; limited computed tomography (CT) of sinuses—cost-effective for evaluation of
unresponsive patient
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| Cough-variant asthma: cough only manifestation; metha-choline challenge—indicated when asthmatic has normal
spirometry; negative predictive value close to 100%; although not used as primary diagnostic test in young children, data
suggest good correlation with pediatric allergy skin test results; chronic cough relieved by prednisone—not diagnostic
of asthma; drug eliminates many diseases that produce postnasal drip and cause coughing, asthma, and eosinophilic bronchitis
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| Eosinophilic bronchitis: resembles asthma; suspect in patient with typical asthma-like symptoms and negative methacholine
challenge; sputum eosinophilia and response to inhaled or oral steroids confirm diagnosis; patient must be
treated indefinitely to avoid irreversible lung obstruction
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| Multiple simultaneous causes of cough: detected in many cases of chronic cough; require additive management approach
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| Gastroesophageal reflux disease: chronic cough may be sole manifestation of silent reflux; PPI therapy—may be
necessary when H2 blockers fail; additional options—avoidance of alcohol and caffeinated beverages; weight reduction;
options when 3 wk of PPI therapy fails in patient with chronic cough and suspected reflux—
esophagogastroduodenoscopy (EGD; unless patient has structural damage, may not detect reflux); 24-hr esophageal pH
monitoring; barium swallow; continuation of aggressive PPI therapy
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| Observations: nonacid reflux—can damage lower end of esophagus and cause laryngopharyngeal reflux and cough; some
patients require double dose of PPI and prokinetic agent to enhance peristalsis; barium swallow or empiric therapeutic trial
useful diagnostic tools, (24-hr esophageal pH assessment detects only acid reflux); surgery—history of surgical management
for reflux does not rule out reflux as cause of chronic cough because some patients may require revision surgery; 24-
hr pH monitoring—good test; slightly inconvenient; not 100% accurate, ie, patient can have reflux even if test negative;
laryngoscopy—cough alone can irritate larynx and produce false-positive readings; presence of edema and erythema does
not mean patient has reflux; sleep apnea and GERD—incidence increasing; reflux and cough can occur when phrenoesophageal
ligament pulls on lower esophageal sphincter
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| Additional aspects: reasons for missed diagnosis—failure to consider common extrapulmonary causes of cough; insufficient
dose of medication or duration of treatment; diagnostic tools—flexible bronchoscopy; CT of neck; points—
lung cancer rare in patients with chronic cough; work-up for chronic cough must be individualized and cost-effective;
habit (psychogenic) cough—can be managed with breathing exercises provided by experienced speech therapist; medical
options include pimozide, risperidone (Risperdal), and amitriptyline; antitussives and protussives—rarely used; goal
should be treatment, not cough suppression; refractory idiopathic cough—rule out possible causes of cough before labeling
problem idiopathic; rare causes of cough—interstitial lung disease; chronic tonsillar enlargement in children;
VCD after viral infection
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Educational Objectives
| The goal of this program is to educate the listener about current techniques for managing airway disease. After hearing and
assimilating this program, the clinician will be better able to:
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| 1. Describe the role of 2-wk recall and pulmonary score (PS) studies in the evaluation of pediatric asthma.
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| 2. Assess the importance of environmental control and early inhaled corticosteroid therapy in the management of pediatric
asthma.
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| 3. Determine the importance of identifying gastroesophageal reflux disease (GERD) and vocal cord dysfunction during
the differential diagnosis of pediatric asthma.
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| 4. Accurately diagnose factors causing chronic cough.
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| 5. Implement appropriate management of chronic cough.
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Discussed on This Program
Albuterol (salbutamol sulphate in United Kingdom) [Proventil, others]
Amitriptyline HCl [Elavil]
Atropine sulfate (Several trade names and preparations
Budesonide [Entocort EC, others]
Codeine
Cromolyn sodium (disodium cromoglycate) [Crolom, others]
Dexbrompheniramine maleate and pseudoephedrine sulfate [Drixomed Tablets, Drixoral Cold & Allergy Tablets]
Famotidine [Pepcid, others]
Fluticasone propionate [Cutivate, others]
Ipratropium bromide [Atrovent]
Lidocaine HCl [Anestacon, others]
Methacholine chloride [Provocholine]
Morphine sulfate (Several trade names and preparations)
Pimozide [Orap]
Ranitidine HCl [Zantac, others]
Risperidone [Risperdal, Risperdal Consta, Risperdal M-TAB]
Suggested Reading
Anbar RE, Hehir DA: Hypnosis as a diagnostic modality for vocal cord dysfunction. Pediatrics 106:E81, 2000; Boulet
LP: Future directions in the clinical management of cough: ACCP evidence-based clinical practice guidelines. Chest
129:287S, 2006; Brightling CE: Chronic cough due to nonasthmatic eosinophilic bronchitis: ACCP evidence-based
clinical practice guidelines. Chest 129:116S, 2006; Castro-Rodriguez JA et al: A clinical index to define risk of
asthma in young children with recurrent wheezing. Am J Respir Crit Care Med 162:1403, 2000; Chang AB et al: Gastro-oesophageal
reflux treatment for prolonged nonspecific cough in children and adults. Cochrane Database Syst Rev
4:CDOO4823, 2006; Doshi DR, Weinberger MM: Long-term outcome of vocal cord dysfunction. Ann Allergy
Asthma Immunol 96:794, 2006; Guerra S et al: Persistence of asthma symptoms during adolescence: role of obesity
and age at the onset of puberty. Am J Respir Crit Care Med 170:8, 2004; Guilbert TW et al: Long-term inhaled corticosteroids
in preschool children at high risk for asthma. N Engl J Med 354:1985, 2006; Lee LY, Undem BJ: Mechanisms
of chronic cough. Pulm Pharmacol Ther 17:463, 2004; Morgan WJ et al: Results of a home-based
environmental intervention among urban children with asthma. N Engl J Med 351:1068, 2004; Pavord ID: Cough and
asthma. Pulm Pharmacol Ther 17:399, 2004; Weldon DR: Differential diagnosis of chronic cough. Allergy Asthma
Proc 26:345, 2005.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. The following has been disclosed:
Pramod Kelkar is a consultant and on the Speakers’ Bureaus for Abbott, AstraZeneca, Aventis, GlaxoSmithKline,
Greer, Merck, Pfizer, Schering Plough, UCB, Verus, and Wyeth.
Drs. Regelmann and Kelkar were recorded at Sneezes & Wheezes: An Update on Asthma and Allergy, held October 6,
2006, in Minneapolis, MN, and sponsored by HealthPartners Institute for Medical Education.The Audio-Digest Foundation
thanks the speakers and the Health Partners Institute for Medical Education for their cooperation in the production of this
program.
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