Clinical Practice Guidelines - Chronic Cough Flashcards Preview

Nelson's Pediatrics > Clinical Practice Guidelines - Chronic Cough > Flashcards

Flashcards in Clinical Practice Guidelines - Chronic Cough Deck (112):
1

acute cough

< 3 weeks

2

chronic cough

≥ 3 weeks

3

_____ should be done before any therapy is prescribed.

CXR

4

Most Common Causes of Chronic Cough

Asthma
Postnasal Drip Syndrome (PNDS)
Gastroesophageal Reflux Disease (GERD)

5

Most Common Causes of Chronic Cough in 0-18 mos.

Aberrant Innominate Artery
GERD
Cough-Variant Asthma

6

Most Common Causes of Chronic Cough in 1.5-6 y.o.

Sinusitis
Cough-Variant Asthma

7

Most Common Causes of Chronic Cough in 6-16 y.o.

Cough-Variant Asthma
Psychogenic Cough
Sinusitis

8

A single cause for cough is found _____ of the time.

38-82%

9

Multiple causes for cough are found _____ of the time.

18-62%

10

Therapies should be initiated in the _____.

same sequence that the abnormalities were discovered

11

Asthma with persistent cough without wheezing

Cough-Variant Asthma

12

_____ of children with chronic cough have cough-variant asthma.

75%

13

_____ of children with cough-variant asthma will develop into classical asthma.

54%

14

_____ of children with chronic cough will eventually develop asthma.

45%

15

When there is an identifiable trigger (exercise, nocturnal occurrence, seasonal and episodic attacks, personal or family history) a child is considered an _____.

asthma suspect

16

_____ cough, wheeze, chest discomfort and shortness of breath can sometimes be the only feature of asthma.

Exercise-Induced

17

Referral to an asthma specialist is done when:

1. diagnosis needs to be confirmed by spirometry
2. normal peak flow in an asthma suspect (> 80%)
3. below normal peak flow and response to β2-agonist is equivocal (< 20% inc.)
4. poor response to therapeutic trial

18

_____ is the recommended initial test for asthma suspects and is feasible starting _____.

Spirometry, 5 y.o.

19

If spirometry is not available, _____ may be used to measure Peak Expiratory Flow Rate (PEFR).

Peak Flow Meter

20

PEFR correlates well with _____.

FEV1

21

Predicted normal PEFR can be calculated for children _____.

6-17 y.o. at least 100 cm tall

22

Predicted Normal PEFR for Males

(ht. in cm - 100)5 + 175

23

Predicted Normal PEFR for Females

(ht. in cm - 100)5 + 170

24

An increase of _____ in PEFR after β2-agonist supports the diagnosis of asthma.

> 20%

25

Further Work-Up for Asthma

Exercise Challenge Test
PEFR 2x/day (diurnal variation)
Steroid + Bronchodilator x 5 days

26

If a peak flow meter is not available, therapeutic trial of _____ may help diagnose asthma.

β2-agonist ± steroid

27

After giving inhaled or nebulized β2-agonist, relief of symptoms are seen in _____ and peaks in _____.

5 min., 60 min.

28

After giving oral β2-agonist, relief of symptoms are seen in _____ and peaks in _____.

30 min., 2-3 hrs.

29

A _____ course of systemic steroids may be given to relieve obstruction and restore response to β2-agonist.

5-day

30

Criteria for Persistent Asthma

> 1 attack/week
nocturnal symptoms > 2x/month
PEFR < 80%
PEFR Variability > 20%
FEV1 < 80%

31

Asthma Self-Management Behaviors

1. avoid triggers
2. peak-flow monitoring
3. asthma diary
4. proper use of medications
5. prompt management of exacerbations
6. asthma action plan

32

Stridor may be produced by _____ or by any _____ which can predispose to recurrent respiratory infection.

aspiration syndrome
anatomic or dynamic problem of the airway

33

_____ is the congenital floppiness or weakness of the airway which can present as stridor.

Tracheomalacia

34

Tracheomalacia should resolve within _____.

18-24 mos.

