Cough

Introduction

Chronic cough is defined as a daily cough that persists for more than 4 weeks^1,2. It is important to differentiate between a chronic cough and recurrent cough from serial respiratory tract infections. Chronic cough should prompt further assessment to establish the underlying diagnosis.

Please refer to Health Pathways-Persistent Cough in Children for more information³.

Assessment

• Age-appropriate cough history including:
  • Onset
  • Quality (in particular “dry” vs “wet” cough)
  • Pattern
  • Triggers
  • Associated features of concern (e.g. dyspnoea, haemoptysis, poor growth, reduced exercise tolerance, swallowing difficulties and choking history)
• Other related factors including:
  • Atopy
  • Relevant family history
  • Environmental factors (including tobacco smoke exposure)
  • Perinatal factors (e.g. prematurity, neonatal respiratory distress)
• Explore parental concerns and expectations.
• Features of concern on physical examination including:
  • Auscultatory findings (e.g. persistent wheeze or crepitations, differential breath sounds)
  • Digital clubbing
  • Chest wall deformity (e.g. asymmetrical chest wall, pectus carinatum)

Specific Features of Concern

• Presence of specific cough pointers may indicate aetiology of chronic cough – refer to the following table²:

Broad differential diagnoses (list not exhaustive):

• Dry cough
  • Prolonged post-infectious cough (consider pertussis or mycoplasma)
  • Asthma (unlikely if no wheeze or dyspnoea)
  • Rhinitis or rhinosinusitis
  • Somatic cough disorder or tic cough
• Moist cough
  • Protracted bacterial bronchitis (PBB), the most common cause of chronic wet cough in children
  • Aspiration syndromes including foreign body inhalation and chronic/feed-related aspiration
  • Cystic fibrosis
  • Bronchiectasis

Pre-referral investigations

• Chest x-ray
• Spirometry if able (consider in children aged > 6years)
  • Direct referral for spirometry only at PCH Respiratory Laboratory without clinical review is available
    • Email a referral request to: RespiratoryLaboratory.PMH@health.wa.gov.au or contact 6456 4227
• Sputum culture in children with wet cough, who can produce a sample

Pre-referral management

• If suspected PBB (chronic wet cough with no pointers to alternative diagnosis):

• Treat with a 2 to 4-week course of oral antibiotics until resolution of wet cough.
• Suggest empirical treatment with broad spectrum antibiotic such as amoxicillin/clavulanic acid 25mg/kg (max 875mg amoxicillin component) twice a day
• If penicillin-allergic, consider azithromycin or co-trimoxazole
• Refer if chronic wet cough does not resolve with antibiotic treatment or recurs

• If suspected asthma:

• Manage as per Australian Asthma Handbook⁴.

• If non-specific dry cough with normal chest x-ray +/- spirometry and no cough pointers, it may be appropriate to adopt a watchful waiting approach. Evaluate exposure to tobacco smoke and other pollutants, as well as reviewing parental expectations and concerns.

• Consider blood tests for respiratory serology (pertussis and mycoplasma) and screening for immunodeficiency and/or atopy
• If dry cough persists after another 2-4 weeks, consider trial of therapy with inhaled corticosteroids (e.g. fluticasone propionate 100mcg twice a day)

When to refer

• When pointers (see Table 1) indicate underlying disease
• Recurrent (3 or more) episodes of PBB or pneumonia
• Suspected PBB with wet cough not responding to prolonged 4-week course of oral antibiotics
• Suspected aspiration, cystic fibrosis, or bronchiectasis
• Refractory asthma
• Non-resolution of a non-specific cough
• Failure to thrive with potential respiratory cause
• Persistent crepitations +/- dyspnoea
• Presence of specific cough pointers
• Significant and persistent abnormalities in chest x-ray and/or spirometry

If significant concerns such as hypoxia or suspected inhaled foreign body, please discuss with the on-call PCH Respiratory team and place urgent referral, as child likely to require same-day review.

How to refer

• Routine non-urgent referrals from a GP or a Consultant are made via the Central Referral Service
• Routine non-urgent referrals from private hospitals are made via the PCH Referral Office (Fax: 6456 0097 or email PCH.Referrals@health.wa.gov.au)
• Urgent referrals (less than seven days) are made via the PCH Referral Office. Please call Perth Children’s Hospital Switch on 6456222 to discuss referral with Respiratory doctor on-call.

Essential information to include in your referral

• Detailed medical history including concerning features on history and examination
• Previous treatment and response
• Results of chest x-ray, spirometry and/or any blood tests

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