Croup (Laryngotracheobronchitis)

ETIOLOGY
• Croup, or laryngotracheobronchitis, is the most common infection
of the middle respiratory tract.
• The most common causes of croup are:
 parainfluenza viruses (types 1, 2, and 3)
 and RSV.
• Laryngotracheal airway inflammation disproportionately affects
children because a small decrease in diameter secondary to
mucosal edema and inflammation exponentially increases airway
resistance and significantly increases the work of breathing.
• During inspiration, the walls of the subglottic space are drawn
together, aggravating the obstruction and producing the stridor
characteristic of croup.
 EPIDEMIOLOGY

• Croup is most common in children 6 months

to 3 years old, with a peak in fall and early
winter.
• Episodes typically follow a common cold.
• Symptomatic reinfection is common;
reinfections are usually mild.
 CLINICAL MANIFESTATIONS
• The manifestations of croup are:
o cough,
o hoarseness,
o inspiratory stridor,
o low-grade fever,
o and respiratory distress that may develop slowly or quickly.
• Stridor is a harsh, high-pitched respiratory sound produced by turbulent
airflow that is usually inspiratory, but may be biphasic; it is a sign of upper
airway obstruction .
• Croup is characterized by a harsh cough that is described as barking or
brassy in quality.
• Signs of upper airway obstruction, such as labored breathing and marked
suprasternal, intercostal, and subcostal retractions, may be evident on
examination.
• Wheezing may be present if there is associated lower airway involvement.
 LABORATORY AND IMAGING STUDIES

• Anteroposterior radiographs of the neck often, but not always, show

the diagnostic subglottic narrowing of croup, known as the steeple
sign.
• Routine laboratory studies are not useful in establishing the diagnosis.
• Leukocytosis is uncommon and suggests epiglottitis or bacterial
tracheitis.
• Many rapid tests (PCR or antigen) are available for parainfluenza
viruses and RSV and other less common viral causes of croup, such as
influenza and adenoviruses.
• The sensitivity of the RSV indirect immunofluorescence tests is 75% to
97%; the sensitivity and positive predictive values for parainfluenza
viruses appear to be less than those for RSV.
 DIFFERENTIAL DIAGNOSIS
• The diagnosis of croup usually is established
by clinical manifestations.

• Stridor in infants younger than 4 months old

or persistence of symptoms for more than 1
week indicates an increased probability of
another lesion (subglottic stenosis or
hemangioma) and the need for direct
laryngoscopy .
• Epiglottitis
 typically occurs in children 1 to 5 years old and is a medical emergency
because of the risk of sudden airway obstruction.
 Hib is historically the principal causative agent, but immunization has
reduced Hib infections markedly.
 Stridor is common, but is distinguished from croup by:
 sudden onset and rapid progression,
 high fever,
 muffled rather than hoarse voice,
 dysphagia and drooling of secretions,
 refusal to eat or drink,
 refusal to sleep,
 and preference for sitting, often with the head held forward, the mouth
open, and the jaw thrust forward (sniffing position).
• Lateral radiograph reveals thickened and bulging epiglottis
(thumb sign) and swelling of the aryepiglottic folds.
• The diagnosis is confirmed by direct observation of the
inflamed and swollen supraglottic structures and swollen,
cherry-red epiglottitis, which should be performed only in
the operating room with a competent surgeon and
anesthesiologist prepared to place an endotracheal tube
or less often to perform a tracheostomy.
• Epiglottitis requires endotracheal intubation to maintain the
airway and antibiotic therapy.
• Clinical recovery is rapid, and most children can be
extubated safely within 48 to 72 hours.
• Bacterial tracheitis
 is a rare but serious super-infection of the trachea that may follow viral
croup and is most commonly caused by S. aureus.
 Symptoms include high fever with cough and stridor.
 The diagnosis requires visualization of the middle airway, with culture of
the thick, mucopurulent subglottic debris.
 Treatment includes endotracheal intubation and antibiotic therapy.
• Spasmodic croup
 describes sudden onset of croup symptoms, usually at night, but without
an upper respiratory tract prodrome.
 These episodes may be recurrent and severe but usually are of short
duration.
 Spasmodic croup has a milder course than viral croup and responds to
relatively simple therapies, such as exposure to cool or humidified air.
 The etiology is not well understood but may be allergic.
 TREATMENT
• Administration of aerosolized racemic (D- and L-) or L-epinephrine
reduces subglottic edema by α-adrenergic vasoconstriction, temporarily
producing marked clinical improvement. The peak effect is within 10 to
30 minutes, but fades within 2 hours. A rebound effect may occur, with
worsening of symptoms as the effect of the drug dissipates. Aerosol
treatment may need to be repeated every 20 minutes (for no more
than 1 to 2 hours) in severe cases.
 Oral or IM dexamethasone for children with mild or moderate croup
reduces the need for hospitalization and shortens hospital stays.
• Children should be kept as calm as possible to minimize forceful
inspiration. One useful calming method is for a child with croup to sit
in the parent's lap.
• Sedatives should be used cautiously and only in the ICU.
• Cool mist administered by tent or facemask may help prevent drying of
the secretions around the larynx.
• Hospitalization often is required for children
with stridor at rest.
• Children receiving aerosol treatment should
be hospitalized or observed for at least 2 to 3
hours because of the risk of rebound.
• Subsidence of symptoms may indicate
improvement or fatigue and impending
respiratory failure.
 COMPLICATIONS
• The most common complication of croup is
viral pneumonia, which occurs in 1% to 2% of
children with croup.
• Parainfluenza pneumonia and secondary
bacterial pneumonia are more common
among immuno-compromised persons.
 PROGNOSIS
• The prognosis for croup is excellent. Illness
usually lasts approximately 5 days. As children
grow, they become less susceptible to the
airway effects of viral infections of the middle
respiratory tract
 PREVENTION
• There is no vaccine for parainfluenza or RSV