Abstract
Cough is one of the most common pediatric complaints with a myriad of causes. Although the etiology of cough is usually self-limited, a detailed history and physical exam can exclude other potentially dangerous conditions.
Keywords
asthma, bronchiolitis, croup, cough, pertussis, pneumonia
1
A 5-year-old boy presents to your urgent care center with a 2-day history of persistent cough, associated with fever, runny nose, and trouble breathing. What is your differential diagnosis?
Cough is one of the most common pediatric complaints with a myriad of causes ( Table 16.1 ). Although the etiology of cough is usually self-limited, a detailed history and physical exam can exclude other potentially dangerous conditions.
| Airway Neoplasm | Congenital Anomalies | Infectious Etiology | Inflammation/Irritation | OTHERS |
|---|---|---|---|---|
| Hemangioma | Cleft palate | Bronchiolitis | Allergic rhinitis | Otic foreign body |
| Lymphoma | Laryngotracheomalacia | Bronchitis | Asthma | Medications (ACE inhibitors) |
| Mediastinal tumors | Laryngeal webs | Bronchiectasis | Cystic fibrosis | Psychogenic |
| Papilloma | Pulmonary sequestration | Croup | Congestive heart failure | Swallowing dysfunction |
| Polyps | Tracheoesophageal fistula | Laryngitis | Chemical fumes/particulates | Vasculitis (Wegener granulomatosis) |
| Tracheal webs | Pleural effusion | Foreign body | Vocal cord dysfunction | |
| Vascular rings/slings | Pleuritis | Gastroesophageal reflux | ||
| Pulmonary abscess | Granulomatous disease | |||
| Tonsillitis | Smoking | |||
| Tuberculosis | ||||
| Sinusitis | ||||
| Upper respiratory infection |
2
A 10-year-old girl with a history of asthma presents to your urgent care center with shortness of breath and difficulty speaking. She is tachypneic with intercostal retractions. What is the first-line treatment for an acute exacerbation?
Acute exacerbations of asthma should be treated with systemic corticosteroids, high-dose beta agonists, and anticholinergics. Timeliness of medication administration is a key principle in management of acute asthma exacerbations as studies have shown decreased length of stay, hospitalization, and symptom scores with early administration of oral steroids such as in triage. Combined treatment regimens take several hours to reach peak effect; thus, timeliness is key ( Table 16.2 ).
| Short-Acting Beta 2 Agonists | |||
|---|---|---|---|
| Weight (kg) | Nebulizer | MDI Puffs | |
| Unit Dose (0.5%) | Continuous | ||
| <5 | 1.25 mg (0.25 mL) | 5 mg/hr | 2 |
| 5–10 | 2.5 mg (0.5 mL) | 10 mg/hr | 4 |
| 10–20 | 3.75 mg (0.75 mL) | 15 mg/hr | 6 |
| >20 | 5 mg (1 mL) | 20 mg/hr | 8 |
| Ipratropium Bromide | |||
|---|---|---|---|
| 5–10 | 250 mcg | Up to 3 doses | |
| >10 | 500 mcg | ||
| Systemic Corticosteroids | |||
|---|---|---|---|
| Prednisone (5-day course) | 2 mg/kg | Max 60 mg | po |
| Dexamethasone (x 1 dose IM, q24h x 2) | 0.6 mg/kg | Max 8–16 mg | po, IM |
3
Should I order a chest x-ray?
Chest x-rays (CXRs) are of limited use in the evaluation of a patient with asthma and rarely lead to a change in management. CXRs should be limited to cases where there is a clinical suspicion of a radiographic abnormality, such as persistent rales and asymmetry of breath sounds, high fever, crepitus in the neck, very poor response to therapy, or sudden deterioration. A CXR may be helpful in distinguishing from other causes of wheezing in early childhood ( Table 16.3 ).
| Infectious/Inflammatory | Intraluminal Obstruction | Extraluminal Obstruction |
|---|---|---|
| Bronchiolitis | Foreign body | Vascular ring/sling |
| Bronchopulmonary dysplasia | Congestive heart failure | Cystic malformation of lung |
| Cystic fibrosis | Alpha-antitrypsin deficiency | Congenital lobar emphysema |
| Pneumonia | Cholinergic poisoning | Masses (tumor, papilloma, hemangioma) |
| Aspiration (GERD, TEF) | Vocal cord dysfunction |
4
What are asthma history risk factors for high-risk/fatal asthma that I should consider when dispositioning my patient?
- •
Prior intubation or intensive care unit (ICU) admission
- •
Greater than two hospitalizations in past year
- •
Greater than three emergency department visits in past year
- •
Use of more than two beta agonist canisters per month
- •
Comorbid conditions
- •
Emergency department visit or hospitalization in past month
- •
Past history of severe sudden exacerbations
- •
Current/recent withdrawal of systemic corticosteroids
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