CROUP

INFECTIOUS / SPASMODIC CROUP

Definition

 Croup, or laryngotracheobronchitis, is a type of respiratory infection typically

caused by a virus. The infection results in swelling inside the trachea which
interferes with normal breathing and produces a "barking" cough, stridor, and a
hoarse voice. Fever and rhinorrhea may also be present.
 Croup is typically caused by influenza and parainfluenza viruses and is rarely a
bacterial infection. Croup is primarily a clinical diagnosis. Consideration of other
potentially life-threatening causes of stridor, such as epiglottitis or an airway
foreign body, must be ruled out first.
 Immunization against influenza and diphtheria can reduce the risk of croup.

*Croup affects mainly children aged 6 mo to 3 yr.

Etiology and Risk Factors
Etiology

 Croup can be further defined to include acute laryngotracheitis, bacterial tracheitis,

spasmodic croup, laryngeal diphtheria, laryngotracheobronchitis, and
laryngotracheobronchopneumonitis. Its etiology is most commonly viral, with
some cases caused by bacteria.
Etiology

Viral
 Parainfluenza virus most commonly causes viral croup or acute laryngotracheitis,
primarily types 1 and 2.
 Other causes include influenza A and B, measles, adenovirus, and respiratory
syncytial virus (RSV).
 Spasmodic croup is caused by viruses that also cause acute laryngotracheitis, but
lack signs of infection.
Etiology

Bacterial
 Bacterial croup is divided into laryngeal diphtheria, bacterial tracheitis,
laryngotracheobronchitis, and laryngotracheobronchopneumonitis.
 Laryngeal diphtheria is caused by Corynebacterium diphtheriae. Bacterial
tracheitis, laryngotracheobronchitis, and laryngotracheobronchopneumonitis
typically begin as viral infections which worsen due to secondary bacterial
growth.
 The common bacterial causes are Staphylococcus aureus, Streptococcus
pneumoniae, Hemophilus influenzae, and Moraxella catarrhalis.
Risk Factors

 Seasonal variation; with the highest incidence in late autumn, however the
condition can occur all year round.
 Viral infection; 75% of all cases are the result of infection with
parainfluenza virus, most commonly type I. Other causes
include respiratory syncytial virus (RSV), metapneumovirus, influenza A
and B, adenovirus, and mycoplasma.
 Prematurity
 Young age (2% of children develop croup annually and it is a common
cause of airway obstruction. Children aged from 6 to 36 months are most
commonly affected, with most of those children being between 1 and 2
years of age.)
 Asthma, specifically for spasmodic croup.
Signs and Symptoms
Signs and Symptoms

 A barking, often spasmodic, cough and hoarseness then occur, commonly

at night
 Inspiratory stridor
The child may awaken at night with:
 Respiratory distress
 Tachypnea
 Retractions
In severe cases:
 Cyanosis with increasingly shallow respirations may develop as the child
tires.
Signs and Symptoms

 The obvious respiratory distress and harsh inspiratory stridor are the most
dramatic physical findings. Auscultation reveals prolonged inspiration and
stridor. Crackles also may be present, indicating lower airway involvement.
Breath sounds may be diminished with atelectasis.
 Fever is present in about half of children. The child’s condition may seem
to have improved in the morning but worsens again at night.
 Recurrent episodes are often called spasmodic croup. Allergy or airway
reactivity may play a role in spasmodic croup, but the clinical
manifestations cannot be differentiated from those of viral croup. Also,
spasmodic croup usually is initiated by a viral infection; however, fever is
typically absent.
Infectious and Spasmodic Croup
Infectious Croup

