Dry barking cough in a child with and without fever: treatment

In pediatric practice, such a catarrhal symptom, like dry barking cough in a child, is seen as the result of irritation of the larynx (the upper part of the respiratory tube where the vocal cords are located) and the trachea (through which the inhaled air passes into the bronchi and lungs). Cough with a sharp sound, similar to barking, without secretion of tracheobronchial secretion can occur both in normal and elevated body temperature.

Physicians recommend that parents in any case, timely contact the doctor, as in young children, such a cough can be accompanied by stenosis of the larynx and suffocation.

[1], [2], [3], [4]

Epidemiology

The prevalence of false croup with dry barking cough in different age groups is not the same: more than 50% of cases occur in two-three-year-old children, a little more often the disease develops in the first and fourth years of life. But after five years the number of cases is sharply reduced.

According to the Journal of Pediatrics and Child Health, more than 15% of cases of respiratory diseases observed in pediatric practice are acute laryngitis with airway stenosis, and the average age of patients is 18 months.

In the US, the incidence rate is five cases per hundred children of the second year of life. Although most cases occur at the end of autumn and winter, false cereals can occur throughout the year. And boys are sick more often than girls.

According to experts from the Canadian Medical Association, a false croup is diagnosed annually in more than 80,000 children (up to 5% are admitted to a hospital), and this is the second most common cause of respiratory distress in children from six months to three years old. The most common pathogen is the human parainfluenza virus (Respirovirus HPIV-1 and HPIV-3).

[5], [6], [7], [8], [9], [10], [11]

Causes of the dry barking cough in a child

The appearance of a sharp non-productive cough in children is due to a number of reasons. Perhaps the irritation of the larynx is too dry, dusty or gassed with air; A foreign object that the child is trying to cough up can get into the trachea.

But more often than not, the causes of dry barking cough in a child are associated with acute respiratory viral infection and inflammation of the throat part of the pharynx and vocal cords (ligaments) -  acute laryngitis (false croup) in children, which may also be called sublugal or obstructive laryngitis. The most typical form of false croup is acute  stenosing laryngotracheitis, which causes airway obstruction in the larynx and trachea.

It is generally accepted that acute laryngotracheitis and spasmodic croup can develop only when infected with viruses, while the attachment of a bacterial infection can lead to the further development of the disease, that is, its complications.

It is impossible to exclude the true (diphtheria) croup -  diphtheria of pharynx in children  with defeat of throat and larynx diphtheria bacillus (Corynebacterium diphtheriae). This infectious disease is accompanied by severe intoxication of the body and dry barking cough with a child's temperature of up to + 38.5 ° C, swallowing of the pharynx and its obstruction with a fibrinous film. Now - thanks to vaccination against diphtheria - this disease is recorded very rarely, although according to WHO for 2016, Ukraine was among the six countries in the world where less than 60% of the population is vaccinated.

Such pediatric cough is noted as the first signs of  whooping cough; bacterial tracheitis; caused by Mycoplasma pneumoniae respiratory mycoplasmosis; pulmonary chlamydia (causative agent - Chlamydia pneumoniae); developing respiratory allergies or bronchial asthma with wheezing during breathing and dyspnea.

Such a cough may be the presence of a cyst or papilloma in the larynx, as well as invasion with ascarids (Ascaris lumbricoides).

Less often dry barking cough without temperature in the child occurs as a result of autoimmune pathologies, for example, with Wegener's granulomatosis.

[12], [13], [14]

Risk factors

Calling key risk factors for the appearance of dry barking cough in young children - in addition to weak general and humoral immunity, frequent respiratory diseases, perinatal CNS damage, prematurity, congenital laryngeal anomalies and predisposition to allergic reactions (atopic phenotype) - otolaryngologists and pulmonologists note the morphological immaturity of the upper respiratory tract in early childhood. In particular, such anatomical and physiological features of the children's larynx and trachea predispose to the development of laryngitis and false croup, as:

• short narrow vestibule and funnel-shaped larynx;
• highly disposed and disproportionately short vocal folds;
• small diameter, softness and compliance of the cartilaginous skeleton;
• hyperexcitability closing the vocal cortex of adductor muscles.

Inflammation caused by infection and edema of the larynx and trachea (and sometimes bronchi) develop more rapidly because of the weak development of the elastic fibers in their submucosa, as well as the abundance of blood vessels and lymphoid tissue.

