Paediatrics JC121: A Child With Cough: Acute And Chronic Cough In Children

Question 1

Cough

Answer 1

Under both Voluntary + Involuntary control

Function:
- Clear airways of secretions: Primary mechanism for secretion removal (when respiratory cilia are damaged by inflammation)

Cough reflex:
- protects airway following inhalation of foreign material (e.g. food, secretions)

Cough receptors:
- located with epithelium of pharynx, larynx, trachea, major bronchi
- stimulated mechanically, chemically, thermally
- stimulated by local mediators: histamine, prostaglandins, leukotrienes
- stimulated by local bronchoconstriction
- also in pharynx, paranasal sinuses, stomach, external auditory canal (source of persistent cough may not be in the lungs, i.e. cough =/= lung problems)

Reflex arc (involuntary):
- afferent fibres from Vagus nerve to cough centre in upper brainstem
- efferent fibres from Vagus nerve + Spinal cord to larynx, diaphragm, abdominal muscles to produce a cough

Higher cortical control of visceral reflex
- cough inhibition + voluntary cough

Question 2

Causes of cough

Answer 2

1. Respiratory
   - URTI
   - Post-nasal drip syndrome (Upper airway cough syndrome)
   - Asthma
   - Aspiration
   - Pneumonia / Pneumonitis
   - Bronchiectasis
2. Non-respiratory
   - Heart failure
   - GER
   - ACEI
   - Psychogenic / Habit cough

Question 3

***History taking in Acute cough

Answer 3

1. Who
   - Age —> Likely organisms (e.g. acute bronchiolitis in <2 yo)
   - Previously healthy? —> Community / Hospital-acquired
   - Immunocompromised? (e.g. HIV-infected) —> Opportunistic organism
   - Neurologically impaired? —> Aspiration pneumonia
   - Atopic? —> Asthma / Post-nasal drip (∵ Allergic rhinitis)
   - Live at home / institution? —> Community-acquired
2. What is the cough?
   - Dry —> Mycoplasma, Psychogenic, Asthma, Coronavirus
   - Productive —> Pneumonia, Bronchiectasis
   - Blood-stained, colour? —> Pneumonia, Bronchiectasis, TB, Excoriated airway
   - Barking? Brassy? —> Croup
   - Wheezy? —> Asthma, Acute bronchiolitis
   - Paroxysmal?
   - Alleviating / Aggravating factors
3. When
   - After feeding? —> GER
   - Middle of night? —> Asthma, Sinusitis
   - Worse when weather changes / turns cold? —> Asthma, Reactive airway
   - When someone smoke?
   - With exertion? —> Heart failure, Asthma
   - With fever? —> Infection
   - With runny nose?
   - Soon after lying down —> Post-nasal drip
   - When nervous / resolves with sleep —> Psychogenic, Habit
4. How long?
   - Acute vs Subacute vs Chronic

Question 4

Dry vs Productive cough

Answer 4

Productive:
- indicate Secretions from LRT —> i.e. Lower airway is involved
- but beware of “sputum” sound described by parents
- beware Sputum (Exudates) vs Mucus

Mucus:
- produced by goblet cells + submucosal glands under normal situation —> may ↑ in illness (e.g. infection, smoking)
—> Nasal mucus
—> Lower airway mucus (trachea, bronchus, bronchioles) —> Sputum / Phlegm

Exudates:
- protein-rich fluid leaked from capillaries
- produced in alveoli (LRT) due to inflammatory process due to usually infection

Question 5

Duration of cough

Answer 5

Distinguish Acute vs Chronic cough
- Acute: recent onset, last <3 weeks
- Most common stimulus of cough: Irritation / Inflammation of respiratory epithelium

Causes of Acute cough:
1. Acute Viral URTI (account for most acute cough at all ages)
- Self-limiting
- lasts 1-3 weeks
- URI: Viral only (influenza, RSV, parainfluenza, adenovirus, rhinovirus, human coronavirus, human metapneumovirus, bocavirus)

2. Acute LRTI
   - LRI: Viral, Bacterial (Strept. pneumoniae, Moraxella catarrhalis, Hib, Pseudomonas if immunocompromised, Chlamydia if neonate)
3. Exacerbation of pre-existing condition
   - Asthma, Bronchiectasis, Post-nasal drip syndrome (Upper airway cough syndrome)

