Cough resident survival guide (pediatrics)

Characterize the symptoms
❑ Chronic wet/productive cough
❑ Chest pain
❑ History suggestive of inhaled foreign body
❑ Dyspnea
❑ Exertional dyspnea
❑ Hemoptysis
❑ Failure to thrive
❑ Choking
❑ Vomiting
❑ Cardiac anomaly
❑ Neurodevelopmental abnormalities
❑ Recurrent sinopulmonary infections
❑ Immunodeficiency
❑ Epidemiologic risk factors for exposure to TB

Examine the patient
❑ Respiratory distress
❑ Digital clubbing
❑ Chest wall deformity
❑ Auscultatory crackles

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)

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:

• Tuberculosis
• Primary ciliary dyskinesia
• Cystic fibrosis
• Bronchiectasis

Asthma Improved
❑ Continue treatment
Asthma not improved
❑ Reassess for other causes of cough

No foreign body
❑ Reassess for other causes of cough

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:

• Preterm birth less than 29 weeks gestation
• Chronic lung disease of prematurity
• Hemodynamically significant congenital heart disease

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^[20]

❑ Oral oseltamivir for:

• Hospitalized patients
• Patients with severe, complicated, or progressive illness
• Patients with risk factors for complications

Cough due to Cystic fibrosis^{[21][22][23][24]}

❑ CFTR modulator such as tezacaftor-ivacaftor or lumacaftor-ivacaftor

• CFTR genotyping should be done first to determine the patient eligibility
  • Patients ≥12 years old with responsive CFTR mutations
  • Younger patients with sufficient evidence for FDA approval

❑ Metered-dose Albuterol Inhaler

❑ Hypertonic saline

❑ DNase such as dornase alfa

❑ Chest physiotherapy

❑ Exercise

❑ Aerosolized antibiotics or long-acting antiasthmatics

❑ Azithromycin

• Chronic treatment with for patients six years and older

❑

Cough due to Chronic bronchitis

protracted bacterial bronchitis

❑ Augmentin (amoxicillin and clavulanate potassium) or Omnicef (cefdinir)

❑

Cough due to Primary ciliary dyskinesia^[25][26][27] 9387968

❑ Treatment should be individualized based on the clinical course of each patient

❑ Supplemental oxygen for a few hours to days after birth for mild respiratory distress (tachypnea, mild hypoxemia)

Bronchiectasis

❑ Daily chest physiotherapy

❑ Oral antibiotics for acute exacerbation and it should be tailored based on the sputum culture results

❑ Preventive antibiotic therapy with Azithromycin may reduce the rate of exacerbations

• Do Sputum cultures prior to Azithromycin use to exclude nontuberculous mycobacteria infection
• Assess for risk of QT interval prolongation prior to Azithromycin use

❑

Cough due to Postnasal drib (Allergic Rhinitis)^[28]

❑ Antihistamines

❑ Nasal steroid sprays reduce swelling and inflammation of the nasal passages promoting proper drainage

❑ Allergy shots (immunotherapy) if no improvement

❑

Cough due to Cough variant asthma^[29]

❑ Inhaler with albuterol, ipratropium, and/or inhaled steroids

❑

Cough due to Recurrent viral bronchitis

❑ Antibiotics are not recommended except with chronic wet cough for ≥ 2-4 weeks, which could be mostly bacterial ❑ Albuterol or terbutaline inhalers ❑ corticosteroids if no improvement ❑ Stepped-up courses of inhaled corticosteroids might be effective ❑

❑

Cough due to Asthma^[30][31]

Mild, persistent asthma ❑ low-dose, daily inhaled glucocorticoids ❑ Daily leukotriene receptor antagonist (Montelukast )

• As an alternative to inhaled glucocorticoids
• Limited use due to neuropsychiatric sede effects