Pediatric emergency medicine trisk 121

Congenital anomalies
Cleft palate
Laryngotracheomalacia
Laryngeal or tracheal webs
Tracheoesophageal fistula
Vascular ring
Pulmonary sequestration
Miscellaneous
Gastroesophageal reflux
Congestive heart failure
Swallowing dysfunction
Granulomatous diseases (e.g., pulmonary tuberculosis)
Vasculitis (e.g., Wegener granulomatosis)
Psychogenic cough
Foreign body in otic canal
Medications (e.g., angiotensin-converting enzyme inhibitors)
Typically, the onset of cough with rhinorrhea suggests a viral URI or
bronchiolitis. However, if a child with an apparent URI becomes more ill or has
persistent symptoms, secondary bacterial infections in the lungs or sinuses,
pertussis, as well as noninfectious etiologies should be considered.
TABLE 19.2
COMMON CAUSES OF COUGH
Upper respiratory infection
Sinusitis
Laryngotracheitis (croup)
Bronchiolitis
Acute bronchitis
Pneumonia
Allergic rhinitis
Reactive airway disease

Expectoration of bloody sputum, or hemoptysis, poses a particular diagnostic
challenge. Blood-streaked sputum, particularly with fever, may suggest
tracheobronchitis or pneumonia. Tracheal foreign bodies may cause hemoptysis,
usually associated with a preceding choking episode. Hematuria associated with
hemoptysis suggests a pulmonary-renal vasculitis, such as granulomatosis with
polyangiitis (formerly called Wegener’s). Other easy bleeding or bruising may
accompany the hemoptysis if due to a coagulopathy, such as von Willebrand
disease or platelet disorders.

Physical Examination
Patients with a cough require evaluation of the entire respiratory system. Usually,
the cause of the cough can be localized to the upper or lower respiratory tract
based on the physical examination. Physical examination should include
inspection of the nares, otic canals, and oropharynx and auscultation of the chest.
Young infants may have respiratory distress with localized upper airway
congestion, but distress in older infants and children usually signifies lower
respiratory tract disease (except in the obvious case of stridor). Rhinorrhea,
congestion, swollen turbinates, sinus tenderness, and pharyngitis are all signs of
upper respiratory tract involvement. Allergic features include boggy nasal
mucosa, an allergic nasal crease, and allergic “shiners.” An otoscopic
examination may reveal a small foreign body (e.g., hair) in the otic canal, which
may cause chronic cough. Visualizing the posterior pharynx with a tongue blade
will often elicit an episode of coughing, allowing the practitioner to gauge the
quality of the cough. Laryngitis and/or stridor generally imply inflammation or
obstruction at the level of the trachea or larynx. Unequal breath sounds, wheezes,
rhonchi, and rales are signs of lower respiratory tract disease. Wheezing may
indicate bronchiolitis, asthma, or, rarely, foreign body aspiration. Patients with
asthma may complain only of cough and deny any wheezing. Careful auscultation
during forced exhalation may detect wheezing or a prolonged expiratory phase. In

an older child, significant lower airway obstruction can be measured with a
handheld peak flow meter. Persistent asymmetric, or focal, wheezing is seen with
lower airway masses and foreign bodies. A careful cardiac evaluation should be
performed to detect evidence of congestive heart failure, and any clubbing should
be noted, as this finding is suggestive of a chronic, cyanotic condition such as
cystic fibrosis.


TABLE 19.3
LIFE-THREATENING CAUSES OF COUGH
Reactive airway disease
Laryngotracheitis (croup)
Bronchiolitis
Foreign body
Pneumonia
Laryngeal edema
Pertussis
Toxic inhalation
Congestive heart failure
Bacterial tracheitis
Significant pulmonary bleeding (e.g., arteriovenous malformation)


FIGURE 19.1 Approach to the child with cough.

Ancillary Studies
For most children with a cough, the history and physical examination should be
sufficient to make a diagnosis. The 2011 Infectious Diseases Society of
America/Pediatric Infectious Diseases Society pediatric pneumonia guidelines
recommend that routine chest radiographs are not necessary to confirm suspected

pneumonia in children well enough to be treated in the outpatient setting (see
Pneumonia, Community-Acquired Pathway, ). These guidelines
recommend anteroposterior and lateral chest radiographs in patients with hypoxia,
significant respiratory distress, in those who failed initial antibiotic therapy for
pneumonia, in all patients hospitalized for pneumonia, those with concern for