Question 6

***P/E of Acute cough

Answer 6

1. Severity
   - need supportive treatment?
2. Etiology
   - infectious vs non-infectious
   - infectious: Can you rule out LRTI? (need to find out likely organism for appropriate treatment e.g. antibiotics)
   - non-infectious: Allergy? (nasal (e.g. post-nasal drip), airway (reactive airway / asthma), both?)
3. Temperature (fever)
4. Vital signs
5. Respiratory distress
   - RR —> tachypnea in children: >60 for <2 months, >50 for 2-12 months, >40 for >1 yo (記: 654, 2-12 months)
   - Retraction / Insucking / Use of accessory muscles
   - Cyanosis, SaO2
   - Dyspnea, SOB
6. Chest exam
   - deformity
   - percussion
   - auscultation (wheeze, crepitations, rhonchi)
7. Associated findings
   - skin rash, eczema, tonsils, LN, rhinorrhoea

Question 7

Evaluation of Acute cough

Answer 7

Absence of fever, tachypnea, chest signs
—> most useful for ruling out LRT involvement

Most children with cough due to simple URTI do ***NOT require any investigations (e.g. CXR)

CXR should be consider when presence of:
1. LRT signs (+/-)
2. Relentlessly progressive cough (e.g. >2 weeks)
3. Haemoptysis
4. Undiagnosed chronic respiratory disorder

Other investigations depending on your DDx:
1. CBC + D/C (e.g. Neutrophils)
2. Nasopharyngeal aspirates / Nasopharyngeal swabs for common viruses + mycoplasma
3. Sputum for Gram stain + Culture (if child old enough to produce sputum)
4. Blood culture (low detection rate even if bacterial etiology)

Question 8

***Approach to arrive at Dx for acute cough

Answer 8

1. Acute URI
   - Coryzal (Nasal) symptoms
   - Fever
   - Sore throat
2. Croup syndrome
   —> Viral croup
   —> Recurrent spasmodic croup
   —> Bacterial tracheitis
   - Stridor
   - Barking (like a seal) / Croupy cough
   - Hoarseness
   - +/- Fever
3. LRT illness
   —> Acute bronchiolitis (wheeze (∵ inflammatory exudates in airway) +/- crepitations, usually due to RSV, HMPV (Human metapneumovirus))
   —> Pneumonia (viral / bacterial)
   —> Asthma
   - Respiratory distress
   - Tachypnea
   - Increased work of breathing
   - Lower chest signs (crepitations, wheeze, rhonchi)
   - Fever
4. Allergic / Atopic illness
   —> Post-nasal drip from allergic rhinitis
   —> Reactive airway / asthma
   - Seasonal, Diurnal variation
   - Associated with Rhinitis, Posture (cough more when lying down), Clearing of throat, Triggers (e.g. dust, pollutant, pollen)
5. Acute exacerbation of chronic respiratory disorder
   —> Bronchiectasis
   - Failure to thrive
   - Finger clubbing
   - Chest deformity
   - Features of atopy

Question 9

Chronic cough

Answer 9

American College of Chest Physician Guideline:
- Paediatric (<15 yo) chronic cough: Daily cough lasting >4 weeks

British Thoracic Society:
- Cough >8 weeks
- Grey area of subacute cough between 2-8 weeks

Subdivided into:
- Specific cough (cough with S/S suggestive of associated problem)
- Nonspecific cough (dry cough in absence of an identifiable respiratory disease of known etiology)

Consider Duration + Intensity!!!

Question 10

***History taking of Chronic cough

Answer 10

1. How did the cough start?
   - Very acute / After choking —> Inhaled foreign body
   - With URI —> Post-viral cough
2. When did it start?
   - Neonatal onset —> Aspiration (e.g. TE fistula), Congenital malformation, Cystic fibrosis, Primary cilial dyskinesia
3. Quality of cough
   - Productive (moist / wet) —> Chronic suppurative disease (e.g. Bronchiectasis)
   - Paroxysmal spasmodic cough +/- Whoop —> Pertussis
   - Haemoptysis —> TB in adolescents (like in adults, TB does not present as haemoptysis in children), Bronchiectasis, AV malformation
   - Bizzare honking cough which ↑ with attention —> Psychogenic cough
   - Dry repetitive, disappears with sleep —> Habit cough
4. What triggers the cough?
   - Exercise, cold air, early morning —> Asthma
   - Feeding —> Recurrent aspiration

