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Reversible airway obstructive disease from cough suppression complicating childhood depression
Volume 96 Number 5
Brief clinical and laboratory observations
another study of 123 newborn infants followed for just one year, it was concluded that the anomaly score as a single measure was unlikely to predict behavior disturbance to a clinically useful degree? ~ A review of other studies also failed to support the practical value of assessing stigmata to predict later aberrant behavior, although significant associations between stigmata and behavior were demonstrated?. 9 High specificity and low false positive rates were noted, based on reported data; however, sensitivity values were low and many if not most hyperactive children would have been missed by screening for stigmata? -~ Thus recording anomalies in young infants offers little promise as a practical tool to predict aberrant behavior at a later date. This obviously does not preclude periodic infant examinations to detect a b e r r a n t physical and mental development. Our data suggest caution in making assumptions about cognitive development and behavioral characteristics on the basis of minor congenital anomalies in infancy. The lack of consistency in our findings and in those of other investigators using different samples and behavioral measures casts doubt on the generality of this procedure as a screening technique. Despite the presence of a positive association between anomalies and behavior in advantaged boys, we find no evidence that this is sufficiently strong to be clinically useful nor true in an environmentally heterogeneous population.
943
REFERENCES
1. Waldrop MF, Bell RQ~ McLaughlin B, and Halverson CF: Newborn minor physical anomalies predict short attention span, peer aggression, and impulsivity at age 3, Science 199:563, 1978. 2. Barnard KE, and Douglas HP: Child health assessment. Part I: A literature review, Bethesda MD, December, 1974, DHEW Pub. No. (HRA) 75-30. 3. Barnard KE, and Gortner SR: Child health assessment. Part 2: Results of the first twelve months of life, Seattle, 1977, University of Washington Nursing Child Assessment Project. 4. Waldrop MF, and Halverson CF: Minor physical anomalies and hyperactive behavior in young children, in Hellmuth J, editor: Exceptional infant, Vol. 2: Studies in abnormalities, New York, 1971, Brunner/Mazel, pp 343389. 5. Brazelton TB: Neonatal behavioral assessment scale, Philadelphia, 1973, JB Lippincott Company. 6. Hedrick DL, Prather EM, and Tobin AR: Sequenced inventory of communication development, Seattle, 1975, University of Washington press. 7. Caldwell BM: Instruction manual for the home inventory for infants, Little Rock, 1970, University of Arkansas Center for Early Development and Education. 8. Rosenberg JB, and Weller GM: Minor physical anomalies and academic performance in young school-age children, Dev Med Child Neurol 15:131, 1973. 9. Quinn PQ, and Rapoport JL: Minor physical anomalies and neurologic status in hyperactive boys, Pediatrics 53:742, 1974. 10. Burg C, Quinn PQ, and Rapoport JL: Clinical evaluation of one-year old infants: possible predictors of risk for the "hyperactivity syndrome," J Pediatr Psychol 3:164, 1978.
Reversible airway obstructive disease from cough suppression complicating childhood depression Jane Andersen, R.N., M.S.,* and Robert B. Mellins, M.D,, New York, N. Y,
S u v P R E S SI 0 N of cough with pooling of secretions and air trapping, although well recognized in obtunded patients, has not been reported in association with childhood depression. This report describes an lll/2-year-old girl who presented with retention of pulmonary secretions and hyperinflation of the chest. Both of these conditions were due to suppression of cough caused by depression. From the Pulmonary Division, Department of Pediatrics, Columbia University, College of Physicians and Surgeons, and Babies Hospital. *Reprint address: Pediatric Pulmonary Division, ColumbiaPresbyterian Medical Center, 622 West 168th St., New York, NY 10032.
0022-3476/80/050943 + 03500.30/0 9 1980 The C. V. Mosby Co.
