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Definition

Croup is one of the most common respiratory illnesses in children. It is an inflammation of the larynx and the trachea. When a child has croup, that portion of the airway just below the vocal cords narrows and becomes swollen, making breathing both noisy and labored.

Description

Croup is a broad term describing a group of illnesses that affect the larynx, trachea, and bronchi. The key symptom is a harsh, barking cough. One of the most common respiratory illnesses in children, croup is frequently noted in infants and children and can have a variety of causes. Before the days of antibiotics and immunizations, croup was a dreaded and often deadly disease usually caused by the diphtheria bacteria. Though in the early 2000s cases of croup are normally mild, it can still be dangerous. Croup affects the vocal cords and the area just below, the voice box, or larynx, and the windpipe, or trachea. The lower breathing passages (bronchi) may also be affected. Swelling of these areas causes the airway to narrow, which makes breathing difficult. It is also sometimes called laryngotracheitis, a medical term describing the inflammation of the trachea and larynx.

The characteristic symptoms of croup can be better understood by knowing the anatomic makeup of a child's larynx. Small children typically have quite a narrow larynx, so even a slight decrease in the airway's radius may lead to a large decrease in the air flow, leading to the symptoms of croup.

There are two primary types of croup: viral and spasmodic. Viral croup is caused by a viral infection in the trachea and larynx. It often starts with a cold that over time develops into a barking cough. When the child's airway becomes increasingly swollen and more mucus is secreted, it becomes more challenging to breathe. Breathing gets increasingly noisy, and a condition known as stridor may occur. (Stridor is a sign of respiratory obstruction that presents as a high-pitched, coarse, musical sound that occurs during breathing.) Children with viral croup usually have a low-grade temperature, but a few may have fevers up to 104°F (40°C). As breathing requires more effort, the child may stop eating and drinking. The child may also become too fatigued to even cough. If the airway continues to swell, it may approach a point at which the child can no longer breathe. Stridor is fairly common with a mild case of croup, especially if the child is active or crying. However, if a child has stridor at rest, the child may have severe croup. Symptoms are usually worse at night. The symptoms peak between 24 and 48 hours and usually resolve within one week.

Spasmodic croup is usually precipitated by an allergy or mild upper respiratory infection. It can be quite alarming, both because of the noise of the cough and because it usually comes on suddenly in the middle of the night. A child may go to sleep with a mild cold and wake up a few hours later, gasping for air. In addition, the child may have a cough that sounds like a seal barking, and will have a hoarse voice. Children with spasmodic croup normally do not have a fever.

Spasmodic croup can sometimes be difficult to differentiate from viral croup. Although spasmodic croup is associated with the same viruses that cause viral croup, spasmodic croup tends to recur and may be an indication of some type of allergic reaction instead of a direct infection.

Transmission

The viruses causing croup are highly contagious and easily transmitted between individuals through sneezing and coughing. It is usually transmitted via the respiratory route, entering through the nose and nasopharynx.

Demographics

Croup accounts for about 15 percent of all respiratory tract infections in children seen by physicians. It typically is seen in late fall and winter, and primarily occurs in children aged six months to three years. It has an annual peak incidence of 50 new cases per 1,000 children during the second year of life. Males are twice as likely as females to get the disease. The incidence decreases significantly after age six.

Causes and Symptoms

Croup is most commonly brought on by a viral infection. The parainfluenza viruses (types 1, 2, and 3) are the most frequent causes of croup, accounting for approximately 75 percent of all cases diagnosed. Human parainfluenza virus 1 (HPIV-1) is the most common cause. Croup may also be caused by influenza A and B, adenovirus, measles, and respiratory syncytial virus (RSV). Other possible causes of croup are bacteria, inhaled irritants, allergies, and acid reflux.

The following are usually true of viral croup:

• It commonly occurs in individuals between the ages six months to six years.
• Stridor, and the classic barking cough are usually present.
• The child may have a fever.
• Wheezing may be present.
• It usually lasts two to seven days.

The following items are characteristic of spasmodic croup:

• The symptoms come on suddenly, often in the middle of the night.
• Stridor occurs along with the barking cough.
• It typically lasts two to four hours.

When to Call the Doctor

Most cases of croup can be safely managed at home, but parents should call their child's doctor for advice, even if it is in the middle of the night. Call 911 for emergency help if any of the following is true:

• The croup is possibly caused by an inhaled object or by an insect sting.
• The child is drooling.
• The child has blue lips or skin.
• The child has a very high fever.
• The child is very anxious, has rapid breathing, and/or is struggling to get a breath.
• The child insists on sitting up or complains of a sore throat and is drooling. This is a possible indication that he or she may have a disease called epiglottitis, which is potentially life-threatening.
• The child makes a whistling sound that gets louder with each breath.
• The child has stridor when resting.

