Cough – Acute

Cough – Acute: Excerpt from In A Page: Pediatric Signs and Symptoms

A cough occurs by increased intrathoracic pressure against a closed glottis (Valsalva maneuver), followed by the abrupt opening of the glottis and a sudden expulsion of air. Increased intrathoracic pressure leads to dynamic compression of the airways. The effect of air flow at high pressure through a compressed trachea (only 1/6 of original area) is a greatly increased velocity; in adults airflow may reach 400–500 miles per hour. The result is a generally effective method of removing debris and secretions from the airway.

Differential Diagnosis

• Upper airway disease
  –URI or common cold accounts for much pediatric coughing (influenza, parainfluenza, rhinovirus)
  –Chronic sinusitis, tonsillitis, laryngitis, and croup are other common infections
  –Allergic disease
  –Vocal cord dysfunction (VCD)

• Lower airway disease
  –Asthma is inflammatory triad of edema, mucus, and bronchospasm, characterized by reversibility with asthma drugs (the most common triggers for asthma are viral disease, irritants such as ETS, allergic disease, and gastroesophageal reflux)
  –Infectious diseases: Bronchiolitis, caused by RSV in babies, causes cough from inflammatory changes and debris; bronchitis is more common in older children and may be secondary to smoking or ETS exposure; other viral lower airway diseases include adenovirus, influenza, and parainfluenza
  –Foreign body aspiration
  –Chronic diseases (e.g., cystic fibrosis and bronchiectasis) and structural abnormalities (e.g., PCD, TEF, or cleft, rings, and slings) may present with intermittent rather than chronic cough

• Parenchymal and pleural disease
  –Infectious diseases account almost exclusively for all parenchymal and pleural causes of cough (i.e., pneumonia and empyema)
  –Usual infectious agents include bacterial disease (e.g., streptococcal, staphylococcal) and atypical pneumonias (e.g., Mycoplasma pneumoniae), TB
  –Irritation of a branch of cranial nerve ten in the external auditory canal can trigger cough

Workup and Diagnosis

• History
  –What started it? History (e.g., infection or FB aspiration) may suggest a mechanism
  –What makes it worse? Activity leading to cough may suggest asthma or structural disease; seasonal onset suggests allergic disease; night cough suggests GER
  –Is the cough productive? Infection is the primary cause of sputum production; also consider asthma, bronchiectasis, smoking, or CF
• Physical exam
  –Loud, “brassy,” vibrato, honking quality suggests tracheomalacia
  –High-pitched stridor suggests a fixed tracheal obstruction (ring, sling, FB, subglottic stenosis)
  –Violent paroxysms with an inspiratory whoop suggests pertussis syndrome
  –A productive, “wet” cough suggests bronchitis or pneumonia
  –A wheezy, “tight” cough suggests asthma
• Studies
  –CXR may demonstrate an atypical pneumonia
  –Pulmonary function tests to diagnose asthma or large airway obstruction
  –Bronchoscopy and lavage to diagnose malacia, infection, FB, VCD
  –V/Q scan may diagnose a pulmonary embolus (rare)
• Exercise testing may provoke symptoms of exercise-induced asthma or VCD

Treatment

• Treatment is often empiric and based on history
• Cough suppression is usually avoided, but may assist with sleep; other OTC therapies of little value
• An empiric “diagnostic trial” of medication may treat asthma, GER, or bacterial infections
• Treatment of “habit component” may help with psychogenic cough or other chronic conditions (e.g., postinfectious bronchitis)
• Speech therapy is very helpful for VCD or habit cough (i.e., using cold water “hard swallow,” benzocaine throat lozenges, breathing exercises)
• Serious psychiatric disease may be associated with VCD but referral to mental health specialists is rarely needed

Book Source Details

• Book Title: In A Page: Pediatric Signs and Symptoms
• Author(s): Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
• Year of Publication: 2007
• Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.

More About Sinusitis

• Back to disease: Sinusitis: Introduction
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: In A Page: Pediatric Signs and Symptoms Authors: Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-4051-0427-9

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