Cough (Case 3)

Chapter 31 Cough (Case 3)



Aaron S. Chidekel, MD




Case


A 5-year-old has a tight, nocturnal cough for 4 weeks with posttussive emesis.




Differential Diagnosis













Infection Asthma Foreign body
Suppurative lung disease Aspiration/dysphagia/gastroesophageal reflux  


Speaking Intelligently


In evaluating a child with cough, my first step is a quick clinical assessment. If the child is ill or in respiratory distress, the immediate focus is stabilization of the ABCs (airway, breathing, and circulation). Otherwise, the evaluation is individualized based on history and physical examination to avoid unnecessary testing. Although protracted cough is a significant parental stress and may disrupt family life, any treatment should focus on the underlying cause. It is critical to communicate the relative ineffectiveness of cough suppressants and the potential danger of adverse effects in young children and reported abuse by adolescents.


Cough is a vagally mediated reflex. An intact cough is critical to airway protection and clearance, and some normal children cough daily. Temporally cough is acute (<2 weeks), subacute (2 to 4 weeks), or chronic (>4 weeks). It may be part of an underlying illness or syndrome, such as cystic fibrosis (CF) or immunodeficiency, or more commonly a manifestation of an intercurrent viral infection. Rarely, there is a life-threatening problem such as foreign body aspiration. In cases of acute or even protracted cough associated with viral infection, no testing may be needed. For chronic cough, chest radiography and spirometry are recommended. Additional evaluation may include allergy testing, otolaryngologic evaluation, and sweat chloride analysis.



Patient Care



Clinical Thinking



• If the child is acutely ill or in respiratory distress, consider foreign body aspiration, pertussis in a young infant, severe laryngotracheitis (croup), bacterial tracheitis, or an asthma exacerbation.

• Viral infection is the most common cause of acute coughing-related illness, whereas asthma and rhinosinusitis predominate in subacute and chronic cough.

• Environmental tobacco smoke (ETS) exposure is common and itself may cause chronic cough.

• A chronic productive or moist cough suggests underlying suppurative lung disease such as cystic fibrosis, or more commonly persistent bacterial bronchitis.

• A specific cause may not be determined, and despite this the cough will resolve.


History



• Consider duration and symptoms of acute or chronic illness.

• Evaluate potential respiratory irritants, particularly ETS.

• Review vaccination status and risk for exposure to infectious agents.

• Review of systems should be tailored, yet comprehensive enough to evaluate for systemic symptoms as well as emotional, neurologic, or other factors.

• Common cough syndromes and clinical clues include:
• Asthma: Wheezing

• Foreign body: Unequal breath sounds, wheezing

• Pertussis: Paroxysmal coughing/inspiratory whoop

• Chlamydia: Staccato cough/conjunctivitis

• Croup: Barky cough/stridor

• Tracheomalacia: Barky cough/stridor

• Dysphagia/gastroesophageal reflux (GER)/aspiration: Cough may be associated with feeding

• Suppurative lung disease*: Wet cough/clubbing/poor growth

• Habit-cough syndrome: Honking sound/absent during sleep

*Examples include CF, ciliary dyskinesia, and immunodeficiency. (Modified from Landau LI: Acute and chronic cough, Paediatr Respir Rev 7S:S64-S67, 2006.)



Physical Examination



• Vital signs: Temperature, respiratory rate, oxygen saturation, and weight; fever suggests infection, weight loss suggests more serious underlying illness.

• Assess work of breathing (see Chapter 44, Difficulty Breathing).

• Characteristics of cough, if heard, should be described.

• Carefully examine head and neck to identify rhinosinusitis, which may be allergic or infectious (see Chapter 36, Fever).

• Assess chest wall symmetry and configuration

• Evaluate breath sounds for clarity and equality.

• Evaluate for clubbing of extremities.


Tests for Consideration



• Complete blood count (CBC): Lymphocytosis in pertussis; eosinophilia in Chlamydia $139

• Serology: For Mycoplasma and hypersensitivity pneumonitis $196 each

• Immunoglobulin levels: If suspected immunodeficiency $167

• Spirometry: For asthma or other obstructive lung disease $1352

• Sweat chloride analysis: If suspect CF $125

• Nasopharyngeal (NP) swab for pertussis polymerase chain reaction (PCR) $168

• NP swab for viral studies: Influenza, parainfluenza, adenovirus, RSV, metapneumovirus $325

• Tuberculin skin testing: If exposure or risk factors $174

• Radioallergosorbent test (RAST), ImmunoCAP, or specific allergen skin testing: If suspected allergy $400

• Bronchoscopy: If foreign body aspiration, chronic infection, or suspected structural airway abnormality $1400

• pH probe or impedence probe testing: In select cases to document GER $5585

• Endoscopy: Is gold standard for GER diagnosis—consider in difficult-to-manage cases $1313


Imaging Considerations



→ Chest radiograph posteroanterior (PA) and lateral views: If chronic cough or suspected pneumonia or asthma complication $231
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Jul 18, 2016 | Posted by in PEDIATRICS | Comments Off on Cough (Case 3)

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