Cough resident survival guide (pediatrics)

Editor-In-Cheif: C. Michael Gibson, M.S., M.D.

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

Overview

Cough in kids is one of the most common presenting complaint to pediatricians. importantly cough is not disease by itself but rather a manifestation of underlying pathology.

A cough is protective action and can be initiated both voluntary and via stimulation of cough respiratory located throughout the respiratory tract (ear – sinus – upper and lower airway )

Classification

Cough is usually classified based on

1.Duration:

- acute< 2 weeks

- Subacute 2 – 4 weeks

- Chronic > 4 weeks

2.Etiology:

- Specific

-  Not specific

3. Quality:

- Dry cough

 - Wet (moist) cough

4. Timing:

- Nocturnal cough

- Seasonal/ geographical variation

Causes

Life Threatening causes

• Congestive heart failure
• Pneumonia
• Acute inhalation injury
• Acute exacerbation of asthma/COPD
• Acute pulmonary embolism

Common Causes

Noninfectious causes

1. Asthma
2. Gastroesophageal reflux disease
3. Forgein-body aspiration
4. Upper-airway cough syndrome
5. Extrinsic airway compression
6. Smoking (active or passive)
7. Cystic fibrosis
8. Interstitial lung disease
9. Nonasthmatic eosinophilic bronchitis

10. Congenital defects (.g., esophageal atresia with/without tracheoesophageal fistula, vascular rings)

Infectious causes

1. Chronic sinusitis with upper-airway cough syndrome
2. Pyogenic bacterial pneumonia
3. Prolonged bacterial bronchitis
4. Tuberculosis
5. Mycoplasma pnumoniae infection
6. Chlamydophila pneumoniae infection
7. Pertussis
8. Respiratory viral infections (influenza, adenovirus, rhinovirus, respiratory syncytial virus, parainfluenza virus

FIRE: Focused Initial Rapid Evaluation

The child will look ill with pneumonia or influenza or, the child is breathing heavily. the child will have short of breath with tachypnea (with asthma or foreign body aspiration). There might be a high fever ( with pneumonia, but some children can run sudden high fevers with otherwise innocuous viral infections.
1. pulse oximetry to detect hypoxia

2. full blood count

3. chest x-ray only for children who have severe pneumonia

Complete Diagnostic Approach

1.  Characterized of cough

- Onset                A)sudden

                            B) gradual (chronic lung diseases )

- Duration            A(acute  2 weeks - URTI -  bronchiolitis

                             B) subacute ( 2 – 4 ) weeks

             C) chronic > 4 weeks – cystic fibrosis

                       - Quality               A) wet (moist)  - bronchiectasis

                                            B) dry cough

                      - Worsening and relieving factor

                      - Diurnal         A) night – Asthma

                                        B) only day habits cough

                       - certain characterized        A) brassy cough (barking)  croup

                                                                      B) paroxysmal  pertussis

                                                                       C) staccato chlamydia

                                                                       D) honking   - habits cough

2 . characterized associated symptoms

non specific   -   sweating -  lethargy    -   headache    -   vomiting

3. cardiac symptoms

                            Chest pain -  palpitation  -     oedema   - exertional dyspnea

4. symptoms  suggestive pulmonary problem

                                 Dyspnea   -  hemoptysis    -  grunting   -   pleural pain

5. symptoms suggestive gastrointestinal etiology

Burn sensation (GERD)- epigastric pain  -   Regurgitation

                 Choking (tracheoesophageal  fistula )

6. inquired about medical history

- previous episode of cough

-  past history of asthma  -allergic rhinitis ,eczema

-  Family history of lung or allergic smoking,  asthma

7.examine the patient

-  general appearance  -  cyanosis -  pallor  - jaundice -  -  nail  clubbing

- general examination

-Inspect nose if there are any polyps (cystic febrosis) , skin rash

-Vital signs  -  heart rate -   respiration rate  - blood pressure ---

Pulse;  pulsus-severe asthma

-  Chest      A) any deformity

                  B) auscultation; symmetrical  air entery  crepitation – wheezing (asthma )

-Heart sounds;  S1 – S2   -S3 or murmur

8. order labs  - tests according to the suspected etiology

-  CBC-  CRP -  ESP

- SPUTUM CULTURE

- SWEAT TEST (CYSTIC FEBROSIS)

- LIPASE – AMYLASE EN TYME (CYSTIC FEBROSIS)

- ABG

- MANTOUX TEST FOR TB

9. order Imaging study

- CXR  A)  consolidation pneumonia

               B) pleural effusion

                C) pneumothorax

- Echocardiography to rule out any heart diseases

-Pulmonary function test

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Treatment

Once the history and physical examination have led to an initial assessment, the fact that

cough is a symptom of an underlying condition should be discussed with the patient and

family. Treatment of the underlying disorder (if necessary) should always be the prime

focus.Empiric therapy, based on primary assessment, can be a reasonable starting point.

