Croup

Croup: Excerpt from Handbook of Diseases

A severe inflammation and obstruction of the upper airway, croup can occur as acute laryngotracheobronchitis (most common), laryngitis, and acute spasmodic laryngitis. It must always be distinguished from epiglottitis.

Croup is a childhood disease affecting boys more commonly than girls (typically between age 3 months and 3 years) that usually occurs during the winter. Recovery is usually complete.

Causes

Croup usually results from a viral infection. Parainfluenza viruses cause two-thirds of such infections; adenoviruses, respiratory syncytial virus (RSV), influenza and measles viruses, and bacteria (pertussis and diphtheria) account for the rest.

Signs and symptoms

The onset of croup usually follows an upper respiratory tract infection. Clinical features include inspiratory stridor, hoarse or muffled vocal sounds, varying degrees of laryngeal obstruction and respiratory distress, and a characteristic sharp, barklike cough. These symptoms may last only a few hours or persist for 1 to 2 days.

As croup progresses, it causes inflammatory edema and, possibly, spasm, which can obstruct the upper airway and severely compromise ventilation. Each form of croup has additional characteristics.

Laryngotracheobronchitis

The symptoms of this form of croup seem to worsen at night. Inflammation causes edema of the bronchi and bronchioles and increasingly difficult expiration, which frightens the child. Other characteristic features include fever, diffusely decreased breath sounds, expiratory rhonchi, and scattered crackles.

Laryngitis

Resulting from vocal cord edema, laryngitis is usually mild and produces no respiratory distress except in infants. Early indications include a sore throat and cough that, rarely, may progress to marked hoarseness, suprasternal and intercostal retractions, inspiratory stridor, dyspnea, diminished breath sounds, and restlessness. In later stages, severe dyspnea and exhaustion may result.

Acute spasmodic laryngitis

This form of croup affects children between ages 1 and 3, particularly those with allergies and a family history of croup. It typically begins with mild to moderate hoarseness and nasal discharge, followed by the characteristic cough and noisy inspiration (which usually awaken the child at night), labored breathing with retractions, rapid pulse, and clammy skin.

The child understandably becomes anxious, which may lead to increasing dyspnea and transient cyanosis. These severe symptoms diminish after several hours but reappear in a milder form on the next night or two.

Diagnosis

When bacterial infection is the cause, throat cultures may help with identifying organisms and their sensitivity to antibiotics as well as rule out diphtheria. A neck X-ray may show areas of upper airway narrowing and edema in subglottic folds; laryngoscopy may reveal inflammation and obstruction in epiglottal and laryngeal areas.

When evaluating the patient, consider foreign-body obstruction (a common cause of croupy cough in young children) as well as masses and cysts.

Treatment

For most children with croup, home care with rest, cool humidification during sleep, and antipyretics, such as acetaminophen, relieve symptoms. However, respiratory distress that interferes with oral hydration requires hospitalization and parenteral fluid replacement to prevent dehydration.

If bacterial infection is the cause, antibiotic therapy is necessary. Oxygen therapy may also be required. Remember: Racemic epinephrine provides temporary relief of stridor. Also, nebulized or parenteral glucocorticoids provide relief in many cases.

Special considerations

❑ Monitor pulse oximetry, and monitor the patient for airway obstruction, which requires endotracheal intubation.

❑ Monitor patient for rebound stridor and respiratory distress, especially if racemic epinephrine is used.

❑ Monitor and support respiration, and control fever. Because croup is so frightening to the child and his family, also provide support and reassurance.

❑ Carefully monitor cough and breath sounds, hoarseness, severity of retractions, inspiratory stridor, cyanosis, respiratory rate and character (especially prolonged and labored respirations), restlessness, fever, and cardiac rate.

❑ Keep the child as quiet as possible, but avoid sedation, which can depress respiration.

❑ If the patient is an infant, position him in an infant seat or prop him up with a pillow.

❑ Place an older child in high Fowler’s position. If an older child requires a cool-mist tent to help him breathe, explain why it’s needed.

❑ Isolate patients suspected of having RSV and parainfluenza infections, if possible. Instruct parents and others involved in the care of these children to wash hands thoroughly to prevent spreading the disorder.

❑ Control fever with sponge baths and an antipyretic. Keep a hypothermia blanket on hand in case the patient’s temperatures goes above 102° F (38.9° C). Watch for seizures in infants and young children with high fevers. Give an I.V. antibiotic as necessary.

Clinical tip  Relieve sore throat with soothing, water-based ices, such as fruit sherbet and ice pops. Avoid thicker, milk-based fluids if the child is producing heavy mucus or has great difficulty swallowing.

❑ Apply petroleum jelly or another ointment around the nose and lips to soothe irritation from nasal discharge and mouth breathing.

❑ To relieve croupy spells, tell parents to carry the child into the bathroom, shut the door, and turn on the hot water. Breathing in warm, moist air quickly eases an acute spell of croup. Suggest the use of a cool-mist humidifier (vaporizer).

❑ Warn parents that ear infections and pneumonia are complications of croup, which may appear about 5 days after recovery. Stress the importance of reporting earache, productive cough, high fever, or increased shortness of breath immediately.

Book Source Details

• Book Title: Handbook of Diseases
• Author(s): Springhouse
• Year of Publication: 2003
• Copyright Details: Handbook of Diseases, Copyright © 2003 Lippincott Williams & Wilkins.

More About Croup

• Back to disease: Croup: Introduction
• Next Book Extract About Croup: Cough, barking (Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Handbook of Diseases Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2003 ISBN: 1-58255-266-5

 » Next page: Cough, barking (Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

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