What is the best management approach for a child with a 10-day history of nocturnal cough, possibly preceded by an upper respiratory tract infection (URTI), and experiencing similar episodes of cough not preceded by URTI that are relieved by an inhaler?

Management of Nocturnal Cough in a Child with Recurrent Episodes Relieved by Inhaler

For this child with a 10-day history of nocturnal cough and recurrent episodes relieved by an inhaler (suggesting asthma), you should obtain both spirometry and chest radiograph as initial investigations, followed by an empirical trial of inhaled corticosteroids if asthma is confirmed. 1

Initial Diagnostic Approach

Recommended Investigations

• Both chest radiograph and spirometry (with pre- and post-bronchodilator testing) should be performed as first-line investigations in children with chronic cough (>4 weeks duration) when age-appropriate. 1, 2 However, this child's cough is only 10 days in duration, which is still in the acute phase.

• The key clinical feature here is the recurrent episodes of cough relieved by inhaler, which strongly suggests underlying asthma. 1 This history of bronchodilator responsiveness is a critical "cough pointer" that indicates the need for objective testing rather than waiting. 1

• Spirometry with bronchodilator testing provides objective evidence of airway reactivity and reversible airflow obstruction, which are cardinal features of asthma. 1, 2 The positive likelihood ratio for abnormal spirometry with bronchodilator reversibility is infinite for ruling in disease. 1

• Chest radiograph helps exclude structural abnormalities and other serious conditions that may present with chronic cough. 1, 2

Important Caveats About Timing

• While formal chronic cough guidelines (requiring chest radiograph and spirometry) technically apply only after 4 weeks of symptoms 1, 3, the history of recurrent similar episodes not preceded by URTI and relieved by inhaler changes the clinical picture. 1 This pattern suggests an underlying chronic condition (likely asthma) rather than a simple post-viral cough.

• The nocturnal pattern of cough is particularly suggestive of asthma. 2, 4 Nocturnal symptoms are a classic feature of asthma and should prompt earlier evaluation.

Management Algorithm Based on Cough Characteristics

Determining Cough Type

• First, determine if the cough is wet/productive versus dry. 1 This is the most important divergence point in pediatric cough algorithms. 1

• For a dry cough with nocturnal pattern and history of bronchodilator response, asthma should be strongly suspected. 2, 4

• If the cough is wet/productive and persists >4 weeks without other specific pointers, consider protracted bacterial bronchitis and treat with 2 weeks of antibiotics targeting common respiratory bacteria. 1, 2

If Asthma is Suspected (Dry Cough with Bronchodilator Response)

• For children >6 years with suspected asthma, testing for airway hyperresponsiveness should be considered. 1

• An empirical trial of inhaled corticosteroids can be used when the cough is dry and features consistent with asthma are present (nocturnal cough, bronchodilator response, recurrent episodes). 1, 2

• However, avoid empirical treatment approaches unless other features consistent with asthma are present. 1 In this case, the nocturnal pattern and bronchodilator responsiveness provide those features.

• If an empirical trial is used, it should be of defined limited duration to confirm or refute the diagnosis. 1, 2

Treatment Considerations

Inhaled Corticosteroids

• Inhaled corticosteroids are the cornerstone of asthma treatment and are effective for cough due to asthma and cough-variant asthma. 4

• Response to inhaled corticosteroids is associated with the presence of airway eosinophilia and supports the diagnosis of asthma. 4

• Children with chronic dry cough and asthma risk factors (such as recurrent episodes with bronchodilator response) may benefit from a short trial of inhaled corticosteroids. 2

Important Pitfalls to Avoid

• Do not use an empirical approach aimed at treating asthma without features consistent with the condition. 1 However, this child has clear features: nocturnal cough, recurrent episodes, and bronchodilator responsiveness.

• Do not routinely perform additional tests (skin prick test, Mantoux, bronchoscopy, chest CT) unless individualized based on clinical findings. 1, 2

• Symptomatic improvement may become apparent before improvement in spirometric parameters in children with asthma after treatment initiation. 5 Don't discontinue treatment prematurely if symptoms improve but spirometry hasn't normalized yet.

Practical Clinical Approach

Given this specific clinical scenario:

1. Obtain spirometry with pre- and post-bronchodilator testing to objectively document airway reactivity 1, 2
2. Obtain chest radiograph to exclude structural abnormalities 1, 2
3. If spirometry confirms bronchodilator reversibility or airway hyperresponsiveness, initiate inhaled corticosteroids 2, 4
4. If spirometry cannot be performed (child too young or unable to cooperate), an empirical trial of inhaled corticosteroids is reasonable given the strong clinical features of asthma 1, 2
5. Assess environmental tobacco smoke exposure and advise cessation 1, 2
6. Follow up to confirm response to treatment within a defined timeframe 1