Acute Cough, BUT — No Upper Respiratory Symptoms, No Shortness of Breath, and No Fever

Let’s say a patient has Just a Cough.  No other symptoms.  It could be asthma or bronchitis.

Here I rely on my lung exam (by stethoscope).  If we hear Bronchospasm, a few possibilities come to mind (see sub-topic Acute Cough, with Some SOB, No Fever).  But if the lungs sound 100% normal, and vital signs are fine, & their oxygen is fine (if we have a pulse oximeter to measure it easily), & they donโ€™t look short of breath or uncomfortable except for the cough — we diagnose Tracheitis.

Tracheitis  —  A viral infection of the trachea.  If theyโ€™re hoarse (implying involvement of the voice box, or larynx), we say viral Laryngotracheitis.  Since bronchitis is also viral, & can look identical, we might even call it โ€œLaryngotracheobronchitisโ€ (the term is actually in the literature!!!).  They all get better on their own.

Cough syrup might help a patient feel better, but I donโ€™t have any faith in over-the-counter preparations.  Low-dose prescription codeine works, but Iโ€™m careful with it because of certain dangers (which also occur with the over-the-counter stuff):

  • Drowsiness (DONโ€™T DRIVE, etc.)
  • Accidental overdose by children (looks good, even tastes yummy)
  • Intentional abuse by teenagers [or anyone]

Actually, a cough protects our lungs from germs trying to drop down in, from the nose & throat.  So do we really want to knock out our cough receptors for the night?  In terms of our bodyโ€™s defenses, it’s good to cough.

Tracheitis in children 3 or under is called “Croup.”  The cough is much worse, kids can get pretty sick, needing hospitalization.  That’s because their tracheas are very narrow, so it doesn’t happen to anyone older.  Thereโ€™s a special treatment with racemic epinephrine.

Asthma —  Some people with Asthma actually have perfectly normal-sounding lungs.  If they’ve had this diagnosis made in recent years, it’s probably the cause of any new cough.  So I treat it as such; the condition is even informally called โ€œcough asthmaโ€.  And if they really had tracheitis?  Well, there’s no real treatment for that anyway, so it doesn’t really matter (and the last thing we want to do is give sedating cough syrup to someone with asthma, because it could make breathing worse).

As long as there’s no SOB, there’s no problem missing a diagnosis of new asthma with normal-sounding lungs for a few weeks.  Then, if the cough is considered “chronic,” which couldn’t be blamed on a virus, it’s much easier to diagnose new asthma.  See our discussion of this under Chronic Cough.

Pertussis (โ€œWhooping Coughโ€)  —  This is todayโ€™s clinical dilemma when diagnosing a new acute cough.  Pertussis is not unusual in adults, because the vaccination against it doesnโ€™t last as long as others do (most vaccines prevent viruses, Pertussis is a bacteria; see Differences Among Germs).  Babies have a classic disease course: 2-3 weeks of runny nose, which turns into a cough thatโ€™s so bad that they โ€œwhoopโ€ to gasp for air.  But in teens & adults, the cough is milder, without any lead-in, and almost never a “Whoop”.

Teens & adults are the โ€œreservoir,โ€ maintaining and spreading the germs and illness in society.  But itโ€™s the small babies who die.

There are no special clinical findings for Pertussis; thereโ€™s no fever, and lung exam usually sounds normal.  The worse the coughing spells, especially if they provoke actual vomiting, the more likely it’s Pertussis.  Tracheitis also causes cough without runny nose or any sign on exam, but coughing isnโ€™t as severe, and viruses only last 1-2 weeks at most.

Treatment for Pertussis involves antibiotics.  The Centers for Disease Control and Prevention (CDC), our national public health agency, considers the diagnosis when a cough has been going on over 2 weeks.  The problem is, antibiotics only help shorten symptoms if given sooner.  Also, to prevent contagion, treatment after 2 weeks is nowhere near as effective as if given earlier.

Another problem: tests arenโ€™t so easy or accurate.  We need a special kit (obtainable from health departments, so not usually immediately available).  The quickest test (PCR) is expensive, and may give false-positive results.  The surest one (culture) takes time, may be false-negative, & is easily spoiled if not processed correctly.

So most clinicians I know deal with Pertussis clinically.  But we certainly donโ€™t want to give antibiotics to everyone with a cough.  I limit my diagnosis to patients with significant cough and no upper respiratory symptoms (like runny nose), a normal lung examination (by stethoscope), plus any of the following:

  • Coughing spells that provoke vomiting
  • Cough going on 2 wks. without any improvement
  • Contact with unvaccinated infants

The last is my most important.  Pertussis in school-age children, teens, and adults gets better on its own.  But Iโ€™d never want it spread to a baby (or a woman in the last half of pregnancy).  Infants require 3 shots of vaccine for protection, at 2, 4, and 6 months of age.  Fortunately, these days pregnant women all get vaccinated, which covers their newborns.

Itโ€™s faddish in some communities (usually upper-middle-class) to refuse childhood vaccination.  Years ago there was rumor of association with autism, though studies have convincingly refuted and debunked any possible connection.  Since autism occurs in young children (thatโ€™s who we immunize), there are certainly cases occurring soon after vaccination, which proves nothing (a child might develop autism after a rainstorm, which also proves nothing).  And the internet provides fertile dissemination of โ€œtestimonials.โ€  Pediatricians donโ€™t even argue with parents anymore — too time-consuming trying to change the mind of true-believers.

I no longer do pediatrics; my only comment to vaccine-disbelievers, is, โ€œCaveat Emptorโ€ (if you speak Latin).ย  During a recent measles outbreak, a woman with leukemia, whose weakenedย immune systemย caused her childhood measles vaccine to lose its effect, got infected and died.ย  An unvaccinated local resident who had just had mild measles, and was likely not the person who infected her, felt potentially guilty enough to reflect publicly.

See also Acute Cough for the clinicianโ€™s condensed thought-process when face-to-face with a patient.

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