Question 11

***S/S of respiratory / systemic disease

Answer 11

1. Wheeze (obstruction of lower airway)
   - Intrathoracic airway lesion (e.g. asthma, foreign body)
   - Extraluminal compression
2. Crepitation
   - Parenchymal disease
3. Chest pain
   - Asthma
   - Increased respiratory distress (parenchymal disease)
   - Arrhythmia
4. Chest wall deformity
   - Chronic airway / parenchymal disease
5. Digital clubbing
   - Chronic suppurative lung disease
6. Daily moist / productive cough
   - Suppurative lung disease
7. Failure to thrive
   - Serious systemic including pulmonary illness
8. Feeding difficulties
   - Serious systemic including pulmonary illness
   - Aspiration
9. Hypoxia / Cyanosis
   - Airway / Parenchymal disease
   - Cardiac disease
10. Neurodevelopmental abnormality (e.g. Cerebral palsy)
    - Aspiration lung disease
11. Recurrent pneumonia
    - Immunodeficiency
    - Congenital lung abnormalities
    - TE fistula

Specific cough:
1. Whooping cough
- Pertussis (∵ small airway in children —> cannot breathe —> deep breath —> whooping noise)

2. Barking / Brassy cough
   - Croup
   - Tracheomalacia (cartilage that keeps the airway (trachea) open is soft such that the trachea partly collapses especially during increased airflow)
   - Habit cough
3. Paroxysmal (+/- Whoop)
   - Pertussis
   - Mycoplasma
   - Parapertussis
   - Virus
4. Nocturnal (middle of night)
   - U/L respiratory allergy
   - Sinusitis
5. Wheezy / Tight
   - Reactive airway
6. Staccato cough (inspiration between each single cough)
   - Chlamydia
7. Honking
   - Psychogenic
   - Habit

—> Non-sensitive / Non-specific: Only validated in Brassy vs Non-brassy cough for tracheomalacia

Question 12

Clues from Age of onset of cough

Answer 12

Infancy:
1. Aspiration
2. Reactive airway
3. Congenital malformation
- Laryngotracheomalacia / Bronchomalacia
- Vascular compression (Ring / Sling innominate artery)
4. Infection
- Chlamydia
- Pertussis
- TB
- Post-RSV
5. Congenital heart disease
6. Passive smoking

Early childhood:
1. Aspiration
2. Asthma (Recurrent reversible obstruction of reactive airway)
3. Bronchiectasis
- Immunodeficiency
- Cystic fibrosis
- Post-infectious
4. Infection
- Viral
- TB
- Mycoplasma
- Fungal
5. Sinusitis

Late childhood / Adolescence:
1. Aspiration (degenerative neuromuscular disease)
2. Asthma
3. Bronchiectasis
- Immunodeficiency
- Cystic fibrosis
- Post-infectious
4. Infection
- Viral
- TB
- Mycoplasma
- Fungal
5. Sinusitis
6. Smoking (active + passive)
7. Psychogenic
8. Mediastinal tumour

Question 13

Non-specific cough

Answer 13

Dry cough in absence of an identifiable respiratory disease of known etiology

Causes:
1. Usually post-viral cough
2. Another episode of acute infection
3. Others (Foreign body, Asthma, GERD etc.)

Evaluate:
1. Tobacco smoking / other pollutants
- prevalence of chronic cough in children <11 yo with 2 smoking parents: 50%
2. Child’s activity (every now and then?)
3. Parental expectations + concerns
4. Watch, Wait, Review

Question 14

***P/E of Chronic cough

Answer 14

1. Growth + Development / Failure to thrive
2. Respiratory distress
3. Finger clubbing
4. URT
   - signs of Sinusitis (facial pain, persistent purulent nasal discharge)
   - signs of Allergic rhinitis (nasal obstruction, nasal discharge)
5. LRT
   - chest deformity (Harrison sulcus (diaphragm always in tension —> pulls the softened bone inward), Pectus carinatum, ***Barrel chest)
   - hyperresonance (air trapping)
   - crepitations, wheeze, rhonchi
6. Cardiac
   - murmur
   - heart failure
7. Skin
   - eczema

