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Cough - acute with chest signs in children - Making a diagnosis
How do I determine the cause of acute cough with chest signs on examination?
- Distinguishing between pneumonia, bronchiolitis, viral-induced wheeze, and an infective exacerbation of asthma:
- The distinguishing features of these conditions are compared in Table 1. No combination of symptoms or signs has been shown to give absolute clinical certainty in diagnosing these conditions, and it is recognized that, at times, it is not possible to confidently distinguish between them.
- Pneumonia should be considered in any child with a fever, and when any of the following are present [National Collaborating Centre for Women's and Children's Health, 2007]:
- Raised respiratory rate or signs of increased work of breathing, such as chest indrawing and nasal flaring.
- Crackles in the chest.
- Cyanosis.
- Oxygen saturation of 95% or less.
- Viral-induced wheeze is a distinct diagnosis from asthma, and the wheeze is caused by a different underlying mechanism. Viral-induced wheeze only occurs in association with infection, and generally only in children between 6 months and 5 years of age.
- An infective exacerbation of asthma is distinguished from viral-induced wheeze in a child of less than 5 years of age by a history of wheeze occurring in the absence of infection, in response to typical stimuli (e.g. exercise or exposure to pollen). An infective exacerbation of asthma and viral-induced wheeze is often indistinguishable in children under 5 years of age who present for the first time with wheeze and a respiratory tract infection, unless there is a history of wheeze in the absence of infection.
- Microbiological investigations and chest radiography are not routinely recommended for children diagnosed with a chest infection, unless they require admission to hospital [British Thoracic Society, 2002].
Table 1. Distinguishing the cause of acute cough associated with chest signs.
| Pneumonia | Bronchiolitis | Viral-induced wheeze | Asthma |
|---|
Age | Any age | Under 1 year, peak incidence at 6 months of age | Over 12 months, under 5 years | Over 12 months |
Respiratory rate‡ | Usually increased | Usually increased | May be normal or increased | May be normal or increased |
Hyperinflation | Not present | Often present | May be present | May be present |
Wheeze | Not usually present* | May be present | Present | Present |
Crackles | Coarse crackles, usually localized | Fine crackles present throughout all lung fields | Not present† | Not present† |
* Except with mycoplasma pneumonia. † If present usually clear with coughing. ‡ May be associated with signs of increased work of breathing; subcostal, intercostal, and subclavicular recession. |
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