Rosen & Barkin's 5-Minute Emergency Medicine Consult (181 page)

• Most frequent causes:
  
  • Asthma
    
  • Viral illness
    
  • Acute bronchitis
    
  • Pneumonia
    
  • Sinusitis
    
  • GERD
    
• Less common causes:
  
  • Tracheobronchomalacia
    
  • Mediastinal tumor
    
  • Acyanotic congenital heart disease
    
  • Ventricular septal defect
    
  • Patent ductus arteriosus
    
  • Pulmonary stenosis
    
  • Tetralogy of Fallot
    
  • Lodged foreign body
    
  • Chronic aspiration of milk
    
  • Environmental exposure
    
• Consider:
  
  • Neonatal history
    
  • Feeding history
    
  • Growth and developmental history
    
  • Allergies
    
  • Eczema
    
  • Sleep disorders
    
• Indications for CXR:
  
  • Suspicion of foreign body ingestion
    
  • Suspect aspiration
    

DIAGNOSIS

• Sputum production:
  
  • Frothy (pulmonary edema)
    
  • Mucopurulent
    
  • Suggestive of bacterial pneumonia or bronchitis but also seen with viral infections
    
  • Rust colored (pneumococcal pneumonia)
    
  • “Currant jelly” (Klebsiella pneumonia)
    
  • Hemoptysis
    
• Post-tussive syncope or emesis (suggests pertussis)
  
• Shortness of breath
  
• Chest pain
  
• Chills/fever
  
• Night sweats
  
• Wheezing
  
• GERD:
  
  • Heartburn
    
  • Dysphagia
    
  • Regurgitation
    
  • Belching
    
  • Early satiety
    
• Malignancy:
  
  • Weight loss
    
  • Poor appetite
    
  • Fatigue
    

• Duration of cough to classify into acute, subacute, and chronic
  
• Description of sputum, if present, including hemoptysis
  
• Post-tussive emesis or syncope and paroxysmal cough suggests pertussis.
  
• History of GI symptoms pointing to GERD
  
• Weight loss and night sweats suggestive of tuberculosis in chronic cough
  

• Vital signs
  
• Abnormal breath sounds:
  
  • Absence or decreased: Reduced airflow vs. overinflation
    
  • Rales (crackles): Popping or rattling when air opens closed alveoli:
    
    • Moist, dry, fine, coarse
      
  • Rhonchi: Snoring-like sounds when large airways are obstructed
    
  • Wheezes: High-pitched sounds produced by narrowed airways
    
  • Stridor: Upper airway obstruction
    
• Evidence of respiratory distress:
  
  • Use of accessory muscles
    
  • Abdominal breathing
    

• Complete medical history:
  
  • Duration
    
  • Associated symptoms
    
  • Sick contacts
    
  • Smoking exposure
    
  • ACE inhibitor use
    
  • HIV/immunocompromised state
    
  • Potential exposure to tuberculosis
    
• EKG:
  
  • History of cardiac disease
    
  • Associated chest pain or abnormal vital signs
    
  • Lack of infectious symptoms
    

Order according to presenting signs and symptoms:

• WBC count with differential
  
• Sputum gram stain, cultures, and sensitivities
  
• Acid fast bacilli (AFB) culture
  
• CD4 count
  
• Pertussis titers
  
• D
  -Dimer
  
• Flu swab (for high-risk patients or those to be admitted)
  

• CXR:
  
  • For immunosuppressed patient
    
  • At least 1 of the following in healthy patients with acute cough and sputum production:
    
    • Heart rate >100 bpm
      
    • Respiratory rate >24 breaths/min
      
    • Oral body temperature of >38°C
      
    • Chest exam findings of focal consolidation, egophony, or fremitus
      
  • Ill appearing
    
  • Change in chronic cough
    
  • Continued cough after discontinuation of ACE inhibitor
    
• CT of chest:
  
  • Abnormal CXR
    
  • Assess for pulmonary embolism
    

• Peak flow
  
• Bronchoscopy:
  
  • For unknown mass on chest radiograph
    
  • Hemoptysis
    
  • Suspected cancer
    

See “Etiology.”

