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APPROACH TO COUGH IN
Hamad Emad Hamad Dhuhayr
Supervised by: dr. Shahid Ghaffar
Classification of cough
Management of cough in children
Cough is a common indication of respiratory illness and is one of the more common
symptoms of children seeking medical attention.
Not only does it cause discomfort for the child, cough also elicits stress and sleepless
nights for their parents.
Before we dive into the clinical approach to cough, let us review the respiratory
physiology of cough.
Mechanics of coughing
Inspiratory phase: air inhalation lengthens the expiratory
muscles (favourable length-tension relationship).
Compressive phase: contraction of expiratory muscles
against a closed glottis leads to an increase in intrathoracic
Expiratory phase: opening of the glottis results in high
expiratory flow and audible coughs. During this phase, the
airway undergoes dynamic compression and the expulsion of
air facilitates airway debris and secretions clearance.
Each cough is elicited by the stimulation of the cough reflex arc.
Cough receptors, which are afferent endings of the vagus nerve (cranial nerve X), are
scattered in the airway mucosa and submucosa.
Some of these receptors are mechanosensitive and some are chemosensitive.
Mechanoreceptors are sensitive to touch or displacement and are located mainly in the
proximal airway such as larynx and trachea.
Chemoreceptors are sensitive to acid, heat, and capsaicin derivatives through the
activation of type 1 vanilloid receptor (TRPV1) and are located mainly in the distal
Classifications of Cough
Cough is usually classified based on its duration, quality or etiology.
They are helpful indicators to guide your differential diagnosis.
1. acute (< 2 weeks)
2. subacute (2-4 weeks)
3. chronic (> 4 weeks)
Quality: moist/wet/productive vs. dry
Etiology: specific (attributable to an underlying problem) or non-specific (absence of
Ask about the age/duration of onset (congenital cause).
Nature of cough; How long has the child been coughing for?
Chronic paroxysmal cough?
Chronic productive (wet-moist) cough?
Honking (Goose-like) sounding?
What time of the day is the cough worst?
What type of exposure triggers the cough?
What relieves the cough? Has the child been on medication before (ex.
Bronchodilators)? Did this help with the present episode?
Is there any shortness of breath (dyspnea)? Is there increased work of
Is there associated vomiting (post-tussive emesis)? Is there hemoptysis?
Is there evidence of fevers, failure to thrive or weight loss?
Is the child passively or actively exposed to smoke from tobacco, marijuana,
cocaine, or wood-burning stove?
Ask about a history of choking (suspect foreign objects in airway).
What pets or animals did the child have contact with?
Ask about prenatal and neonatal history.
Is there a family history of atopy (eczema, allergies, asthma), cystic fibrosis,
and/or primary ciliary dyskinesia?
During the physical examination, you should pay attention
to the following signs:
Vital signs, including O2 saturation.
Growth parameters – signs of poor growth and/or failure to thrive.
Assess work of breathing.
If patient able, listen to their cough.
Inspect chest wall for signs of hyperinflation and deformities.
General inspection for stigmata of chronic disease.
Examine for nasal polyps and other nasal passage obstruction.
Auscultate: is air entry symmetric? Are there adventitious sounds? Describe
its location and quality (crackles, crepitations, wheeze)
Auscultate for heart sounds.
Examine for edema, cyanosis, clubbing of fingers/toes, and skin lesions.
Chest radiograph can provide
you with additional
information, such as
atelectasis and chronic lung
Pulmonary Function Test
Can help delineate
obstructive vs. restrictive
Required in the diagnosis of
asthma (child must be
>6yo and cooperative)
Useful if suspicion for foreign body is high.
Mantoux Testing (Tuberculin Skin Test)
To screen for tuberculosis infection.
Management of cough in children
The goal should always be to identify an underlying cause of cough in children.
In the majority of children presenting with cough, the etiology is related to URTI and
requires only supportive measures (e.g., antipyretics, good hydration, and saline
Over-the-counter antitussives, antihistamines and decongestants are as effective as
placebo for acute cough and have the potential to cause adverse effects; thus, they
should be avoided in children less than 2 years of age. Intranasal steroids can be
effective in children with allergic rhinitis presenting with cough during pollen season.
Bronchodilators are not effective and should be avoided in non-asthmatic children
presenting with acute cough.
Antibiotics are generally not effective and should be avoided in children presenting
with acute cough caused by viral URTI. When pertussis infection is diagnosed,
macrolide antibiotics should be prescribed early (1–2 weeks of illness).
Specific causes of acute cough (e.g., asthma, bronchiolitis, croup, and community-
acquired pneumonia) should be managed based on the evidence-based guidelines
specific for such entities.
Honey products are a natural and safe therapeutic option with a slight effect that can
be considered for acute cough following URTI in children greater than 2 years of age.
Parental and community education is indicted to increase the awareness of the natural
course and supportive measures for acute cough caused by URTI in young children.
Children with cough should be managed according to child-specific
guidelines, which are different from adult guidelines. Treatment of cough
in children should be based on the cough's underlying etiology.
Pediatric cough is commonly encountered by primary care physicians
and allergists. Physicians should be aware of the various potential causes
of cough in children to properly determine the cause so that testing and
treatment can proceed appropriately.
ICS are effective in improving asthma-like symptom burden,
exacerbations, and lung function in high risk toddlers.