Airway Clearance for a 12-Month-Old with Cough
For a previously healthy 12-month-old infant with acute cough, airway clearance techniques are not recommended, as there is little evidence supporting their use in children without underlying chronic respiratory disease. 1
When Airway Clearance is NOT Indicated
Routine chest physiotherapy should not be prescribed for previously healthy infants with acute respiratory illness, as few studies demonstrate efficacy and physicians routinely prescribing these techniques should question their practice. 1
The evidence base for airway clearance in acute pediatric respiratory conditions is extremely limited, with poorly specified techniques and inconsistent terminology (often confusing "chest physiotherapy" with chest clapping, vibration, or postural drainage). 1, 2
Chest physiotherapy for airway clearance and sputum evacuation cannot be considered standard of care in general pediatric populations. 3
Essential First Step: Identify the Underlying Cause
Before considering any airway clearance intervention, the etiology of chronic cough (>4 weeks duration) must be determined through systematic evaluation:
All children with chronic cough require careful evaluation for specific diagnostic indicators rather than empiric airway clearance therapy. 3
The most common causes of chronic cough in infants and children include cough-variant asthma, sinusitis, gastroesophageal reflux, and structural airway abnormalities. 4
A chest radiograph is the minimum required investigation for any child with chronic cough. 3
Endoscopy is particularly helpful in establishing precise diagnosis in infants under 18 months of age and is underutilized in practice. 4
When Airway Clearance IS Indicated
Airway clearance techniques are reserved for specific chronic conditions, not acute cough in previously healthy children:
Cystic Fibrosis or Bronchiectasis
Positive expiratory pressure (PEP) devices are recommended as they are approximately as effective as conventional chest physiotherapy, inexpensive, safe, and self-administered. 3, 5
Huffing should be taught as an adjunct to other sputum clearance methods. 3, 6
Autogenic drainage can substitute postural drainage and has the advantage of being performed without assistance in one position. 3, 6
Neuromuscular Disease with Impaired Cough
Mechanical insufflation-exsufflation devices are recommended to prevent respiratory complications when maximal expiratory pressures are <60 cm H₂O or assisted peak cough flows decrease to <270 L/min. 3, 5
Manually assisted cough (abdominal thrust or lateral costal compression) should be considered to reduce respiratory complications. 3
Cough-assist techniques combined with non-invasive ventilation should be considered to prevent extubation failure. 3
Critical Contraindications
- In persons with airflow obstruction (COPD-like conditions), manually assisted cough may be detrimental and should not be used, as it can decrease peak expiratory flow rate by 144 L/min. 3, 5, 6
Common Pitfalls to Avoid
Do not prescribe "chest physiotherapy" without specifying the exact technique, as this term is poorly defined and often misunderstood. 1
Do not assume airway clearance will speed recovery in acute respiratory illness in previously healthy children—the evidence does not support this practice. 1, 2
Do not use routine endotracheal suctioning or saline instillation without specific indication, as there is no scientific basis for routine use. 3
Recommended Clinical Approach for This 12-Month-Old
Focus on identifying and treating the underlying cause of cough rather than initiating airway clearance:
Obtain detailed history focusing on duration (acute vs. chronic >4 weeks), presence of fever, rhinorrhea, wheezing, feeding difficulties, or respiratory distress. 3, 4
Perform chest radiograph if cough is chronic or concerning features are present. 3
Treatment should be etiologically based once the cause is identified (e.g., bronchodilators for asthma, antibiotics for bacterial infection, reflux management for GERD). 3
If cough is nonspecific and acute (<4 weeks), it may spontaneously resolve, but the child should be reevaluated for emergence of specific diagnostic indicators. 3