Also, it is necessary to take into account a certain functional inadequacy of the reflexogenic zones of the respiratory system organs and increased parasympathicotonia, characteristic for this age, when the parasympathetic part of the autonomic nervous system is more active, providing innervation of the muscular and mucous tissues of the pharynx, larynx and lungs through the branches of the vagus nerve.

Whooping cough and diphtheria are at risk of getting infected with children who do not have vaccinations against these diseases, and any child can pick up the ascaris: enough dirty hands or consumption of poorly washed vegetables.

[15], [16], [17], [18], [19]

Pathogenesis

With acute respiratory viral infection and false croup - acute laryngotracheitis in children of the first years of life - the pathogenesis of cough is caused by the defeat of the upper respiratory tract and trachea by influenza viruses, HRSV viruses, rhinovirus, coronavirus, Metapneumovirus HMPV and Adenoviridae, but in almost 70% of cases parainfluenza viruses -1, HPIV-3 and Rubulavirus HPIV-2). Bacterial laryngitis (caused by group A streptococci, Moraxella catarrhalis or Haemophilus influenzae) is extremely rare.

As with most respiratory infections, a viral infection in acute laryngotracheitis starts in the nasopharynx and extends to the larynx and trachea where it develops, since the part of the trachea below the larynx is the narrowest in the upper respiratory system of the child. There is a diffuse inflammation, erythema and limiting the mobility of the vocal cords edema of the trachea walls.

As a result, there are classic symptoms of dry barking cough in a child with pain behind the sternum, wheezing (inspiratory stridor) and hoarseness of the voice. There may be fever and rhinitis, cyanosis (cyanosis) of the skin around the mouth, retraction of the chest wall (intercostal retraction). Also characteristic is a dry barking cough at night in a child, since all the symptoms of croup often deteriorate at night and can change rapidly depending on how child is excited or calm. Often the degree of their severity depends on this - from moderate to severe (with a decrease in the lumens of the lower respiratory tract). Croup refers to life-threatening diseases.

With spasmodic croup, edema of the submucosal trachea tissue is non-inflammatory, and it is suggested that its pathogenesis is most likely allergic in nature. That is, the production of specific antibodies (IgE) to viral antigens provokes the release of histamine into the trachea, causing the onset of edema and narrowing of its lumen.

In whooping cough, the mucosa of the respiratory tract is affected by pertussis (Bordetella pertussis), which secretes several types of toxins that irritate the receptors of the mucosal epithelium and lead to an intensification of the cough reflex.

In the case of ascariasis, irritation of the respiratory tube and coughing appear due to migration of the larvae of this helminth from the intestine to the respiratory tract (with blood flow).

[20], [21], [22], [23]

Complications and consequences

A reactive inflammatory response in acute laryngotracheitis and spasmodic croup causes such consequences and complications as pharyngeal edema, airway obstruction and the development of progressive hypoxia. This condition can be life-threatening for infants and children under three years old. In Western countries, the death rate due to respiratory arrest on average does not exceed one case for every 30,000 ill children.

The further spread of acute laryngitis from the trachea to the bronchi and lungs alveoli leads to laryngotraheronchethritis and bronchopneumonitis, respectively. However, progressive obstructive disease at this level is usually the result of secondary bacterial damage.

Pertussis can also lead to the development of inflammation of the lower respiratory tract - bronchitis, bronchiolitis, pneumonia and bronchopneumonia. In addition, because of a strong cough, hernias can form, pulmonary hypertension, lung atelectasis and even a violation of their innervation at the cerebral level are possible. Acute congestive heart failure and asphyxia in whooping cough - the reason for stopping breathing and death in infants and children up to a year (in 1-2% of cases). In such situations, endotracheal intubation or intensive therapy with artificial ventilation should be performed.

A frequent consequence of an allergic dry cough is the development of obstructive bronchitis in chronic form and bronchial asthma.

[24], [25], [26]

Diagnostics of the dry barking cough in a child

Since dry barking cough in a child is a symptom, it is necessary to diagnose the diseases in which it appears.

The physical examination of the child performed by the doctor (listening to the breath, pericutaneous examination of the lungs, examination of the pharynx and pharynx) in some cases reveals cough, hoarseness, runny nose, a normal or slightly inflamed pharynx and slightly rapid breathing. The rate of progression and the degree of respiratory distress can vary significantly, which is manifested in an increase in the severity of obstruction, a significant increase in respiration, cyanosis, and tachycardia. The condition of false croup is urgent and is usually diagnosed on the basis of clinical signs with an assessment of their intensity according to the Westley scale. Further studies, such as blood tests, sowing on viral culture, are usually not needed.

