Cough resident survival guide (pediatrics)

Resident Survival Guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Maysoon Fatahi, MD[2],Tayyaba Ali, M.D.[3], Huda A. Karman, M.D.

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:

• Pulmonary embolism
• Pneumonia
• Acute exacerbation of asthma

Common Causes

Acute cough (less than 3 weeks)

Subacute (3 to 8 weeks) or chronic cough (3 to 4 months)

Common cold Bronchitis or Bronchiolitis Asthma Pertussis Croup Influenza Foreign body Pneumonia Second-hand smoke Gastroesophageal reflux disease (GERD)

Isolated cough: otherwise healthy child Recurrent viral bronchitis Postnasal dribbling Cough variant asthma Psychogenic cough Habit cough (tic like) Bizarre honking cough Gastroesophageal reflux Cystic fibrosis Retained foreign body Primary ciliary dyskinesia Immune deficiencies Chronic bronchitis Airway lesions Compression, e.g. tuberculous gland Malacia, often with viral infection, e.g. Tracheoesophageal fistula cough

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.

Cough

Characterize the symptoms ❑ Chronic wet/productive cough ❑ Chest pain ❑ History suggestive of inhaled foreign body ❑ Dyspnea ❑ Exertional dyspnea ❑ Hemoptysis ❑ Failure to thrive ❑ Choking ❑ Vomiting ❑ Cardiac anomaly ❑ Neurodevelopmental abnormalities ❑ Recurrent sinopulmonary infections ❑ Immunodeficiency ❑ Epidemiologic risk factors for exposure to TB

Examine the patient ❑ Respiratory distress ❑ Digital clubbing ❑ Chest wall deformity ❑ Auscultatory crackles

Order Chest X-ray or spirometry (if child is able to perform)

Wet Cough or Productive Cough with sputum

Dry Cough

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 rigid bronchoscopy for foreign body removal

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: Tuberculosis Primary ciliary dyskinesia Cystic fibrosis Bronchiectasis

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 ❑ Supportive care such as hydration, saline nasal drops, nasal bulb suction ❑ Prevention includes Palivizumab for infants with the following conditions: Preterm birth less than 29 weeks gestation Chronic lung disease of prematurity Hemodynamically significant congenital heart disease

Cough due to Common Cold ❑ 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 ❑ 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 ❑ 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 ❑ 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 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 ❑ 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 ❑ 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 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) ❑ 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 ❑ 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 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)."
• "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."

Don'ts

• According to Chang et al., "for children aged less than 14-years with chronic cough (> 4 weeks duration) without an underlying lung disease, treatment for gastroesophageal reflux disease (GERD) should not be used when there are no clinical features of gastroesophageal reflux such as recurrent regurgitation, dystonic neck posturing in infants, or heartburn/epigastric pain in older children (Grade1B)."
• 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, acid suppressive therapy should not be used solely for their chronic cough (Grade 1C).
• According to CHEST guidelines 2017, "For children aged less than 14-years with chronic cough, basing the management on the etiology of the cough is recommended. An empirical approach aimed at treating upper airway cough syndrome due to a rhinosinus condition, GERD and/or asthma should not be used unless other features consistent with these conditions are present."
• “In otherwise well children with nonspecific cough, empirical gastroesophageal reflux therapy is unlikely to be beneficial and is generally not recommended.”