Diagnosis

The diagnosis of croup is usually made based on the description of symptoms by the parent, as well as a physical examination. Sometimes other studies, such as x rays, may be required. The doctor may note chest retractions with breathing and may hear wheezing and decreased breath sounds when listening to the chest with a stethoscope. Sometimes a foreign object or narrowing of the trachea is seen on a neck x ray.

Treatment

The most important part of treating patients with croup is maintaining an open airway. If a child wakes up in the middle of the night with croup, he or she should be taken to the bathroom. The door should be closed and the shower turned on to allow the bathroom to steam up. The parent should then sit in the steamy bathroom with the child. The moist, warm air should assist the child in breathing within 15 to 20 minutes, though the child will still have the barking cough. For the rest of that night and for two to three nights following, a humidifier or cold-water vaporizer should be placed in the child's room. If another attack of croup recurs that night or the next, the steam treatment should be repeated. If the steam does not work, sometimes taking the child outside, where he or she can inhale the cool, moist night air will be enough to improve breathing. Though a study in the early 2000s cast some doubt on the efficacy of using steam or mist, it does seem to be helpful for most children with croup. Parents may also give acetaminophen to reduce fevers and increase the child's comfort level. Cough medicines should usually be avoided.

Several other treatments are possible if the croup is severe enough to warrant the child's being seen by a physician. Aerosolized racemic epinephrine as well as oral dexamethasone (a steroid) may be used to help shrink the upper airway swelling. A bacterial infection will require antibiotics. If the airway becomes increasingly obstructed, the child may require intubation (the placing of a tube through the nose or mouth through the larynx into the main air passage to the lungs.) If the patient is dehydrated, intravenous fluids will be administered.

Prognosis

Croup is normally a self-limiting disease with an excellent prognosis. Only a few who are diagnosed require hospitalization, and less than 5 percent require intubation. If proper airway management is maintained, death is rare. There is some speculation that children with a history of croup may be at a higher risk for developing asthma, but the evidence was not clear as of 2004.

Prevention

The best way to prevent croup is to prevent the causative infections. Parents should practice excellent hand washing, especially during the cold and flu season, and avoid close contact with anyone who has a respiratory infection.

Parental Concerns

The onset of croup can be frightening, especially when it comes on suddenly. Parents can help their child by not panicking or appearing anxious, as this may increase anxiety in the child, which can worsen symptoms. If they are at all unsure about how their child is responding to home treatment, parents should not hesitate to seek medical advice or treatment, no matter the time of day or night.

See also Influenza.

Resources

Periodicals

Colletti, James E. "Myth: Cool Mist Is an Effective Therapy in the Management of Croup." Canadian Journal of Emergency Medicine 6 (September 2004): 5, 357–9.

Knutson, Doug, and Ann Aring. "Viral Croup." American Family Physician 69 (February 1, 2004): 3, 535–40.

"Patient Education Guide: What to Do When Your Child Has Croup." Journal of Respiratory Diseases 23 (March 2002): 23, 192–5.

Organizations

American Academy of Pediatrics. 141 Northwest Point Boulevard, Elk Grove Village, IL 60007–1098. Web site: www.aap.org.

Web Sites

"Croup." MedlinePlus. Available online at www.nlm.nih.gov/medlineplus/ency/article/000959.htm (accessed January 11, 2005).

[Article by: Deanna M. Swartout-Corbeil, RN]

1. the muscular area around and above the base of the tail in the horse.
2. acute obstruction of the larynx caused usually by allergy or respiratory infection. Used with reference to children and chickens.

• Diseases and Infestations - croup: inflammation and obstruction of larynx in young children due to viral respiratory infections, characterized by harsh cough

Croup also refers to the rump of a quadruped and the crop of a bird. For the work of a casino employee, see croupier.

Croup
Classification and external resources
The steeple sign as seen on an AP neck X-ray of a child with croup
ICD-10	J05.0
ICD-9	464.4
DiseasesDB	13233
MedlinePlus	000959
eMedicine	ped/510 emerg/370 radio/199
MeSH	D003440

Croup (or laryngotracheobronchitis) is a respiratory condition that is usually triggered by an acute viral infection of the upper airway. The infection leads to swelling inside the throat, which interferes with normal breathing and produces the classical symptoms of a "barking" cough, stridor, and hoarseness. It may produce mild, moderate, or severe symptoms, which often worsen at night. It is often treated with a single dose of oral steroids; occasionally epinephrine is used in more severe cases. Hospitalization is rarely required.

