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Adherence to empiric therapies urged for treating chronic cough
AAP 2011 National Conference
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BOSTON — Most children with persistent cough are suffering from a respiratory infection, but those infections may not be serious, according to a presentation here at the American Academy of Pediatrics 2011 National Conference and Exhibition.
Frank S. Virant, MD, chief of the Allergy Department at Seattle Children’s Hospital and partner in the Northwest Asthma & Allergy Center, provided a broad overview of cough-related strategies and treatments. He divided coughs into normal and abnormal cough categories, and raised five key questions about abnormal coughs:
- How long has the child coughed?
- What is the character of the cough?
- Is the cough wet or dry?
- Is the cough nocturnal?
- How old is the child?
Virant defined an acute cough as lasting less than 3 weeks, a subacute cough as lasting between 3 and 8 weeks, and a chronic cough as lasting more than 8 weeks.
“Most acute and many subacute coughs are associated with viral upper respiratory infections,” Virant said. “Sinusitis should be considered a subacute cough if it is associated with significant nasal congestion, nocturnal cough and coughing to the point of vomiting.”
Regarding the character of the cough, Virant said that a barking cough may be a sign of pertussis, and a wet cough may be a sign of sinusitis, bronchitis or pneumonia. He noted that a wet cough may be “productive,” but was typically linked to infection.
“A wet cough is unusual in uncomplicated asthma,” he said. “If refractory purulent sputum is present, it may be a sign of cystic fibrosis, bronchiectasis or ciliary dysmotility.”
If the cough worsens at night, it may indicate rhinitis or sinusitis, and is also typical for asthma.
“If the cough is suppressed at night, it may be a habitual cough,” Virant said.
An abnormal cough in an infant or a young child may be linked to an anatomic abnormality in the upper or lower respiratory tract, or the gastrointestinal tract, according to Virant. Foreign body aspiration also should be considered in these instances.
Virant outlined empiric treatments for asthma, allergic rhinitis, chronic sinusitis, GERD, protracted bacterial bronchitis and upper airway cough syndrome, and then offered some general perspectives on approaching coughs.
“For a non-specific cough, you should try to watch and wait for 2 to 3 more weeks if you can get away with it,” Virant said. “In general, empiric antibiotics should be used for a wet cough and empiric inhaled corticosteroids should be used for a dry cough.”
Virant reminded the audience that amoxicillin clavulanate and cefdinir are recommended for sinusitis and bronchitis; moderate doses of inhaled corticosteroids are recommended for asthma-related coughs; and that antihistamines or immunotherapy are recommended for allergy-related coughs.
“H2 agonists, prokinetics or proton pump inhibitors may be helpful for GERD,” Virant said. “For coughs lasting longer than 8 weeks, chest or sinus imaging may be considered. If the child is able, spirometry also may be considered.” — by Rob Volansky
Disclosure: Dr. Virant reports doing clinical research for Alcon Labs, ALK Abello, Allergy Therapeutics, AstraZeneca, Boehringer Ingelheim, Ception, Dey, Genentech, GlaxoSmithKline, Icagen, MAP, Merck and Novartis; he reports being a consultant for AstraZeneca, GlaxoSmithKline and Sanofi Aventis; and he reports being a speaker for Alcon Labs, AstraZeneca, Genentech, GlaxoSmithKline, Merck, Novartis, Sanofi Aventis and Teva.
For more information:
- Virant FS. #X1008. Approach to the child with chronic cough. Presented at: AAP 2011 National Conference and Exhibition. Oct. 15-18, 2011; Boston.
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