APPROACH TO A CHILD

WITH COUGH/
DIFFICULTY IN
BREATHING / NOISY
BREATHING
Dr Krishna Badal
 INTRODUCTION
 Cough is an important defense mechanism of the
respiratory system that helps to bring out the
infected secretions from the trachea & bronchi.

 Elicited by stimulation of receptors located

throughout the respiratory tract, from the
pharynx to terminal bronchioles.

 Triggered by various inflammatory, mechanical,

chemical and thermal stimuli.
 INTRODUCTION
Cough reflex
 Centre- medulla
 Afferent- Vagus and Glossopharyngeal nerve
 Efferent- Nerve supply to Larynx & respiratory
muscles.
 NOISY BREATHING
Sound Causes Character
Snoring Oropharyngeal Inspiratory, low-pitched
obstruction irregular
Grunting By partial Expiratory, occurs in hyaline
closure of glottis membrane disease
Rattling Secretions in Inspiratory, coarse
trachea/bronchi
Stridor Obstruction Inspiratory sound, may be
larynx/trachea associated with an expiratory
component
Wheeze Lower airway Continuous musical sound
obstruction expiratory in nature
 DIFFICULTY IN BREATHING
 Subjective sensation of shortness of breath
accompanied by air hunger which occurs in
response to hypoxia.
 In Children characterized by:
 Increased respiratory rate
 Head nodding , nasal flaring
 Use of accessory muscles of respiration
 Subcostal / intercostal indrawing
 Added sounds – wheezing, stridor, grunting
 CAUSES OF COUGH

I. Acute cough
1. Upper respiratory tract infection – common
cold, sinusitis, rhinitis, hypertrophied tonsils &
adenoids, pharyngitis, laryngitis and
tracheobronchitis.
2. Nasobronchial allergy & asthma
3. Bronchiolitis, pneumonia
4. Measles
5. Whooping cough
6. Foreign body in air passages
7. Empyema
 CAUSES OF COUGH

II. Chronic recurrent cough

1. Inflammatory disorder of airway
a. Asthma , Tropical eosinophilia, hypersensitivity pneumonitis.

b. Infection- viral, bacterial, chlamydia, mycoplasma,

tuberculosis, fungal, parasitic etc.

c. Inhalation of environmental irritant- smoke, dust, tobacco.

2. Suppurative lung disease
a. Bronchiectasis, cystic fibrosis
b. Foreign body retained in the bronchi: lung abscess
 CAUSES OF COUGH

3. Anatomic lesions
Vascular ring compressing airway; tracheal
stenosis; tracheo-esophageal fistula; laryngeal
web, cyst or stenosis; vocal cord paralysis

4. Psychogenic- habit cough

5. Post nasal discharge, sinusitis

6. Gastroesophageal reflux disease (chronic

aspiration)
 CAUSES OF COUGH

7. Interstitial lung disease

8. Pressure to trachea/main bronchus:
enlarged LN, cysts,& tumors in
mediastinum.
9. Pulmonary hemosiderosis
10.Cardiac causes:
a. Pulmonary edema
b. Congestive cardiac failure
c. Pericarditis
d. Myocarditis
e. congenital heart disease
 CAUSES OF COUGH

11.Drugs
a. ACE inhibitors
b. Beta antagonists

12. Abdominal Causes

a. Diaphragmatic hernia
b. eventeration of diaphragm
c. intra-abdominal masses
d. Massive ascites
 CAUSES NEEDING IMMEDIATE ATTENTION

 Croup
 Laryngeal edema
 FB
 CCF
 Pertusis
 Asthma
 Severe Pneumonia
 Bronchiolitis
 Toxic inhalation
 PHYSICAL EXAMINATION

 General examination
 Consciousness level
 Noisy breathing
 Difficulty in breathing
 Nasal flaring, head nodding
 Use of accessory muscles of respiration
 Intercostal , subcostal recession
 Nutritionalstatus
 Vitals- Temp, PR, RR, BP, Spo2
 JVP, edema, cyanosis, clubbing, pallor
 Lymph nodes
 PHYSICAL EXAMINATION

Systemic examination:
 Respiratory system
 Inspection
 RR and rhythm, type of breathing
 Appearance of chest
 Movement of chest
 Apical impulse if visible
 PHYSICAL EXAMINATION

 Palpation
 Swelling or tenderness
 Position of trachea
 Cardiac impulse
 Chest expansion
 Tactile vocal fremitus
 Percussion
 Pain & Tenderness
 Dull/ Resonant/Hyperesonant
 Percuss for upper margin of liver
 PHYSICAL EXAMINATION

 Auscultation:
 Breath sounds- Air entry, vesicular breath
sound/Bronchial breath sound
 Added sounds
 Vocal resonance

 CVS examination and P/A examination

 ENT examination
 Other system examinations
 INVESTIGATIONS
 CXR:
 Pneumonia- opacities with bronchovascular
markings.
 Collapse- overcrowding of ribs, volume loss.
 Fibrosis- fibrotic bands with pull effect on
diaphragm.
 Pleural effusion- homogenous opacity with
upward turned curve at upper margin,
mediastinal shift.
 Pneumothorax- Hyperluscent lung field with no
bronchovascular markings
X-RAY CHANGES IN PNEUMONIA
 Viral- overinflation, BL symmetrical hilar
increased density.
 Streptococcal- lobar pneumonia
 Chlamydial- overinflation, diffuse infiltrate,
X-ray looks worse than patient.
 Staphylococcal- localised consolidation,
pneumatocele
 Primary TB- Peripheral infiltrate, UL hilar
prominence.
 Disseminated TB- Miliary pattern.
 X-RAY CHANGES
 Sinus films – sinusitis.

 Lateral neck X-rays – acute epiglottitis,

retropharyngeal abscess.

 Barium swallow –TEF, GERD.

 INVESTIGATIONS
 Blood count
Hb -anemia
Total and differential count- infections.
Eosinophilia – Tropical pulmonary eosinophilia

 Blood culture
In sepsis , infective causes
Routine or specific cultures

 Throat swab- C/S

Throat infections
 INVESTIGATIONS
 Sputum examination-
Staining- Gram’s, AFB
Eosinophils- asthma, hypersensitive lung diseases
PMN- infective causes
Lipid laden macrophage- recurrent infection
C/S for specific organism

 Mantoux test

 Arterial blood gas analysis: Respiratory failure,

Sepsis or shock causing metabolic acidosis
 INVESTIGATIONS
 CT scan chest
 Bronchiectasis (HRCT).
 Lymph nodes, pleural pathologies.

 Pulmonary Function Tests

 To diagnose and follow the course of chronic respiratory
illness.
 Immune workup
 Ig levels
 HIV testing

 Bronchoscopy
 To remove foreign body or obtain samples (BAL).