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 CAHS clinical disclaimer

Aim

To guide Emergency Department (ED) 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 tract infection (URTI)
• Adhere to standard and transmission based precautions. Refer to Standard and Transmission Based Precautions Policy – Infection Prevention and Control Manual (internal WA Health only)

Defining the spectrum of paediatric cough¹

• 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 symptoms
• Cough characteristics and typical time of day
• Recurrent acute episodes vs chronic continuous cough
• Wheeze or recurrent lower respiratory tract infections
• Symptoms of atopy, allergic rhinitis, sinusitis
• Feeding difficulties or choking episodes
• Growth and nutrition
• Neurodevelopmental problems
• Medication
• Specific features suggestive of an underlying diagnosis (see below)
• Previous treatment strategies.

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	Habit cough ('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

General and chest examination

• Vital signs (including temperature)
• Nutritional status (beware loss of muscle bulk and subcutaneous fat stores)
• Clubbing
• Cardiovascular system (beware abnormal cardiac examination)
• Chest signs: wheeze, crepitations, asymmetrical breath sounds.

Investigations

• Chest X-ray
• Spirometry (if age appropriate)
• Specimen collection – microbiology (if appropriate)

Differential diagnosis²

Acute cough

URTI - commonest cause COVID-19 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 ('Canada goose') 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 (rare)  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 Airway malformation or malacia, often with viral infection e.g. trachea-oesophageal fistula

Management²

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.
• Education - Advise of infection control precautions
• When to return to the ED and/or GP
• Avoidance of passive smoke exposure.

Management of habit cough (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.

References

1. Chang AB, Landau LI, Van Asperen PP, et al. Cough in children: definitions and clinical evaluation. Med J Aust. 2006;184(8):398-403. doi:10.5694/j.1326-5377.2006.tb00290. Available from: Cough in children: definitions and clinical evaluation | The Medical Journal of Australia (mja.com.au)
2. Irwin RS, Baumann MH, Bolser DC, et al. Diagnosis and management of cough executive summary: ACCP evidence-based clinical practice guidelines. Chest. 2006;129(1 Suppl):1S-23S. doi:10.1378/chest.129.1_suppl.1S
3. Textbook of Paediatric Emergency Medicine 3rd Edition Cameron P, Browne GJ, Mitra B, et al (2018) Publisher: Elsevier Edition updated
4. Nelson Textbook of Pediatrics: 21st Edition Robert M. Kliegman, St Geme JW, Blum MJ et al. 2020 Publisher: Elsevier

Endorsed by:	Nurse Co-director, Surgical Services	Date:	Jun 2022
		Review date:	May 2024

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