Friday, July 1, 2011

Vomiting With Cough a Symptom of Asthma in Children

A team at Walter Reed Army Medical Center in Washington, DC, believes that posttussive emesis is a probable sign of asthma in children.

If that is the case, then treatment should be directed more toward airway management than toward suppression of cough, principal investigator Joseph Turbyville, MD, from the Department of Allergy and Immunology at Walter Reed Army Medical Center, told Medscape Allergy & Clinical Immunology during poster sessions here at the American Academy of Asthma, Allergy and Immunology (AAAAI) 2009 Annual Meeting.

The investigators distributed 780 questionnaires during a 2-week period to parents of children aged 2 to 17 years attending the pediatric and allergy clinics at Walter Reed. Questions pertained to age, sex, previous diagnosis of pertussis, frequency of respiratory infections, gastroesophageal reflux (GERD), and a prior diagnosis of asthma.

Five hundred questionnaires were returned and evaluations of 144 children were completed.

The prevalence of physician-diagnosed asthma was 23%, occurring in 33 children. Of those, 48% reported a history of posttussive emesis.

There were 37 children who had "surrogate markers suggestive of asthma," but had not been given a formal diagnosis. Surrogate markers included wheeze, chest tightness, recurrent respiratory infections and sinusitis, and nighttime cough. Posttussive emesis was reported in 49% of this group.

No evidence of asthma was seen in 74 children, of whom 11% reported a history of posttussive emesis.

Posttussive emesis, either with asthma or a suspicion of asthma, was significantly more prevalent than in children without asthma (P < .0005), Dr. Turbyville reported.

"We think it's a simple, mechanical thing," he explained. "There is a flattening of the diaphragm, which compromises the stomach and puts pressure on it, causing it to empty.

"Another possibility is that the airway obstruction pushes air into the esophagus. There is a significant obstruction at the tracheal-esophageal junction in these kids," he said.

"The mechanical explanation would also explain the link with GERD and obstructive sleep apnea," Dr. Turbyville added.

"Our finding, if it is confirmed, would lead us toward treatment with a long-acting beta-agonist and anti-inflammatory agents rather than an antitussive agent," Dr. Turbyville concluded. "The cough may signal asthma rather than a respiratory infection if the child is vomiting with it."

"These findings give us one more clue to think about when considering a diagnosis of asthma," Andy Nish, MD, an allergist with Allergy and Asthma Care Center in Gainesville, Georgia, commented in an interview with Medscape Allergy & Clinical Immunology after Dr. Turbyville's presentation.

"It can be hard to sort out a cough and whether it has segued into bronchospasm," Dr. Nish observed. "We have to look at the whole ball of wax...whether there is wheezing, chest tightness, if it increases on exercise or with stress, whether there is smoke exposure, and so on.

"We need to do a complete physical examination, with pulmonary function testing...listening to the lungs for wheezing or decreased airflow, checking changes in the inspiration/expiration ratio, peak flow changes, possibly a chest x-ray, and so on," he said.

"The presence of posttussive emesis should raise your level of suspicion, and you should conduct follow-up testing, specifically pulmonary function tests, sooner rather than later, if posttussive emesis is present," Dr. Nish advised.

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