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 donโt look short of breath or uncomfortable except for the cough — we diagnose Tracheitis.
Tracheitis — A viral infection of the trachea. If theyโre 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 โLaryngotracheobronchitisโ (the term is actually in the literature!!!). They all get better on their own.
Cough syrup might help a patient feel better, but I donโt have any faith in over-the-counter preparations. Low-dose prescription codeine works, but Iโm careful with it because of certain dangers (which also occur with the over-the-counter stuff):
- Drowsiness (DONโT 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 bodyโs 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. Thereโs 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 โcough 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 (โWhooping Coughโ) — This is todayโs clinical dilemma when diagnosing a new acute cough. Pertussis is not unusual in adults, because the vaccination against it doesnโt 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 thatโs so bad that they โwhoopโ 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 โreservoir,โ maintaining and spreading the germs and illness in society. But itโs the small babies who die.
There are no special clinical findings for Pertussis; thereโs 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 isnโt 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 arenโt 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 donโt 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 Iโd 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.
Itโs 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 (thatโs 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 โtestimonials.โ Pediatricians donโt 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, โCaveat 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 clinicianโs condensed thought-process when face-to-face with a patient.