Cough resident survival guide (pediatrics)

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Tayyaba Ali, M.D.[2]

Synonyms and Keywords: Cough in childhood, Cough in children, An approach to cough in children

Cough resident survival guide (pediatrics) Microchapters
Overview
Causes
Diagnosis
Treatment
Do's
Don'ts

Overview

Cough is a sudden, often repetitive, spasmodic contraction of the thoracic cavity, resulting in a violent release of air from the lungs, and usually accompanied by a distinctive sound. A cough by itself is not a complete diagnosis but rather a symptom of an underlying condition, despite this, it accounts as one of the most common indications for visits to the general practitioners and family physicians with a good proportion of these cases resulting in a pulmonology referral. Coughing is an action the body takes to get rid of substances that are irritating the air passages. The act of coughing can be triggered by a myriad of conditions physiologic and otherwise, A cough is mostly initiated to clear a buildup of phlegm within the trachea. Coughing can also be triggered by a bolus of food entering the trachea and other parts of the respiratory tree rather than the esophagus due to a failure of the epiglottis function.

Causes

Life Threatening Causes

Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated.

Common Causes

Acute cough (less than 3 weeks)[4] Subacute (3 to 8 weeks) or chronic cough (3 to 4 months)[5]

Isolated cough: otherwise healthy child

Diagnosis

The approach to diagnosis of Cough in children is based on a step-wise testing strategy. Below is an algorithm summarising the identification and laboratory diagnosis of Cough.[6][7]

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Order Chest X-ray or spirometry (if child is able to perform)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider the diagnosis of Bacterial bronchitis
 
 
 
Consider the diagnosis of Asthma
❑ History of bilateral wheeze and exertional dyspnea
❑ Absence of other cough symptoms
❑ Absence of findings on lung examination
Reversible obstructive defect or normal finding on spirometry (if performed)
 
Consider the diagnosis of Retained foreign body
❑ History of choking or sudden onset of symptoms
❑ Monophonic or unilateral wheeze
❑ Chest X-ray finding suggesting foreign body
 
Consider the other type of cough
Tracheomalacia
Pertussis
Habit cough/ tic cough (typically absent at night or when distracted and may be honking or short/dry)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Antibiotics for 2 to 4 weeks
 
 
 
Trial of Asthma therapies for 2 to 4 weeks
 
 
Perform tests to confirm the diagnosis and treat as appropriate
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Cough resolves
❑ Likely bacterial bronchitis
❑ Reassess in 3 to 4 months to confirm that child remains well
 
Productive cough continues after 4 weeks
❑ Consider the diagnosis of:
 
Asthma Improved
❑ Continue treatment
Asthma not improved
❑ Reassess for other causes of cough
 
No foreign body
❑ Reassess for other causes of cough

Treatment

Shown below is an algorithm summarizing the treatment of underlying conditions that cause cough.

Acute cough

 
 
 
 
 
 
 
 
 
 
 
 
Treat the underlying causes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Cough due to Bronchiolitis[8]
❑ Supportive care such as hydration, saline nasal drops, nasal bulb suction
❑ Prevention includes Palivizumab for infants with the following conditions:
 
Cough due to Common Cold[9]
❑ Supportivr care such as hydration, saline nasal drops
❑ Combination of over the counter medications such as antihistamines, decongestants, antitussives, expectorants, mucolytics, antipyretics/analgesics
❑ For fever, acetaminophen (for children older than three months) or ibuprofen (for children older than six months)
 
Cough due to Asthma[10][11]

❑ Humidified oxygen by nasal cannula or facemask

❑ Inhaled short-acting beta-2 agonists (SABAs) such as (albuterol/salbutamol)

❑ Systemic glucocorticoids (Oral prednisone or dexamethasone)

❑ ICU admission for severe exacerbation

  • Systemic beta-agonists, methylxanthines, and magnesium sulfate
  • noninvasive positive pressure ventilation and high-flow nasal cannula

❑ Antibiotics for bacterial pneumonia or sinusitis

 
Cough due to Pertussis[12][13]

❑ Macrolides erythromycin, clarithromycin, and azithromycin are preferred for the treatment of pertussis in persons 1 month of age and older

❑ Azithromycin remains the drug of choice for treatment or prophylaxis of pertussis in infants younger than 1 month of age,

❑ Monitor the infant for the development of infantile hypertrophic pyloric stenosis (IHPS) with the use of oral erythromycin and azithromycin


❑ An alternative to macrolides is trimethoprim-sulfamethoxazole in infants 2 months of age and older
 
Cough due to Croup[14][15][16]