Question 15

Investigations of Cough

Answer 15

Has to be Developmental appropriate:
1. CXR
2. Peak flow +/- Lung function study
- for obstructive / restrictive diseases
- usually >=7 yo (∵ need cooperation)
3. CBC + D/C
4. Mantoux test / PPD / IGRA / Sputum / Early-morning gastric aspirate (for TB)
5. HRCT / MRI
6. Cilia study (for primary ciliary dyskinesia)
7. Immunoglobulin pattern (for Ig deficiency)
8. 24 hours pH study (for reflux)
9. Video fluoroscopy (for aspiration)
10. Bronchoscopy

Question 16

Treatment of Cough

Answer 16

1. Treat underlying cause (very diverse)
   - Bronchodilator
   - Surgery
   - Antibiotics
   - Anti-TB
   - Anti-fungal
   - Stop smoking
2. Viral infection
   - No specific antiviral drug available in most viral infection
   —> Bronchitis
   —> Pneumonia
   - Anti-virals available for influenza
   —> Oseltamivir, Zanamivir
   —> Not to treat cough by itself (neuraminidase inhibitors shown to shorten symptoms by 1.5 days)
   —> Problems with increasing resistance
3. Bacterial infection
   - CAP (S. pneumoniae, Hib, Moraxella catarrhalis): Augmentin
   - Atypical (Mycoplasma pneumoniae): Clarithromycin, Doxycycline (avoid in 8 yo: permanent staining of teeth), Quinolone
   - Pneumonia in children with underlying disease (Pseudomonas, S. aureus)

Question 17

Cough suppressants

Answer 17

No good evidence for / against effectiveness of OTC medicine in acute cough

Question 18

Common ingredients in Cough + Cold medications

Answer 18

1. Antihistamine
   - Diphenhydramine
   - Chlorpheniramine
   - Cryproheptadine
   - Brompheniramine
2. Antipyretic / Analgesic
   - Paracetamol
   - Ibuprofen
3. Antitussive
   - Dextromethorphan
   - Codeine
   - Hydrocodone
4. Expectorant
   - Guaifenesin
5. Nasal decongestant (sympathomimetic)
   - Ephedrine
   - Phenylephrine
   - Pseudoephedrine
   - Phenylpropanolamine

Question 19

Dextromethorphan and Codeine

Answer 19

Both works by central suppression of medullary cough centre

Codeine:
- Narcotic with addictive potential
- Dose-related toxicity: respiratory depression, narcosis
- somnolence, ataxia, miosis, vomiting, rash, swelling, itching

Dextromethorphan:
- considered non-addictive but abused by teenagers (results in bizarre behaviour)
- CNS depression

Combination commonly used:
- Nasal decongestant + Antihistamine + Cough suppressants + Expectorants

Conclusion:
- NO well-controlled studies to support efficacy in children
- AAP recommend against Codeine / Dextromethorphan for cough
- FDA recommend against Codeine / Hydrocodone in children <18 yo
- Antihistamine, Decongestant NOT effective in relieving nasal symptoms / cough in children
- Expectorants / Mucolytics not proven to be beneficial in children
- Suppression of cough —> may result in retention of secretions + potentially harmful airway obstruction
—> importance of carer education

Question 20

Cough relievers

Answer 20

1. Oral hydration with warm liquids
2. Honey in >=1 year (risk of infant botulism, gut not mature enough to inactivate spores in honey)
   - 0.5-1 teaspoon straight / diluted
   - modest beneficial effective on nocturnal cough (more effective than placebo / diphenhydramine)

Question 21

Responsibility of paediatrician

Answer 21

1. Child’s advocate
   - treat the child
   - work with carers
2. Educate
   - natural course of illness
   - preventive measures when applicable (e.g. influenza vaccination)
   - symptomatic relief is not everything
   - appropriate therapy includes avoiding inappropriate therapy (e.g. antibiotics)
3. Patients are not customers

Question 22

Summary: Causes of Acute and Chronic cough

Answer 22

Acute cough:
- URTI (Viral croup, Recurrent spasmodic croup, Bacterial tracheitis)
- Post-nasal drip syndrome (Upper airway cough syndrome)
- Aspiration
- Asthma / Reactive airway
- Acute exacerbation of Bronchiectasis
- Pneumonia / Pneumonitis
- Acute bronchiolitis / bronchitis
- Pertussis

Chronic cough:
- Post-viral cough
- Post-nasal drip syndrome (Upper airway cough syndrome)
- Recurrent aspiration
- Asthma / Reactive airway / Allergic rhinitis
- Bronchiectasis (Chronic suppurative)
- Cystic fibrosis, Primary ciliary dyskinesia
- TB
- Heart failure
- GER
- ACEI
- Psychogenic / Habit cough

