Cough

Question 1

What are the causes of cough in infancy

Answer 1

Infections: URTI, bronchiolitis, pneumonia
Congenital malformations of the airway e.g. laryngomalacia
Viral induce wheeze
Gastro-oesophageal reflux
Cystic fibrosis

Question 2

What are the causes of cough in pre-school

Answer 2

Infections: URTI, croup, bronchiolitis, pneumonia, pertussis, viral induced wheeze
Foreign body
Asthma
Cystic fibrosis
Passive smoking

Question 3

What are the causes of cough in school-age to adolescence

Answer 3

Asthma
Infections: URTI, pneumonia
Cigarettes smoking
Postnasal drip
Psychogenic
Cystic fibrosis

Question 4

What are the red flag symptoms for cough

Answer 4

Productive cough which improves with antibiotics but quickly recurs
Restriction of activity
Failure to thrive
Clubbing
Persistent tachypnoea

Question 5

What is suggested by a loose, productive cough

Answer 5

Bronchitis, wheezy bronchitis, cystic fibrosis, bronchiectasis

Question 6

What is suggested by a wheezy cough

Answer 6

Asthma, wheezy bronchitis, viral induced wheeze

Question 7

What is suggested by a barking cough

Answer 7

Croup

Question 8

What is suggested by a paroxysmal cough

Answer 8

Cystic fibrosis, pertussis, foreign body, asthma

Question 9

What is suggested by a nocturnal cough

Answer 9

Asthma, sinusitis

Question 10

What is suggested by a cough most severe on waking

Answer 10

Cystic fibrosis, bronchiectasis

Question 11

What is suggested by a cough that occurs with vigorous exercise

Answer 11

Exercise-induced asthma, cystic fibrosis, bronchiectasis

Question 12

What is suggested by a cough that disappears with sleep

Answer 12

Habit cough

Question 13

What should be looked for on examination for a cough

Answer 13

General: ?tachpnoea, ?fever
Weight and height: ?FTT
Resp:
- Bronchial breathing / stridor
- Wheeze
- Crackles: course (pneumonia, bronchiectasis), or fine (bronchiolitis)
- Inspiratory whoop
- Reduced chest wall movements unilaterally
- Clear chest
- Use of accessory muscles

Question 14

What investigations should be done for a cough of unknown cause

Answer 14

Bedside: pernasal swab
Bloods: FBC, blood culture
Other: CXR, CXR and barium swallow, sweat testing, videofluoroscopy and bronchoscopy (foreign body), trial of bronchodilators

Question 15

What are the red flag symptoms for children with cough

Answer 15

Check on the child regularly, including through the night. Seek help if:
Breathing rate increases
Any episodes of apnoea
Signs of increased effort of breathing
Baby takes <50% of normal feeds
Signs of dehydration: dry mouth, infrequent passage of urine
Baby becomes less responsive or difficult to rouse
Persistent worsening of fever

Question 16

What causes whooping cough

Answer 16

Bordetella pertussis (bacteria) → produces pertussis toxin
Transmitted by aerosol droplets
Infectious for 21 days (unless Abx)
A previously infected person can become re-infected, but the subsequent infections are usually less severe

Question 17

What are the symptoms of whooping cough

Answer 17

3 phases:
1. Catarrhal phase (1-2 weeks)
- nasal discharge, conjunctivitis, malaise, sore throat, fever, dry unproductive cough
2. Paroxysmal phase (1-6 weeks)
- Paroxysms/cough: severe dry cough
- May vomit/be apnoeic after/between
- More common at night
- May be productive: thick mucous plug/watery secretion
- Inspiratory ‘whoop’ heard
- Otherwise well, sleep undisturbed
3. Convalescent phase (up to 3 months)
- Gradual improvement in cough frequency and severity

Question 18

What are the differentials for whooping cough

Answer 18

Mycoplasma infection
Chlamydia pneumoniae/trachomatis
Adenoviruses
Bronchiolitis
Asthma
URTI
GORD

Question 19

What are the signs of whooping cough on examination

Answer 19

No crackles/crepitations and no wheeze

Question 20

What investigations should be done for whooping cough

Answer 20

bedside: nasopharyngeal swab/aspirate for PCR and culture
Bloods: anti-pertussis toxin IgG serology

Question 21

What is the criteria for whooping cough diagnosis

Answer 21

Clinical features with:
1. Bordetella pertussis isolated from a nasopharyngeal aspirate or nasopharyngeal/pernasal swab, or
2. Detection by real-time PCR of the pertussis toxin S1 promoter region (ptxA-pr), and the insertion element IS481, or
3. Anti-pertussis toxin IgG detected in serum or oral fluid in the absence of vaccination within the past year.

Question 22

What is the management for whooping cough

Answer 22

Notify local public health england (PHE) centre within 3 days (notifiable disease)
First line: Abx (presenting within 21 days)
- <1 month: clarithromycin
- >1 month: azithromycin

+ advice
- Rest (rest only if >21 days)
- Adequate fluid intake
- Paracetamol/ibuprofen
- Even with treatment there may be a non-infectious cough
- Isolate until 48h of abx treatment OR 21 days after symptoms started
- Contacts may require prophylaxis

Question 23

Who requires prophylaxis for whooping cough

Answer 23

Premature (<32w) unimmunised infants <2 months of age
Unimmunised infants (>32w birth) <2 months of age, no maternal pertussis vaccine
unimmunised/partially unimmunised >2 months
Pregnant women >32w
Healthcare workers working with infants and children
Those who share a household with infants too young to be fully vaccinated

Question 24

Describe the whooping cough vaccine

Answer 24

Reduces risk of developing pertussis, does NOT provide absolute protection
Protection level declines during childhood
Immunisation of mothers in pregnancy → reduces risk of pertussis of the infant in the first few months
Offered at 16-32 weeks

Question 25

What are the complications of whooping cough

Answer 25

Post-infectious cough: May last for 3 months or more - “the one hundred day cough”
Apnoea
Pneumonia
Seizures
Encephalopathy
Otitis media
Unilateral hearing loss
Bronchiectasis
Increased intra-thoracic and intra-abdominal pressure: pneumothorax, umbilical and inguinal hernia, rectal prolapse, rib fracture, herniation of lumbar intervertebral discs, urinary incontinence, subconjunctival or scleral haemorrhage
Frequent post-tussive vomiting can lead to severe dehydration and/or malnutrition.

Question 26

What is the prognosis for whooping cough

Answer 26

For people who have not previously contracted whooping cough AND are not vaccinated: may be left with a protracted cough that can last 3 months or more
Previous vaccination or infection: short-lived, mild symptoms and an isolated persistent cough
Mortality rate in children <6 months is 3.5%