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ULY CLINIC

26 Mei 2025, 11:18:35

Barking cough

Definition and clinical relevance

A barking cough is a harsh, brassy, seal-like sound that commonly occurs in children with croup syndrome, an umbrella term encompassing a group of conditions that cause upper airway obstruction due to inflammation and edema of the larynx, trachea, and bronchi.

Differential diagnoses involving barking cough

Laryngotracheobronchitis (LTB or viral croup)
Spasmodic croup
Epiglottitis
Foreign body aspiration
Bacterial tracheitis (less common but severe)
Allergic laryngeal edema

Epidemiology

Most common in children aged 6 months to 3 years
Peaks in fall and early winter
Often follows a viral upper respiratory tract infection
More prevalent in boys than girls
Recurrent episodes are common, especially with spasmodic croup

Pathophysiology

The subglottic region of the airway is the narrowest part in children and becomes critically compromised with mucosal edema.
Viral infection or allergic reaction induces inflammation, vasodilation, and increased capillary permeability, resulting in airway narrowing, inspiratory stridor, and barking cough.
Children have smaller airway diameters and less cartilage support, making them more susceptible to obstruction.

Clinical presentation

Key Signs and Symptoms

Symptom	Significance
Barking cough	Hallmark of laryngeal involvement
Inspiratory stridor	Indicates subglottic airway narrowing
Hoarseness	Inflammation of the vocal cords
Retractions	Increased work of breathing
Nasal flaring	Sign of respiratory effort
Cyanosis	Late sign of hypoxemia
Tachycardia	May indicate hypoxia or systemic stress
Restlessness → Lethargy	Progressive respiratory failure

Positional Clue

Child may sit in a tripod position, leaning forward to optimize airflow.

Emergency evaluation and management

Initial assessment (ABCs)

Airway: Check patency, presence of stridor or gurgling
Breathing: Observe for respiratory rate, depth, effort, and symmetry
Circulation: Monitor perfusion, HR, capillary refill, skin color

Vital signs and observations

Look for tachycardia, tachypnea, SpO₂ <92%
Assess neurologic status (alertness, agitation, or lethargy)

Critical observations

Cyanosis, especially perioral or nail beds
Sternal/intercostal retractions
Drooling or refusal to lie down (suggests epiglottitis)

Major causes of barking cough in pediatrics

1. Laryngotracheobronchitis (Viral Croup)

Most common cause
Caused by parainfluenza virus, RSV, influenza A/B, adenovirus
Gradual onset after URI: nasal congestion → hoarseness → barking cough
Low-grade fever
Worse at night and in dry air

2. Spasmodic Croup

Sudden onset at night, typically without fever
Possibly allergen or GERD-related
Rapid resolution and frequent recurrences
Good response to cool air or steam

3. Epiglottitis

True medical emergency
Sudden onset with high fever, dysphagia, drooling, tripod posture
Caused by Haemophilus influenzae type B (Hib) (less common due to vaccination)
Avoid throat exam unless airway secured
Requires immediate airway management, IV antibiotics

4. Foreign body aspiration

Sudden cough, choking, stridor, localized wheeze, diminished breath sounds
Consider in toddlers with acute respiratory symptoms and no fever
Chest or neck X-ray and bronchoscopy may be required

Medical causes of Barking cough

Below ia a comprehensive table of medical causes of a barking cough, including the conditions listed above and additional relevant causes. The table outlines the mechanism/pathology, associated clinical features, and special considerations for diagnosis and management.

