(Croup’s Syndrome)

Introduction
 All over the world, croup is a common upper respiratory infection of childhood, which is
easily treated if recognized and assessed properly. It can be severe respiratory failure in
children.
 It is a self-limited disease.
 Croup is a viral infection of upper respiratory tract often present in young children
characterized by barking cough, inspiratory stridor, and low-grade fever.
 Croup syndromes affects to varying degree the larynx, trachea and bronchi. However,
laryngeal involvement often dominates the clinical picture because of the voice and
breathing.
 Croup refers to inflammation of the larynx characterized by crocking cough, stridor,
hoarseness; cold and fever with increasing dyspnea, cyanosis and restlessness develop.

Definition
Croup is an upper respiratory tract infection characterized by barking cough, dyspnea, cyanosis,
restlessness, inspiratory stridor and fever, mostly caused by virus, which includes acute
epiglottitis, acute laryngitis, acute laryngotracheobronchitis and acute spasmodic cough.

Epidemiology
 An estimated 3% to 5% of children have at least one episode of croup during childhood.
 Most commonly occurs in children 6 to 36 months of age.
 It is more common in boys, with a male: female ratio of about 4:1
 Most cases occur in the fall or early winter
 Family history of croup is a risk factor for croup and recurrent croup

Acute epiglottitis
It is an acute inflammation and infection of the epiglottis – a flap at the base of tongue, which
keeps food from going to trachea. It is a medical emergency as it produces respiratory arrest.

Sign and symptoms of epiglottis

Starts with mild upper respiratory tract illness which rapidly progresses to
 High fever, difficulty in swallowing, noisy breathing (stridor)
 Severe sore throat.
 Difficulty breathing, which may improve when leaning forwards.
 Irritability and restlessness.
 Muffled or hoarse voice.
 Drooling.
 Tripod position - The child is very anxious and prefers to breathe by sitting up and
leaning forward with the mouth open and the tongue out.
Diagnosis
 Laryngoscopy- epiglottis appears angry red and swollen
 x-ray of lateral neck shows epiglottal enlargement. (conform diagnosis)
 CBC, blood culture.

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Management
 Manage respiratory arrest: when a child has respiratory arrest, the first step is to
administer humidifier oxygen .Moist air is necessary to help reduce the inflammation of
the epiglottitis. Be ready for endotracheal intubation. If endotracheal intubation is
unsuccessful, perform a tracheostomy or cricothyrotomy, these treatments should
prevent cerebral anoxia, arrest, and death.
 Pulse oximetry: Pulse oximetry is required to monitor oxygen requirements.
 Avoid unnecessary handling of child that may induce laryngeal spasm.
 Administer IV infusion to maintain body fluid.
 Antibiotics cefotaxime or ceftriaxone 100mg/kg/day.

Nursing Management
Nursing management of a child with epiglottitis include:
Nursing Assessment
Assessing a child with epiglottitis should include:
 Respiratory assessment: assess the child’s breathing, any history of injury to the throat,
breathing through the mouth, stridor, and hypoxia.
 Cardiovascular assessment: assess the child’s pulse; assess for tachycardia and a
thready pulse.
 Gastrointestinal assessment : assess if there is an inability to swallow.

Nursing Diagnosis
Based on the assessment data, the major nursing diagnoses are:
 Ineffective breathing pattern related to upper airway edema.
 Anxiety related to respiratory distress.
 Hyperthermia related to inflammatory process.
 Deficient knowledge related to lack of knowledge on the disease process.

Nursing Interventions
The nursing interventions for a child with epiglottitis are:
 Anxiety control: the child and the family should display personal actions to eliminate or
reduce feelings of apprehension and tension from an unidentifiable source.
 Learning facilitation: the nurse should promote the ability to process and comprehend
information, and encourage improvement of the ability and willingness to receive
information.
 Medications: administer antibiotics as prescribed.
 Hydration: regulate IV fluid accordingly, since the child could not swallow.

Acute laryngitis
Laryngitis refers to inflammation of the larynx. This is often due to an acute viral infection,
which is typically a mild and self-limiting condition that lasts for a period of 3 to 7 days. It is a
common illness in older children and adolescent, characterized by hoarseness of voice, coryza,
sore throat, nasal congestion, fever, headache, and malaise.

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 Acute laryngotracheobronchitis (LTB)
Acute laryngotracheobronchitis is an infectious croup characterized by inflammation and
narrowing of the laryngeal and tracheal areas. It is the most common form of croup and usually
affects children less than five years of age.
Acute laryngotracheobronchitis is caused by virus. Common viruses are parainfluenza influenza
virus, respiratory syncytial virus and adeno viruses. After getting infection there is production of
tenacious mucous, this cannot be coughed out easily, and increases the respiratory obstruction.

Acute spasmodic croup

Acute spasmodic croup is manifested by paroxysmal attack of laryngeal obstruction that occurs
mainly at night. This condition has associated with genetic, allergic or emotional factors.
Spasmodic croup reoccurs with respiratory tract infections and common in children between the
ages of 1-3 years.
The child goes to bed well or with mild respiratory symptoms but wakes up suddenly in the early
morning with brassy cough and noisy breathing, restlessness, anxious, and frightened. The
symptom subsides in a few hours and may reoccur on subsequent days. The child is recovering
completely.

