Cough

Disclaimer

These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline. 

Read the full PCH Emergency Department disclaimer.

Aim

To guide staff with the assessment and management of cough.

Key points

  • Cough may be the only presenting symptom of an underlying respiratory illness.
  • However it is most commonly caused by an upper respiratory infection (URTI).

Defining the spectrum of paediatric cough

  • On duration of cough:
    • acute cough: cough duration of < 2 weeks (usually 5-7 days)
    • protracted acute cough: cough duration between 2 and 4 weeks
    • chronic cough: cough duration of > 4 weeks
  • On likelihood of an underlying disease or process:
    • expected cough
    • specific cough
    • non-specific cough
  • On cough quality:
    • classically recognised cough
    • wet/moist or productive cough versus dry cough
    • protracted bronchitis.

General

  • Although cough is burdensome, the function of cough serves as a vital defensive mechanism for lung health
  • Cough prevents pulmonary aspiration, promotes ciliary activity and clears airway debris.

Assessment

History

  • Associated URTI symptons
  • Cough characteristics
  • Specific features suggestive of an underlying diagnosis
  • Wheeze or recurrent lower respiratory tract infections
  • Feeding difficulties
  • Medications
  • Neurodevelomental problems
  • Malnutrition
  • Failure of previous treatment.

Signs and symptoms (primarily of chronic cough)

Sign/symptom Possible Underlying aetiology
Auscultatory findings (wheeze, crepitations/crackles, differential breath sounds) Asthma, bronchiolitis, congenital lung disease, foreign body aspiration, airway abnormality
Cough characteristics (e.g. cough with choking, cough quality, cough starting from birth)
Congenital lung abnormalities

Cardiac abnormalities (including murmurs)
Any cardiac illness
Chest pain Asthma, functional, pleuritis
Chest wall deformity Any chronic lung disease
Daily moist or productive cough Chronic bronchitis, suppurative lung disease
Digital clubbing Suppurative lung disease
Dyspnoea (exertional or at rest) Compromised lung function of any lung or cardiac disease
Failure to thrive Compromised lung function, immunodeficiency, cystic fibrosis
Feeding difficulties (including choking and vomiting) Compromised lung function, primary aspiration
Haemoptysis Bronchitis
Immune deficiency Atypical and typical respiratory infections
Medications or drugs Angiotensin-converting enzyme (ACE) inhibitors, puffers, illicit drug use
Neurodevelopmental abnormality Primary and secondary aspiration 
Recurrent pneumonia Immunodeficiency, congenital lung problem, airway abnormality
Symptoms of upper respiratory tract infection May coexist or be a trigger for an underlying problem

Note: this is a non-exhaustive list; only the more common respiratory diseases are mentioned.

Examination

Classical recognised cough

Cough type Suggested underlying process
Barking or brassy cough Croup, tracheomalacia, habit cough
Honking Psychogenic
Paroxysmal (with or without respiratory 'whoop') Pertussis and parapertussis
Staccato Chlamydia in infants
Cough productive of casts Bronchitis/asthma
Chronic wet cough in mornings only Suppurative lung disease

Investigations

  • Chest X-ray
  • Spirometry (if age appropriate)

Differential diagnosis

Acute cough
  • URTI - commonest cause
  • Asthma
    • Children with asthma can present with cough
    • If absent of wheeze and/or dyspnoea on exertion, it is usually not representative of asthma
  • Viral induced wheeze
  • Croup
  • Pneumonia
  • Inhaled foreign body
  • Pertussis
  • Rhinitis
    • Cause and effect is unlikely
  • Atopy
    • The presence of atopy (positive skin prick test) does not predict the response of cough to asthma therapies
  • Psychogenic cough
    • Habit ('tic' like)
    • Bizarre honking cough
    • Symptoms typically disappear at night during sleep or when child is engrossed in activity

Chronic cough
Isolated cough, otherwise healthy child 
  • Recurrent viral bronchitis
  • Post-infectious cough
  • Pertussis-like illness
  • Cough variant asthma 
  • Postnasal drip
  • Gastro-oesophageal Reflux
    • In the absence of secondary aspiration, GOR in children rarely causes chronic cough
Isolated cough, significant underlying cause
  • Chronic suppurative lung disease
    • Cystic fibrosis
    • Immune deficiencies
    • Primary ciliary dyskinesia
    • Recurrent pulmonary aspiration
    • Retained inhaled foreign body
    • Chronic bronchitis
  • Airway lesion
    • Compression - e.g. tuberculous gland
    • Malacia, often with viral infection e.g. trachea-oesophageal fistula

Management

Management of acute cough - URTI

  • Over the counter cough and cold medications are not recommended due to lack of proven efficacy and the possibility that they may represent a safety risk
  • Education: Advise that the expected duration of cough is 5-7 days. Resolution in 90% by 1-3 weeks.
  • When to return to the ED and/or GP
  • Avoidance of passive smoke exposure.

Management of psychogenic cough

  • Treatment can range from benign neglect (shifting the focus of attention away from the symptom)
  • Hypnosis
  • Family therapy.

Management of the otherwise well child with a persistent dry non-productive cough

  • Reassurance with watchful anticipation as the cough will usually disappear in the next 4-8 weeks
  • Exposure to cigarette smoke should be removed wherever possible
  • Non-prescription cough remedies have not been shown to be efficacious
  • Cough suppressants may have side effects when given to young infant
  • It is reasonable to recommend one teaspoon of honey before bedtime for children aged over one year

Referrals and follow-up

  • Common indications for referral in chronic childhood cough:
    • Chronic cough (>4 weeks) of unclear aetiology (with or without failure to thrive)
    • Suspected airway malformation e.g. tracheo-oesophageal fistula, vascular ring
    • Cough and feeding difficulties (suspected aspiration disease)
    • Clinical features of chronic lung disease e.g. clubbing
    • Persisting auscultatory findings e.g. crepitations
    • Recurrent pneumonias
    • Abnormalities on chest X-ray or spirometry
    • Failure to respond to treatment e.g. in asthma.

Bibliography

  1. Textbook of Paediatric Emergency Medicine 2nd Edition Cameron Elesevier 2012
  2. Nelson Textbook of Pediatrics: 20th Edition Robert M. Kliegman, Bonita M.D. Stanton, Joseph St. Geme, Nina F Schor Publisher: Elsevier 
  3. Introduction to the diagnosis and management of cough: ACCP evidence-based clinical practice guidelines. Irwin RS Chest. 2006;129(1 Suppl):25S.


Endorsed by:  Director, Emergency Department  Date:  Jun 2018


 Review date:   Jun 2020


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