The hyperinflation was rapidly reversed with vigorous chest physical therapy and induction of cough. CASE REPORT
Six months prior to admission and shortly after the family moved to a new town, this 1l%-year-old girl developed hoarse5 ness and a croupy cough. During the following three months, the cough increased in frequency and severity, became barking in character, and showed no response to a variety of cough medications, tranquilizers, or cortisone. Repeated physical examinations and radiographs of the chest were interpreted as normal. The cough was not present during sleep and was finally diagnosed as a tic or habit cough. Gross evidence of depression developed during this time, characterized by lack of interest in
944
Brief clinical and laboratory observations
The Journal of Pediatrics May 1980
Figure. A, Lateral chest radiograph on the day of admission, demonstrating hyperinflation. B, Lateral chest radiograph the same day but immediately following induction of cough, demonstrating a marked decrease in the anteroposterior diameter. being with other children and family members despite their continued interest in her; she did not attend school during most of this period. After about three monihs, the cough gradually subsided. Shortly thereafter she developed a respiratory infection concomitant with other members of her family. This was followed by a period during which there was obvious rattling in the chest during breathing, but no cough. Occasionally, the mother heard some muffled cough as the patient turned her face into the pillow at night. Two months prior to admission, she was admitted to a local hospital for what was presumed to be pneumonia and left lower lobe atelectasis. She did not respond to treatment with antibiotics. 9Because of her depression, refusal to cough, and progressive hyperinflation of the chest, she was transferred to Babies Hospital. Her father sustained a serious episode of depression the year previously. A 13-year-old sister who is congenitally deaf and 5-year-old twin siblings appeared to be well adjusted. There was no family or past history of allergy or serious respiratory illness. The patient had, however, always been more dependent on the mother than were the siblings and frequently refused to go t o school. On admission to Babies Hospital she manifested depressive symptoms: mutism, a sad and sullen appearance, poor appetite, and decreased psychomotor activity. There was no cyanosis or
clubbing. Spontaneous cough was absent even though there was grossly audible rattling of secretions in the upper airways. The patient refused to cough on command. There was an increased anterior-posterior diameter of the chest and prominent rhonchi bilaterally. The remainder of the physical examination, including neurologic evaluation, was unremarkable. Chest radiographs demonstrated marked air trapping and hyperinflation in frontal and lateral projections (Figure, A). Cough was induced by vigorous chest physical therapy, postural drainage, and nasopharyngeal suctioning, immediately following which there was marked decrease in the anterior-posterior diameter of the chest both on gross inspection and by c h e s t radiograph (Figure, B). The first studies of arterial blood were made after the initial induction of cough and revealed pH of 7.4, Pa~,% 38 m m Hg, Pa,, 90 m m Hg, base excess 0, bicarbonate 24 mEq/1, and 0._,saturation 97%. Hematocrit was 33%, and hemoglobin 12 gm/dl. Results of the following laboratory studies were normal: serum electrolyte concentrations, erythrocyte sedimentation rate, sweat test, tuberculin test, alpha~-antitrypsin level, serum immunoglobulins A, G, and M, mycoplasma titers, thyroid hormone (T:~ and T4) blood levels, bone age, electrocardiogram, and electroencephalogram. Pulmonary function tests, also performed after the initial induction of cough but before complete recovery, provided evidence of airway obstruction with air trapping. There was a~,
Volume 96 Number 5
BHef clinical and laboratory observations
945
Table. Results of pulmonary function tests*
Age (yr) 117/,2
Vital capacity (1)
Residual volume
Total lung capacity
(1)
(0
1.53
0.77 (135%) 0.50 (88%)
2.30 (92%) 2.77 (11,0%)
(78%)
111~
2.27 (1i5%)
R V~ TLC (%)
FE V,/ FEV (%)
33
70
MMEF (I/sec)
PEFR (l/see)
1.27
--
f/max 50% VC (l/sec) -
(/max 25% VC (l/sec) -
DLCO (ml/min/mm Hg) --
(56%)
18
97
2.84 (125%)
3.10 (91%)
2.65 (102%)
1.70 (118%)
16 (90%)