35

Patients with vascular rings present with symptoms during _____.

infancy or early childhood

36

Most Common Types of Vascular Rings

R Aortic Arch w/ L Ligamentum Arteriosum (95%)
Double Aortic Arch (85%)

37

Vascular rings can present as _____ cough.

high-pitched, brassy

38

Vascular Rings:
CXR

ill-defined arch
compression of trachea
hyperinflation
atelectasis

39

Vascular Rings:
Barium Esophagogram

posterior compression of the esophagus

*diagnostic in most cases

40

Vascular Rings:
Therapy

surgery

41

_____ is the single most common cause of chronic cough in adults and in children.

Postnasal Drip Syndrome (PNDS)

42

Postnasal Drip Syndrome:
Symptoms

something dripping down the throat
need to clear throat frequently
mucoid or mucopurulent secretions
cobblestone appearance of mucosa

43

Postnasal Drip Syndrome:
Pathophysiology

chronic laryngeal irritation → mechanical stimmulation of the afferent limb of the cough reflex

44

Postnasal Drip Syndrome:
Causes

sinusitis (39%)
allergic rhinitis (23%)
perennial non-allergic rhinitis (37%)
post-infectious rhinitis (6%)
vasomotor rhinitis (2%)
environmental irritant (2%)

45

_____ is the inflammation of the paranasal sinuses with concomitant inflammation of the nasal passages and surrounding bone.

Sinusitis

46

Bacterial sinusitis is associated with symptoms lasting _____.

≥ 10 days

47

Bacterial Sinusitis:
Symptoms

purulent nasal/postnasal discharge (3-4 days)
daytime cough which may worsen at night
high fever (≥ 39° C)

48

Bacterial Sinusitis:
Duration - Acute

> 10-14 days
< 30 days

49

Bacterial Sinusitis:
Duration - Subacute

30-90 days

50

Bacterial Sinusitis:
Duration - Recurrent Acute

< 30 days
≥ 10 day intervals

51

Bacterial Sinusitis:
Duration - Chronic

90 days

52

Bacterial Sinusitis:
Pathogens

S. pneumoniae
H. influenzae
M. catarrhalis

53

Bacterial Sinusitis:
Treatment

Beta-Lactam (Amoxicillin)

54

Bacterial Sinusitis:
Treatment - S. pneumoniae

Penicillin
Co-Trimoxazole
Chloramphenicol

55

Bacterial Sinusitis:
Treatment - H. influenzae

Ampicillin
Co-Trimoxazole
Chloramphenicol

56

Bacterial Sinusitis:
Treatment - Duration

once the patient becomes symptom free then +7 days

57

Bacterial Sinusitis:
Treatment - Antibiotic Response

48-72 hours

58

Bacterial Sinusitis:
Complications

periorbital and intraorbital infections

59

_____ is the IgE-mediated inflammation of the nasal membranes after allergen exposure.

Allergic Rhinitis

60

Allergic Rhinitis:
Criteria for Diagnosis

allergen
causal relationship
immunologic mechanism
history of atopy

61

Allergic Rhinitis:
Symptoms

rhinorrhea
nasal obstruction
nasal itching
sneezing

62

Allergic Rhinitis:
Symptoms - Nasal Congestion

postnasal drainage
chronic cough
frequent sore throats
dry mouth and oropharynx
nasal twang
snoring
sleep disturbance

63

Allergic Rhinitis:
Physical Examination

facial pallor
mouth breathing
pale bluish gray edematous nasal mucosa
watery nasal secretions
cobblestoning of posterior pharyngeal wall
postnasal drip
injection of palpebral conjunctivae
watery eye discharge
puffy eyelids

64

Allergic Rhinitis:
Classification - Intermittent

< 4 days/week
< 4 weeks

65

Allergic Rhinitis:
Classification - Persistent

> 4 days/week
> 4 weeks

66

Allergic Rhinitis:
Classification - Mild

does not interfere with daily living

67

Allergic Rhinitis:
Classification - Moderate-Severe

abnormal sleep
impairment of activities
problems at work or school
troublesome symptoms

68

Oral Antihistamines decrease the symptoms of _____ but have less effect on _____.

allergy, nasal congestion

69

_____ are the mainstay treatment of allergies.

Oral Antihistamines

70

1st Generation Antihistamines may cause _____.

sedation
impair performance
anti-cholinergic effects

71

_____ may help smaller children due to their sedative effect.

1st Generation Antihistamines

72

2nd and 3rd Generation Antihistamines have a greater _____ ratio with less _____ and are shown to have _____ effects.

benefit:risk, sedation and side effects, anti-inflammatory

73

_____ are used as first-line therapy for allergic rhinitis.

Nasal Antihistamines

74

Nasal Antihistamines decreases _____ but causes _____.

nasal congestion, sedation

75

Nasal Antihistamines are comparable with _____ but are inferior to _____.

Oral Antihistamines
Nasal Corticosteroids

76

The limitation of Nasal Antihistamines is the _____.

bitter taste

77

Nasal Antihistamines:
Age

≥ 5 y.o.

