OK, so this is a newer one for me, it was certainly not a diagnosis I made during training. However, in the ED you will most certainly see children with persistent cough. Many referrals to pulmonary medicine for instance are for ongoing cough. Though this entity exists, and you may encounter it there are several important caveats in the ED setting that you should be mindful of.
What causes it? How do we treat it?
H. influenzae, Streptococcus pneumoniae, and Moraxella catarrhalis. These are the organisms that also cause community acquired pneumonia and acute otitis media of course. This illness, in some form or another has mainly received attention in cystic fibrosis. The airways have their own microbiome, and more recently attention has been turned towards children with no previous medical problems and the management of chronic cough.
The antibiotic choices are similar to community acquired pneumonia. Think amoxicillin, amoxicillin/clavulanate, cefdinir etc,. Treatment is two weeks initially.
What are the main clinical criteria?
- Wet cough of at least four weeks’ duration
- No other cause suspected based on signs and symptoms
- The child has normal spirometry and chest X-Ray
- Resolution of the cough following a two week course of antibiotics
Ok, so wait – some of those criteria aren’t applicable to the ED. Namely, spirometry and resolution following two-weeks of antibiotics. Bronchoscopy is not required, but generally mucopurulent discharge is seen, and cultures grow the above organisms.
So why don’t we just start every kid with four weeks of cough on antibiotics? Let’s take a step back for a moment before everyone gets prescribed augmentin forever.
How should we approach chronic cough?
Take a good history and think about the following:
- Have they actually been coughing every day for four weeks? Like really every day? Is it more at night? Was this just two URIs in a row which totally happens all the time.
- Is there any wheezing or more prominent nighttime cough. Is there also a history of eczema or allergies. Could this actually be asthma?
- Was there a choking event? Even a few weeks back. Airway foreign bodies are super common actually. Get a decubitus film along with your chest X-Ray looking for air trapping.
- Is this a little infant who coughs a lot? Do they have other reflux symptoms? Could this be an H-Type TEF?
- Are there any other markers of chronic disease or immunodeficiency to worry about? If the child has had recurrent pneumonia in a single lobe then congenital malformations should be suspected.
- Where doe they live? Should you be worried about Histoplasmosis, like in the Ohio and Mississippi River valleys in the US. Coccidiomycosis is endemic in the Southwestern US.
OK, so wait, is this is real thing or not?
Yes, it is. But, I think at this point, in the ED at least the considerations for antibiotic stewardship win out. Unless you can say absolutely, positively YES to each of the diagnostic criteria I wouldn’t make a presumptive diagnosis of protracted bacterial bronchitis on an otherwise normal kid and start antibiotics. It is far more likely that it is actually just two Uris in a row, or another cause. However, chronic cough, especially when you consider the possibility of asthma or foreign bodies definitely needs further workup, which you should discuss with the family, the primary care team, and strongly consider a referral to Pulmonary Medicine.
