Croup is an acute viral disease of childhood marked by a barking cough, suffocative and difficulty breathing and laryngeal spasm.

CAUSES: Laryngotracheobronchitis orLTB is the most common form of croup affecting children 3 months to 3 years of age and is usually viral in origin. LTB usually follows an upper respiratory infection that descends to the lower respiratory tract and has a gradual, progressive onset. Other viral etiologies include influenza A and B , measles, adenovirus and respiratory syncytial virus or RSV. 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 cells. Acute epiglottitis is a severe potentially life threatening bacterial infection of the epiglottis in older children and is usually caused by H influenza type B. However with the use of HIB vaccine, episodes of epiglottitis caused by H influenza have been decreased. The inflamed epiglottis becomes very red and swollen which can lead to total airway obstruction. Before the era of immunizations and antibiotics croup was a deadly disease caused by diphtheria bacteria. Today, most cases of croup are mild. But it can still be dangerous. In the Northern hemisphere is it most common between October and March.

In severe cases of croup, there may also be a bacterial super infection of the upper airway. This is a condition is called bacterial tracheitis and requires hospitalization and intravenous antibiotics. If the epiglottis becomes infected, the entire windpipe can swell shut, becoming fatal. SYMPTOMS: Croup features a cough that sounds like a seal barking. Most children have what appears to be a mild cold for several days before the barking cough becomes evident. As the cough gets more frequent, the child may have labored breathing or strider, which is a harsh crowing noise, made during inspiration. The stridor is worsened by agitation or crying and if it can be heard at rest, it may indicate critical narrowing of the airways. Croup is typically much worse at night and if often last for 5 or 6 nights but the first night or two are usually the most severe. Other symptoms include fever, drooling, and chest wall indrawing The child was LTB initially demonstrates hoarseness, stridor tachypnea, nasal flaring, barking cough and chest wall indrawing. Body temp is normal. The nurse should check for drooling, dyspenea, dysphonia and dysphagia which is called the four Ds. The child with epiglottitis is acutely ill with high fever, muffled voice, drooling, progressive respiratory distress, anxiety and fear.

DIAGNOSTIC TESTS

Children with croup are usually diagnosed based on the parents description of the symptoms and a physical exam. The first step is to exclude other obstructive conditions of the upper airway, especially epiglottiitis, an airway foreign body, subglottic stenossis, angioedema, retropharyngeal abscess and a bacterial tracheitits. A frontal x-ray of the neck is not routinely performed but if it is done, it may show a narrowing of the trachea, called the steeple sign. The steeple sign is suggestive of a croup diagnosis. The most commonly used system for classifying the severity of croup is the Westley score. The sum of points assigned for five factors: level of consciousness, cyanosis, stridor, air entry, and retractions. The points given for each factor is listed in the table to the right, and the final score ranges from 0-17. The diagnosis of LTB is based on a history of a preceding upper respiratory infection, CBC, and clinical signs and symptoms through a physical exam. Acute epiglottitis is established by clinical symptoms and is considered a medical emergency. In the ER an immediate intubation or tracheostomy is ready in the event of further obstruction during exam of the pharynx. TREATMENT Treatment is focused on maintaining an open airway. Children with croup should be kept as calm as possible. Steroids are given routinely, with epinephrine used in severe cases. Epinephrine by aerosol is administered to decrease airway edema

by vasoconstriction and improve oxygenation by bronchodilator. The effects of epinephrine are short lived and the child will most likely need repeated doses as the airway edema returns a few hours after epinephrine administration. So monitor these children very closely. During the acute phase the child receives nothing by mouth because rapid respirations predispose to aspiration. Sedative are never used because they mask restlessness which is a clinical indication of hypoxia and a deteriorating condition. Children with oxygen saturations under 92% should receive oxygen and those with severe croup may be hosptialization for observation. If oxygen is needed blow-by administration is recommended which is holding an oxygen source near the childs face as it causes less agitation than use of a mask. With treatment, most children do not need endotracheal intubation. Increased obstruction of the airway requires intubation which is placing a tube through the nose or mouth through the larynx into the main air passage to the lungs. IV fluids are given for dehydration. A bacterial infection requires antibiotic therapy. Other therapies include a cool or moist air by bringing the child into a steamy bathroom or outside into the cool night air. You can set up a cool air vaporizer in the childs bedroom and use it during the night. Acute epiglottitis required immediate treatment which includes an artificial airway. Respiratory care includes humidification, gentle oral suctioning and constant observation of respiratory status.

Oxygen and epinephrine are also used. IV antibiotics and fluids are started. Epiglottal edema decreases after 24 hours of antibiotic therapy and by the third day the epiglottis is nearly normal in size, and the child can be safely extubated at this time. NURSING INTERVENTIONS: LTB or acute epglottitis can be a frightening experience for the child and the family. Never attempt to examine the mouth or throat in LTB as this will result in epiglottal spasm and stopped breathing. The nurse should respond in a calm manner supporting and reassuring parents that everything possible to being done for their child. Continuous airway and signs of response to therapy or increasing obstruction. Treatment changes can be based on the nurses observations. Maintain the child in the Fowlers position Monitor respiration for rate, depth, retractions and nasal flaring. Monitor the childs cardiac status is monitored for restlessness and tachycardia, as these are signs of increasing hypoxia. Vital signs are monitored frequently. Keep intubation and tracheostomy by the bedside for possible respiratory failure. Provide rest periods for the patient from nursing interventions to conserve the patients energy.

Keep parents informed of their childs progress and encourage their participation in the childs care. Most children recover in three to seven days. The most deaths from croup are from laryngeal obstruction and without prompt treatment the course of epiglottitis can cause death within a few hours.