 Infectious croup is caused by an infection with a virus, bacterium or other

germ. In the United States, most cases of croup are caused by a virus.
These infections usually occur in the fall and winter when people spend
more time indoors.
 Under these conditions, the virus spreads easily through coughing and
sneezing.
 Once the virus enters the body, it usually begins to attack the upper parts
of the breathing system. For this reason, a child with croup may first
complain of cold symptoms. These may include a runny nose or nasal
congestion. The child also may have a low-grade fever or a mild sore
throat.
 Later, the virus spreads farther down the throat. The linings of the voice
box and windpipe become red, swollen, narrowed and irritated. This
triggers hoarseness, a barking cough, and loud, raspy breathing (stridor).
Infectious Croup Signs and
Symptoms
Among the few who do develop more severe forms of the illness, symptoms
can include:
 Breathing faster than normal
 Having difficulty breathing
 Flaring nostrils
 An abnormal sucking in of the chest and abdominal muscles (retractions)
as the child struggles to take a breath
 Unusual restlessness or agitation
 A bluish color of the skin, especially at the lips and fingernails
Infectious Croup Signs and
Symptoms
 Children with infectious croup often have a low-grade fever and mild cold
symptoms before a cough begins. In many cases, the sick child also has a
history of being exposed to a family member, friend or classmate with a
cough, runny nose or other signs of a respiratory infection.
 Most children with infectious croup are mildly ill and do not develop
significant breathing problems.
Spasmodic Croup

 Spasmodic croup is very similar to infectious croup. It can be triggered by

infection, but it isn't caused by infection. It tends to run in families, and may
be triggered by an allergic reaction.
 Spasmodic croup tends to come on suddenly, without fever. Sometimes it
can be hard to tell spasmodic croup from infectious croup.
 Infectious croup is most common in children younger than age six.
Spasmodic croup usually affects children who are between three months
and three years old. Before the age of three months, a child's risk of either
type of croup is fairly low.
Spasmodic Croup Signs and
Symptoms
 A child with spasmodic croup often looks fairly healthy before coughing
starts. Episodes of cough and loud, raspy breathing generally start without
warning. They typically occur in the middle of the night.
 These symptoms often will pass if the child is carried into cool night air or
taken into a steamy bathroom.
 Symptoms from spasmodic croup usually improve within a few hours.
However, it is common for the symptoms to reappear several nights in a
row.
Pathophysiology
Croup Pathophysiology
Pathophysiology

 The infection causes inflammation of the larynx, trachea, bronchi,

bronchioles, and lung parenchyma. Obstruction caused by swelling and
inflammatory exudates develops and becomes pronounced in the
subglottic region. Obstruction increases the work of breathing; rarely, tiring
results in hypercapnia. Atelectasis may occur concurrently if the
bronchioles become obstructed.
Diagnostics
Diagnostics

 Clinical presentation (eg, barking cough, inspiratory stridor)

 Anteroposterior (AP) and lateral neck x-rays as needed
Diagnostics

 Diagnosis of croup is usually obvious by the barking nature of the cough.

Similar inspiratory stridor can result from epiglottitis, bacterial tracheitis,
airway foreign body, diphtheria, and retropharyngeal abscess. Epiglottitis,
retropharyngeal abscess, and bacterial tracheitis have a more rapid onset
and cause a more toxic appearance, odynophagia, and fewer upper
respiratory tract symptoms. A foreign body may cause respiratory distress
and a typical croupy cough, but fever and a preceding URI are absent.
Diphtheria is excluded by a history of adequate immunization and is
confirmed by identification of the organism in viral cultures of scrapings
from a typical grayish diphtheritic membrane.
Diagnostics

 If the diagnosis is unclear, patients should have AP and lateral x-rays

of the neck and chest; subepiglottic narrowing (steeple sign) seen
on AP neck x-ray supports the diagnosis. Seriously ill patients, in
whom epiglottitis is a concern, should be examined in the operating
room by appropriate specialists able to establish an airway. Patients
should have pulse oximetry, and those with respiratory distress should
have ABG measurement.
 Consider primary or secondary bacterial etiology if a patient is not
responding to standard treatments.
Diagnostics

 The most commonly used system for classifying the severity of croup
is the Westley Score although it is not commonly used in clinical
practice. The Westley Score is the sum of points assigned for five
factors: level of consciousness, cyanosis, stridor, air entry, and
retractions.
Diagnostics

 Less than or equal to 2 indicates mild croup (barking cough and

hoarseness, but no stridor at rest). 3 to 5 indicates moderate croup
(easily heard stridor but with few other signs). 6 to 11 indicates
severe croup (obvious stridor but also marked chest wall indrawing).
More than or greater than 12 indicates impending respiratory failure
(barking cough and stridor may no longer be prominent at this
stage).
 More than 85% of children present with mild disease; severe croup is
rare (< 1%).
Treatment
Treatment

