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Croup is an illness of young children that results from routine infection of the airway. What would be little more than a benign cold in adults can be distressing for children due to the narrow airway that begins to close off with even minor swelling, such as that seen during infections.
This section will review the two types of croup, signs, and symptoms of the condition, possible complications, and its management.
Signs and Symptoms
The medical name of croup is "Laryngotracheitis" or inflammation of the larynx and trachea. This results in several airway findings:
Stridor: An abnormal airway sound present over the neck which is greater during inspiration as opposed to expiration.
Cough: The defining symptom of the condition. The cough in croup is often referred to as a "seal-like barking," which comes in spells that get worse throughout the day.
Hoarseness: present in the early and late stages of the condition in children and may be the only symptom in older children and adults. This is also known as dysphonia
Types of Croup
1) Viral ("classic") croup. Caused by viruses, especially one named parainfluenza. This form is milder and generally results in a continuous fever, nasal congestion, and the aftermentioned cough in children 6 months to 3 years of age. These symptoms are continuous over the course of about 3 days, this time course is the key difference between the two types of croup.
2) Spasmodic croup: This form of croup is triggered by infection but is caused by unknown genetic factors, it tends to run in families. It has the same age range as classic croup, but can often present later in life as well. As opposed to classic croup, spasmodic croup occurs in spells; sudden attacks of coughing and hoarseness generally in the evenings over the course of 2 to 4 days.
Children are generally well-appearing between the attacks, without fever, prolific drooling, or other dramatic signs of illness.
PATHOLOGY: The airway just below the larynx becomes edematous, and the cricoid cartilage--a complete ring--can't expand to accommodate, this results in narrowing of the airway due to the inflamed cartilage. This results in a classic "seal-like" cough, hoarness, and possible airway obstruction.
The most dangerous complication of croup is respiratory exhaustion. Like asthma, croup makes breathing difficult, especially in children who often take 20 to 30 breaths per minute at rest. Impending respiratory failure due to exhaustion or upper airway obstruction has the following signs:
- Fatigue and listlessness.
- Intercostal Retractions (Warning: may decrease with increased obstruction and decreased air inspiration).
- Decreased or absent breath sounds in one or both lungs.
- Depressed level of consciousness.
- Tachycardia out of proportion to fever.
- Cyanosis or pallor.
As you can see, many of these signs rely on regular re-assessment of the patient, it is generally always a good idea to re-assess children's status extremely often, as they can change from a stable to a critical state in a matter of seconds.
Prehospital management of croup revolves around making a transport decision and keeping the patient comfortable. Is this classic or spasmodic croup? Is the child still able to run and play with their cough, or are they exhausted? Based on the severity of illness some treatments can be attempted at home to reduce airway swelling.
- Mild croup: mists, humidifiers, oral fluids, humidity (such as a steamed bathroom from a hot shower); a single dose of dexamethasone; fever control.
- Moderate croup (stridor at rest): nebulized racemic epinephrine and transport.
- Severe croup (stridor at rest and severe agitation): transport and supportive care, in rare cases some ambulances may be provided with nebulized epinephrine which rapidly relieves the airway obstruction temporarily. Positive pressure ventilation is indicated if the patient ceases spontaneous ventilation or begins to lose blood oxygenation.
Avoid any anxiety-producing movements or commotion/loud noises. Have the parent hold the child for reassurance.
In the field, prehospital treatment of croup is the same as epiglottitis:
- Make sure they have sufficient oxygenation and tidal volume,
- use blow-by oxygen, and
- don’t mess with them too much.