Question 23

SpC Revision: Infection with No focus

Answer 23

No Focus:
Neonates:
- Bacteremia +/- Meningitis (GBS, Gram -ve enterics, Listeria)

Infants:
- Meningitis, Bacteremia (Strep pneumoniae > Meningococcemia), UTI
- Older infants (>6 m): can be Roseola (HHV6/HHV7) / EBV infection

Neutropenic patient:
- Bacteremia (Gram -ve esp. Pseudomonas)

Clinical sepsis:
- Usually in infant / young child
- May / may not look ill
- No focus but there is suspicion that there is a serious bacteria infection
- UTI, Bacteremia, Meningitis (in infants <1-2m of age in whom signs may be nonspecific)

Occult Bacteremia:
- Usually in infant or young child
- Usually does not look ill
- No focus or site identified
- Most common etiology: Strep pneumoniae
- Others: Neisseria meningitidis, Haemophilus influenza type b

Question 24

Common Infections according to sites

Answer 24

1. Otitis media
2. Sinusitis and mastoiditis
3. URTI
   - Tonsillitis
   - Croup
   - Respiratory viral infections
4. Adenitis
5. LRTI
   - Pneumonia
   - Pneumonitis (viral)
   - Acute bronchiolitis
6. UTI
7. GE
8. Viral syndrome
   - EBV: Infectious mononucleosis
   - Enterovirus: Herpangina
   - HSV: Gingivostomatitis
9. Rashes (viral, scarlet fever)
10. Cellulitis
11. TB

Question 25

Not so common but potentially serious infections

Answer 25

1. Meningitis, Meningoencephalitis, Brain abscess, Encephalitis 2. Bacteremia 3. Bone and joint infection 4. Periorbital cellulits 5. Orbital cellulitis 6. Necrotising fasciitis 7. Malaria

Question 26

Complications of infections

Answer 26

1. GE - Dehydration - Electrolyte imbalance - Hypoglycaemia 2. Oral ulcers - Dehydration 3. Meningitis - Seizure - SIADH 4. Salmonella GE in <3 months - Bacteraemia - Meningitis - Bone and joint infection (Osteomyelitis, Septic arthritis) 5. URTI - Acute otitis media - Bacterial pneumonia 6. Pneumonia - Empyema - Pleural effusion 7. Streptococcus pneumoniae / E. coli infection - Hemolytic uremic syndrome 8. EV71 - Meningoencephalitis

Question 27

Recurrent Infections

Answer 27

1. Anatomical defect - TE fistula —> Recurrent pneumonia 2. Functional defect - Reflux and recurrent aspiration —> Recurrent pneumonia - VUR —> Recurrent UTI - VP shunt —> Shunt infection - Ascites —> SBP 3. Immunodeficiency - Opportunistic organisms - Infection from live vaccines - More severe infections (organisms like Pseundomonas) - Different arms of immune system

Question 28

Basic treatment knowledge

Answer 28

1. UTI - Empiric use of Augmentin for increasing ESBL-producing enterobacteraciae 2. Community acquired pneumonia - Amoxicillin / Augmentin 3. Mycoplasma - Macrolide (erythromycin, clarithromycin, azithromycin) - Levofloxacin for < 8 yrs, Doxycycline for those older (∵ teeth staining) if resistant to macrolide 3. Community acquired meningitis - **3rd gen Cephalosporin + Vancomycin** 4. Kawasaki - **2 g/kg IVIG + High dose Aspirin** 5. Emesis, Diarrhoea - 2 ml/kg ORS for each emesis - 5 ml/kg ORS for each significant diarrhoea 6. Fever - Paracetamol instead of aspirin in children with URI (∵ Reye's syndrome) 7. Bronchodilation - Ventolin 200 mcg qid for 3-5 days prn (outpatient); 600mcg or 1200 mcg (inpatient); nebuliser frequency according to severity - Inhaled steroid (Becotide, Pulmicort) usually BD dosing every day

Question 29

Acute upper airway obstruction (SpC Paed E-learning: Common Respiratory Problems)

Answer 29

Important causes: 1. Foreign body aspiration 2. Infection - Epiglottitis - Croup (Laryngotracheobronchitis)

