CROUP – inflammation of respiratory tract
The word “croup” is derived from the Anglo-Saxon word kropan which means “to cry aloud”. Croup is an acute viral inflammation of the upper and lower respiratory tracts (the larynx, trachea, and bronchi ) characterized by inspiratory stridor, barking cough, subglottic swelling, and respiratory distress. Sometimes, croup will be misdiagnosed with acute epiglottitis.
Viral croup is the most common form of airway obstruction in children from 6 months to 6 years of age. The annual incidence is up to 6 cases per 100 children younger than 6 years. Croup accounts for 15 percent of respiratory tract infections among children in practice. The disease is self-limited and usually lasting for four to seven days. In average, about 5% children with croup who present to emergency department require hospitalization.
The etiologic viruses consist of Parainfluenza virus, adenovirus, respiratory syncytial virus (RSV) and influenza virus. Parainfluenza virus is responsible for 75% of cases. As addition, measles and bacterial super infection also may lead to croup.
Clinical presentation of Croup:
Viral croup typically is preceded by 12 to 72 hours of low-grade fever and coryza. As the illness progresses, hoarseness and the characteristic “croupy” or barking cough will then develop. Other symptoms include dyspnea (difficulty of breathing), hoarseness (of the voice) and stridor. Symptoms are worse at night, peak between 24 and 48 hours, and generally resolve within one week. Agitation and crying tend to aggravate symptoms, and children often prefer to sit up or be held upright.
Clinical assessment of Croup (Wagener):
· Mild : stridor with excitement or at rest with no respiratory distress
· Moderate : stridor at rest with intercostal, subcostal or sternal recession
· Severe : stridor at rest with marked recession, decreased air entry and altered level of conciousness
Other than this clinical assessment, there are 2 scores that have been widely used to clarify the severity of croup. They are Modified Westley Croup Score and Pediatric Croup Score
Indication for admission:
Moderate to severe viral croup require admissions for treatment and observation. Poor oral intake is another indication for admission. If the family lives a long distance from hospital and there is a lacking of reliable transport, admission should be done for proper monitoring of the patient. Other criteria includes toxic looking patients, very young age (< 6 months) and no reliable caregivers at home.
Diagnosis:
· Diagnosis is mainly made clinically after taking full history and o full physical examination
· Neck x-ray is rarely needed, however, in doubtful diagnosis it will be ordered, for eample if there is any suspicion of foreign body
Management of Croup:
In general, we should initiate general patient care
· Allow children to assume their own position of comfort
· Allow parent to remain with child for emotional support
Mist therapy:
Since the 19th century, mist treatment has been used to relieve croup symptoms. Theoretically, it will result in mucosal cooling, vasoconstriction, and lessened edema. In addition, cool mist moistens secretions, soothes inflamed mucosa, and decreases the viscosity of mucous secretions. However, there is no clinical evidence to support this.
Steroids:
There are some meta-analysis studies have been done and the results showed that treatment with glucocorticoids is effective in improving symptoms within six hours, for up to 12 hours, with significant improvement in croup scores, shorter hospital stays, and less use of epinephrine.(Evidence level A: meta-analysis of randomized controlled trials A Cochrane review [Evidence level A: meta-analysis of RCTs] )
Dexamethasone and budesonide are effective in relieving the symptoms of croup as early as six hours after treatment. Fewer return visits and readmissions are required, and the length of time spent in the hospital is decreased in inpatients. Dexamethasone also is effective in patients with mild croup. Oral dexamethasone (0.6 mg per kg), 2 mg of nebulized budesonide and oral dexamethasone are equally effective reduce croup score. It is the preferred intervention because of its ease of administration, lower cost, and more widespread availability.Oral dexamethasone in a dose of 0.15 mg/kg is as effective as 0.3 or 0.6 mg/kg in relieving symptoms and results in a similar duration of hospitalization in children with croup. There is no significant difference was detected between oral and intramuscular dexamethasone (0.6 mg per kg). A single oral dose of dexamethasone (0.6 mg per kg) improves short-term symptoms and reduces the likelihood that a child with mild croup will have to return for additional care. The dexamethasone is well tolerated, and considering the well-documented benefits of steroids in children with more severe disease, steroids in some form should be considered for most children with croup. (Level of Evidence: 1b)
Alpha-adrenergic receptor agonist:
Desired action:
· Local vasoconstriction in the large airways, which reduces airway edema and obstruction
· Decreased systemic effects with inhalation
· Decreased inspiratory stridor and intercostal retractions are observed within 30 minutes of administering epinephrine, and the duration of action is about two hours.
· Caution: rebound phenomenon because the effect of epinephrine is brief.
· Common adverse effects include tachycardia and hypertension, so it should be used with caution in patients who have heart conditions or arrhythmias.
L-epinephrine is at least as effective as racemic epinephrine in the treatment of laryngotracheitis and does not carry the risk of additional adverse effects. It is also more readily available worldwide, is less expensive, and can be recommended for this purpose.
References:
1. Waisman Y – Pediatrics – 01-FEB-1992; 89(2): 302-6
2. Bjornson CL, et al. N Engl J Med September 23, 2004;351:1306-13
3. Rittichier KK – Pediatrics – 01-DEC-2000; 106(6): 1344-8
4. Geelhoed GC – Pediatr Pulmonol – 01-DEC-1995; 20(6): 362-8
5. Klassen TP – JAMA – 27-MAY-1998; 279(20): 1629-32
6. Cochrane Rev Abstract. 2007
7. Paediatrics For Malaysian Hospitals 2nd Edition
8. National Center for Emergency Medicine Informatics
9. J Pediatr 115:323,1989
10. Viral Croup: A Current Perspective J Pediatr Health Care 18(6):297-301, 2004
11. IIlustrated textbook of paediatrics, 3rd Edition, 2008 Mosby
Tags: barking cough, croup, epiglottitis, mist therapy, modified westley croup score, parainfluenza, respiratory, steroid, stridor
Technorati Tags: barking cough, croup, epiglottitis, mist therapy, modified westley croup score, parainfluenza, respiratory, steroid, stridor
Very basic writing. Before reading your blog I am not aware of CROUP but now i am know bit well. Thanks for discussing this article very precisely
Ya I like your post w.r.t content and best part is you have discussed every part related to Health Awareness.
Is bronchitis in child cause by pertusis also include into croup?? thanks
Pertussis is a whopping cough that is cause by several pathogens, most commonly Bordetella pertussis. Croup is a viral laryngotracheobronchitis that is most commonly caused by parainfluenza virus. Acute bronchitis is a clinical term implying a self-limited inflammation of the large airways of the lung that is characterized by cough without pneumonia. The disorder affects approximately 5% of adults annually. Recent study noted that B. pertussis comprised only 1% of cases of acute bronchitis. (Ward JI, Cherry JD, Chang S-J, et al. Efficacy of an acellular pertussis vaccine among adolescents and adults. N Engl J Med 2005;353:1555-1563). Acute bronchitis may occur in children but chronic bronchitis will only occur in adult. Most of children bronchitis is caused by viruses and is self limiting.
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