78

Nasal Corticosteroids are anti-inflammatory agents which affects _____.

sneezing
pruritus
rhinorrhea
nasal blockage

*except ocular syptoms

79

Nasal Corticosteroids:
Age

≥ 3 y.o.

80

Nasal Corticosteroids:
Onset of Effect

2-4 hours

81

_____ are mast stabilizers which include sodium cromoglycate and nedocromil sodium.

Nasal Chromones

82

The limitation of Nasal Chromones is _____.

QID dosing

83

When decongestants are used alone, they may cause _____.

insomnia
anorexia
nervousness

84

When decongestants are used with _____ they may significantly improve symptoms of allergic rhinitis.

antihistamines

85

_____ are anti-inflammatory agents acting on the lipo-oxygenase pathway.

Antileukotrienes
(Montelukast, Zafirlukast)

86

Allergic Rhinitis:
Parameters of Response to Therapy

Nasal Symptoms
Physical Signs
Quality of Life
Concomitant Medical Conditions
Side Effects

87

Short Term Complications of Allergic Rhinitis

asthma exacerbation
acute sinusitis
eustachian tube dysfunction
serous otitis media with effusion
sleep-disordered breathing
chronic mouth breathing
decreased cognitive functioning
neuropsychiatric concerns
anosmia
aqeusia

88

Long Term Complications of Allergic Rhinitis

asthma
chronic sinusitis
acute and chronic otitis media
hearing and speech impairment
sleep apnea
craniofacial abmormalities
decrease in productivity
allergic irritability syndrome
anosmia
ageusia

89

Allergic Rhinitis:
Follow-Up Checklist

control of symptoms
maintenance of improved quality of life
no impairment of activities
absence of side effects

90

Allergic Rhinitis:
Indications Allergologist/Immunologist Consultation

prolonged duration
identification of triggers
implementation of avoidance of triggers
immunotherapy
decreasing cost of multiple medications
complications/co-morbidities
systemic corticosteroids
significantly affected quality of life

91

_____ are conditions with prominent nasal congestion but lack the criteria for the diagnosis of allergic rhinitis.

Non-Allergic Rhinitidis

92

Non-Allergic Rhinitidis

infectious
idiopathic/vasomotor
idiopathic neonatal (autonomic prematurity, GER)
non-allergic rhinitis with eosinophilia syndrome (NARES)
food-induced
mucosal abnormalities
hormonal
drug-induced
foreign bodies
structural abnormalities
tumors

93

GERD-related cough occurs predominantly during the _____ and in the _____ position.

day, upright

94

Cough due to GERD has a duration of _____.

13-58 mos.

95

GERD can cause _____.

heartburn
hoarseness
sore throat
dysphonia

96

_____ of patients with chronic cough have GERD.

10-20%

97

_____ of children with chronic respiratory symptoms have silent GER.

40-50%

98

GERD
Symptoms

recurrent vomiting
poor weight gain
irritability
heartburn
esophagitis
dysphagia
feeding refusal
apnea
asthma
recurrent pneumonia
upper airway symptoms

99

A therapeutic trial with a _____ or a _____ is a common approach to the diagnosis of GERD.

Histamine-2 Receptor Antagonist (H2RA)
Proton Pump Inhibitor (PPI)

100

Relief of symptoms with _____ had a sensitivity of 75% and a specificity of 55% in diagnosing GERD.

1 week of Omeprazole

101

Treatment with Omeprazole _____ showed resolution of GERD symptoms within _____.

40 mg BID
5-14 days

102

Lansoprazole has been shown to be effective in healing _____ due to GERD.

erosive esophagitis

103

GERD:
Lifestyle Changes for Infants

changing/thickening formula
prone/lateral decubitus position
1-2 week trial of hypoallergenic formula

104

Thickening of formula should be done by adding _____.

1 tbsp. of rice cereal to 1 oz. of formula

105

GERD:
Lifestyle Changes for Children and Adolescents

avoid caffeine, chocolate and spicy foods

106

GERD:
Lifestyle Causes

obesity
alcohol intake
tobacco exposure

107

_____ is the gold standard for diagnosing GERD.

24 Hour Esophageal pH

108

Acid-induced cough occurs simultaneously with the pH drop _____ after an acid reflux episode.

5 min.

109

_____ is diagnosed in 3-10% of children with cough of unknown etiology that persists for more than 1 month.

Psychogenic Cough

110

Psychogenic Cough is more common in _____.

girls

111

Psychogenic Cough is described as _____.

barking or honking

112

Psychogenic Cough is managed with _____.

suggestion therapy
psychological counseling
psychiatric intervention