Etiology of croup
Viral
• Parainfluenza virus most commonly causes viral croup or acute laryngotracheitis.
• 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.

Bacterial
• Secondary bacterial infection from Staphylococcus aureus (S. aureus).
• Other bacteria that cause croup include S. pyogenes, S. pneumonia, Haemophilus influenza, and
Moraxella catarrhalis.

Pathophysiology
The viral pathogen is inhaled and infects the cells of the respiratory epithelium. Consequently
leading to localized inflammatory response including

Inflammation of the subglottic area

Mucosal oedema, increased mucous production, swelling of the involved airway particularly
involving the lateral walls of the trachea just below the vocal cords

The combination of swelling, oedema and excess mucous production leads to narrowing of the
internal airway lumen- this is aggravated by inspiration where further inflammation can results
from walls of the subglottic space are drawn in during inspiration

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Clinical manifestation
 Croup preceded by upper respiratory infection symptoms. A barking, cough and
hoarseness of voice commonly occur at night
 Inspiratory stridor may be present as well, the child may awaken at night with respiratory
distress, tachypnea, and retractions of chest.
 In severe cases, cyanosis with increasingly shallow respirations may develop.
 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 improve in
the morning but worsen 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

Diagnostic evaluation
 History taking
Chief complain, Present illness, Past illness
 Physical examination
Chest x-ray, steeple sign (The steeple sign, also called the wine bottle sign, refers to the
tapering of the upper trachea on a frontal chest radiograph reminiscent of a church
steeple)
 Complete blood count
 Blood culture

Management
1. General care
 Keep patient in comfortable position like semi sitting position, right lateral side as it enhance
the easy respiration.
 Supportive treatment like antipyretics is beneficial for reducing fever and discomfort.

2. Steroid
 Corticosteroids, such as dexamethasone, results in faster resolution of symptoms, decreased
return to medical care, and decreased length of stay.
 Dexamethasone is superior to budesonide for improving symptom scores, but there is no
difference in readmission rates.
 Dexamethasone at 0.6 mg/kg is the most commonly used.

3. Epinephrine
 For moderate to severe cases, nebulized racemic epinephrine has been found to improve
symptom .
 Current recommendations advocate for a prolonged period of observation in patients
receiving racemic epinephrine.

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 If symptoms do not worsen after 4 hours of observation, consider discharge home with close
follow-up.
 0.5 mL per kg of L-epinephrine 1:1000 via nebulizer was more effective than racemic
epinephrine at two hours because of its longer effects.

4. Oxygen
 Deliver oxygen by "blow-by" administration as it causes less agitation than the use of a mask
or nasal cannula.
5. 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 according to IMNCI

 Keep baby calm, do not do throat examination.
 Admit to hospital if severe croup-Spo₂<90%, stridor at rest and respiratory distress.
 Steroid- single dose Inj. Dexamethasone(0.6mg/kg) IM/IV
 Epinephrine(adrenaline ) – nebulized epinephrine (1:1000 solution) 0.4 ml/kg maximum
5ml.
 Oxygen therapy.
 Intubation or tracheostomy
If no above sign, treat as mild croup with home care
 Fluid, feeding, when to return
 Oral corticosteroids
Nursing management
Nursing Assessment
Gathering of subjective and objective data through
 History taking
 Physical assessment
 Patient observation
 Review of investigation report
 Record analysis
 Compare the data gathered to ascertain the patient’s condition and identify the problem

Nursing diagnosis
 Ineffective breathing pattern related to inflammatory process as evidence by fast
breathing.
 Ineffective airway clearance related to mechanical obstruction, inflammation, increased
secretion, pain as evidence by low saturation level.
 Fluid volume deficit related to dehydration due to fever and anorexia.
 Activity intolerance related to inflammatory process, imbalance oxygen demand and
supply.

Nursing intervention
 Maintain position for comfort.

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  Provide humidifier oxygen
 Maintain airway patency through nebulization
 Monitor oxygen saturation
 Promote rest and sleep
 Do nasal toileting
 Obtaining intravenous access for IV fluid and IV medication
 Administering medications, cold sponging.
 Providing emotional support
 Providing nutritional diet
 Explain the therapy and child behavior.
 Explore family’s feeling and problems surrounding hospitalization and illness.
 Encourage family centered care and encourage family to become involved in child care.
 Explain the food rich in iron and food fortification for very young child.
 Maintain infection prevention.
 Explain about vaccine preventable disease and immunization schedule.
 Provide emotional support.

Complications of croup
 Airway obstruction leads to respiratory distress and respiratory arrest.
 Secondary infection- pneumonia, bronchiolitis, bacterial tracheitis
 Middle ear infection
 Lymphadenitis.

Prognosis
 Croup is usually a self-limiting disease with an excellent prognosis.
 The children who develop croup, only a few will require inpatient care, and less than 5
percent of those will require intubation.
 Death from croup is rare, provided good airway management is carried out