Hi, welcome back. I’m pediatric pulmonologist, Dr. Mindy Ross. You may have caught my previous webinar about the evaluation of chronic cough, and today’s talk continues from there and is about the treatment of chronic cough. So if you have any questions, please tweet them or comment on the Facebook livestream. The outline of the talk today will be to go through a quick review again about the definition of chronic cough, we’ll discuss options for treatment of chronic cough, including home remedies, medications, and prevention, and then finally we’ll review when and why to visit a pediatric pulmonologist. So first up, why do we cough? We cough for many reasons. We cough to protect our airway from irritants. We cough to clear the mucus we make on a daily basis and the extra mucus we have when we’re sick, and coughs can be an early warning sign of disease, and the “how” of “How do we cough?” We have many cough receptors in our body. This picture here, the dots show where they all are strategically located throughout the airway, and their job is to sense irritants and send signals up to the brain, and that sends signals back to the body to produce that cough, and so, the definition– How do we know when a cough is chronic? The definition of chronic cough is based on time, and for comparison an acute cough, or a shorter term cough, is one that lasts for less than a month, and these are usually caused by viral illnesses. The symptoms last 7 to 14 days, and in 90% of the cases, the symptoms and the cough goes away on their own. But the cough is called chronic if this cough lasts for more than a month. There are some viral illnesses that cause a cough that lasts for more than 4 weeks, but the pediatric community uses this cut-off to make sure we’re not missing any more serious underlying conditions. So when the cough becomes chronic, if it affects daily functioning, or is associated with any other health problems, then this is when we become concerned and start looking for causes other than viral illness, and discovering the cause of the chronic cough can be challenging because there are many causes. First up on listing the more common causes that we’re looking for, and this is asthma, foreign body in the airway or even in the ears that can trigger those cough receptors, gastrointestinal issues can actually cause chronic cough, this would be gastroesophageal reflux, or GERD, where food is coming up towards the airway and irritating and causing coughs, or people can–children can have trouble swallowing, and food can go towards their airway. Also, there is a tic cough, and then there could be habit coughs. A habit cough is a cough that often starts as a viral illness, but over time the cough receptors become more sensitive, and it turns into this vicious cycle of this harsh, honking loud cough, and actually the habit cough can go away, sometimes fairly quickly, with specialized therapy and cough biofeedback, and then also there are infections that can cause chronic cough, a variety of them bacterial, sometimes viral, and then there’s something called the upper airway cough syndrome, formerly known as post nasal drip, and this is actually caused by underlying issues such as allergies, sinusitis, irritants such as smoke, or sometimes the tissue in the upper airway called the adenoids can be large and cause congestion, and lead to cough–post nasal drip and cough. And there are many–there are other common causes that are less common, and these often are conditions that children are born with. Sometimes there are some acquired causes, such as lung damage after an infection, or because of some of the other conditions, and unfortunately there can be tumors, so we have to be aware of such as that. And that’s why it’s important to involve a pediatric pulmonologist, because there are so many causes we’re trained to identify and treat and manage them. So next up, I’ll review the treatment for the chronic cough. Before I get into the details, just a couple words about the expectations when we’re treating a chronic cough, and I wanted to get the bad news out of the way first. So, there’s not always a quick fix to treat chronic cough, unfortunately. The mainstay of treatment is symptom management, close monitoring, and reassurance. And also, the chronic cough can be very frustrating. It leads to poor sleep, and children sometimes miss school, work for parents, and sometimes even the cough becomes chronic, and at some point, it’s not contagious anymore, but children may get sent home from school. And you know, it’s also frustrating for health care providers because we all really want to get rid of this cough very quickly and sometimes, it’s just not possible. But then the good news–the good news is that the cause of the cough usually will be found. This may take thorough evaluation and frequent followup with the pediatric pulmonologist, but the cause is usually discovered, and many times the cough will go away, depends on the underlying cause of what’s causing the cough, and the good news is that we’re here, pediatric pulmonologists, for you, and experts exist in this field who are trained to help treat chronic cough, So then first up, which is what I know a lot of people are interested in, our home remedies and things we can do at home that don’t involve prescription or medication, and the one caveat for this is that the home remedies. They aren’t usually specifically for chronic coughs, they’re often for colds or viral illnesses, the acute cough, but I’m mentioning them here. because As long as they don’t cause harm, they can be used often as, what we say, an adjunct, or in addition to, a treatment for the chronic cough, and If the cough doesn’t improve, or it’s getting worse with things you’re trying at home, please seek medical attention right away. And so first up is nasal saline rinse, and this acts as a decongestant and can help with cough thats caused from post nasal drip, and and in younger kids they’ll need the saline drops and some bulb suctioning, and older kids will be able to blow their nose. And these saline rinses can be done as often as you think your child needs them throughout the day, just be careful to avoid irritating the nose with the suctioning. And next is honey So honey has actually been studied, and it’s been shown that it can decrease the coughing for children at night and also help children get better sleep, and as well as the parents can sleep better too, and the actual mechanism of this isn’t known of why it works. There’s a lot of theories. It’s