*Normal values for lung volumes, FEV,/FEV, MMEF, PEFR, and D~,,,,,from Polgar G, and Promadhattavedi V: Pulmonary function testing in children, Philadelphia, 1971, WB Saunders Company; normal values for Vmax 50% and Vmax 50% VC from Zapletal A. Motoyama EK, Van De Woestijne KP, et al: J Appl Physiol 26:308, 1969. Abbreviations used: RV = Residual volume; TLC = total lung capacity; FEV, = forced expiratory volume in one second; MMEF = maximum mid-expiratory flow;PEFR = peak expiratory flowrate; ~rmax50% VC = maximum expiratoryflowrate at 50% of vital capacity; s 25%VC = maximum flow rate at 25% of vital capacity; DLco = single breath diffusing capacity for carbon monoxide. elevated residual volume and a reduced forced expiratory volume in one second per forced expiratory volume and maximum mid-expiratory flow (Table). These were all unresponsive to inhalation of isoproterenol. The subsequent therapeutic regimen consisted of chest physical therapy, including tracheal stimulation, encouragement to physical activity, and gradually increasing doses ofimipramine which reached 25 mg four times a day. Although her lungs were kept clear on this regimen, the depression was refractory and required a combined course of imipramine therapy and hospitalization on the psychiatric service for three months before improvement was seen; the imipramine was discontinued shortly afterward. Repeat Pulmonary function tests (several months after the initial study) revealed completely normal findings (Table). Results of repeat chest roentgenographic examination was also normal. There has been no recurrence of retained secretions or pulmonary hyperinflation in the year since her discharge. DISCUSSION This case is unusual in that a period of excessive cough was followed by cough suppression. Whereas psychogenic cough (cough tic) is a well-recognized entity in childhood, 1-3 suppression of cough in the absence of obtundation has not been described previously. One possible explanation for the decreased cough in this patient is a decrease in afferent impulses from airway receptors. Experimental studies in animals using mechanical and chemical stimulation Of the larynx suggest that there are individual variations in the strength of afferent impulses for cough? The role of retained respiratory tract secretions in stimulating afferentreceptors has not been studied? A second possible reason for the decreased cough is an abnormality in the processing of cough impulses by the central nervous system. The extent to which cough may be voluntarily controlled is not well understood, 6 but cough is known to be suppressed by painful stimuli arising from thoracic injury or thoracoabdominal surgery? -~ There is also evidence that the severity and frequency of cough
may be reduced by hypnosis, direct suggestion, or psychotherapy. 1-3 Finally, cough is known to be decreased during states of altered consciousness including sleep. ~ The underlying mechanism by which depression led to suppression of cough in this patient is unknown. Depression occurs commonly in patients with chronic lung disease such as cystic fibrosiss Although it is generally assumed that depression is a consequence of chronic lung disease, it is possible that in some patients depression also leads to worsening of the lung disease by suppression of cough. N o w that there are new approaches to the diagnosis and treatment of children with childhood depression, 8, " it may be especially desirable to study the relationship between cough and depression. REFERENCES
1. Berman B: Habit cough in adolescent children, Ann Allergy 24:43, 1966. 2. Bernstein L: A respiratory tic: "the barking cough of puberty," Laryngoscope 73:315, 1963. 3. Kravitz H, Gomberg R, Burnstein R, Hagler S, and Korach A: Psychogenic cough tic in children and adolescents, Clin Pediatr 8:580, 1969. 4. Boushey HA, Richardson PS, and Widdicombe JG: Reflex effects of laryngeal irritation on the pattern of breathing and total lung resistance, J Physiol 224:501, 1972. 5. Widdicombe JG: Respiratory reflexes and defense, in Brain JD, Proctor DF, and Reid LM, editors: Respiratory defense mechanisms, part 2, vol 5 of Lung biology in health and disease, New York, 1977, Marcel Dekker, Inc., pp 593630. 6. L e i t h D : Cough, in Brain JD, Proctor DF, and Reid LM, editors: Respiratory defense mechanisms, part 2, vol 5 of Lung biology in health and disease, New York, 1977, Marcel Dekker, Inc., pp 545-592. 7. Wood RE, Be/at TF, and Doershuk CF: State of the art cystic fibrosis, Am Rev Resp Dis 113:833, 1976. 8. Puig-Antich J, Blow S, Marx N, Greenhill LL, and Chambers W: Prepubertal major depressive disorder, J Am Acad ChiId Psychiatry 17:695, 1978. ~. Puig-Antieh J: Modern developments in the treatment of major depressive disorder in prepubertal school-age children, Psychiatric Ann (in press).
