Pediatric emergency medicine trisk 122

complications of pneumonia, such as empyema or abscess, and in those in whom
the diagnosis is in question. A chest radiograph is also warranted in patients with
unexplained cough, or significant or persistent pulmonary signs. In children with
an uncomplicated exacerbation of their asthma, a radiograph is unnecessary.
Inspiratory and expiratory or decubitus films have traditionally been
recommended if a radiolucent foreign body is suspected; however, these studies
have been found to have only fair-to-moderate sensitivity and specificity and thus
their clinical utility is unknown. If the suspicion for aspiration is high based on
history and examination, bronchoscopy may be warranted without additional
imaging beyond standard radiographs to identify radiopaque foreign bodies (see
Chapter 32 Foreign Body: Ingestion and Aspiration ). All patients with
hemoptysis should have chest radiographs performed. Chest computed
tomography is indicated in patients with persistent or moderate-to-severe
hemoptysis, particularly if chest radiographs are normal. Other studies that could
be useful in selected patients include lateral neck radiographs, barium swallow,
and computed tomography of the sinuses, neck, or chest.
Laboratory testing for a patient presenting to the emergency department with
cough is not routinely warranted, though may be useful or necessary for specific
diagnoses. In the case of pneumonia, blood cultures should only be obtained in
those hospitalized with moderate-to-severe disease, complicated pneumonia,
failure to improve after 48 to 72 hours of antibiotic therapy, immunosuppressed
patients or those with indwelling catheters with fever (see Pneumonia,
Community-Acquired
Pathway,
). Additional tests for
use in specific circumstances include a complete blood count and differential,
tuberculin test, nasopharyngeal swab for rapid assays (commonly respiratory
syncytial virus, and influenza), pertussis testing, and sputum culture and Gram
stain (neutrophils and gram-positive diplococci with pneumococcal pneumonia)
in those old enough to produce an adequate sample. Pulmonary function testing
can be useful to diagnose or follow obstructive airway disease. In cases of airway

masses, airway anomalies, foreign bodies, or atypical pneumonias, bronchoscopy
may be necessary.

Approach
The magnitude of a child’s respiratory distress is the most immediate concern for
any child who presents with cough. Any child with significant respiratory distress
needs immediate attention to address their oxygenation and ventilation. If not in
significant distress, the next consideration is whether the onset of the cough is
acute or chronic. If acute in onset, the major considerations in the evaluation, as


alluded to above, include the quality of the cough (e.g., paroxysmal, barking),
associated stridor, associated choking or emesis, and the findings of lower
respiratory tract signs or fever ( Fig. 19.1 ). Most patients with cough of acute
onset will have a simple URI, asthma, bronchiolitis, or pneumonia. Although
rales, decreased breath sounds, or focal wheezing are signs associated with
pneumonia, some patients with pneumonia may not have any findings by
auscultation. Therefore, in cases of significant cough, especially in very young
children and those with high fever or elevated white blood cell counts, a chest
radiograph may be useful to exclude the diagnosis of pneumonia.
Children with chronic cough are likely to have reactive airway disease, allergic
rhinitis, or sinusitis. In young children with failure to thrive or recurrent
pulmonary infections, cystic fibrosis (see Chapter 99 Pulmonary Emergencies )
should be considered. Chronic cough with a history of recurrent pneumonias or
chronic bronchitis can also be suggestive of immunodeficiency or anatomic
lesions (see Chapters 99 Pulmonary Emergencies , 124 Thoracic Emergencies ).
Choking with feeding or emesis followed by cough or wheezing in young infants
is typical of gastroesophageal reflux. Newborns who exhibit a cough deserve
special consideration for airway anomalies, atypical pneumonias, and congestive
heart failure (see Chapters 94 Infectious Disease Emergencies , 99 Pulmonary

Emergencies , and 118 ENT Emergencies ). Persistent cough during the day that
stops with distraction or sleep is supportive of a psychogenic cause.

TREATMENT
The primary goal should be to treat the underlying process rather than to attempt
to suppress the cough. Patients with any distress or hypoxia need supplemental
oxygen and immediate assessment of the airway and breathing. Wheezing from
asthma is primarily treated with inhaled beta-2 agonists (see Asthma, Emergent
Care Pathway , Chapter 84 Wheezing , and Chapter 99 Pulmonary
Emergencies ). The treatment for bronchiolitis is mainly supportive, including
nasal suctioning, ensuring hydration, and providing supplemental oxygen as
needed. The 2014 American Academy of Pediatrics Clinical Practice Guideline
for bronchiolitis recommends against a trial of a bronchodilator in infants with
bronchiolitis. However, a carefully monitored trial of a bronchodilator may be
beneficial in some infants but should always be accompanied by an objective
assessment of response after administration. If there is no improvement, these
agents should be stopped (see Bronchiolitis, Emergent Evaluation Pathway
/>

clinical-pathway ). In children with suspected reactive airway disease based on
history alone, a trial of bronchodilator therapy is warranted. Follow-up with the
primary care physician is crucial for establishing an ongoing treatment plan.
Children with suspected foreign bodies or airway masses (intrinsic or extrinsic to
the airway) need appropriate intervention for diagnosis and removal. Croup
treatment consists of corticosteroid therapy in all cases, and the addition of
racemic epinephrine and oxygen for more severe episodes with stridor at rest or
significant respiratory distress (see Chapters 75 Stridor , 94 Infectious Disease
Emergencies ). Treatment of pneumonia depends on the age and suspected
pathogen
(see

Pneumonia,
Community-Acquired
Pathway
and Chapter 94 Infectious Disease Emergencies ). Patients with pertussis
require antibiotics for eradication of the organism, and young infants or any child
with significant paroxysms need hospitalization. Patients with recurrent or
moderate-to-severe hemoptysis require attention to airway, breathing, and
circulation first and foremost. Timely consultation with otolaryngology and
pulmonology is warranted to assist in medical and procedural treatment of
persistent bleeding.
Antitussive medications have limited value and should not be used routinely in
young infants. It is better to give specific therapy (e.g., bronchodilators in asthma,
antibiotics in sinusitis) and avoid suppressing a cough in conditions with
increased sputum production (e.g., asthma, pneumonia). In children older than 1
year of age, honey may be a useful treatment for symptomatic relief of acute
cough. In older children with a nonproductive cough that interrupts sleep,
antitussives can be prescribed. Using cool mist humidifiers, elevating the head
during sleep and suctioning the nares with nasal saline spray in infants can be
beneficial for coughs associated with viral URIs.
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