Coughs & Asthma! What to do?!? With pediatric pulmonologist, Dr. Chavarria

This weeks Ask Dr Jessica episode is all about coughs! Coughs are often so difficult for families; they can be so uncomfortable and persistent, and many families don't know how to best help their children.  In this episode, with pediatric pulmonologist, Dr Cesar Chavarria, we discuss what is a normal length of time for coughs to last, what medications can be offered, and also when to see a doctor.  We also talk about asthma (starting @18:55). We discuss common signs of asthma, how to know the difference between asthma and a regular cold virus cough, how to treat asthma and what demographic it typically affects. 

Dr. Chavarria is a pediatric pulmonologist with more than 30 years of experience in treating pediatric respiratory conditions. He attended undergraduate school at Madrid College and medical school at the National Autonomous University of Mexico, both in Mexico City. He completed his pediatric internship at the University of Colorado Health Sciences Center in Denver, and his residency in pediatrics and fellowship in pediatric pulmonology and critical care at the Long Beach Memorial Medical Center.  Dr. Chavarria is board certified in Pediatrics and in Pediatric Critical Care.

Cesar Chavarria, M.D., is a third-generation physician. Outside of his work, Dr  Chavarria likes to spend his time with his wife and daughter. His wife is a psychiatrist, and his daughter is completing her psychiatry residency. To schedule an appointment, call 818-342-0793. He can also be found on his website: https://www.brthez.com/

Dr Jessica Hochman is a board certified pediatrician, mom to three children, and she is very passionate about the health and well being of children.  Most of her educational videos are targeted towards general pediatric topics and presented in an easy to understand manner. 

Do you have a future topic you'd like Dr Jessica Hochman to discuss?  Email your suggestion to: askdrjessicamd@gmail.com. 

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The information presented in Ask Dr Jessica is for general educational purposes only.  She does not diagnose medical conditions or formulate treatment plans for specific individuals.  If you have a concern about your child's health, be sure to call your child's health care provider.

Dr Jessica Hochman is a board certified pediatrician, mom to three children, and she is very passionate about the health and well being of children. Most of her educational videos are targeted towards general pediatric topics and presented in an easy to understand manner.

Do you have a future topic you'd like Dr Jessica Hochman to discuss? Email Dr Jessica Hochman askdrjessicamd@gmail.com.

Follow her on Instagram: @AskDrJessica
Subscribe to her YouTube channel! Ask Dr Jessica
Subscribe to this podcast: Ask Dr Jessica
Subscribe to her mailing list: www.askdrjessicamd.com

The information presented in Ask Dr Jessica is for general educational purposes only. She does not diagnose medical conditions or formulate treatment plans for specific individuals. If you have a concern about your child's health, be sure to call your child's health care provider.