Brief clinical and laboratory observations
another study of 123 newborn infants followed for just one year, it was concluded that the anomaly score as a single measure was unlikely to predict behavior disturbance to a clinically useful degree? ~ A review of other studies also failed to support the practical value of assessing stigmata to predict later aberrant behavior, although significant associations between stigmata and behavior were demonstrated?. 9 High specificity and low false positive rates were noted, based on reported data; however, sensitivity values were low and many if not most hyperactive children would have been missed by screening for stigmata? -~ Thus recording anomalies in young infants offers little promise as a practical tool to predict aberrant behavior at a later date. This obviously does not preclude periodic infant examinations to detect a b e r r a n t physical and mental development. Our data suggest caution in making assumptions about cognitive development and behavioral characteristics on the basis of minor congenital anomalies in infancy. The lack of consistency in our findings and in those of other investigators using different samples and behavioral measures casts doubt on the generality of this procedure as a screening technique. Despite the presence of a positive association between anomalies and behavior in advantaged boys, we find no evidence that this is sufficiently strong to be clinically useful nor true in an environmentally heterogeneous population.
943
REFERENCES
1. Waldrop MF, Bell RQ~ McLaughlin B, and Halverson CF: Newborn minor physical anomalies predict short attention span, peer aggression, and impulsivity at age 3, Science 199:563, 1978. 2. Barnard KE, and Douglas HP: Child health assessment. Part I: A literature review, Bethesda MD, December, 1974, DHEW Pub. No. (HRA) 75-30. 3. Barnard KE, and Gortner SR: Child health assessment. Part 2: Results of the first twelve months of life, Seattle, 1977, University of Washington Nursing Child Assessment Project. 4. Waldrop MF, and Halverson CF: Minor physical anomalies and hyperactive behavior in young children, in Hellmuth J, editor: Exceptional infant, Vol. 2: Studies in abnormalities, New York, 1971, Brunner/Mazel, pp 343389. 5. Brazelton TB: Neonatal behavioral assessment scale, Philadelphia, 1973, JB Lippincott Company. 6. Hedrick DL, Prather EM, and Tobin AR: Sequenced inventory of communication development, Seattle, 1975, University of Washington press. 7. Caldwell BM: Instruction manual for the home inventory for infants, Little Rock, 1970, University of Arkansas Center for Early Development and Education. 8. Rosenberg JB, and Weller GM: Minor physical anomalies and academic performance in young school-age children, Dev Med Child Neurol 15:131, 1973. 9. Quinn PQ, and Rapoport JL: Minor physical anomalies and neurologic status in hyperactive boys, Pediatrics 53:742, 1974. 10. Burg C, Quinn PQ, and Rapoport JL: Clinical evaluation of one-year old infants: possible predictors of risk for the "hyperactivity syndrome," J Pediatr Psychol 3:164, 1978.
Reversible airway obstructive disease from cough suppression complicating childhood depression Jane Andersen, R.N., M.S.,* and Robert B. Mellins, M.D,, New York, N. Y,
S u v P R E S SI 0 N of cough with pooling of secretions and air trapping, although well recognized in obtunded patients, has not been reported in association with childhood depression. This report describes an lll/2-year-old girl who presented with retention of pulmonary secretions and hyperinflation of the chest. Both of these conditions were due to suppression of cough caused by depression. From the Pulmonary Division, Department of Pediatrics, Columbia University, College of Physicians and Surgeons, and Babies Hospital. *Reprint address: Pediatric Pulmonary Division, ColumbiaPresbyterian Medical Center, 622 West 168th St., New York, NY 10032.
0022-3476/80/050943 + 03500.30/0 9 1980 The C. V. Mosby Co.
