Pediatric emergency medicine trisk 120

compression of the trachea (vascular ring, tumor), or laryngeal pathology
(papilloma, hemangioma).

EVALUATION AND DECISION
The history and physical examination are the keys to establishing a diagnosis in a
patient with cough. The first priority is to recognize and treat any life-threatening
conditions. Patients with significant respiratory distress should receive
supplemental oxygen and rapid assessment of their airway and breathing ( Fig.
19.1 ).

History
Cough can occur as an acute or chronic symptom, depending on the underlying
process. Most common and serious causes of cough have an acute onset ( Fig.
19.1 ). Certain conditions, such as asthma, may present with an acute or a chronic
history of cough.
The relationship of the cough to other factors is helpful. Cough in the neonate
must raise the possibility of congenital anomalies, gastroesophageal reflux,
congestive heart failure, and atypical pneumonia (e.g., Chlamydia ). If the cough
began with other upper respiratory tract symptoms or fever, an infectious cause is
likely. A cough that started with a choking or gagging episode, especially in an
older infant or toddler, suggests a foreign body aspiration (see Chapter 32 Foreign
Body: Ingestion and Aspiration ). Concern for button battery and peanut
aspirations require emergent evaluation and removal when present. Cough
associated with exercise or cold exposure, even in the absence of wheezing, may
be a sign of reactive airway disease. A primarily nocturnal cough often stems
from allergy, sinusitis, or reactive airway disease. Systemic complaints should
also be considered in patients with a cough: headache, fever, facial pain or
pressure (sinusitis), acute dyspnea (asthma, pneumonia, cardiac disease), chest
pain (asthma, pleuritis, pneumonia), dysphagia (esophageal or pharyngeal foreign
body), dysphonia (laryngeal edema or tracheal mass), or weight loss (malignancy
or tuberculosis).

The quality of the cough may also be helpful in determining etiology. A
barking, seal-like cough, with or without stridor, supports the diagnosis of
laryngotracheitis (croup). A paroxysmal cough associated with an inspiratory
“whoop,” cyanosis, or apnea is characteristic of pertussis. Infants younger than 6
months of age with pertussis may present with severe cough, poor feeding, apnea,
or bradycardia without the classic paroxysms of cough or “whoop.” Tracheitis
gives a deep “brassy” cough, whereas conditions accompanied by wheezing
(asthma or bronchiolitis) typically produce a high-pitched “tight” (often termed


bronchospastic ) cough. Vocal cord dysfunction can result in cough and audible
wheeze that may mimic asthma and should be considered in older children and
adolescents with multiple cough and wheezing episodes that do not respond to
repeated courses of standard asthma therapy. Determining whether a cough is
productive can be difficult in young children who often swallow, rather than
expectorate, their sputum. Although a productive-sounding cough may be seen
with uncomplicated URIs, sinusitis and lower respiratory tract infections are more
commonly accompanied by a productive cough. Contrary to popular belief, the
color of expectorated sputum does not necessarily indicate infectious or bacterial
etiology.


TABLE 19.1
CAUSES OF COUGH IN CHILDREN


Infection
Upper respiratory infection
Sinusitis
Tonsillitis

Laryngitis
Laryngotracheitis (croup)
Tracheitis/tracheobronchitis
Bronchiolitis
Acute bronchitis
Pneumonia/empyema
Pleuritis/pleural effusion
Bronchiectasis/pulmonary abscess
Inflammation/allergy
Allergic rhinitis
Laryngeal edema
Reactive airway disease
Chronic bronchitis
Cystic fibrosis
Vocal cord dysfunction
Mechanical or chemical irritation
Foreign body aspiration
Neck/chest trauma
Chemical fumes
Inhaled particulates
Smoking
Neoplasm
Pharyngeal or nasal polyp
Hemangioma of the larynx or trachea
Papilloma of the larynx or trachea
Lymphoma compressing airway
Mediastinal tumors