Transcript

Unknown: 0:00

Hey everybody, welcome back to ask Dr. Jessica the podcast where I aim to provide you with quality and useful information to help you along your parenting journey. I'm your host and paediatrician Dr. Jessica Hochman. Okay. So right now in my paediatric office, I would say that the most common question I'm getting from parents is about coughs. And I completely understand this. Coughs can be really tricky to manage. They're uncomfortable to watch. They can be really persistent. And parents just want to know what to do to help. So today I have on as a guest, Dr. stays out of Sheva via Dr. Shah Bhatia is a paediatric pulmonologist, which is a doctor who specialises in the lungs. He's an incredible doctor and human being. And I'm really happy to welcome him on today. Thank you so much for coming on the podcast. Thank you very much for inviting me. I'm so excited to have you here. Because something that I see every day multiple times a day as a general paediatrician is complaints about children and their coughs and questions about how they breathe. And so I'm so lucky to have you here to ask all of the common questions that I hear. Sure, my pleasure, I'll try. So tell me about yourself. Tell me about who you are and what your training is and what you do. I spend all my days treating children with with coughs and unusual breathing patterns and breathing complaints. I was born in Mexico. Like you from a young age, I was exposed to my dad the paediatrician. So, I got a little bit of exposure to the tempo and the feel and the evolution for illnesses from a very young age just like you did. I did my medical school in Mexico, and then I did a master's in public health. And then I went to do a residency and fellowship and I started the paediatric intensive care unit at Tarzana Hospital, which was a big jump. And now I don't do critical care anymore. I just do office pulmonary. So most of the what I see is just coughs and asthma and similar complaints. Now question for you. You said most of what you see are a coughs and asthma. What? What is the most common? What are the most common types of cops that you see? You know, what I see in my practice, is a lot of my patients that I follow for a long time who had asthma or hyperreactive airways or allergies or a combination and then when they get a respiratory infection on top of that, then their breathing tubes act up and they do some coughing. So a lot of what I see is asthmatic tendency, hyper reactive airways. Now, when you say hyper reactive airways, what does that mean exactly? Well, everybody's airways react appropriately. When the breathing tubes perceive a threat or a challenge or an insult or an irritation. We all develop cough flaming as congestion. But some people, children, adults, react a lot. You know that the breathing tubes do not just get little Flemmi a little congested. It kind of reacts a lot. And so the coughs persist for a while, the costs are more noticeable than otherwise. Some children go around and they have a cold just with a runny nose and nobody really pays much attention to them. But some other children cough a lot it just everybody's different. So some children get a lot of inflammation get a lot of phlegm Enos a lot of secretions in the airways and a lot of cough. So you're saying some kids, they may not not necessarily have asthma per se, but when they get a cold their airways just overreact more than then let's say their sibling does who does not have a reactive airways? Right, right, right. Many, many children spend many, many weeks without any cough any problems, but when they get a virus, then they get very congested, then they get very Flemmi. Then they cough a lot. And the cough can last a long time, it is more noticeable, and it lasts longer. So that's when I frequently get involved. I'm curious during the pandemic when there are so many fewer viruses circulating. Did you notice that in your practice that kids were having coming in with fewer coughs Absolutely, absolutely. Everybody was doing great. No wheezing, no coughing, not going to school. Not going out a lot, either. But But yeah, everybody was doing so well. I agree with you. It was an eye opener. How well they were all doing. Yeah, it was definitely a silver lining. I have to say hardly. I hardly had patients coming in with asthma exacerbations and bad cough. So yes, I'm glad things are back getting back to normal. Yes, I agree. I agree with silverline. Yeah. Yeah. It was a very unusual time. Very challenging, very stressful. But yeah, we learned more things. When we saw how children were behaving, how the lungs were behaving, how they were not having symptoms, it was great. Now a big question that parents asked about coughs they want to know, what is the root cause of the cough? So I'm curious when you talk about the various types of coughs that you see, how can parents distinguish one from the other? So for example, how can we tell an asthmatic cough? versus a regular cough or a cough that's made worse by allergies? Do you have any quick tips or thoughts for parents to think about? Yeah, it is sometimes difficult to know for sure what is the root cause of the cough. And frequently, at least in my practice, there's an overlap like concentric circles where there's some involvement of allergy, some involvement of irritation, some involvement of asthmatic type symptoms, and in my practice, even sometimes some element of habit or just repetitive movement, habit, cough components, so, so there's, especially in my practice, frequently a coexistence of various things that are annoying the children and are making them cough. So how to