Question 30

Acute epiglottitis

Answer 30

Clinical diagnosis: 1. **Tripod position** 2. **Drooling** 3. **High fever** 4. Toxic appearance Medical emergency: - First priority: **Definitive airway placement** - **No manipulation including throat examination / XR neck / IV placement** which may precipitate complete obstruction Management: 1. **Supplemental O2 + Secure airway** 2. Keep child propped up + undisturbed, have parent accompany child 3. Have physician accompany patient at all times 4. Call - **Senior ICU paediatrician** - **Anaesthetist** - **ENT surgeon** 5. Escort patient to **OT where intubation to be done under anaesthesia** 6. Place IV catheter in OT before induction of anaesthesia, with patient fully monitored + ENT surgeon present with tracheostomy set ready 7. **After airway secured** - Draw blood for CBC + D/C, Culture - Broad spectrum antibiotics (For **Hib**, Strept. pneumoniae, Staph. aureus) —> **IV Cefotaxime +/- IV Vancomycin** (if suspicious of MRSA) - To ICU - **Rifampicin prophylaxis for close contacts**

Question 31

Croup (Laryngotracheobronchitis)

Answer 31

- More common than Epiglottitis - Watch out for signs of severe upper airway obstruction —> Mild: **Barky cough** with no stridor, no sternal / intercostal recession at rest —> Moderate: Barky cough with stridor + **sternal recession** at rest —> Severe: Barky cough with stridor, sternal / intercostal recession, with **agitation / lethargy** Impending respiratory failure: 1. Sternal / intercostal retraction 2. Asynchronous chest wall + abdominal movement 3. Fatigue (may present with diminished stridor / retraction / absent breath sound) 4. Signs of hypoxia: Pallor, Cyanosis, Tachycardia 5. Signs of hypercarbia: Decreased GC 6. Diminished stridor / retraction Management of moderate to severe croup: 1. Minimal handling 2. Clinical diagnosis - No X-ray in child with typical S/S 3. No manipulation including throat examination - Any procedures like XR neck, vein puncture / IV placement may precipitate immediate respiratory failure 4. O2 as needed 5. AR/RR Q1H 6. SpO2 monitoring 7. **Steroid on admission** - **Dexamethasone PO/IM** 0.6mg/kg - **Nebulised Budesonide (Pulmicort)** 2mg (consider in children with severe hypoxia, persistent vomiting, respiratory distress) 8. **Nebulised adrenaline** 1:1000 0.5ml/kg (max 5ml) for temporary relief (effects subside in 2 hours) 9. To ICU if progressive deterioration / signs of severe obstruction Investigations (**only when patient stable**): 1. Blood culture 2. Blood gas, RFT 3. Lateral XR neck 4. NPA x viral IF Recurrent court / slow to resolve croup —> consult ENT for airway evaluation (e.g. subglottic stenosis)

Question 32

Acute bronchiolitis

Answer 32

- Occurs in infants under **2 yo** - Watch out for complications e.g. **apnea** in young infants (esp. RSV bronchiolitis) DDx: - **Viral-induced wheeze** - **Early-onset asthma** (if have persistent wheeze without crackles / recurrent episodic wheeze / personal or family history of atopy) Common causative agents: - **RSV** - **Human metapneumovirus** - **Rhinovirus** - **Parainfluenza virus** - **Adenovirus** S/S: - Child with **coryzal prodrome** lasting 1-3 days, followed by —> **Persistent cough + Tachypnea + Wheeze / Crackles** - Fever may not be present (30% afebrile) Investigations: 1. CBC + D/C 2. NPA x Viral IF 3. CXR 4. Capillary blood gas (consider in children with severe respiratory distress) Management (Supportive): 1. **DAT / NG / IV isotonic fluid** for infants who cannot maintain oral hydration / NPO with IV isotonic fluid (if in significant respiratory distress) 2. **AR/RR Q1-4H** 3. **SpO2 monitoring** 4. **Nasal O2** to keep SpO2 >92% (High flow nasal cannula) 5. **Nebulised hypertonic saline** 6. **Antibiotics for secondary bacterial pneumonia** (high fever / persistent focal crackles) 7. Explore + counsel caregivers about environmental tobacco smoke + smoking cessation Note: - **No routine use of salbutamol**: consider in patients with suspicion of **reactive airway component**, reassess for response for continuing treatment - **IV MgSO4 no benefit and maybe harmful** - **Systemic steroid not recommended** - **Chest physiotherapy not recommended**