Congenital anomalies Cleft palate Laryngotracheomalacia Laryngeal or tracheal webs Tracheoesophageal fistula Vascular ring Pulmonary sequestration Miscellaneous Gastroesophageal reflux Congestive heart failure Swallowing dysfunction Granulomatous diseases (e.g., pulmonary tuberculosis) Vasculitis (e.g., Wegener granulomatosis) Psychogenic cough Foreign body in otic canal Medications (e.g., angiotensin-converting enzyme inhibitors) Typically, the onset of cough with rhinorrhea suggests a viral URI or bronchiolitis However, if a child with an apparent URI becomes more ill or has persistent symptoms, secondary bacterial infections in the lungs or sinuses, pertussis, as well as noninfectious etiologies should be considered TABLE 19.2 COMMON CAUSES OF COUGH Upper respiratory infection Sinusitis Laryngotracheitis (croup) Bronchiolitis Acute bronchitis Pneumonia Allergic rhinitis Reactive airway disease Expectoration of bloody sputum, or hemoptysis, poses a particular diagnostic challenge Blood-streaked sputum, particularly with fever, may suggest tracheobronchitis or pneumonia Tracheal foreign bodies may cause hemoptysis, usually associated with a preceding choking episode Hematuria associated with hemoptysis suggests a pulmonary-renal vasculitis, such as granulomatosis with polyangiitis (formerly called Wegener’s) Other easy bleeding or bruising may accompany the hemoptysis if due to a coagulopathy, such as von Willebrand disease or platelet disorders Physical Examination Patients with a cough require evaluation of the entire respiratory system Usually, the cause of the cough can be localized to the upper or lower respiratory tract based on the physical examination Physical examination should include inspection of the nares, otic canals, and oropharynx and auscultation of the chest Young infants may have respiratory distress with localized upper airway congestion, but distress in older infants and children usually signifies lower respiratory tract disease (except in the obvious case of stridor) Rhinorrhea, congestion, swollen turbinates, sinus tenderness, and pharyngitis are all signs of upper respiratory tract involvement Allergic features include boggy nasal mucosa, an allergic nasal crease, and allergic “shiners.” An otoscopic examination may reveal a small foreign body (e.g., hair) in the otic canal, which may cause chronic cough Visualizing the posterior pharynx with a tongue blade will often elicit an episode of coughing, allowing the practitioner to gauge the quality of the cough Laryngitis and/or stridor generally imply inflammation or obstruction at the level of the trachea or larynx Unequal breath sounds, wheezes, rhonchi, and rales are signs of lower respiratory tract disease Wheezing may indicate bronchiolitis, asthma, or, rarely, foreign body aspiration Patients with asthma may complain only of cough and deny any wheezing Careful auscultation during forced exhalation may detect wheezing or a prolonged expiratory phase In an older child, significant lower airway obstruction can be measured with a handheld peak flow meter Persistent asymmetric, or focal, wheezing is seen with lower airway masses and foreign bodies A careful cardiac evaluation should be performed to detect evidence of congestive heart failure, and any clubbing should be noted, as this finding is suggestive of a chronic, cyanotic condition such as cystic fibrosis TABLE 19.3 LIFE-THREATENING CAUSES OF COUGH Reactive airway disease Laryngotracheitis (croup) Bronchiolitis Foreign body Pneumonia Laryngeal edema Pertussis Toxic inhalation Congestive heart failure Bacterial tracheitis Significant pulmonary bleeding (e.g., arteriovenous malformation) FIGURE 19.1 Approach to the child with cough Ancillary Studies For most children with a cough, the history and physical examination should be sufficient to make a diagnosis The 2011 Infectious Diseases Society of America/Pediatric Infectious Diseases Society pediatric pneumonia guidelines recommend that routine chest radiographs are not necessary to confirm suspected pneumonia in children well enough to be treated in the outpatient setting (see Pneumonia, Community-Acquired Pathway, https://www.chop.edu/clinicalpathway/pneumonia-community-acquired-clinical-pathway ) These guidelines recommend anteroposterior and lateral chest radiographs in patients with hypoxia, significant respiratory distress, in those who failed initial antibiotic therapy for pneumonia, in all patients hospitalized for pneumonia, those with concern for ... sufficient to make a diagnosis The 2011 Infectious Diseases Society of America /Pediatric Infectious Diseases Society pediatric pneumonia guidelines recommend that routine chest radiographs are not