tell one from the other is sometimes difficult. Sometimes the seasonal variation can be helpful, you know, if they only cough when the Santa Ana winds that are happening, and there's all this junk in the air, or if the only Coughlin that is fires in Southern California, that gives us clues. Certainly the the cough with a runny nose and a fever, that's very likely to be a viral illness. So a fever, when it is present. It is a good indicator that is some infection. Usually allergic coughs do not have a fever. If it is an allergic type of a situation, frequently they will have an itchy nose, or sneezing or other symptom that can can contribute. So the seasonality helps the fever helps the accompanying symptoms help. The pattern helps. You know at some point moms get really good at saying oh, you know every, every time he goes to the aunt's house where there's a lot of cats, he's itchy, uneasy and coughs and so moms get there. The pattern of the children really well. Yeah, but sometimes it's definitely difficult. Yes, no, that was definitely me as a kid when I would go to my friend Monica's house and she had cats I definitely noticed my my watery eyes, itchy nose and some scratchy throat. So yeah, it's true. You get to know your symptoms. Yeah. And now what about chronic coughs that are just from Back to Back colds? I feel like that's a very common situation that I see where kids you know, they get a cold call typically linger for a couple of weeks and then they're in preschool or early years of elementary school and they get another cold. Is that something that you see often back to back colds and maybe not as often as I do, but yeah, because you know, some people are tall. Some people are short. Some people are dark, some people are light. Some children cough a lot. Some children don't cough so much. So you probably know this better than I do. But at certain ages the average child can have a lot of respiratory infections per year. So those children that tend to cough a lot when they have a cold. It is a lot of noise. He does a lot of coughing and it's a lot of and the parents worry so yeah, that that is a very common reason for for a call. If that is driving everybody crazy, you know, one virus, a lot of cough, then it resolves, and then another one comes and it results. In my practice, sometimes it rarely becomes a vicious cycle the children that cough a lot and have a really harsh, loud, brassy, BARCHI cough your data and I had one like that a long time ago. Then it is like a habit component like a tracheal irritation, they just cough so loud, that the cough itself it kind of irritates their airway. So there's a great many different presentation of the children. But yeah, the child who coughs a lot when he has a cold. And when he or she has a lot of colds per year, then yeah, people start to worry. And Grandma starts to ask, why does he cough so much? And the pressure builds up? On him pressure builds up? Yeah, they for you to make it go away, right? Yes, yes, yes. So now Now a couple of questions here. So those coughs that linger in their habit cough, so coughs that kids just sort of get accustomed to coughing, and they're not causing them any harm, per se, maybe a nuisance annoying to those around them, but not not harmful for them. What kind of advice do you give to parents to help ease the cough? Well, medications, as you well know, don't work well. The cough is a very powerful reflex. It's a very good reflex that is designed or intended to get the junk out of the airway. So the cough is a powerful reflux that it's very difficult to forcefully stop with medications. So the medications don't really work well. And occasionally, the medications can have side effects. So in general, simple as it may sound, I think that we should tell moms and dads to you know, give reassurance to the child and give a lot of love and give a lot of fluids and assure hydration. And, you know, just keep an eye on that. Nothing serious. Usually there's nothing, nothing very serious. But one has to keep an eye on that. Maybe, you know, you probably are better at least then I am but maybe maybe some honey maybe some tea. Just you know, nothing works well. But my guess I guess main thing is tried to cause no harm and just give reassurance and love and hydration and nutrition and temperature control if necessary. But I That's right. Nothing works really well, actually. I know I think that's so frustrating for parents and for kids. But that's, that's also my advice. When as soon as I know that it's not anything dangerous going on that it's a cough that I know will get better over time. My advice is just to do what it takes to make the child more comfortable. So whether it's getting a humidifier or giving them popsicles Tylenol, like you said TLC and then just reassurance that eventually it will go away. Yeah, I agree. It can be hard when mom and dad are up all night and so children throw up after they cough a lot. So it becomes more dramatic. And some children tell my mom I can't breathe and that then the when the mom hears that mom I cannot breathe in totally. Oh my god alarms alarms go up. So. So yeah, it's it's the perils of early parenthood. That is a big challenge. Ya know, honestly, if there was a quick fix or an easy solution or medication for the common cough with a cold Oh, my goodness, that would be so wonderful. Yeah, but But Mother Nature is aware that the cough has its function and it helps us get the phlegm out of the chest. So it's hard to go against Mother Nature. Yes. And I think that's a really important reminder. It makes it seem not as bad if we know it's helping in some way. Absolutely. Yeah. Yeah. It