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Croup, The On-The-Spot Diagnosis

General

Cough is a common symptom of many diseases. In this article, I am going to discuss a particular cough caused mainly by viruses. It is called the viral croup.

What is croup?

In this illness, viruses invade the larynx, [voice box] the trachea, [windpipe] and sometimes the bronchus. A characteristic barking [dog-like] cough with an underlying loss of voice – hoarseness or [croupy – voice], constitutes a clinical diagnosis of croup.

Depending on the parts of the airways involved, croup is also called laryngotracheitis, or laryngotracheobronchitis.

Viral Croup is on- the- spot diagnosis

Great physicians make ‘on- the- spot’ diagnosis all the time. A six- year- old boy in Nigeria, who develops fever and chills, has malaria until proven otherwise. A 3- year- old girl, who is unable to raise her hand up after being pulled forcefully by a caretaker, suffered a condition known as nursemaid elbow. Croup is one of those conditions in which clinicians can make ‘on- the -spot’ diagnosis

Narrative

A week ago, I overheard a child in the waiting room coughing. It was a cough with a barking sound. Before seeing that child, I had the diagnosis of croup in my mind.

Symptoms and signs of croup

From their fruits, you shall know them and from the cough you shall know it. In kindergarten, we learned of the various sounds animals make. Dogs bark, cats meow, ducks quack and hummingbirds twitter. Physicians, first and foremost think of croup when they hear a barking sound in a child who has colds.

Like many infections caused by viruses in children, croup may begin with a runny nose, cough, loss or change of voice. Fever sometimes accompanies this illness. The hallmark of croup is the characteristic barking cough, also known as croupy cough. Most cases of croup get worse before getting better.

This illness tends to affect children between 6 months and 3 years of age. Older children can also be targeted, but less frequently. In the United States, croup occurs commonly during the cold seasons. Croup occurs in different levels of severity: mild, moderate and severe. Croup tends to recur.

Fever sometimes accompanies this illness. In addition to the barking sound, a child suffering from croup may also have stridor.

Stridor

Stridor is a high-pitched musical-like noise heard during breathing. It may occur when the child is breathing in, or when he is breathing out or during both. Stridor is usually an indication of severe croup.

Physical Examination of children with Croup

During the physical exam of a child with croup, the doctor looks for signs of difficulty in breathing. Rapid breathing, exaggerated chest movement and flaring of the nose signal a child whose respiration has been compromised. Levels of the child’s oxygen are checked using a finger- attached pulse oximeter.

Viral Causes of croup

Of the viruses, Parainfluenza virus is often responsible. Influenza virus, respiratory influenza virus and adenoviruses are some of the other viruses that cause croup. Measles virus is a major cause of severe croup in developing countries. The viruses spread from one person to another person through sneezing and coughing.

When viruses invade the inner linings, the epithelium of the upper windpipe; the larynx, the trachea, and the bronchus, they trigger inflammation, swelling and edema. This leads to the narrowing of the lumen of the upper airways.

Investigation

None is needed when clinical diagnosis is straightforward and the child is responding to management. If for some reasons a clinician decides to get an x-ray of the neck, it will show a narrowing of the lumen of the upper part of trachea, also known as the steeple sign.

Treatment

Many children who have moderate to severe croup are encountered in the emergency room.

Physicians and other practitioners know that they should not aggravate children with croup. These children will remain in their mothers’ comforting arms while they are being evaluated and treated.

Some clinicians will start with a gentle cool mist near the child’s face while definitive treatment is on the way.

Two treatments are popular; the use of nebulized [inhaled] racemic epinephrine and a shot or oral administration of steroid. Both treatments decrease edema around the windpipe and by so doing work to open it up so that more air can get through.

When treatment succeeds, the clinical outcome is dramatic. Parents are relieved when they notice that the croup cough is gone and that the child is less apprehensive.

Dexamethasone shot is the drug of choice.

Oral dose of Dexamethasone is equally effective.

Prednisolone is given for a couple of days in places where the dexamethasone is not readily available.

Racemic epinephrine as an alternative treatment in croup, is given as a nebulized solution.

Children who did well on epinephrine must still be watched by health care providers for at least two hours. This is because when the effect of epinephrine wears out, the airways might tighten up again, the so called rebound airway obstruction. Signs of an epinephrine rebound effect include the returning of croupy cough and resumption of breathing difficulty.

Humidifier

For the very mild croup, humidification of room air can help soothe an inflamed throat and perhaps hasten dislodge secretions. Adding menthol or other substances to humidifier is unnecessary.

Complications

Croup resolves over a period of several days. Before resolution, croup may create a fertile ground for more serious infections. Ear infection can develop as an extension of croup. Pneumonia and bacterial tracheal infection are some other diseases that can complicate croup.

Summary

• Croup is a viral infection of the upper airways: the larynx, the trachea and sometimes the bronchus
• It is a disease of infants and toddlers, age 6 months through 3 years
• Boys are affected more than girls
• Croup attacks in a dramatic fashion, often waking up a sleeping child in the middle of the night. Parents, alarmed by the sudden onset of cough, will often make the decision to take their child to the ER. The disease gets worse during the second and the third day.
• Most cases of croup get worse before they start getting better
• Severity of the disease can vary widely from mild, moderate to severe
• Children with re-occurring croup need to be investigated for sinister conditions masquerading as viral croup

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