Croup is diagnosed on clinical grounds, once potentially more severe causes of symptoms have been excluded (i.e. epiglottitis or an airway foreign body). Further investigations—such as blood tests, X-rays, and cultures—are usually not needed. It is a relatively common condition that affects about 15% of children at some point, most commonly between 6 months and 5–6 years of age. It is almost never seen in teenagers or adults. Once due primarily to diphtheria, this cause is now primarily of historical significance in the Western world due to the success of vaccination, and improved hygiene and living standards.

Contents 1 Signs and symptoms 2 Causes 2.1 Viral 2.2 Bacterial 3 Pathophysiology 4 Diagnosis 5 Prevention 6 Treatment 6.1 Steroids 6.2 Epinephrine 6.3 Other 7 Prognosis 8 Epidemiology 9 History 10 References 11 External links

Signs and symptoms

	Stridor Inspiratory and expiratory stridor in a 13 month child with croup.
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Croup is characterized by a "barking" cough, stridor, hoarseness, and difficult breathing which usually worsens at night.^[1] The "barking" cough is often described as resembling the call of a seal or sea lion.^[2] The stridor is worsened by agitation or crying, and if it can be heard at rest, it may indicate critical narrowing of the airways. As croup worsens, stridor may decrease considerably.^[1]

Other symptoms include fever, coryza (symptoms typical of the common cold), and chest wall indrawing.^[1][3] Drooling or a very sick appearance indicate other medical conditions.^[3]

Causes

Croup is usually deemed to be due to a viral infection.^[1][4] Others use the term more broadly, to include acute laryngotracheitis, spasmodic croup, laryngeal diphtheria, bacterial tracheitis, laryngotracheobronchitis, and laryngotracheobronchopneumonitis. The first two conditions involve a viral infection and are generally milder with respect to symptomatology; the last four are due to bacterial infection and are usually of greater severity.^[2]

Viral

Viral croup or acute laryngotracheitis is caused by parainfluenza virus, primarily types 1 and 2, in 75% of cases.^[5] Other viral etiologies include influenza A and B, measles, adenovirus and respiratory syncytial virus (RSV).^[2] Spasmodic croup is caused by the same group of viruses as acute laryngotracheitis, but lacks the usual signs of infection (such as fever, sore throat, and increased white blood cell count).^[2] Treatment, and response to treatment, are also similar.^[5]

Bacterial

Bacterial croup may be divided into laryngeal diphtheria, bacterial tracheitis, laryngotracheobronchitis, and laryngotracheobronchopneumonitis.^[2] Laryngeal diphtheria is due to Corynebacterium diphtheriae while bacterial tracheitis, laryngotracheobronchitis, and laryngotracheobronchopneumonitis are usually due to a primary viral infection with secondary bacterial growth. The most common bacteria implicated are Staphylococcus aureus, Streptococcus pneumoniae, Hemophilus influenzae, and Moraxella catarrhalis.^[2]

Pathophysiology

The viral infection that causes croup leads to swelling of the larynx, trachea, and large bronchi^[4] due to infiltration of white blood cells (especially histiocytes, lymphocytes, plasma cells, and neutrophils).^[2] Swelling produces airway obstruction which, when significant, leads to dramatically increased work of breathing and the characteristic turbulent, noisy airflow known as stridor.^[4]

Diagnosis

The Westley Score: Classification of croup severity^[5][6]

Feature	Number of points assigned for this feature
	0	1	2	3	4	5
Chest wall retraction	None	Mild	Moderate	Severe
Stridor	None	With agitation	At rest
Cyanosis	None				With agitation	At rest
Level of consciousness	Normal					Disoriented
Air entry	Normal	Decreased	Markedly decreased

Croup is a clinical diagnosis.^[4] The first step is to exclude other obstructive conditions of the upper airway, especially epiglottitis, an airway foreign body, subglottic stenosis, angioedema, retropharyngeal abscess, and bacterial tracheitis.^[2][4]

A frontal X-ray of the neck is not routinely performed,^[4] but if it is done, it may show a characteristic narrowing of the trachea, called the steeple sign, because of the subglottic stenosis, which is similar to a steeple in shape. The steeple sign is suggestive of the diagnosis, but is absent in half of cases.^[3]