is definitely helping. It is clearing I think of the respiratory mucus and the secretions and the snot that children have as filters in your home. Morin your vacuum cleaner in your car, you know, the all that flame is designed to catch the dust and the pollen and the viruses and, and then when you sneeze and cough and clear your throat and get it all out, basically, you're changing the filter, you're catching all the bad stuff. And then you're blowing it out into a Kleenex. So it's the biological changing of the filters. So it has its, its its role, its function, its benefit. That's a good way to say it. It's a good reminder. Now, do you ever find that patients tell you they have trouble getting a breath, I have a lot of kids that will come in from time to time, where they just say they can't get a good breath. And when you look at them, they look great. They're not having trouble breathing, their lungs are clear. How can this is sort of a leading question, but sometimes I wonder about anxiety. How can parents distinguish between true trouble breathing and feeling anxious and nervous? And that leading to the feeling of not being able to get a good breath? Yeah, it's it's a difficult situation, because there is frequently a huge overlap. And I would say that most of the time, there is coexistence of cough, irritation, noise, sleep deprivation, and anxiety. So very rarely is it just one versus the other. You know, very rarely is it all this is just anxiety, nothing else. I think it's really true. Sometimes you you have a cough, and you feel like you can't breathe well. And that leads to you feeling more anxious about not breathing, and they definitely interplay. Yeah, so I think we have to treat them both at the same time, because they both exist, they're both giving us trouble. So I think we have to figure out why the coffee is can we do something for the coffee, some cups, you can do certain things. But also, you know, give reassurance to the child, be available to the family try to understand what what what they're going through. And I think we have to treat them both try our best to treat them both. Because when when they go away, they both go away to when they cough goes away, and you get a good night's sleep and you go on vacation. Everybody's feeling better. So I think we treat them. That's the truth. I once heard a trick that if you can ask a child to walk up the stairs, if they're if they walk up the stairs comfortably and they're not at a breath, it's probably more likely an anxiety state then, you know, pneumonia or an asthma. But I don't know if that's reliable enough. No, but it's a good point because you are distinguishing shortness of breath. Because one thing is cough. Another one is shortness of breath or respiratory distress. And another thing is the coexisting anxiety. So yeah, I think that's good, good advice that if, if the can be active and playing, it's a really good sign. I mean, sometimes my parents told me yeah, he's making a lot of noise, but he's playing and running. Can't stop him. So we all feel better when when the child is running around and everybody's worried about the cough except him. He's he or she are just jumping running. And so that makes us all feel better. I think it's a good point. Yes. No, I always say that if the number one is to look at how a child's acting so if they're acting normal and they have a cough, you know, they're eating playing have normal energy. That's always a really reassuringly. Yeah. Now, I want to ask you about asthma because asthma is something that comes up very often with children and parents get nervous about asthma. I want to talk to you about I wanted to sort of ask you what what it is and and the prognosis and what we can do about it. So let's start off how how common is asthma? Do you see it often with little kids? Yes, there are many different subtypes. But it is a very common condition, especially early in childhood. virally induced wheezing or coughing is super common is one of the most common conditions in early childhood. And when you say viral induced to can you explain what that means? Yeah. So when a child wheezes or coughs a lot in the presence of a cold or a respiratory infection, then there's certain pathways in the body's inflammation that get activated and triggered and the virus produced This is inflammation and congestion and cough. So okay, so asthma. So it's what age groups do you mostly see it in? By far, the little, the little ones are the ones that have with, you know, it's difficult to distinguish I mean, we, as doctors try to give labels and but the the proclivity to have inflammation of the airways and the tendency to with without a doubt little children, especially when they started going to daycare is when when I see it the most. And most of the time by later childhood or early teenage years, it gets much better or goes away completely. So this is really, really good to hear. Because I think a lot of parents that I meet when they hear their child has asthma, they worry, it's going to be a lifelong condition. But from your experience, it does get better over time. The vast majority of the time, yeah. Yeah, I know myself, I had asthma as a kid. And I would get I would wheeze if I drank milk, and I remember wheezing with colds. And then as I got older, it definitely went away completely for myself. So I'm one of those statistics. Yeah, that's the most common and it also runs in family. If the mom or the dad had a similar pattern of wheezing when they were little, and then it just went went away, then probably that same pattern will run in that family and the child will also have a