Condition	Mechanism/Pathology	Associated Clinical Features	Special Considerations
Aspiration of Foreign Body	Mechanical obstruction and airway irritation	Sudden onset of hoarseness, barking cough, inspiratory stridor, gagging, wheezing, decreased breath sounds, dyspnea, cyanosis	Medical emergency; requires bronchoscopy for diagnosis and removal
Epiglottitis	Inflammation and swelling of epiglottis due to bacterial infection (often H. influenzae type B)	High fever, barking cough, drooling, dysphagia, tripod positioning, inspiratory stridor, cyanosis, retractions, restlessness	True emergency; avoid throat exam unless airway secured; intubation may be needed
Laryngotracheobronchitis (Viral Croup)	Viral infection (usually parainfluenza virus) causing subglottic inflammation	Barking cough, hoarseness, inspiratory stridor, low-grade fever, rhinorrhea, poor appetite, tachypnea, cyanosis, retractions	Common in children <3 years; humidified air and steroids (e.g., dexamethasone) often effective
Spasmodic Croup	Sudden laryngeal spasm in predisposed children, often triggered by allergens or GERD	Abrupt nocturnal onset of barking cough, hoarseness, restlessness, retractions, no fever, rapid recovery	May mimic viral croup but afebrile; self-limiting, recurrences are common
Tracheomalacia	Weakness of the tracheal wall leading to airway collapse during breathing	Barking cough, noisy breathing (especially when crying or feeding), recurrent respiratory infections	Often congenital; diagnosed with bronchoscopy or dynamic airway imaging
Allergic Laryngitis	Inflammation of larynx due to allergic reaction	Barking cough, hoarseness, wheezing, nasal congestion, history of allergies or asthma	Improves with antihistamines and avoiding allergens
Laryngeal Papillomatosis	HPV-induced benign tumors in the airway	Progressive hoarseness, chronic barking cough, stridor	Requires laryngoscopy for diagnosis; may need surgical removal
Pertussis (Whooping Cough)	Bordetella pertussis infection causing paroxysmal cough	Paroxysms of coughing with inspiratory "whoop," post-tussive vomiting, possible barking quality early on	Suspect in unimmunized children; diagnosed with PCR or culture; treat with macrolides
Subglottic Stenosis	Narrowing of the airway below the vocal cords	Chronic barking cough, stridor, voice changes	Can be congenital or acquired (post-intubation); requires imaging or endoscopy
Diphtheria (laryngeal)	Corynebacterium diphtheriae infection with pseudomembrane formation	Barking cough, hoarseness, stridor, gray-white pharyngeal membrane, fever, malaise	Rare in vaccinated populations; emergency; airway obstruction risk; antitoxin and antibiotics required

Investigations

Pulse oximetry
Lateral neck X-ray ("steeple sign" in croup, "thumbprint sign" in epiglottitis)
Chest X-ray: Rule out pneumonia or foreign body
Flexible laryngoscopy or bronchoscopy: For uncertain diagnosis or suspected obstruction
CBC and CRP: If bacterial etiology suspected

Pharmacologic and supportive management

Treatment	Indication
Humidified oxygen	All patients with moderate–severe symptoms
Nebulized epinephrine	For stridor at rest; rapid temporary improvement
Dexamethasone (PO/IM/IV)	Reduces inflammation; onset in 2–3 hours; long half-life
Heliox	Severe upper airway obstruction not responding to O₂ alone
IV fluids	For patients with poor oral intake
Antibiotics	Only in bacterial causes (e.g., epiglottitis, tracheitis)

Avoid sedation and unnecessary agitation.

Special considerations

Never attempt direct throat examination in suspected epiglottitis unless in a controlled setting.
Maintain a calm environment to reduce oxygen demand.
Keep emergency airway equipment at bedside.
Monitor closely for deterioration in respiratory status.
Hospitalize patients with moderate/severe symptoms or poor response to initial therapy.
Age is crucial: Viral and spasmodic croup primarily affect toddlers, while epiglottitis typically affects unvaccinated or partially vaccinated children.
Onset and duration help distinguish between acute (e.g., aspiration) and chronic (e.g., tracheomalacia).
Presence of fever is more consistent with infectious causes.
Immunization status should be reviewed, especially for pertussis, diphtheria, and epiglottitis.

Discharge and home management

Educate caregivers on:
- Signs of respiratory distress
- Home management (steam inhalation, cool air)
- When to seek urgent care
Prescribe oral dexamethasone for continued symptom control
Advise rest, adequate hydration, and avoidance of dry environments

Complications

Airway obstruction and respiratory failure
Secondary bacterial infection (e.g., tracheitis, pneumonia)
Pulmonary edema from epinephrine overuse (rare)

References

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