thought that it can coat or smooth the throat. It’s also thought to have antibacterial properties, antioxidant or anti-inflammation properties, as well. It’s also thought that it can make more saliva, and this can trigger nerve receptors by the tongue that can decrease activation of cough, but nobody really knows. But it has been shown to have some effect. And the other big “but” about honey is that it is not recommended. Do not give it to children who are under a year old, and this is because they’re– these younger children are at risk for a toxin that can be found in honey that can cause infant botulism, and this is a life-threatening condition. So children under 1 do not get honey, but if they’re old enough, then you can give toddlers and younger kids half a teaspoon at night, and older kids can get 1-2 teaspoons. And next is always, as very commonly you’ll hear this, is to drink liquids and stay hydrated. This is because, you know, when you’re hydrated, also the mucus layer in your body, in your airway is hydrated, so the mucus is more thin and less sticky and can move out of your airways better when you cough. We actually want the mucus to move out of your airway, and also involving fluids, are to drink warm flavorful liquids, and we have to say and this is thought to loosen secretions, but your elders were right that that chicken soup, or the tea with lemon can have an effect on cough and help it in theory, and yes, thought to loosen secretions and also may stimulate some receptors near the tongue that can decrease cough activation. And then also some records, some therapies that are commonly recommended but have not been studied as much as the others that I mentioned are the cool mist humidifier, and so this can put mist into the air and humidify the airway and hydrate. The only Issue or risk with this is for people who have allergies because the equipment is at risk for growing mold or fungus. So the thing to remember is to clean the equipment regularly and keep it in a well ventilated area, and if the cough is worsening or symptoms are worsening, or it’s not working, then stop the therapy. The other one is cough drops. This is for older children and the thought–or lozenges they’re also called, and these are thought to be able to soothe and coat the airway and also for people with habit cough. It can help distract them from coughing. And again, the risk with this one is that it can be a choking hazard, so just be careful that when children are using the throat lozenges, are upright, and they’re not laughing or things like that. So, we always want to think of risks and benefits of all the treatments that we give. The other thing people–it’s not on here, but people wonder about is the vapor rub, aromatic vapor rub on the chest. That’s more–that’s not indicated for chronic cough. People do try to use that for the acute short-term cough and nasal congestion that has been shown to relieve the sensation of nose congestion in people. But because there are risks of rash, and if people use it incorrectly it can actually worsen breathing symptoms, so it’s not recommended in chronic cough. And the next step, I’ll talk about medications you can use. So first, the over-the-counter medications. Unfortunately, these are for the coughs and cold therapy and cough suppressant medications, these are not recommended in children under 6 years old, and they’re not encouraged in children under 12 years old, either. This is–they’re not encouraged for acute or chronic cough, and this is because research has shown that they are not much more effective than doing nothing or placebo, and there are many reports of toxic side effects, so nausea, dizziness, seizures, problems breathing, and there have been cases of overdose and death, so because of all those things, again we’re weighing the risks and benefits of all the therapy we use, risks of using these medications with side effects, versus the benefits, which might not be as high, so they are not recommended in young children and even for older children who can take the medicine. There’s still these considerations of side effects, so if your child is using the medicine and they have any side effects, or it’s not working, please stop the medication immediately. And also a quick note on the medications that suppress coughs, this would be such as dextromethorphan, that’s found in Robitussin or Delson or some brand names, we often don’t recommend those either because of the side effects, but also, again, we really encourage cough because that’s what’s helping to clear the mucus, and if mucus is stuck down in the throat, it can actually–you’re in the airway, it can actually lead to more problems and infection, so we do want people to clear the mucus. And so there are medications that are very targeted towards certain causes of chronic cough, and that’s what I’ll talk about next. The first one is asthma, and asthma is a condition that’s often under-diagnosed and undertreated. So with the chronic cough, if your child has any other signs that suggest asthma–wheezing, triggers that are common for asthma, or lung function testing that suggests it–they will be started on a trial of asthma controller medication, and usually, by the time they– they end up at the pediatric pulmonologist, the symptoms have been going on long enough and are often enough that they will need that daily control or medicine–medication, instead of an as-needed medication. And this is the inhaled corticosteroid, which is the inhaler, slow-acting medication to help calm down the inflammation in the airways and prevent it from becoming worse with triggers or illness. And other medication, there are medication by mouth that are asthma controller medications as well, or the oral steroids if the cough is very bad and affecting your child greatly. They will be put on a 5 day course of oral steroids to help calm down the symptoms, and the important thing to remember, if you have an inhaler for asthma, if you have an asthma medication inhaler, to always use the chamber or spacer with it because this helps the particles be delivered properly down into the lungs instead of without it. It’s oftentimes squirted more into the mouth and swallowed, so the space is very important because you’re using medications, but we have to make sure they’re being used properly. Another condition is allergies that there’s specific treatment for, and these medications are called antihistamines. Some brand names are Zyrtec, Claritin, Allegra, and they help block this molecule called