Biochemical blood test, enzyme immunoassay (for antibodies) and PCR, for eosinophils; bacterial tracheitis, pulmonary chlamydia, allergy, or ascariasis. If the condition of the child does not improve with standard treatment, there is every reason to suspect pertussis, bacterial tracheitis, pulmonary chlamydia, allergy or ascaridosis.

Instrumental diagnostics - anteroposterior and lateral radiographs of the upper respiratory tract - can help with an accuracy of 93% differentiate cereals from other causes of stridor and respiratory distress, such as a foreign body, epiglottitis, or retrofaringueal / parapharyngeal abscess. You may need to visualize the airways with ultrasound or laryngoscopy. More information in the article -  Diagnosis of acute laryngitis

[27], [28], [29], [30]

Differential diagnosis

Differential diagnostics is also designed to detect congenital airway abnormalities (laryngomalacia and tracheomalacia); hypoplasia of the folds of the larynx; laryngocel, papilloma, neoplasm or hemangioma; mediastinal tumors, Ridel's thyroiditis, and others.

Treatment of the dry barking cough in a child

The etiological treatment of dry barking cough in a child is to eliminate the causes of this symptom.

In whooping cough it is important to provide increased humidity and minimize any external irritating factors so as not to provoke coughing attacks. Children of two or three years are prescribed physiotherapeutic treatment in the form of oxygen therapy, the administration of antitoxic antitussive gammaglobulin, and in more severe cases - antibiotics (groups of erythromycin, macrolides, cephalosporins). Read more -  Treatment of whooping cough

How to relieve dry barking cough in a child? Methods of treatment of acute inflammation of the trachea, as well as medications prescribed for this disease, are described in detail in the material -  Tracheitis in a child

In acute stenosing laryngitis or false croup (requiring urgent hospitalization of the child in 5-15% of cases), oxygen therapy and nebulizer inhalations with dry barking cough in a child with glucocorticosteroids - Dexamethasone (Decadron), Pulcicortum (Budesonide) or Fluticasone (Flixotide) . If necessary, GCS can be administered orally and parenterally. Also make inhalations of epinephrine - in severe cases; racemic adrenaline usually leads to a reduction in the severity of the condition for 10-20 minutes approximately the next two hours. With obstruction of the airways and the development of progressive hypoxia, endotracheal intubation is performed -  intubation of the trachea. In critical situations - with stenosis of the larynx and asphyxia - resort to intensive therapy with the use of artificial ventilation.

Since false groats are usually a viral disease, antibiotics are not needed, and the Cochrane Review of the Use of Antibiotics for Acute Laryngitis (2016) confirmed that antibacterial drugs do not do any good. However, if a secondary bacterial infection is suspected, antibiotics (Azithromycin, Vancomycin, Cefotaxime, etc.) are prescribed. In severe cases associated with influenza A or B, antiviral inhibitors of viral n-proteins can be used.

What cough medicines, with which dry cough becomes productive (with sputum discharge), what inhalations are recommended and how to correctly apply alternative treatment and herbal therapy, is described in detail in publications -  Treatment of dry cough in a child  and  Barking cough in a child

And if cough has an allergic etiology, then antihistamines are prescribed for the removal of edema (Suprastin, Tavegil, Fenistil, etc.), as well as funds for the expansion of bronchial tubes (bronchodilators). For more details see -  Allergic cough in children

Ascaride is usually taken out by Pyrantel in the form of a suspension or syrup: the drug is taken once, and the dosage is calculated by the weight of the child -10 ml per kilogram. Nausea and intestinal disorders are possible as side effects of this drug.

Prevention

To prevent diseases that cause unproductive barking cough in children, timely vaccination against diphtheria and pertussis (DTP), as well as preventing the infection of children with viral infections during the epidemic of influenza, is very important. It is also necessary to ensure the intake of all the necessary vitamins and sufficient amount of liquid in the child's body; compliance with hygiene rules and carrying out hardening procedures.

[31], [32], [33], [34], [35]

Forecast

With adequate therapy of acute stenosing laryngotracheitis or pertussis, the prognosis is favorable.

Viral croup is usually a self-limiting condition with a peak of symptoms on the second day from the manifestation of the disease (in eight cases out of ten). As a rule, cough weakens for two days, less often - throughout the week. However, the consequences in the form of development of acute inflammation of the trachea (bacterial character), pneumonia and pulmonary edema are not excluded.

[36], [37]