Cough

1. In patients presenting with an acute cough:
   1. Include serious causes (e.g., pneumothorax, pulmonary embolism [PE]) in the differential diagnosis.
   2. Diagnose a viral infection clinically, principally by taking an appropriate history.
   3. Do not treat viral infections with antibiotics. (Consider antiviral therapy if appropriate.)
2. In pediatric patients with a persistent (or recurrent) cough, generate a broad differential diagnosis (e.g., gastroesophageal reflux disease [GERD], asthma, rhinitis, presence of a foreign body, pertussis).
3. In patients with a persistent (e.g., for weeks) cough:
   1. Consider non-pulmonary causes (e.g., GERD, congestive heart failure, rhinitis), as well as other serious causes (e.g., cancer, PE) in the differential diagnosis. (Do not assume that the child has viral bronchitis).
   2. Investigate appropriately.
4. Do not ascribe a persistent cough to an adverse drug effect (e.g., from an angiotensin-converting enzyme inhibitor) without first considering other causes.
5. In smokers with persistent cough, assess for chronic bronchitis (chronic obstructive pulmonary disease) and make a positive diagnosis when it is present. (Do not just diagnose a smoker’s cough.)

General Overview

• Acute <3w
• Subacute 3-8w
• Chronic >8w

Cough

Common

• Post infectious (URTI/pneumonia/sinusitis/bronchitis)
• Upper Airway Cough Syndrome (UACS, previously Postnasal Drip)
• Asthma
• COPD
• GERD
• Medication - ACE-inhibitor

Always Consider

• Respirology
  • Pneumothorax
  • Pulmonary Embolism
  • Tuberculosis
  • Pneumonia
  • Lung cancer or mets
  • Aspiration/Foreign body
  • Interstitial lung disease
  • Workplace exposure
  • OSA
• Heart failure
• Complicated GERD

History

• Exposures
  • Occupation/Irritants (smoke, respiratory hazards)
  • Travel/Sick Contacts
• Red Flags
  • Systemic symptoms
    • Weight loss, Fever, night sweats (Constitutional)
    • Peripheral edema
  • Dyspnea
  • Hemoptysis
  • Exposure (smoker)
  • Chest pain
• ACE-inhibitor (10% patients on ACE-inhibitor will develop a cough, but most may not be due to ACE-i)
• Measure 0-10 cough severity and impact on quality of life

Limited evidence in management of Subacute Cough

Chronic Cough Management

• Smoking cessation
• Consider ACE-inhibitor
• Post-infectious cough (3w-8w after acute respiratory infection)
  1. Self-limited will resolve spontaneously
  2. Trial of inhaled ipratropium
  3. Trial of combined inhaled ipratropium with inhaled corticosteroids
• CXR (2-view) if >8w, r/o tuberculosis or lung mass (malignancy, sarcoidosis)
• If normal CXR, no ACE-i, no exposure to irritants (smoking/occupational), consider Upper Airway Cough Syndrome (UACS), asthma and GERD
  • Sequential treatment (18%-62% of patients have ≥2 causes of cough)
    • UACS (previously "post-nasal drip syndrome")
      • Sensation of secretions/irritation of back of the throat, nasal congestion and discharge, throat clearing
      • Allergic rhinitis
        • Allergen avoidance
        • Nasal corticosteroids
        • Second generation antihistamines
        • Combination corticosteroid/antihistamine inhaler and/or cromolyn
      • Non-allergic rhinitis
        • First-generation antihistamine plus decongestant (care in hypertension), glaucoma
        • Nasal ipratropium bromide spray
    • Asthma (cough-variant)
      • Spirometry, add methacholine challenge if non-diagnostic
      • Inhaled corticosteroids
    • GERD
      • Dietary modifications
      • PPI twice daily
      • Addition of prokinetic if no response
      • If failed, objective testing for GERD (barium esophagography, upper endoscopy, 24h esophageal pH)
  • If all failed, diagnose cough sensitivity syndrome (idiopathic, refractory cough)
    • Speech pathology treatment
    • Neuromodulating medication
      • Gabapentin (300-1800mg daily x 10w), Pregabalin 300mg PO daily x4w
    • CT scan if suspect lung cancer, bronchiectasis or ILD
    • Referral to specialty

Children ≤ 14 years

History

• Immunization
• Choking, foreign body

DDx

• Infection
  • Bordetella Pertussis (paroxysms of coughing, post-tussive vomiting/whoop, age 8-11yo)
  • URTI / Pneumonia
  • Recurrent viral infection (infants and toddlers)
  • Bacterial bronchitis or rhinosinusitis (Productive/wet cough)
  • Bronchiectasis/Cystic fibrosis (wet productive cough, weight loss)
  • Croup (Barky night time cough)
• Lung
  • Physical/Chemical irritants
  • Asthma (nighttime, wheeze)
• Cardiac (heart failure)
• Allergy
• GI
  • Foreign Body (new onset after choking, age 0-2yo, diminished breath sounds)
  • GERD (after meals)
• Congenital anomalies (neonatal onset)
  • Tracheoesophageal fistula (choking with feeds)
  • Laryngotracheomalacia
• Empiric approach for treatment not used first-line unless conditions present
  • If inhaled corticosteroids are used, trial of therapy should be limited
• CXR and spirometry (if age appropriate)
• Consider watch and wait if suspect post-viral cough