What is the treatment for a patient presenting with a barking (honking) cough?

Honking Cough: Diagnosis and Treatment

Critical First Step: Rule Out Organic Causes Before Labeling as Functional

A honking or barking cough should NOT be used to diagnose or exclude psychogenic/habit/tic cough, and you must first systematically evaluate and treat all common organic causes of cough before considering a functional diagnosis. 1

Differential Diagnosis by Age and Clinical Context

In Children: Croup is the Primary Consideration

• Viral croup presents with a barking cough, hoarse voice, stridor, and variable respiratory distress, typically following upper respiratory symptoms with low-grade fever and coryza 2, 3, 4
• Croup is caused most commonly by parainfluenza virus (types 1-3) and accounts for up to 15% of pediatric emergency department visits for respiratory disease 2
• The barking/honking quality of cough in croup is characteristic but can also occur with tracheomalacia 1

In Adults and Children: Pertussis (Whooping Cough)

• When cough lasting ≥2 weeks is accompanied by paroxysms, post-tussive vomiting, and/or an inspiratory whooping sound, diagnose Bordetella pertussis infection unless another diagnosis is proven 1
• The "honking" quality can be part of the paroxysmal coughing pattern of pertussis 1

Functional Cough Disorders (Diagnosis of Exclusion Only)

• The presence of a barking or honking cough character should NOT be used to diagnose or exclude psychogenic cough, habit cough, or tic cough 1
• These diagnoses can only be made after extensive evaluation ruling out tic disorders, Tourette syndrome, and all organic causes, AND only if cough improves with specific behavioral or psychiatric therapy 1

Treatment Algorithm

For Suspected Croup (Children)

Immediate treatment with corticosteroids is indicated for all severity levels:

• Administer dexamethasone 0.15-0.60 mg/kg orally as a single dose (most commonly 0.15 mg/kg is effective) 2, 3, 4
• For moderate-to-severe croup (stridor with intercostal retractions), add nebulized epinephrine 2, 4
• Nebulized budesonide 2 mg is an alternative for children who cannot tolerate oral dexamethasone 3, 4
• Humidification therapy has NOT been proven beneficial and should not be relied upon 2
• Most cases resolve within 2 days; only 1-8% require hospitalization 2

For Suspected Pertussis

Early antibiotic treatment is critical:

• Administer a macrolide antibiotic and isolate the patient for 5 days from treatment start 1
• Early treatment within the first few weeks diminishes coughing paroxysms and prevents disease spread 1
• Treatment beyond the first few weeks may be offered but response is unlikely 1
• Confirm diagnosis with nasopharyngeal culture (gold standard) or paired acute/convalescent sera 1
• Do NOT use long-acting β-agonists, antihistamines, corticosteroids, or pertussis immunoglobulin—there is no evidence of benefit 1

For Chronic Cough with Honking Quality (After Ruling Out Acute Causes)

Follow systematic evaluation protocol:

1. Obtain chest radiograph immediately to exclude pneumonia, structural abnormalities, masses, or interstitial disease 5

2. Evaluate and treat the three most common causes sequentially 5:

   • Upper airway cough syndrome (UACS): Trial first-generation antihistamine-decongestant combination for 1-2 weeks 5
   • Asthma: Consider spirometry with bronchodilator response; trial of asthma therapy (response within 1 week, complete resolution may take 8 weeks) 5
   • GERD: High-dose PPI therapy with dietary/lifestyle modifications for 8-12 weeks 5

3. Only after adequate therapeutic trials of all common causes have failed, consider advanced testing (HRCT chest, 24-hour pH monitoring, bronchoscopy) 5

4. For truly refractory unexplained cough, consider gabapentin (300 mg daily, escalating to maximum 1,800 mg daily) or multimodality speech pathology therapy 5

Critical Pitfalls to Avoid

• Never diagnose psychogenic/habit cough based solely on honking quality or absence of nighttime cough—these features occur in multiple organic diseases including bronchiectasis, GERD, and postnasal drip 1
• Do not delay corticosteroid treatment in children with croup—benefits clearly outweigh risks, and treatment decreases symptoms and hospitalization need 2, 3
• Do not use antibiotics for most acute cough—they are not indicated except for confirmed pertussis or bacterial pneumonia 6
• In pertussis, do not waste time with symptomatic treatments (β-agonists, steroids, antihistamines)—only macrolide antibiotics have proven benefit 1