What type of cough has a barking quality?

Barking Cough: Causes and Clinical Significance

A barking cough is most commonly associated with croup, but can also be present in tracheomalacia, habit cough (now referred to as tic cough), and other conditions affecting the upper airway. 1, 2

Primary Causes of Barking Cough

Croup

• Characterized by a distinctive barking cough that sounds like a seal, typically accompanied by stridor, hoarse voice, and respiratory distress 1, 2
• Most commonly affects children 6 months to 6 years of age, but can occur in older children up to 15 years 3, 4
• Usually caused by parainfluenza viruses (types 1-3), with influenza viruses often causing more severe presentations 3, 5
• Symptoms typically begin like an upper respiratory infection with low-grade fever and coryza, followed by the characteristic barking cough 2, 6

Tracheomalacia

• Can present with a barking cough in children 7
• Characterized by weakness of the tracheal cartilage, leading to dynamic airway collapse 7

Tic Cough (Previously Known as Habit Cough)

• May present with a barking or honking quality 7
• Current guidelines recommend using the term "tic cough" rather than "habit cough" as it better aligns with DSM-5 terminology 7
• Core clinical features include suppressibility, distractibility, suggestibility, variability, and presence of a premonitory sensation 7

Diagnostic Considerations

Important Clinical Points

• The presence of a barking or honking cough alone is not sufficient to diagnose or exclude psychogenic or tic cough 7
• Barking cough has been reported in various conditions including bronchiectasis, gastroesophageal reflux disease, and upper airway cough syndrome (previously called postnasal drip syndrome) 7
• In children, the quality of cough can be more diagnostically useful than in adults 7

Differential Diagnosis

• When evaluating a barking cough, consider:
  • Croup (viral laryngotracheobronchitis) 1, 2
  • Tracheomalacia 7
  • Tic cough/somatic cough syndrome 7
  • Foreign body aspiration 3, 2
  • Bacterial tracheitis 3, 4
  • Epiglottitis (less common since Hib vaccination) 2, 4

Clinical Approach

Assessment

• Evaluate for signs of respiratory distress, including stridor, retractions, and altered mental status 1, 6
• Consider the age of the patient, as croup typically affects younger children but can occur in older children as well 3, 4
• Assess for fever, which is common in infectious causes like croup but not typically present in tic cough 2, 5

Common Pitfalls

• Do not use the presence or absence of night-time cough or cough with a barking character as the sole criteria to diagnose or exclude psychogenic or tic cough 7
• Avoid excessive investigations in children with suspected tic cough, as this may cause iatrogenic harm 7
• Don't assume that a barking cough in an older child or adolescent cannot be croup, as it can occur in this age group, though less commonly 3

Management Considerations

• For croup with barking cough:
  • A single dose of dexamethasone (0.15 to 0.60 mg/kg) is recommended for all patients, including those with mild disease 2, 4
  • Nebulized epinephrine should be reserved for moderate to severe cases 5, 6
• For tic cough with barking quality:
  • Behavioral therapy approaches may be beneficial 7
  • Rule out organic causes before making this diagnosis 7

By understanding the various causes of a barking cough and their clinical presentations, clinicians can more effectively diagnose and manage these conditions while avoiding unnecessary testing and treatments.