Cough, barking

Cough, barking: Excerpt from Handbook of Signs & Symptoms (Third Edition)

Resonant, brassy, and harsh, a barking cough is part of a complex of signs and symptoms that characterize croup syndrome, a group of pediatric disorders marked by varying degrees of respiratory distress. It's most prevalent in the fall and may recur in the same child.

GENDER CUE: Croup syndrome is more common in boys than in girls.

A barking cough indicates edema of the larynx and surrounding tissue. Because children's airways are smaller in diameter than those of adults, edema can rapidly lead to airway occlusion — a life-threatening emergency.

Emergency interventions

Check for cyanosis in the lips and nail beds. Observe the patient for sternal or intercostal retractions or nasal flaring. Next, note the depth and rate of his respirations; they may become increasingly shallow as respiratory distress increases. Observe the child's body position. Is he sitting up, leaning forward, and struggling to breathe? Observe his activity level and facial expression. As respiratory distress increases from airway edema, the child will become restless and have a frightened, wide-eyed expression. As air hunger continues, the child will become lethargic and difficult to arouse.

If the child shows signs of severe respiratory distress, try to calm him, maintain airway patency, and provide oxygen. Endotracheal intubation or a tracheotomy may be necessary.

History and physical examination

Ask the child's parents when the barking cough began and what other signs and symptoms accompanied it. When did the child first appear to be ill? Has he had previous episodes of croup syndrome? Did his condition improve upon exposure to cold air?

Spasmodic croup and epiglottiditis typically occur in the middle of the night. The child with spasmodic croup has no fever, but the child with epiglottiditis has a sudden high fever. An upper respiratory tract infection typically is followed by laryngotracheobronchitis.

Medical causes

Aspiration of foreign body.

Partial obstruction of the upper airway first produces sudden hoarseness, and then a barking cough and inspiratory stridor. Other effects of this life-threatening condition include gagging, tachycardia, dyspnea, decreased breath sounds, wheezing and, possibly, cyanosis.

Epiglottiditis.

 Epiglottiditis is a life-threatening disorder that has become less common since the use of influenza vaccines. It occurs nocturnally, heralded by a barking cough and a high fever. The child is hoarse, dysphagic, dyspneic, and restless and appears extremely ill and panicky. The cough may progress to severe respiratory distress with sternal and intercostal retractions, nasal flaring, cyanosis, and tachycardia. The child will struggle to get sufficient air as epiglottic edema increases. Epiglottiditis is a true medical emergency.

Laryngotracheobronchitis (acute).

Also known as viral croup, laryngotracheobronchitis is most common in children between ages 9 and 18 months and usually occurs in the fall and early winter. It initially produces a low to moderate fever, a runny nose, a poor appetite, and an infrequent cough. When the infection descends into the laryngotracheal area, a barking cough, hoarseness, and inspiratory stridor occur.

As respiratory distress progresses, substernal and intercostal retractions occur along with tachycardia and shallow, rapid respirations. Sleeping in a dry room worsens these signs. The patient becomes restless, irritable, pale, and cyanotic.

Spasmodic croup.

 Acute spasmodic croup usually occurs during sleep with the abrupt onset of a barking cough that awakens the child. Typically, he doesn't have a fever, but may be hoarse, restless, and dyspneic. As his respiratory distress worsens, the child may exhibit sternal and intercostal retractions, nasal flaring, tachycardia, cyanosis, and an anxious, frantic appearance. The signs usually subside within a few hours, but attacks tend to recur.

Special considerations

Don't attempt to inspect the throat of a child with a barking cough unless intubation equipment is available. If the child isn't in severe respiratory distress, a lateral neck X-ray may be done to visualize epiglottal edema; a negative X-ray doesn't completely rule out epiglottal edema. A chest X-ray may also be done to rule out lower respiratory tract infection. Depending on the child's age and degree of respiratory distress, oxygen may be administered. Rapid-acting epinephrine and a steroid should be considered.

Make sure to observe the child frequently, and monitor the oxygen level. Provide the child with periods of rest with minimal interruptions. Maintain a calm, quiet environment and offer reassurance. Encourage the parents to stay with the child to help alleviate stress.

Teach the parents how to evaluate and treat recurrent episodes of croup syndrome. For example, creating steam by running hot water in a sink or shower and sitting with the child in the closed bathroom may help relieve subsequent attacks. The child may also benefit from being brought outside (properly dressed) to breathe cold night air.

Book Source Details

• Book Title: Handbook of Signs & Symptoms (Third Edition)
• Author(s): Springhouse
• Year of Publication: 2006
• Copyright Details: Handbook of Signs & Symptoms (Third Edition), Copyright © 2006 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Handbook of Signs & Symptoms (Third Edition) Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2006 ISBN: 1-58255-402-1

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