similar evolution with time. Now, you mentioned wheezing with asthma, are there any other common symptoms that you notice that come with asthma or anything else that parents should be aware of if they're wondering if their child fits into this camp? Well, again, if the respiratory infections are prolonged, or if the respiratory infections have a lot of cough, or if exposure to perfumes, triggers coughing, or wheezing, or chest tightness or chest discomfort, so the symptoms are very varied. And but again, the triggers are also are also highly varied. Some some triggers for wheezing are seasonal. Some triggers for wheezing are chemical, such as strong cleaning solutions or strong perfumes. Some of them are, you know, there's a high variety altitude, humidity. Exercise, exercise. Yeah, absolutely. Exercise is a big one. Yeah. Because you know, a lot of Olympic athletes have exercise induced chest tightness or exercising this bronchospasm. So it's a very common condition. Yeah. What about coughing at night? Hmm? Yeah. Coughing at night. Again, there's many factors. It can be post nasal drip with a lot of phlegm running back the throat it can be reflux heartburn. It can be the pillow is irritating. But yeah, if your windpipes are a little irritated. During the night, we don't move quite so much. We don't sigh quiet too much. We don't laugh quite quite so much. We don't clear our throats quite so much. So the secretions tend to build at night. So yeah, the cough at night would be another symptom. Yeah, absolutely. But you're saying it's it's more nonspecific finding it could be many things if a child coughs a lot at night. Yeah, it doesn't. It doesn't have to be asthma. Right. But you right? It doesn't have to be asthma. But if it's like, kind of very frequently throughout the year, then yes. wakens them with cough, right? You have to think about it right. Now, let's talk about the treatments for asthma. A lot of parents get nervous when they're placed on the recommended treatments for asthma. Specifically, I want to talk about the inhaled steroids. Parents hear about steroids and it makes them nervous. Can you talk about the treatment? Is it Are they safe for kids? What do we know? I do not want to say that they're 100% risk free. Because if we don't have to use them, we would not use them. But I do want to save the they're very very safe on the are better for the child in the long run. The inhaled puffers There is a dilution of the medicine, from the time it comes from the puffer or the nebulizer machine to the time it goes through the nose and the back of the throat and big windpipe the trachea. So by the time it gets to the part of the lungs, when where it's supposed to work in the small airways, a small, very small percentage of this very low dose of steroids actually, is making it to to the area where it works. So the dose that makes it to the lungs is very low. And then the amount of steroid that gets absorbed into the bloodstream, it's another factor of huge dilution and very little absorption. So the absorption to the rest of the body, in most cases is negligible, very minimal. It doesn't mean that we get to now Yeah, it is just it gets diluted in the air and gets diluted in the nose, it gets a little in the throat against that unit in the airway, it gets diluted in the small airway. And then after that super, super little gets absorbed into the bloodstream. Some children, if they have to use it every single day, twice a day for very high doses for a long period of time. Yeah, it can interfere with their growth, it can interfere with their behaviour, it can interfere with their mood, they can get a little behaviour religious. So you and I monitor the the doses and the need and the adjustments, so we want to find the lowest those that will do the job. But the bottom line, they're very low dose and very safe. And I think it's a great, great example of weighing the risks and the benefits. Because if a child's really having trouble breathing, that's really uncomfortable. Yeah, what a terrible way to be feeling and if you can offer medication that's safe with the risks that you described in higher more concentrated doses sounds like, you know, sounds worth it to me if a child's really having trouble breathing. Absolutely. Without a doubt. Yeah, they're live normalises talk about stress and emotional well being and happiness and activity. Yeah, the children are much better if they're well controlled and happy and free of wheezing. Yeah. So in, in your experience, do you ever find do you find children do very well with these medications? Yeah, yeah, they do very well, they they work well. They're not perfect. And now we have the next generation of biological agents that we can use when in the rare setting when a child really needs very high doses of steroids inhale or if they need to take them by mouth, which is a much, much bigger dose. But yeah, they weren't really well. They weren't really well. So I'm excited to talk to you about this. So okay, so now, the first line asthma or the first the first step is to is to offer an inhaled steroid, right? On this, it's something that is very rare. If somebody just needs a little bit of albuterol once every two weeks, then you can give them a little bit of a bureau once every two weeks, but but for the most part, anti inflammatory medications is really treating the issue. Okay, I mentioned this because I know you know, when I first started in practice, the first line or the first medication to offer was albuterol. And then it's recently switched to first line being inhaled steroids. Yes, because we're all realising that they work really well and