Other investigations (such as blood tests and viral culture) are discouraged, as they may cause unnecessary agitation and thus worsen the stress on the compromised airway.^[4] While viral cultures, obtained via nasopharyngeal aspiration, can be used to confirm the exact cause, these are usually restricted to research settings.^[1] Bacterial infection should be considered if a person does not improve with standard treatment, at which point further investigations may be indicated.^[2]

Severity

The most commonly used system for classifying the severity of croup is the Westley score. It is primarily used for research purposes rather than in clinical practice.^[2] It is the sum of points assigned for five factors: level of consciousness, cyanosis, stridor, air entry, and retractions.^[2] The points given for each factor is listed in the table to the right, and the final score ranges from 0 to 17.^[6]

• A total score of ≤ 2 indicates mild croup. The characteristic barking cough and hoarseness may be present, but there is no stridor at rest.^[5]
• A total score of 3–5 is classified as moderate croup. It presents with easily heard stridor, but with few other signs.^[5]
• A total score of 6–11 is severe croup. It also presents with obvious stridor, but also features marked chest wall indrawing.^[5]
• A total score of ≥ 12 indicates impending respiratory failure. The barking cough and stridor may no longer be prominent at this stage.^[5]

85% of children presenting to the emergency department have mild disease; severe croup is rare (<1%).^[5]

Prevention

Many cases of croup have been prevented by immunization for influenza and diphtheria. At one time, croup referred to a diphtherial disease, but with vaccination, diphtheria is now rare in the developed world.^[2]

Treatment

Children with croup are generally kept as calm as possible.^[4] Steroids are given routinely, with epinephrine used in severe cases.^[4] Children with oxygen saturations under 92% should receive oxygen,^[2] and those with severe croup may be hospitalized for observation.^[3] If oxygen is needed, "blow-by" administration (holding an oxygen source near the child's face) is recommended, as it causes less agitation than use of a mask.^[2] With treatment, less than 0.2% of people require endotracheal intubation.^[6]

Steroids

Corticosteroids, such as dexamethasone and budesonide, have been shown to improve outcomes in children with all severities of croup.^[7] Significant relief is obtained as early as six hours after administration.^[7] While effective when given orally, parenterally, or by inhalation, the oral route is preferred.^[4] A single dose is usually all that is required, and is generally considered to be quite safe.^[4] Dexamethasone at doses of 0.15, 0.3 and 0.6 mg/kg appear to be all equally effective.^[8]

Epinephrine

Moderate to severe croup may be improved temporarily with nebulized epinephrine.^[4] While epinephrine typically produces a reduction in croup severity within 10–30 minutes, the benefits last for only about 2 hours.^[1][4] If the condition remains improved for 2–4 hours after treatment and no other complications arise, the child is typically discharged from the hospital.^[1][4]

Other

While other treatments for croup have been studied, none have sufficient evidence to support their use. Inhalation of hot steam or humidified air is a traditional self-care treatment, but clinical studies have failed to show effectiveness^[2][4] and currently it is rarely used.^[9] The use of cough medicines, which usually contain dextromethorphan and/or guiafenesin, are also discouraged.^[1] While breathing heliox (a mixture of helium and oxygen) to decrease the work of breathing has been used in the past, there is very little evidence to support its use.^[10] Since croup is usually a viral disease, antibiotics are not used unless secondary bacterial infection is suspected.^[1] In cases of possible secondary bacterial infection, the antibiotics vancomycin and cefotaxime are recommended.^[2] In severe cases associated with influenza A or B, the antiviral neuraminidase inhibitors may be administered.^[2]

Prognosis

Viral croup is usually a self-limited disease, but can very rarely result in death from respiratory failure and/or cardiac arrest.^[1] Symptoms usually improve within two days, but may last for up to seven days.^[5] Other uncommon complications include bacterial tracheitis, pneumonia, and pulmonary edema.^[5]

Epidemiology

Croup affects about 15% of children, and usually presents between the ages of 6 months and 5–6 years.^[2][4] It accounts for about 5% of hospital admissions in this population.^[5] In rare cases, it may occur in children as young as 3 months and as old as 15 years.^[5] Males are affected 50% more frequently than are females, and there is an increased prevalence in autumn (fall).^[2]

