CROUP

CROUP
DR ODOCHI EWURUM
MBBS, FWACP, FMCPaed.
INTRODUCTION
• Croup refers to a heterogeneous group of
mainly acute subglottic airway lesions in which
varying degrees of inflammatory obstruction
of the larynx, trachea and bronchi occurs.
• Croup is associated with a triad of;
i. inspiratory stridor
ii. Hoarse voice or cry
iii. Loud brassy (metallic) cough
AETIOLOGY
• Viral causes: Haemophilus influenza A and B,
adenovirus, respiratory syncytial virus (RSV),
and measles.
• Bacterial causes: Mycoplasma pneumonia,
Streptococcus pyogenes, Streptococcus
pneumoniae, and Staphylococcus aureus.
EPIDEMIOLOGY
- More common in ages of 3 months and 5 yr, with
the peak in the 2nd yr of life.
-The incidence of croup is higher in males.
- it occurs most commonly in the dry season but
may occur throughout the year.
- Recurrences are frequent from 3–6 yr of age and
decrease with growth of the airway.
-Approximately 15% of patients have a strong
family history of croup.
CLASSIFICATION OF CROUP
• Its classified into 3, viz;
(1) Viral croup
(2) Bacterial trachetis (membraneous croup)
(3) Spasmodic croup
VIRAL CROUP (ALTB)
• Also termed Acute laryngitis, laryngotracheitis
or acute laryngotracheobronchitis(ALTB).
• It is the most common cause of stridor and
acute upper airway obstruction in pre-school
children aged <3years in Nigeria.
• The peak age range is 18-24 months.
VIRAL CROUP (ALTB)
AETIOLOGY
- Mainly viral and include:
i. Parainfluenza types 1,2 and 3
ii. Influenza type A and B
iii. Adenoviruses
iv. Mycoplasma pneumoniae
v. Measles virus
vi. Others (rarely)
VIRAL CROUP(ALTB)
PATHOGENESIS/PATHOPHYSIOLOGY:
• The pathogenic organism is acquired either
through direct person to person contact, or
with the respiratory secretions of affected
household/daycare sources, or via inhalation of
aerosolized respiratory secretions.
• The virus replicates and sheds in the upper
respiratory tract with a variable downward
extension along the respiratory tract.
VIRAL CROUP(ALTB)
PATHOGENESIS/PATHOPHYSIOLOGY:
• Mucosal oedema occurs and with the age-
related narrower dimension of the upper
airway of under-3 children, leads to a
relatively small decrease in the mucosal
diameter and is followed by significant airway
obstruction/resistance to airflow.
VIRAL CROUP (ALTB)
CLINICAL FEATURES
- Rhinorrhea
- pharyngitis
- low-grade fever
- the characteristic “barking” cough
- Hoarseness
- Continuos inspiratory stridor worsening with
increasing severity of the obstruction.
VIRAL CROUP (ALTB)
CLINICAL FEATURES
- restlessness in the child, lethargy or impaired
consciousness in severe cases.
- normal to moderately inflamed pharynx,
- increasing respiratory rate evidenced by nasal
flaring, suprasternal, infrasternal, and
intercostal retractions.
VIRAL CROUP (ALTB)
CLINICAL FEATURES CONTD.
-Alveolar gas exchange is usually normal because
croup is a disease of the upper airway.
-Hypoxia and low oxygen saturation are seen only
when complete airway obstruction is imminent.
-Cyanosis may be evident, but this constitutes a
late indicator of a potentially fatal hypoxaemia
Subjective assessment and scoring of clinical severity of viral croup,
modified after Taussig et al, 1975
0 1 2 3
Stridor None Mild Moderate at Severe on

rest inspiration/ex
piration, or
none with
markedly ↓
A/E
Retraction None Mild moderate Severe,

marked us e of
accessory
muscles
Air Entry Normal Mildly Moderately Markedly

decreased decreased decreased
Subjective assessment and scoring of clinical severity of
viral croup, modified after Taussig et al, 1975
0 1 2 3
Mucosal Normal Normal (o- Normal (o- Dusky or

colour score) score) cyanotic
(scored 3)
Level of Normal Restless when Anxious, Lethargic,
consciousness disturbed agitated, even depressed
when
score of 4-5 is mild, 5-6 is mild/moderate, 7-8 is
undisturbed
moderate and 9 – 15 is severe.

