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Croup - Causes, Symptoms and Treatment

Croup is a severe inflammation and obstruction of the upper airway and can occur as acute laryngotracheobronchitis (most common), laryngitis, and acute spasmodic laryngitis; it must always be distinguished from epiglottitis. It is a childhood disease affecting boys more often than girls (typically between ages 3 months and 3 years) that usually occurs during winter months. Up to 15% of patients have a strong family history of croup. Recovery is usually complete.

Causes of Croup

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, diphtheria, and mycoplasma) account for the rest.

Signs and Symptoms of Croup

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, barking, seal-like cough. These symptoms may last only a few hours or persist for a day or two.

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:

In laryngotracheobronchitis, the symptoms 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, diffrusely decreased breath sounds, expiratory bronchi, and scattered crackles.

Laryngitis, which results from vocal cord edema, 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 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 often awakens 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 one or two nights.

Diagnosis of Croup

The clinical features are very characteristic so that the diagnosis should be suspected immediately. When bacterial infection is the cause, throat cultures may identify organisms and their sensitivity to antibiotics as well as rule out diphtheria. A posterior-anterior X-ray of the chest may reveal narrowing at the upper airway (steeple sign). Laryngoscopy may reveal inflammation and obstruction in epiglottal and laryngeal areas.

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

Treatment for Croup

For most of the children suffering from 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.

Special Consideratians and Prevention Tips for Croup

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

2. 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.

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

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

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

6. Isolate patients suspected of having RSV and parainfluenza infections, if possible. Wash your hands carefully before leaving the room to avoid transmission to other children, particularly infants. Instruct parents and others involved in the care of these children to take similar precautions.

7. Control fever with sponge baths and antipyretics. Keep a hypothermia blanket on hand for temperatures above 102° F (38.9° C). Watch for seizures in infants and young children with high fevers. Give I.V. antibiotics as necessary.

8. 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 in swallowing.

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

10. Maintain a calm, quiet environment and offer reassurance. Explain all procedures and answer any questions.

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