History

The word croup comes from the Early Modern English verb croup, meaning "to cry hoarsely"; the name was first applied to the disease in Scotland and popularized in the 18th century.^[11] Diphtheritic croup has been known since the time of Homer's Ancient Greece and it was not until 1826 that viral croup was differentiated from croup due to diphtheria by Bretonneau.^[12] Viral croup was then called "faux-croup" by the French, as "croup" then referred to a disease caused by the diphtheria bacteria.^[9] Croup due to diphtheria has become nearly unknown due to the advent of effective immunization.^[12]

References

1. ^ ^{a b c d e f g h i j} Rajapaksa S, Starr M (May 2010). "Croup – assessment and management". Aust Fam Physician 39 (5): 280–2. PMID 20485713. 
2. ^ ^{a b c d e f g h i j k l m n o p q r s} Cherry JD (2008). "Clinical practice. Croup". N. Engl. J. Med. 358 (4): 384–91. doi:10.1056/NEJMcp072022. PMID 18216359. http://content.nejm.org/cgi/content/full/358/4/384. 
3. ^ ^{a b c d} "Diagnosis and Management of Croup" (PDF). BC Children’s Hospital Division of Pediatric Emergency Medicine Clinical Practice Guidelines. http://www.childhealthbc.ca/resources/category/5-croup?download=13%3Acroup-guideline. 
4. ^ ^{a b c d e f g h i j k l m n o p} Everard ML (February 2009). "Acute bronchiolitis and croup". Pediatr. Clin. North Am. 56 (1): 119–33, x–xi. doi:10.1016/j.pcl.2008.10.007. PMID 19135584. 
5. ^ ^{a b c d e f g h i j k l} Johnson D (2009). "Croup". Clin Evid (Online) 2009. PMC 2907784. PMID 19445760. //www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=2907784. 
6. ^ ^{a b c} Klassen TP (December 1999). "Croup. A current perspective". Pediatr. Clin. North Am. 46 (6): 1167–78. doi:10.1016/S0031-3955(05)70180-2. PMID 10629679. 
7. ^ ^{a b} Russell KF, Liang Y, O'Gorman K, Johnson DW, Klassen TP (2011). Klassen, Terry P. ed. "Glucocorticoids for croup". Cochrane Database Syst Rev 1 (1): CD001955. doi:10.1002/14651858.CD001955.pub3. PMID 21249651. 
8. ^ Port C (April 2009). "Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. BET 4. Dose of dexamethasone in croup". Emerg Med J 26 (4): 291–2. doi:10.1136/emj.2009.072090. PMID 19307398. 
9. ^ ^{a b} Marchessault V (November 2001). "Historical review of croup". Can J Infect Dis 12 (6): 337–9. PMC 2094841. PMID 18159359. //www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=2094841. 
10. ^ Vorwerk C, Coats T (2010). Vorwerk, Christiane. ed. "Heliox for croup in children". Cochrane Database Syst Rev 2 (2): CD006822. doi:10.1002/14651858.CD006822.pub2. PMID 20166089. 
11. ^ Online Etymological Dictionary, croup. Accessed 2010-09-13.
12. ^ ^{a b} Feigin, Ralph D. (2004). Textbook of pediatric infectious diseases. Philadelphia: Saunders. p. 252. ISBN 0-7216-9329-6. 

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Dansk (Danish)
1.
n. - kryds, bagpart

2.
n. - strubehoste, krup

Nederlands (Dutch)
kroep

Français (French)
1.
n. - croupe (de cheval)

2.
n. - (Méd) croup

Deutsch (German)
1.
n. - Kruppe, Kreuz, Hinterteil (bes. von Pferden)

2.
n. - Krupp

Ελληνική (Greek)
n. - διφθεριτική λαρυγγίτιδα (κν. χλαπάτσα)

Italiano (Italian)
difterite

Português (Portuguese)
n. - garupa (f), crupe (m) (Med.)

Русский (Russian)
круп

Español (Spanish)
1.
n. - crup, garrotillo

2.
n. - anca, grupa, posaderas

Svenska (Swedish)
n. - krupp, kruppa (anat.)

中文（简体）(Chinese (Simplified))
1. 格鲁布性喉头炎

2. 臀部

中文（繁體）(Chinese (Traditional))
1.
n. - 格魯布性喉頭炎

2.
n. - 臀部

한국어 (Korean)
1.
n. - 위막성 후두염

2.
n. - 엉덩이

日本語 (Japanese)
n. - 偽膜性喉頭炎
v. - クルピエをする

العربيه (Arabic)
‏(الاسم) مرض يصيب الأطفال‏

עברית (Hebrew)
n. - ‮אסכרה, דלקת גרון‬
n. - ‮עכוז של בעל-חיים‬

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