they're really very safe. Okay, so albuterol obviously still has a role. Can you describe albuterol for people listening and what that does and what when patients should use it? Yeah, so albuterol is a good medication that works and the wind pipes have some muscles around the windpipe. So under certain circumstances, like if we are suddenly exposed to cold air, let's say that you have a little bit of a twitchy windpipe, you have a cold you go skiing, you are in a warm cabin with with with the wood fire, burn burning, and then all of a sudden you sprint out on your run and you ski and you suddenly get exposed to cold air, the windpipe sometimes in that setting those muscles around the windpipe just squeezed down and tighten the windpipes. So they are beautiful. The survey is a very good substance that just relaxes the breathing tubes instead of being all tight and squeezed and in spasm. It just relaxes them for about three or four hours, and it allows you to breathe better. And we call that the as needed medication Correct. as needed or rescue medication. Yeah, something that will just make you feel better quickly. But it only gives you the benefit for about four hours. The main side effect that I like to draw attention to for parents, so that they're aware is that the heart rate goes up temporarily. So a lot of parents might notice that. Right after taking the albuterol the heart rate goes up, but it's temporary, and it doesn't cause anything long term. Yeah, so children get a little shaky hands for a little while. But not so much. It's mainly the heart. And as you will have very healthy hearts. So a little bit of fast heart rate is very well tolerated by them. Yes. Now and you mentioned the new medications, the biologics, can you touch on those medications, what the names are and what they do? Yes, I, I, they all end with NAB for monoclonal antibodies. But they are medications that have to be injected every two or four weeks. But they really go to treat the root cause of these allergic symptoms and inflammation. So if somebody has a very elevated allergic protein, the IGE there's some antibodies that wrap themselves around the IGE. And it decrease the decrease the the excessive manifestation of these substances. There are some that wrap themselves around, or there are substances that are called interleukins. So there's three or four. biologicals, Xolair Nucala. And I forget the other ones, that that are new, and but they are really wonderful because they're very safe. They're very expensive, but they're very safe. And they can be used for childhood asthma, they can be used for childhood eczema. And the beauty is that it decreases the use of steroids, especially with steroids by mouth that, as we said, the steroids by mouth is something that we don't like to use very often because they're much higher those doses than the ones that are just inhaled from a nebulizer. Yeah, it's so nice that there is better treatment for asthma because so many kids suffer from it. So I'm so glad there's better treatments. My dad always says when he compares to when how much better times are now than when he first was in practice. He said, they used to use the offline and epinephrine these medications that made kids feel really lousy. Yes, yes. You've come a long way. Yes, so many, so many people had to use these medications in the past with with a lot of side effects. And I've heard stories from adults, that they couldn't go out and play and they would get these shots and they would get all shaky and they would feel unwell. Yeah, it's the beauty of the advances of medicine. Yeah. If you could offer any wisdom to parents listening, any any advice that you've gathered from over the years about cough? Do you have anything you could share with us? Not to put you on the spot. Um, you know, the good news is that while cough is very annoying and very disruptive, and it can be a red flag that something could be going on underneath the coffee itself, while noisy and disruptive and keeps you up at night. The coffee itself is not a dangerous thing. It's a it's the body doing its work trying to clean up the mess and getting the phlegm out of the chest and getting the junk out of the chest and getting all these things that are not necessarily out of the chest. So it is loud it is not noisy. Some children had a lot of drama and you know, especially at night we are worried but the good thing is that most children just will get better pretty much by themselves. So I would worry if there's accompanying signs such as fever, lethargy, shortness of breath, not eating not drinking other things but just the noisy cough. Yeah, it's very annoying, but it's usually not dangerous and and can be can be monitored by Dr. Jessica and her team. Thank you. That's really that's really, really reassuring to hear. So I appreciate appreciate you, you saying that as as the expert as the as the lung expert, my pleasure. And tell me where where can patients find you if they have questions about their children and they want to see a pulmonologist. Yeah, we have a website. It is some abbreviation of Breathe Easy is www.brthez.com. That's where we are. Excellent. Thank you so much. My pleasure. Thank you so much for tuning into this week's episode. I sure hope you found it helpful. If you're enjoying this podcast, I would be so appreciative. If you would take the time to rate review, subscribe, and share it with a friend. Also, thank you so much to Dr. Chavarria for joining the podcast today. If you can believe it, he told me this was his first podcast ever and I'm so appreciative that he took the time to answer my questions. See you next Monday.