❑ Comfort measures (keep the child calm as crying worsen airway obstruction

❑ A single dose of dexamethasone if symptoms persist for>3-5 days or worsen

❑ An inhaled epinephrine using a nebulizer for more severe symptoms
 
Cough due to Pneumonia[17][18][19]

Inpatient treatment

❑ Supportive care

  • Antipyretics and/or analgesics (acetaminophen, ibuprofen)


❑ Supplemental oxygen to maintain oxygen saturation ≥95 percent

❑ IV fluid therapy

❑ IV empiric antibiotic treatment

  • 1-6 months old (Ceftriaxone or Cefotaxime)
  • ≥6 months (Ampicillin or penicillin G is preferred)
  • For C. trachomatis, M. pneumoniae or C. pneumoniae (Azithromycin)

❑ For Severe pneumonia

  • Ceftriaxone or Cefotaxime plus Macrolide (Azithromycin)

❑ ICU admission

  • Vancomycin plus Ceftriaxone or Cefotaxime plus Azithromycin plus Antiviral if hospitalized during influenza season)

❑ Complicated pneumonia

  • Ceftriaxone or Cefotaxime plus Clindamycin if S. aureus or anaerobic is suspected
 
Cough due to Influenza[20]

❑ Oral oseltamivir for:

  • Hospitalized patients
  • Patients with severe, complicated, or progressive illness
  • Patients with risk factors for complications

Chronic cough

 
 
 
 
 
 
 
 
 
 
 
 
Treat the underlying causes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Cough due to Cystic fibrosis[21][22][23][24]

❑ CFTR modulator such as tezacaftor-ivacaftor or lumacaftor-ivacaftor

  • CFTR genotyping should be done first to determine the patient eligibility
    • Patients ≥12 years old with responsive CFTR mutations
    • Younger patients with sufficient evidence for FDA approval

❑ Metered-dose Albuterol Inhaler

❑ Hypertonic saline

❑ DNase such as dornase alfa

❑ Chest physiotherapy

❑ Exercise

❑ Aerosolized antibiotics or long-acting antiasthmatics

❑ Azithromycin

  • Chronic treatment with for patients six years and older
 
Cough due to Chronic bronchitis

protracted bacterial bronchitis

❑ Augmentin (amoxicillin and clavulanate potassium) or Omnicef (cefdinir)

 
Cough due to Primary ciliary dyskinesia[25][26][27] 9387968

❑ Treatment should be individualized based on the clinical course of each patient

❑ Supplemental oxygen for a few hours to days after birth for mild respiratory distress (tachypnea, mild hypoxemia)

Bronchiectasis

❑ Daily chest physiotherapy

❑ Oral antibiotics for acute exacerbation and it should be tailored based on the sputum culture results

❑ Preventive antibiotic therapy with Azithromycin may reduce the rate of exacerbations

  • Do Sputum cultures prior to Azithromycin use to exclude nontuberculous mycobacteria infection
  • Assess for risk of QT interval prolongation prior to Azithromycin use
 
Cough due to Postnasal drib (Allergic Rhinitis)[28]

❑ Antihistamines

❑ Nasal steroid sprays reduce swelling and inflammation of the nasal passages promoting proper drainage

❑ Allergy shots (immunotherapy) if no improvement

 
Cough due to Cough variant asthma[29]

❑ Inhaler with albuterol, ipratropium, and/or inhaled steroids

 
Cough due to Recurrent viral bronchitis

❑ Antibiotics are not recommended except with chronic wet cough for ≥ 2-4 weeks, which could be mostly bacterial ❑ Albuterol or terbutaline inhalers ❑ corticosteroids if no improvement ❑ Stepped-up courses of inhaled corticosteroids might be effective ❑

 
Cough due to Asthma[30][31]

Mild, persistent asthma ❑ low-dose, daily inhaled glucocorticoids ❑ Daily leukotriene receptor antagonist (Montelukast )

  • As an alternative to inhaled glucocorticoids
  • Limited use due to neuropsychiatric sede effects

Do's

  • "For children aged less than 14-years with chronic cough (> 4 weeks duration) without an underlying lung disease but who have symptoms and signs or tests consistent with gastroesophageal pathological reflux, they should be treated for GERD in accordance to evidence-based GERD specific guidelines (Grade 1B)." [32][33]
  • "Children with chronic cough and typical symptoms of GERD should undergo medical treatment—dietary, lifestyle modifications and acid suppression therapy. A three-stage therapeutic trial should be completed before diagnosing reflux-related cough:
(1) clear-cut response to a 4 to 8-week treatment with PPI
(2) relapse on stopping medication
(3) new response to recommencing medication, with weaning down therapy as appropriate to the child’s symptoms." [34]

Don'ts

References

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