Деякі причини кашлю у дітей

Cause

Suggestive Findings

Diagnostic Approach

Acute

Bacterial tracheitis (rare)

URI-like prodrome, stridor, barky cough, high fever, respiratory distress, toxic appearance, purulent secretions

Anteroposterior and lateral neck x-rays

Possibly bronchoscopy

Bronchiolitis

Rhinorrhea, tachypnea, wheezing, crackles, retractions, nasal flaring, possible posttussive emesis

In infants up to 24 months; most common among those 3–6 months

Clinical evaluation

Sometimes chest x-ray

Sometimes nasal swab for rapid viral antigen or PCR assays or viral culture

COVID-19

Fever, nasal congestion and rhinorrhea, sore throat, chest tightness, tachypnea, wheezing, crackles, hypoxia

Clinical evaluation

Rapid viral antigen or PCR testing

Sometimes chest x-ray

Croup

URI-like prodrome, barky cough (worsening at night), stridor, nasal flaring, retractions, tachypnea

Clinical evaluation

Sometimes anteroposterior and lateral neck x-rays

Environmental pulmonary toxicants

Exposure to tobacco smoke, perfume, or ambient pollutants

Clinical evaluation

Epiglottitis (rare)

Abrupt onset, high fever, irritability, marked anxiety, stridor, respiratory distress, drooling, toxic appearance

If patient is stable and clinical suspicion is low, lateral neck x-ray

Otherwise, examination in operating room with direct laryngoscopy

Foreign body

Sudden onset of cough and/or choking

No fever initially

No URI prodrome

Chest x-ray (inspiratory and expiratory views)

Sometimes bronchoscopy

Pneumonia (viral, bacterial)

Viral: URI prodrome, fever, wheezing, staccato-like or paroxysmal cough, possible muscle soreness or pleuritic chest pain

Possible increased work of breathing, diffuse crackles, rhonchi, or wheezing

Bacterial: Fever, ill appearance, chest pain, shortness of breath, possible stomach pain or vomiting

Signs of focal consolidation including localized crackles, rhonchi, decreased breath sounds, egophony, and dullness to percussion

Chest x-ray

Sinusitis

Coughing at the beginning of sleep or in the morning with waking

Sometimes nasal discharge, congestion; pain on either side of the nose; pain in the forehead, upper jaw, teeth, or between the eyes; headache and sore throat

Clinical evaluation

Sometimes CT

URI

Rhinorrhea, red swollen nasal mucosa, possible fever and sore throat, shotty cervical adenopathy (many small nontender nodes)

Clinical evaluation

Chronic*

Airway lesions (tracheomalacia, tracheoesophageal fistula)

Tracheomalacia: Congenital stridor or barky cough, possible respiratory distress

Tracheoesophageal fistula: History of polyhydramnios (if accompanied by esophageal atresia), cough or respiratory distress with feeding, recurrent pneumonia

Tracheomalacia: Airway fluoroscopy and/or bronchoscopy

Tracheoesophageal fistula: Attempt passage of a catheter into the stomach (helps in diagnosis of tracheoesophageal fistula with esophageal atresia)

Chest x-ray

Contrast swallowing study, including esophagography

Bronchoscopy and endoscopy

Asthma

Intermittent episodes of cough with exercise, allergens, weather changes, or URIs

Nighttime cough

Family history of asthma

History of eczema or allergic rhinitis

Clinical evaluation

Trial of asthma drugs

Pulmonary function tests

Atypical pneumonia (mycoplasma, Chlamydia)

Gradual onset of illness

Headache, malaise, muscle soreness

Possible ear pain, rhinitis, and sore throat

Possible wheezing and crackles

Persistent staccato cough

Chest x-ray

Polymerase chain reaction testing

Birth defects of the lungs (eg, congenital adenomatoid malformation)

Several episodes of pneumonia in the same part of the lungs

Chest x-ray

Sometimes CT or MRI

Cystic fibrosis

History of meconium ileus, recurrent pneumonia or wheezing, failure to thrive, foul-smelling stools, clubbing or cyanosis of nail beds

Sweat chloride test

Molecular diagnosis with direct mutation analysis

Foreign body

History of acute onset of cough and choking followed by a period of persistent cough

Possible development of fever

No URI prodrome

Presence of small objects or toys near child

Chest x-ray (inspiratory and expiratory views)

Bronchoscopy

Gastroesophageal reflux

Infants and toddlers: History of spitting up after feedings, irritability with feeding, stiffening and arching of the back (Sandifer syndrome), failure to thrive, recurrent wheezing or pneumonia (see Gastroesophageal Reflux in Infants)

Older children and adolescents: Chest pain or heartburn after meals and lying down, nighttime cough, wheezing, hoarseness, halitosis, water brash, nausea, abdominal pain, regurgitation (see Gastroesophageal Reflux Disease)

Infants: Clinical evaluation

Sometimes upper gastrointestinal study for determination of anatomy

Trial of H2 blockers or a proton pump inhibitor

Possible esophageal pH or impedance probe study

Older children: Clinical evaluation

Trial of H2 blockers or proton pump inhibitors

Possible endoscopy

Pertussis or parapertussis

1–2 weeks catarrhal phase of mild URI symptoms, progression to paroxysmal cough, difficulty eating, apneic episodes in infants, inspiratory whoop in older children, posttussive emesis

Intranasal specimen for bacterial culture and polymerase chain reaction testing

Allergic rhinitis with postnasal drip

Headache, itchy eyes, sore throat, pale nasal turbinates, cobblestoning of posterior oropharynx, history of allergies, nighttime cough

Trial of antihistamine and/or intranasal corticosteroids

Possible trial of a leukotriene inhibitor

Postrespiratory tract infection

History of respiratory infection followed by a persistent, staccato cough

Clinical evaluation

Primary ciliary dyskinesia

History of repeated upper (otitis media, sinusitis) and lower (pneumonia) respiratory tract infections

Chest x-ray

Sinus x-ray or CT

Chest CT

Microscopic examination of living tissue (typically from sinus or airway mucosa) for cilia abnormalities

Psychogenic cough

Persistent barky cough, possibly prominent during classes and absent during play and at night

No fevers or other symptoms

Clinical evaluation

Tuberculosis

History or risk of exposure

Immunocompromise

Sometimes fever, chills, night sweats, lymphadenopathy, weight loss

Tuberculin skin test (PPD)

Sputum culture (or morning gastric aspirate culture for children < 5 years)

Interferon-gamma release assay (especially if there is a history of bacille Calmette-Guérin [BCG] vaccination)

Chest x-ray

* All patients require a chest x-ray when they present for the first time with chronic cough.

PCR = polymerase chain reaction; URI = upper respiratory infection.

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