histamine, which causes all the allergic response in the body. And there’s also some nasal corticosteroids sprays that can be used every day. They’re slow-acting. They also help to calm down the inflammation, such as Flonase or Nasonex, and those might be trialed as well. The other condition that has specific treatment is gastroesophageal reflux, or GERD. And this is, as I mentioned before, when the food comes up, or the acid can trigger coughs and wheezing, and so there are medication like Zantac or Prilosec that can help suppress or block the stomach acid. There’s also medication that helps the gut move, so the food stays down and doesn’t come up towards the airway, but both of these conditions, you may have a trial of the treatment, and/or you may be referred to a specialist for treatment and further medication choices, or testing or evaluation. And then lastly, a specific condition that might be causing the cough, and how the treatment would be bacterial infections, and the treatment for this is antibiotics, and there are many different types of infections out there. So, sometimes the recommendation will be a certain type of antibiotic for days, and sometimes it will be months, so the key is to have close guidance with your physicians and to come up with the proper diagnosis, and we really want to avoid overprescribing of antibiotics, so before you’re started on the antibiotics there might be other testing that’s done first. And the key is if you are prescribed the antibiotic, make sure that you complete the whole course. And then next up on the treatment, I’m putting prevention because that’s always number one. If you can prevent getting a cough, that’s the best, or if you can prevent irritating your cough, that is great, too. This is the first one I have on the list, to avoid the triggers that worsen cough, so just tobacco smoke or allergens, if you have allergies or asthma. Also important is not catching cough or sharing germs with others, so always remember the good cough hygiene to cover your mouth, not with your hand, which you touch people and things with your hand after you sneeze, but cover your mouth with your elbow like this, and cough in here, and also remember good hand-washing. And also there are options available, in terms of vaccines for some conditions that are known to cause chronic cough, such as pertussis, which causes the whooping cough, and also the flu vaccine can prevent influenza, and that’s more known to cause long-term lung damage. So if we can prevent that, that is wonderful. And lastly, when and why to visit us, the pediatric pulmonologist. So, the when: if the cough–if your child’s cough is lasting more than a month, please come see us. If the cough–if it’s been less than a month, but the cough is worsening, or if there are any red flag symptoms, or other symptoms that are going along with the cough that seems more than a viral illness, and that would be if your child has any weight loss, other infections, also poor growth, or any other concerns that you may have, and the why: why visit pediatric pulmonology? We all have years of extra training in pediatric lung disease, and when you come into the clinic we have specialized lung function testing that’s performed by respiratory therapists or experts, and they’re very familiar with performing these tests with children. There are comprehensive symptom evaluation surveys and intake forms that we have, and I think really important is that we are a multidisciplinary team with a big team approach. We have respiratory therapists, certified pulmonary nurse specialists, dieticians, social work, and everyone’s trained to teach and provide you with the best knowledge that we can about pediatric lung disease. And so here’s our contact information. You can always go online and look us up, UCLA pediatric pulmonology, and in summary, for chronic cough, chronic cough is treatable, and there are many treatment–successful treatment options. The treatment depends on what we think is causing the cough, and when the cough is chronic, we strongly encourage evaluation by a pediatric pulmonology because we can provide testing, monitoring, and close follow-up. And that’s it, and if you have any questions, please tweet, and I will answer some questions. All right, “is there a treatment for wet versus dry cough?” That’s a good point. So, the the treatment that we choose is usually based on what we think is causing the cough, not exactly what the cough sounds like, but the sound of the cough can give us some clues. So, the wet cough will make us think more of the gastroesophageal reflux of food coming up or post nasal drip or one of the possibly congenital lung diseases that makes it more difficult to clear mucus, whereas the dry cough may make us think more of asthma or a foreign body. But it’s not always 100%, the sound of the cough. “What if I don’t bring my child to the doctor for a chronic cough?” Yeah, yeah, we all do hope that coughs go away, but a lot of times the chronic cough is more than just a viral illness, so we want to treat and identify that underlying cause of the cough as soon as we can, and this is so we can prevent any lung damage–long-term lung damage or, like I mentioned, there–if there’s something like a lung tumor, we want to identify that as soon as possible and treat it right away. “Can the color of phlegm– color of the phlegm tell me anything about the cause of the cough?” and, like the sound, the color of the phlegm doesn’t tell us exactly what’s causing the cough, but there can be hints of clues of conditions going on, like a yellow or green phlegm can mean an infection, viral or bacterial, so it can’t–doesn’t–we can’t tell the difference between those. Clear phlegm can be more like viral illness potentially, or allergies, and brown or red phlegm can mean something like blood, and and “what about air filters for chronic cough?” and that’s good, I didn’t mention that. On the air filters, they have been studied, and there is mixed evidence on that, and that’s mixed evidence whether it works or not, but it’s that people have allergies to animal dander, dogs and cats. It seems like the air filters can help. We won’t say don’t try them, so we always would say try them. They can be expensive, but welcome to try them, and if they help, that’s wonderful, but we can’t say that we would guarantee that they would help the cough. And I think that’s it. So, thank you for joining me today, and you can check out our group’s other pulmonary webinars on our website. And have a great day.