Cough resident survival guide (pediatrics): Difference between revisions

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❑ Oral oseltamivir is recommended by the CDC for the treatment of patients hospitalized with influenza; for patients with severe, complicated, or progressive illness; and those with risk factors for complications from influenza 
❑ Oral oseltamivir for patients with severe, complicated, or progressive illness; for those with risk factors for complications, or for hospitalized patients





Revision as of 05:35, 4 October 2020


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


❑ Oral oseltamivir for patients with severe, complicated, or progressive illness; for those with risk factors for complications, or for hospitalized patients

Chronic cough

 
 
 
 
 
 
 
 
 
 
 
 
Treat the underlying causes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Cough due to Cystic fibrosis

 
Cough due to Chronic bronchitis

 
Cough due to Primary ciliary dyskinesia

 
Cough due to Postnasal dribbling

 
Cough due to Cough variant asthma

 
Cough due to Recurrent viral bronchitis

 
Cough due to Asthma

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)." [20][21]
  • "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." [22]

Don'ts

References

  1. Patocka C, Nemeth J (2012). "Pulmonary embolism in pediatrics". J Emerg Med. 42 (1): 105–16. doi:10.1016/j.jemermed.2011.03.006. PMID 21530139.
  2. Tan TQ, Mason EO, Wald ER, Barson WJ, Schutze GE, Bradley JS; et al. (2002). "Clinical characteristics of children with complicated pneumonia caused by Streptococcus pneumoniae". Pediatrics. 110 (1 Pt 1): 1–6. doi:10.1542/peds.110.1.1. PMID 12093940.
  3. "Acute Asthma: Observations Regarding the Management of a Pediatric Emergency Room | American Academy of Pediatrics".
  4. 4.0 4.1 "www.ncbi.nlm.nih.gov" (PDF).
  5. 5.0 5.1 de Jongste JC, Shields MD (2003). "Cough . 2: Chronic cough in children". Thorax. 58 (11): 998–1003. doi:10.1136/thorax.58.11.998. PMC 1746521. PMID 14586058.
  6. Rochwerg B, Brochard L, Elliott MW, Hess D, Hill NS, Nava S; et al. (2017). "Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure". Eur Respir J. 50 (2). doi:10.1183/13993003.02426-2016. PMID 28860265.
  7. Weinberger M, Hoegger M (2016). "The cough without a cause: Habit cough syndrome". J Allergy Clin Immunol. 137 (3): 930–1. doi:10.1016/j.jaci.2015.09.002. PMID 26483178.
  8. King VJ, Viswanathan M, Bordley WC, Jackman AM, Sutton SF, Lohr KN; et al. (2004). "Pharmacologic treatment of bronchiolitis in infants and children: a systematic review". Arch Pediatr Adolesc Med. 158 (2): 127–37. doi:10.1001/archpedi.158.2.127. PMID 14757604.
  9. "Treatment of the Common Cold - American Family Physician".
  10. Ben-Zvi Z, Lam C, Hoffman J, Teets-Grimm KC, Kattan M (1982). "An evaluation of the initial treatment of acute asthma". Pediatrics. 70 (3): 348–53. PMID 7110806.
  11. Rodrigo GJ, Rodriquez Verde M, Peregalli V, Rodrigo C (2003). "Effects of short-term 28% and 100% oxygen on PaCO2 and peak expiratory flow rate in acute asthma: a randomized trial". Chest. 124 (4): 1312–7. doi:10.1378/chest.124.4.1312. PMID 14555560.
  12. Tozzi AE, Celentano LP, Ciofi degli Atti ML, Salmaso S (2005). "Diagnosis and management of pertussis". CMAJ. 172 (4): 509–15. doi:10.1503/cmaj.1040766. PMC 548414. PMID 15710944.
  13. Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R, CDC; et al. (2004). "Guidelines for preventing health-care--associated pneumonia, 2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee". MMWR Recomm Rep. 53 (RR-3): 1–36. PMID 15048056.
  14. Gates A, Gates M, Vandermeer B, Johnson C, Hartling L, Johnson DW; et al. (2018). "Glucocorticoids for croup in children". Cochrane Database Syst Rev. 8: CD001955. doi:10.1002/14651858.CD001955.pub4. PMC 6513469 Check |pmc= value (help). PMID 30133690.
  15. Westley CR, Cotton EK, Brooks JG (1978). "Nebulized racemic epinephrine by IPPB for the treatment of croup: a double-blind study". Am J Dis Child. 132 (5): 484–7. doi:10.1001/archpedi.1978.02120300044008. PMID 347921.
  16. Klassen TP, Watters LK, Feldman ME, Sutcliffe T, Rowe PC (1996). "The efficacy of nebulized budesonide in dexamethasone-treated outpatients with croup". Pediatrics. 97 (4): 463–6. PMID 8632929.
  17. Bradley JS, Byington CL, Shah SS, Alverson B, Carter ER, Harrison C; et al. (2011). "The management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America". Clin Infect Dis. 53 (7): e25–76. doi:10.1093/cid/cir531. PMC 7107838 Check |pmc= value (help). PMID 21880587.
  18. Harris M, Clark J, Coote N, Fletcher P, Harnden A, McKean M; et al. (2011). "British Thoracic Society guidelines for the management of community acquired pneumonia in children: update 2011". Thorax. 66 Suppl 2: ii1–23. doi:10.1136/thoraxjnl-2011-200598. PMID 21903691.
  19. Chang CC, Cheng AC, Chang AB (2014). "Over-the-counter (OTC) medications to reduce cough as an adjunct to antibiotics for acute pneumonia in children and adults". Cochrane Database Syst Rev (3): CD006088. doi:10.1002/14651858.CD006088.pub4. PMID 24615334.
  20. Rosen R, Vandenplas Y, Singendonk M, Cabana M, DiLorenzo C, Gottrand F; et al. (2018). "Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition". J Pediatr Gastroenterol Nutr. 66 (3): 516–554. doi:10.1097/MPG.0000000000001889. PMC 5958910. PMID 29470322.
  21. "Overview | Gastro-oesophageal reflux disease in children and young people: diagnosis and management | Guidance | NICE".
  22. 22.0 22.1 de Benedictis FM, Bush A (2018). "Respiratory manifestations of gastro-oesophageal reflux in children". Arch Dis Child. 103 (3): 292–296. doi:10.1136/archdischild-2017-312890. PMID 28882881.
  23. 23.0 23.1 "journal.chestnet.org".
  24. Chang AB, Oppenheimer JJ, Weinberger MM, Rubin BK, Grant CC, Weir K; et al. (2017). "Management of Children With Chronic Wet Cough and Protracted Bacterial Bronchitis: CHEST Guideline and Expert Panel Report". Chest. 151 (4): 884–890. doi:10.1016/j.chest.2017.01.025. PMID 28143696.