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).