Judicious use of laboratory testing, as previously discussed, can be helpful in confirming

the diagnosis and allaying parental anxiety. Furthermore, in some conditions, cough is

an important component of the body’s natural response to the primary illness, and

suppressing the cough in the absence of effective therapy of the primary disorder may actually

worsen the problem.

Treatment of the underlying disorders causing cough is discussed in other sections of

this book; this chapter is limited to a review of medications used to treat cough itself. The

decision to use a cough medicine as an adjunct to the treatment of the primary disease is left

to the primary care physician and family. When cough is limiting or otherwise debilitating

the patient, symptomatic treatment may be attempted; however numerous studies question

whether over-the-counter cough preparations offer any significant clinical benefit.

In addition these cough and cold medications should not be given to children younger than

4 years because serious and potentially life-threatening side effects can occur from their

use. Finally, several studies have shown that honey may be beneficial in children older

than 2 years of age.

Expectorants

Expectorants such as guaifenesin (formerly known as glyceryl guaiacolate) may be used

in an attempt to make secretions more fluid and reduce sputum thickness, however the

effectiveness of this treatment has been called into question. This therapeutic approach

may be useful when drainage of secretions is important, as with sinusitis. Because expectorants

work by increasing the fluid content of secretions, water is probably the most

effective expectorant. Saline nose sprays can make secretions more fluid and easily cleared

by the patient and systemic hydration, but not overhydration, should always be optimized.

Despite widespread use, expectorants have not been shown to decrease cough in children.

Other older expectorants, such as potassium iodide and ammonium chloride, are no

longer prescribed to children because of their adverse effects when used at effective doses.

                   

Mucolytic Agents

Acetylcysteine was previously used as a mucolytic agent to help liquefy thick secretions,

especially in diseases such as cystic fibrosis; however, its propensity for inducing airway

reactivity and inflammation has lately made it less popular.

Cough Suppressants

Cough suppressants, which can be divided into peripheral and centrally acting agents,

can be effective in transiently decreasing cough severity and frequency. Peripheral agents

include demulcents (eg, throat lozenges), which soothe the throat, and topical anesthetics,

which can be sprayed or swallowed. Topical agents block the cough receptors, but their

effects are short-lived because oral secretions rapidly wash them away. Centrally acting

cough suppressants, including both narcotic and nonnarcotic medications, suppress

the cough reflex at the brain stem level. The narcotic agent most commonly used in

children is codeine. Although it has been shown to be effective in adults, studies on its

safety and efficacy in children are lacking. Furthermore, data from adults should not be

extrapolated to children, particularly those younger than 2 years, because the metabolic

pathway for clearance of codeine is immature in infants. In older children, codeine should

still be avoided and only used in extreme cases and with very clear instructions because of

the unpredictable and potentially dangerous variation of its metabolism in the pediatric

population. Other agents, such as hydrocodone, have no demonstrated advantage and

pose a greater risk of dependency. Dextromethorphan (the dextro-isomer of codeine) is

the most commonly used nonnarcotic antitussive; and despite data from adults, evidence

of efficacy for children is lacking.

Decongestants

Decongestants such as pseudoephedrine can be used either topically or systemically

to decrease nasal mucosal swelling. Decongestants can also facilitate sinus drainage by

decreasing sinus ostia obstruction, and may work well in combination with expectorants

to optimize treatment of chronic sinusitis. Care should be taken in the use of these

agents because they have been shown to lead to tachyarrhythmias in individuals who use

them in excess. In addition, these agents have not been studied in children and should

be avoided in children younger than 2 years. Multiple reviews of the data from children

between 2 and 6 years old also show lack of efficacy combined with a risk of side effects

in this age group. It is therefore recommended that these agents not be used in children

younger than 6 years.

Antihistamines

Antihistamines, which can be helpful in the treatment of cough triggered by allergy, have

minimal effect when cough is the result of viral or bacterial infection and may actually be

detrimental because they can increase the thickness of secretions. First-generation H1-receptor

antagonists may decrease nasal drip by exerting an anticholinergic effect. Additionally,

diphenhydramine may have a modest direct effect on the medullary cough center. The

clinical benefits of these agents are unclear.

When to Refer

• Cough persists despite adequate therapy of primary disease

• Cough thought to be from hyperreactive airways is not easily reversible with _Beta-2 agonist

• Cough recurs more frequently than every 6 to 8 weeks

• Cough associated with failure to thrive

• Cough associated with other systemic illness

When to Admit

• Patient has respiratory distress

• Infant is unable to feed

• Cough is associated with bacterial pneumonia not responsive to oral antibiotic trial

Do's

1. Increase fluids
2. Rest in an upright position
3. add some humidity
4. Eliminate irritants
   

Don'ts

• Dont give cough medicine for children under 6
  

References

1.  Paediatrics signs and symptoms sorter_2^nd ed

2.  Signs and symptoms in pediatric_AAP

3.  Nelson symptom based diagnosis

4.  Symptoms based diagnosis in pediatric_McGraw Hill