Keep the patient calm. Steroids typically are prescribed, and epinephrine
is used in severe cases. Patients with diminished oxygen saturation should
receive supplemental oxygen. Moderate to severe cases may require
longer periods of observation or hospitalization.
Oxygen
 Deliver oxygen by "blow-by" administration as it causes less agitation
than the use of a mask or nasal cannula.
Intubation
 Approximately 0.2% of children require endotracheal intubation for
respiratory support.
 Use the tube that is a one-half size smaller than normal for age/size of
the patient to account for airway narrowing due to swelling and
inflammation.
Treatment

Steroids
 Corticosteroids, such as dexamethasone and budesonide improve
outcomes in children with croup. However, response time is 6 to 8
hours after administration.
 Administration may be oral, by injection, or by mouth. Single dose
administration has been shown to be as effective as multi-dose
regimens.
 Dexamethasone at a dose of 0.15 mg/kg, 0.3 mg/kg, and 0.6 mg/kg
all appear to be equally effective.
Treatment

Epinephrine
 For moderate to severe cases, nebulized racemic epinephrine can
improve symptoms, but the benefits may wear off after 2 hours.
Current recommendations advocate for a prolonged period of
observation in patients receiving racemic epinephrine. If symptoms
do not worsen after 2 to 4 hours of observation, consider discharge
home with close follow-up.
Treatment

Hot Steam
 Studies have not demonstrated a significant improvement with the
administration of inhaled hot steam or humidified air.
Cough Medicine
 Cough medicines, which usually contain dextromethorphan or
guaifenesin, are discouraged.
Heliox
 There is little evidence to support the routine use of heliox in the
treatment of croup.
Treatment

Antibiotics
 Croup is most commonly a viral disease. Antibiotics are reserved for
cases when primary or secondary bacterial infection is suspected.
 In cases of secondary bacterial infection, vancomycin and
cefotaxime are recommended.
 In severe cases associated with influenza A or B, antiviral
neuraminidase inhibitors may be used.
Treatment

Most children recover without medical treatment.The condition can be

distressing and parents should try to keep the child calm.
 Sitting upright or carrying the child in cool fresh air can aid
breathing.
 Plenty of cool drinks will prevent dehydration.
 If the child has a fever, paracetamol liquid (Calpol or Disprol, for
example) or ibuprofen should be given.
 The child’s clothing can be removed if the room is warm.
 Cough medicines that cause drowsiness should be avoided.
 The child should avoid smoky environments.
Nursing Management
Nursing Management

 Humidified air. Cool mist from a humidifier and/or sitting with the
child in a bathroom (not in the shower) filled with steam generated
by running hot water from the shower, help minimize symptoms.
 Antipyretics. Treat fever with an antipyretic such as acetaminophen
or ibuprofen.
 Fluid intake. Encourage oral intake, and frozen juice popsicles also
can be given to ease throat soreness.
Nursing Management

 Education on smoking. Educate caregivers to avoid smoking in the

home; smoke can worsen a child’s cough.
 Head elevation. Keep the child’s head elevated; an infant can be
placed in a car seat; a child may be propped up in bed with an
extra pillow; and pillows should not be used with infants younger
than 12 months of age.
Nursing Management

 Decreasing anxiety. Young children should be kept as comfortable

as possible, allowing him or her to remain in a parent’s arms and
avoiding unnecessary painful interventions that may cause
agitation, respiratory distress, and lead to increased oxygen
requirements; persistent crying increases oxygen demands, and
respiratory muscle fatigue can worsen the airway obstruction.
 Vital signs monitoring. Concurrently, careful monitoring of heart rate
(for tachycardia), respiratory rate (for tachypnea), respiratory
mechanics (for sternal wall retractions), and pulse oximetry (for
hypoxia) are important.
Nursing Management

 Cool mist administration. Historically, cool mist administration was

the mainstay of treatment for croup; hospitals had “croup rooms”
filled with cool mist; theoretically, mist moistens airway secretions,
decreases their viscosity, and soothes the inflamed mucosa.
CROUP
INFECTIOUS / SPASMODIC CROUP