Cough, barking
Cough, barking: Excerpt from Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series
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. Croup syndrome is most common in boys. It’s most prevalent in the fall and may recur.
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.
Act Now: When a child presents with barking cough, quickly evaluate his respiratory status. Then take his vital signs. Stay particularly alert for tachycardia and signs of hypoxemia. Also, check for a decreased level of consciousness. Try to determine if the child has been playing with a small object that he may have aspirated.
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 respirations, which 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.
Assessment
History
Determine when the barking cough began and other associated signs and symptoms. Determine when the child first appeared to be ill and ask if there have been previous episodes of croup syndrome.
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 high fever of sudden onset. An upper respiratory tract infection typically is followed by laryngotracheobronchitis.
Physical examination
Assess the respiratory system, noting rate and pattern of respirations. Assess the patient for signs of hypoxia. Stay alert for signs of airway obstruction (nasal flaring, sternal retraction, stridor).
Pediatric pointers
In children, respiratory status and airway maintenance can disintegrate rapidly. In children who are too young to speak, close observation is of utmost importance.
Geriatric pointers
A barking cough is generally not seen in elderly patients.
Medical causes
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 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.
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 low to moderate fever, runny nose, poor appetite, and infrequent cough. When the infection descends into the laryngotracheal area, 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 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.
Nursing 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 (racemic epinephrine) and a steroid should be considered.
Be sure to observe the child frequently, and monitor the oxygen level if used. 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.
Patient teaching
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 outdoors (properly dressed) to breathe cold night air.
Book Source Details
- Book Title: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series
- Author(s): Springhouse
- Year of Publication: 2007
- Copyright Details: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, Copyright © 2007 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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