The hyperinflation was rapidly reversed with vigorous chest physical therapy and induction of cough. CASE REPORT
Six months prior to admission and shortly after the family moved to a new town, this 1l%-year-old girl developed hoarse5 ness and a croupy cough. During the following three months, the cough increased in frequency and severity, became barking in character, and showed no response to a variety of cough medications, tranquilizers, or cortisone. Repeated physical examinations and radiographs of the chest were interpreted as normal. The cough was not present during sleep and was finally diagnosed as a tic or habit cough. Gross evidence of depression developed during this time, characterized by lack of interest in
944
Brief clinical and laboratory observations
The Journal of Pediatrics May 1980
Figure. A, Lateral chest radiograph on the day of admission, demonstrating hyperinflation. B, Lateral chest radiograph the same day but immediately following induction of cough, demonstrating a marked decrease in the anteroposterior diameter. being with other children and family members despite their continued interest in her; she did not attend school during most of this period. After about three monihs, the cough gradually subsided. Shortly thereafter she developed a respiratory infection concomitant with other members of her family. This was followed by a period during which there was obvious rattling in the chest during breathing, but no cough. Occasionally, the mother heard some muffled cough as the patient turned her face into the pillow at night. Two months prior to admission, she was admitted to a local hospital for what was presumed to be pneumonia and left lower lobe atelectasis. She did not respond to treatment with antibiotics. 9Because of her depression, refusal to cough, and progressive hyperinflation of the chest, she was transferred to Babies Hospital. Her father sustained a serious episode of depression the year previously. A 13-year-old sister who is congenitally deaf and 5-year-old twin siblings appeared to be well adjusted. There was no family or past history of allergy or serious respiratory illness. The patient had, however, always been more dependent on the mother than were the siblings and frequently refused to go t o school. On admission to Babies Hospital she manifested depressive symptoms: mutism, a sad and sullen appearance, poor appetite, and decreased psychomotor activity. There was no cyanosis or
clubbing. Spontaneous cough was absent even though there was grossly audible rattling of secretions in the upper airways. The patient refused to cough on command. There was an increased anterior-posterior diameter of the chest and prominent rhonchi bilaterally. The remainder of the physical examination, including neurologic evaluation, was unremarkable. Chest radiographs demonstrated marked air trapping and hyperinflation in frontal and lateral projections (Figure, A). Cough was induced by vigorous chest physical therapy, postural drainage, and nasopharyngeal suctioning, immediately following which there was marked decrease in the anterior-posterior diameter of the chest both on gross inspection and by c h e s t radiograph (Figure, B). The first studies of arterial blood were made after the initial induction of cough and revealed pH of 7.4, Pa~,% 38 m m Hg, Pa,, 90 m m Hg, base excess 0, bicarbonate 24 mEq/1, and 0._,saturation 97%. Hematocrit was 33%, and hemoglobin 12 gm/dl. Results of the following laboratory studies were normal: serum electrolyte concentrations, erythrocyte sedimentation rate, sweat test, tuberculin test, alpha~-antitrypsin level, serum immunoglobulins A, G, and M, mycoplasma titers, thyroid hormone (T:~ and T4) blood levels, bone age, electrocardiogram, and electroencephalogram. Pulmonary function tests, also performed after the initial induction of cough but before complete recovery, provided evidence of airway obstruction with air trapping. There was a~,
Volume 96 Number 5
BHef clinical and laboratory observations
945
Table. Results of pulmonary function tests*
Age (yr) 117/,2
Vital capacity (1)
Residual volume
Total lung capacity
(1)
(0
1.53
0.77 (135%) 0.50 (88%)
2.30 (92%) 2.77 (11,0%)
(78%)
111~
2.27 (1i5%)
R V~ TLC (%)
FE V,/ FEV (%)
33
70
MMEF (I/sec)
PEFR (l/see)
1.27
--
f/max 50% VC (l/sec) -
(/max 25% VC (l/sec) -
DLCO (ml/min/mm Hg) --
(56%)
18
97
2.84 (125%)
3.10 (91%)
2.65 (102%)
1.70 (118%)
16 (90%)
