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3 Ways to Distinguish Coughs

All coughs are not created equal.

We know this, right? I mean, some kids cough so loud and hard that you’re fairly sure part of their lungs will come up. Others seem like they need a firm pat on the back and a lesson in “just cough it up already.” And there’s everything in between. As for my own kids, I have the two extremes. One child seems only able to muster up what I’d term as “half a cough,” and I feel compelled to cough myself after I hear the lame attempt. The other one tests my psychological stability with an ongoing cough that lasts for days and reverberates throughout the entire house.

So how do I distinguish various types of coughs and determine which ones are concerning?

And how do I handle the situation of “her cough is really loose and keeps getting worse?” Because this is what I see often in my practice. Allow me to share my classification scheme here in the hopes that it will provide some insight should you find yourself hearing that dreadful noise from your child’s room late one night.

First, there’s the croupy cough that always gets my attention.

These are the kids who sound like seals barking at the National Aquarium. It’s such a distinctive sound that once you hear it, you’ll never forget it. Hearing a croupy cough always makes me nervous because croup can potentially cause respiratory distress and compromise. When it’s accompanied by noisy breathing called stridor, it can be a true emergency requiring supplemental oxygen, breathing treatments, and even hospitalization.

However, in many cases, a croupy cough can be simply managed by cool, humid air, either from sitting in a steamy bathroom, spending some time breathing the outdoor air, or breathing the cold air standing in front of an open freezer. Croup is a viral infection, so if symptoms are not causing respiratory distress, time and supportive care are in order.

Another way to describe a cough is to use the word ‘tight’.

A tight cough is typically not productive of any mucus and doesn’t “rumble” in the chest. It almost sounds like a “wheezy” cough.Tthat’s because this cough is often associated with asthma or similar conditions that cause wheezing, like bronchiolitis, a viral infection of the lower, smaller diameter airways. For children with asthma, sometimes that tight cough is all I hear. They need treatment with aerosolized bronchodilators and oral anti-inflammatory steroid medicines to help their breathing. These medicines don’t help most children with viral bronchiolitis. These kids just need time and supportive care to recover, but some do require supplemental oxygen and hydration support.

When I hear a tight cough, I can get some more information from listening to the lungs. If there is wheezing on my exam but only heard on one side in one lung field and the patient is a younger child, I get concerned about an aspirated foreign body into the lungs. An inhaled piece of popcorn or even a small bead or toy part can obstruct a segment of the airway and cause focal, isolated wheezing.

An x-ray with 2 views, one with the child lying on one side, and then the other, can help increase or decrease the likelihood of this situation. If suspicion of an aspirated foreign body is high, then the child needs a study called a bronchoscopy in the operating room. During this procedure, a physician introduces a scope into the lung to look for a possible object that is stuck there. And then removed if so.

But by far what seems to be the most difficult to handle cough for parents is the loose cough.

I know it is for me. This one is a little more tricky to decipher. A loose cough often means that it is also productive, which of course opens up the can of worms of “what color was the mucus?” While green/yellow mucus doesn’t always indicate pneumonia, when there’s a loose cough I want to make absolutely sure that there isn’t one going on. Especially in the presence of fever.

But just as often as not, fever and a loose, junky cough that echoes throughout the tri-state area can be caused by a viral upper respiratory infection as well as pneumonia. The lung exam can help differentiate between the two.

When there are crackly noises heard through the stethoscope, especially when they are on one side and don’t go away with coughing, then I lean more towards pneumonia as opposed to a viral URI. Clear lungs are reassuring regardless of the sound of the cough. The bottom line is that a loose cough does not automatically mean that a child has pneumonia.

What does raise my index of suspicion?

A toxic appearing child who is working so hard to breathe that (s)he can’t adequately oxygenate or hydrate, or a cough that seemed to get better and then got worse, or any extra sounds while breathing at rest. Beyond that, understanding that there are different types of cough and that, when considered in isolation, they aren’t always perfectly diagnostic but the differences can help sort out the underlying cause to a certain degree.

My advice? Pay attention to the cough nuances but don’t always hook your star to a specific diagnosis if that cough sounds rattle-y and kind of loose. Just make sure you get it checked out.

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About the Expert

headshot of Dr. Christina Johns

Dr. Christina Johns is a nationally recognized pediatric emergency physician and Senior Medical Advisor at PM Pediatric Care. An official spokesperson for the American Academy of Pediatrics, she is board-certified in both pediatrics and pediatric emergency medicine. With extensive media experience, the proud mom of two teenagers shares over 20 years of pediatric expertise with patients and families everywhere. Follow Dr. Johns for more insights on children’s health!