compression of the trachea (vascular ring, tumor), or laryngeal pathology (papilloma, hemangioma) EVALUATION AND DECISION The history and physical examination are the keys to establishing a diagnosis in a patient with cough The first priority is to recognize and treat any life-threatening conditions Patients with significant respiratory distress should receive supplemental oxygen and rapid assessment of their airway and breathing ( Fig 19.1 ) History Cough can occur as an acute or chronic symptom, depending on the underlying process Most common and serious causes of cough have an acute onset ( Fig 19.1 ) Certain conditions, such as asthma, may present with an acute or a chronic history of cough The relationship of the cough to other factors is helpful Cough in the neonate must raise the possibility of congenital anomalies, gastroesophageal reflux, congestive heart failure, and atypical pneumonia (e.g., Chlamydia ) If the cough began with other upper respiratory tract symptoms or fever, an infectious cause is likely A cough that started with a choking or gagging episode, especially in an older infant or toddler, suggests a foreign body aspiration (see Chapter 32 Foreign Body: Ingestion and Aspiration ) Concern for button battery and peanut aspirations require emergent evaluation and removal when present Cough associated with exercise or cold exposure, even in the absence of wheezing, may be a sign of reactive airway disease A primarily nocturnal cough often stems from allergy, sinusitis, or reactive airway disease Systemic complaints should also be considered in patients with a cough: headache, fever, facial pain or pressure (sinusitis), acute dyspnea (asthma, pneumonia, cardiac disease), chest pain (asthma, pleuritis, pneumonia), dysphagia (esophageal or pharyngeal foreign body), dysphonia (laryngeal edema or tracheal mass), or weight loss (malignancy or tuberculosis) The quality of the cough may also be helpful in determining etiology A barking, seal-like cough, with or without stridor, supports the diagnosis of laryngotracheitis (croup) A paroxysmal cough associated with an inspiratory “whoop,” cyanosis, or apnea is characteristic of pertussis Infants younger than months of age with pertussis may present with severe cough, poor feeding, apnea, or bradycardia without the classic paroxysms of cough or “whoop.” Tracheitis gives a deep “brassy” cough, whereas conditions accompanied by wheezing (asthma or bronchiolitis) typically produce a high-pitched “tight” (often termed bronchospastic ) cough Vocal cord dysfunction can result in cough and audible wheeze that may mimic asthma and should be considered in older children and adolescents with multiple cough and wheezing episodes that not respond to repeated courses of standard asthma therapy Determining whether a cough is productive can be difficult in young children who often swallow, rather than expectorate, their sputum Although a productive-sounding cough may be seen with uncomplicated URIs, sinusitis and lower respiratory tract infections are more commonly accompanied by a productive cough Contrary to popular belief, the color of expectorated sputum does not necessarily indicate infectious or bacterial etiology TABLE 19.1 CAUSES OF COUGH IN CHILDREN Infection Upper respiratory infection Sinusitis Tonsillitis Laryngitis Laryngotracheitis (croup) Tracheitis/tracheobronchitis Bronchiolitis Acute bronchitis Pneumonia/empyema Pleuritis/pleural effusion Bronchiectasis/pulmonary abscess Inflammation/allergy Allergic rhinitis Laryngeal edema Reactive airway disease Chronic bronchitis Cystic fibrosis Vocal cord dysfunction Mechanical or chemical irritation Foreign body aspiration Neck/chest trauma Chemical fumes Inhaled particulates Smoking Neoplasm Pharyngeal or nasal polyp Hemangioma of the larynx or trachea Papilloma of the larynx or trachea Lymphoma compressing airway Mediastinal tumors