*Normal values for lung volumes, FEV,/FEV, MMEF, PEFR, and D~,,,,,from Polgar G, and Promadhattavedi V: Pulmonary function testing in children, Philadelphia, 1971, WB Saunders Company; normal values for Vmax 50% and Vmax 50% VC from Zapletal A. Motoyama EK, Van De Woestijne KP, et al: J Appl Physiol 26:308, 1969. Abbreviations used: RV = Residual volume; TLC = total lung capacity; FEV, = forced expiratory volume in one second; MMEF = maximum mid-expiratory flow;PEFR = peak expiratory flowrate; ~rmax50% VC = maximum expiratoryflowrate at 50% of vital capacity; s 25%VC = maximum flow rate at 25% of vital capacity; DLco = single breath diffusing capacity for carbon monoxide. elevated residual volume and a reduced forced expiratory volume in one second per forced expiratory volume and maximum mid-expiratory flow (Table). These were all unresponsive to inhalation of isoproterenol. The subsequent therapeutic regimen consisted of chest physical therapy, including tracheal stimulation, encouragement to physical activity, and gradually increasing doses ofimipramine which reached 25 mg four times a day. Although her lungs were kept clear on this regimen, the depression was refractory and required a combined course of imipramine therapy and hospitalization on the psychiatric service for three months before improvement was seen; the imipramine was discontinued shortly afterward. Repeat Pulmonary function tests (several months after the initial study) revealed completely normal findings (Table). Results of repeat chest roentgenographic examination was also normal. There has been no recurrence of retained secretions or pulmonary hyperinflation in the year since her discharge. DISCUSSION This case is unusual in that a period of excessive cough was followed by cough suppression. Whereas psychogenic cough (cough tic) is a well-recognized entity in childhood, 1-3 suppression of cough in the absence of obtundation has not been described previously. One possible explanation for the decreased cough in this patient is a decrease in afferent impulses from airway receptors. Experimental studies in animals using mechanical and chemical stimulation Of the larynx suggest that there are individual variations in the strength of afferent impulses for cough? The role of retained respiratory tract secretions in stimulating afferentreceptors has not been studied? A second possible reason for the decreased cough is an abnormality in the processing of cough impulses by the central nervous system. The extent to which cough may be voluntarily controlled is not well understood, 6 but cough is known to be suppressed by painful stimuli arising from thoracic injury or thoracoabdominal surgery? -~ There is also evidence that the severity and frequency of cough
may be reduced by hypnosis, direct suggestion, or psychotherapy. 1-3 Finally, cough is known to be decreased during states of altered consciousness including sleep. ~ The underlying mechanism by which depression led to suppression of cough in this patient is unknown. Depression occurs commonly in patients with chronic lung disease such as cystic fibrosiss Although it is generally assumed that depression is a consequence of chronic lung disease, it is possible that in some patients depression also leads to worsening of the lung disease by suppression of cough. N o w that there are new approaches to the diagnosis and treatment of children with childhood depression, 8, " it may be especially desirable to study the relationship between cough and depression. REFERENCES
1. Berman B: Habit cough in adolescent children, Ann Allergy 24:43, 1966. 2. Bernstein L: A respiratory tic: "the barking cough of puberty," Laryngoscope 73:315, 1963. 3. Kravitz H, Gomberg R, Burnstein R, Hagler S, and Korach A: Psychogenic cough tic in children and adolescents, Clin Pediatr 8:580, 1969. 4. Boushey HA, Richardson PS, and Widdicombe JG: Reflex effects of laryngeal irritation on the pattern of breathing and total lung resistance, J Physiol 224:501, 1972. 5. Widdicombe JG: Respiratory reflexes and defense, in Brain JD, Proctor DF, and Reid LM, editors: Respiratory defense mechanisms, part 2, vol 5 of Lung biology in health and disease, New York, 1977, Marcel Dekker, Inc., pp 593630. 6. L e i t h D : Cough, in Brain JD, Proctor DF, and Reid LM, editors: Respiratory defense mechanisms, part 2, vol 5 of Lung biology in health and disease, New York, 1977, Marcel Dekker, Inc., pp 545-592. 7. Wood RE, Be/at TF, and Doershuk CF: State of the art cystic fibrosis, Am Rev Resp Dis 113:833, 1976. 8. Puig-Antich J, Blow S, Marx N, Greenhill LL, and Chambers W: Prepubertal major depressive disorder, J Am Acad ChiId Psychiatry 17:695, 1978. ~. Puig-Antieh J: Modern developments in the treatment of major depressive disorder in prepubertal school-age children, Psychiatric Ann (in press).