TREATMENT

Assess airway, breathing, and circulation.

Specific treatment related to cause:

• Respiratory infection: Consider antibiotics, antivirals (flu), decongestants, and antitussives.
  
• Asthma: Inhaled β
  ₂
  -agonist and steroids
  
• GERD: H
  ₂
  -blockers, proton pump inhibitors, and antacids
  
• Suspicion of pertussis: Macrolide and 5 days isolation
  
• Exacerbation of chronic bronchitis: Inhaled β
  ₂
  -agonist and steroids
  
• Malignancy: Supportive care
  

• Antibiotics:
  
  • Pick appropriate coverage for suspected bacteria.
    
• Antivirals:
  
  • Tamiflu: 75 mg (peds: 30–75 mg PO BID × 5 days) PO daily
    
• Antitussives:
  
  • Codeine: 10–20 mg (peds: 1–1.5 mg/kg/d) PO q4–6h
    
  • Dextromethorphan: 10–20 mg (peds: 1 mg/kg/d) PO q6–8h
    
  • Hydrocodone: 5–10 mg (peds: 0.6 mg/kg/d q6–8h) PO q6–8h
    
• Bronchodilators:
  
  • Albuterol: 2.5 mg in 2.5 NS (peds: 0.1–0.15 mg/kg/dose q20min) q20min inhaled
    
  • Ipratropium: 0.5 mg in 3 mL NS (peds: Nebulizer 250–500 μg/dose q6h) q3h
    
• Decongestants:
  
  • Chlorpheniramine: 4–12 mg (peds: 2 mg PO q4–6h) PO q4–12h
    
  • Phenylpropanolamine: 25–50 mg (peds: 6.25–12.5 mg PO q4h) PO q4–8h
    
• Mucolytics:
  
  • Guaifenesin: 200–400 mg (peds: 2--5 yr 50–100 mg PO, 6–11 yr 100–200 mg) PO q4h PRN
    
• Steroids:
  
  • Dexamethasone: 2 sprays/nostril BID
    
  • Methylprednisolone: 60–125 mg IV (peds: 1–2 mg/kg/dose IV/PO q6h)
    
  • Prednisone: 40–60 mg (peds: 1–2 mg/kg/d q12h) PO
    

FOLLOW-UP

• Hypoxemia or critical illness
  
• Suspected tuberculosis with positive chest radiograph result
  
• Immunocompromised with fever
  
• Risk of bacteremia or sepsis
  

• Oxygenation at baseline for patient
  
• Oral medications
  
• Safe environment at home
  

Close follow-up by primary care physician for outpatient management

• Stop smoking, avoid being around smokers or other harmful substances such as asbestos.
  
• Change diet:
  
  • Avoid coffee, tea, and soda.
    
  • Avoid eating for at least 4 hr prior to sleeping.
    
• Use pillows to keep head elevated at night.
  
• Seek care immediately with:
  
  • Chest pain
    
  • Coughing blood
    
  • Shortness of breath
    
  • Fainting
    

• For patients fitting the clinical profile for cough due to GERD, it is recommended that treatment be initially started in lieu of testing.
  
• For patients with a presumed diagnosis of acute bronchitis, routine treatment with antibiotics is not justified and should not be offered.
  

• Irwin RS. Unexplained cough in the adult.
  Otolaryngol Clin North Am.
  2010;43(1):167–180, xi–xii.
  
• Irwin RS, Baumann MH, Bolser DC, et al. Diagnosis and management of cough executive summary: ACCP evidence-based clinical practice guidelines.
  Chest.
  2006;129:1S.
  
• Schroeder K, Fahey T. Over-the-counter medications for acute cough in children and adults in ambulatory settings.
  Cochrane Database Syst Rev.
  2004;18(4):CD001831.
  

CODES

• 306.1 Respiratory malfunction arising from mental factors
  
• 786.2 Cough
  
• 786.30 Hemoptysis, unspecified