Now let's talk about the
signs and symptoms of croup.
It typically starts as a mild cold,
but it can progress quickly.
The cough associated with
croup is very characteristic,
and the parents will often say that
their child has a croupy cough
when they bring them in for care.
It sounds like a barking or a seal-like
cough, and you'll know it when you hear it.
Signs and symptoms of the respiratory
tract include difficulty breathing,
fast breathing or tachypnea, noisy breathing,
shortness of breath, wheezing, and stridor.
As the respiratory status worsens and
the work of breathing increases,
the child may become anxious or
agitated as they become air hungry.
They may also have a lot
of secretions to clear
and also have a sore throat
from all of the coughing
and the irritation in their airway.
Their nose may have clear nasal congestion,
and the child may have a
hoarse voice or laryngitis.
Symptoms of croup are always worse at night
and when children are crying or upset.
The clinician will want to limit
their agitation during the exam
to minimize exacerbating
these symptoms even further.
Croup is a clinical diagnosis.
There's not an actual lab
test to diagnose this.
It's based on the history.
Has the patient had any recent colds,
including a fever, runny nose,
nasal congestion, a sore throat
or cough, and the physical exam.
The clinician's going to
interpret the vital signs
and will perform a full physical exam,
including the head, eyes, ears, nose, throat,
cardiac, respiratory, and skin systems.
The child will also have usually a
barking cough during the visit,
and have a hoarse voice and
some inspiratory stridor.
The child may have a low-grade fever
and typically, with croup, there's
an absence of wheezing.
This is different than children
with asthma or a reactive airway.
How do you manage croup?
Well, most cases are a mild viral
illness that can be managed at home,
but rarely, croup can be
severe or life threatening.
Unfortunately, we don't have any medications
that will make the inciting
virus go away any faster.
So the focus on croup is on
making the child more comfortable
while the virus can run its course.
Remember, antibiotics do not
treat viral infections.
The first step in managing croup
is to administer corticosteroids.
This could be dexamethasone or prednisone,
and this is a mainstay treatment to help
decrease the swelling in the upper airway.
Unfortunately, these medications
take a while to work.
They can take 4 to 6 hours, so you want to
give them early in an outpatient setting
so they can get on board before
the symptoms worsen that night.
Another option in more extreme
cases is racemic epinephrine.
This is when the patient's airway
is being acutely compromised
and the patient does not have hours
to wait on their steroids to work.
This is administered via
a nebulizer treatment.
It will very quickly decrease
the airway swelling
and should be done in a hospital setting
because any patient that
requires racemic epinephrine
is at risk for airway compromise due
to the severity of their croup.
Here's a child receiving racemic
epinephrine nebulizer treatment,
and you can see they also have a nasal
cannula with some supplemental oxygen.
Another management technique is to
administer acetaminophen or ibuprofen.
This can help decrease the sore
throat associated from the coughing,
and can also make the child
just generally feel better.
Remember, ibuprofen can only be
administered in >6 month olds.
A controversial management
technique is humidified air.
It has debatable efficacy.
It used to be the mainstay, but
delivery devices have been evolving
and humidifying crib tents
are no longer used.
In studies, they found that
the particle size created by
blow by humidifiers is not optimal
for deposition in the larynx.
And also, they've studied warm
and dry or cool and dry air,
and that actually produced the greatest
reduction in airway resistance,
whereas there was no reduction
in the moist air group.
Some countries have completely
abandoned this treatment regimen,
although in the United States,
the standard for inpatient
and outpatient management of croup
still includes humidified air.
In the primary care setting, you're going
to want to create a steam-filled bathroom
or bundle the child up and take
them outside into the moist air.
If it's cool outside, the parents can
also roll the windows down in the car.
Complications of croup are rare.
They can include secondary
after the viral infection has passed.
This includes ear infections,
sinus infections, and pneumonia.
Dehydration can develop, and this can be
because the child's breathing faster,
they're going to lose more fluids
through their insensible water
loss with their breathing.
In addition, they may feel really lousy
and they just might be
napping most of the day,
missing out on opportunities to drink,
and they may also have a sore throat.
And all of these factors can put
the child at risk for dehydration.
Encourage the parents to push fluids
and encourage water-rich foods
such as Jell-O, applesauce,
pudding, fruits, and popsicles.
Respiratory distress can
also develop with croup.
Some children are going
to develop complications
that need additional respiratory support.
It's important for the clinician
to perform frequent
and thorough respiratory exams
to watch for signs of decline.
The child may need additional
support including oxygen,
IV fluids, and racemic epinephrine.
Children with increased risk
factors include those
with a history of lung or neurologic
disorders, such as asthma,
and children who are more likely
to develop severe croup symptoms
may require hospitalization.