VIRAL CROUP (ALTB)
LABORATORY INVESTIGATIONS
(1)X-RAY: of the neck may show the typical
subglottic narrowing or “steeple sign” of croup
on the posteroanterior view.
(2) FBC
(3) Serial pulse oximetry for SPO2
(4) Arterial blood gases
VIRAL CROUP (ALTB)
DIFFERENTIAL DIAGNOSIS
i. Acute epiglottitis
ii. Bacterial tracheitis
iii. Spasmodic croup
iv. Foreign body aspiration
VIRAL CROUP (ALTB)
TREATMENT
(A) Medical
i. Humidification of inspired air/oxygen or steam
inhalation.
ii. Corticosteriod therapy: dexamethazone,
prednisolone, budesonide.
iii. Nebulized adrenaline(epinephrine)
iv. Close monitoring for worsening severity of
obstruction/ hypoxaemia
VIRAL CROUP (ALTB)
TREATMENT CONTD.
Surgical
i. Tracheostomy
ii. Controlled nasotracheal intubation; the
required tube size in mm is one that is
o.5mm smaller than the estimated tube size
using the formula {[age in yrs ÷4]+4}
BACTERIAL TRACHEITIS
• Also known as membraneous croup,
pseudomembraneous croup, bacterial croup or
purulent tracheobronchitis.
• Usually starts like viral ALTB but almost always ends
with an eventual pyogenic bacterial invasion and
endoscopic evidence of mucopurulent exudates
below the cricoid.
• It is an uncommon cause of acute upper airway
obstruction but its in-between mild ALTB and severe
acute epiglottitis.
EPIDEMIOLOGY
- Vulnerable age group is infancy to
adolescence (6months-14 years, with a mean
age of 3-8years)
- More common in the winter months
- M:F varies between 1:1 and 5:1
AETIOLOGY
-Antecedent viral infections from parainfluenza
viruses, Haemophilus influenza, measles and
rarely enteroviruses.
-Bacteria such as Staphylococcus aureus,
Moraxella catarrrhalis, α-hemolytic
streptococcus, pneumococcus and anaerobes.
Less commonly gram negative enteric agents
and pseudomonas species.
PATHOGENESIS
• An antedating viral infection weakens the
tracheal mucosa leading to bacterial invasion
with resultant Local and systemic inflammatory
response.
• The pathological lesions in bacterial tracheitis
include mucosal ulceration, erythema, and
pseudomembrane formation on the tracheal
surface.
PATHOGENESIS
• Consequently, sloughing of the tracheal mucosa
and a resultant formation of a mucopurulent
exudent ensue.
• These pathlogical sequence of events in
addition to age-related smaller airways may
eventually culminate in variable degrees of
obstruction at the level of trachea and the main
stem bronchi.
CLINICAL FEATURES
I. Rhinorhea
II. Fever
III. Sore throat
IV. Triad of loud stridor, a barky or brassy cough
and a hoarse cry
V. Tachypnoea
INVESTIGATIONS
(1) NECK X-RAY:
i. Pencil tip or steeple sign of supraglottic
narrowing and in viral croup.
ii. Candle-dripping sign of the diffuse haziness
and/or irregularity of the anterior wall of the
trachea which is specific.
(2) Chest X-ray: for features of concurrent
pneumonia.
INVESTIGATIONS CONTD.
(3) Endoscopy (laryngobronchoscopy)
(4) Microbiological; m/c/s and gram stain of
tracheal aspirates, blood culture
(5) FBC; generally non specific but may show
polymorphonuclear leucocytosis.
STEEPLE SIGN
CANDLE DRIPPING SIGN
COMPLICATIONS
i. Pneumonia, atelectasis, pneumothorax
ii. Pulmonary edema
iii. Cardiopulmonary arrest
iv. Septicemia, septic shock, lymphadenitis
v. Toxic shock syndrome
vi. Adult respiratory distress syndrome
vii. Sub-glottic stenosis from protracted intubation
DIFFERENTIAL DIAGNOSIS
i. Viral Croup
ii. Acute epiglottitis
iii. Retropharyngeal abscess
TREATMENT
Surgical: Endotracheal intubation, airway
stabilization and airway toileting.
Medical: Intravenous broad spectrum empirical
antibiotics to cover for commonly isolated
bacterial agents like S.aureus, M. catarrhalis,
S.pneumonia and H.Influenza. A change of
medication will be required depending on the
culture and sensitivity.
TREATMENT CONTD.
Supportive:
i. Control of tracheal pain with analgesics.
ii. Chest physiotherapy to encourage coughing
and secretion clearance.
iii. Humidification of inspired air for its
ameliorating effect and to prevent plugging of
mucus.
SPASMODIC CROUP
• Also known as recurrent croup or laryngismus
stridulus.
• It appears and disappears spontaneously
especially at night.
• It is presumed to be of non infective or probably
allergic origin.
• In majority of the affected children, there is no
preceeding viral upper respiratory tract infection
or nasopharyngitis.
SPASMODIC CROUP
• The children are not usually febrile.
AETIOLOGY
i. Atopy: The tendency for recurrence and
constellation of cases in families with allergic
conditions like asthma, atopic eczema and
allergic rhinoconjunctivitis suggests atopy as a
possible aetiology.
ii. Psychological factors
iii. Viral in some cases
SPASMODIC CROUP
CLINICAL FEATURES
i. Characteristic barking metallic cough.
ii. Noisy inspiration.
iii. Respiratory distress.
iv. Anxious and frightened.
v. The symptoms diminish within several hours
and patient becomes better the next one or
two days.
SPASMODIC CROUP
TREATMENT
i. Mainstay of treatment is airway
management and treatment of hypoxia.
ii. Treatment is the same for viral croup.
.
• THANKS FOR
LISTENING
SUGGESTED READING
(1)Johnson ABR, Gobir AA, Abdulkadir MB, Ibraheem
RA. Acute upper respiratory infections(URI). In
Azubuike JC, Nkanginieme KEO. Paediatrics and
Child Health in a Tropical region.3rd ed. Owerri:
African Educational services; 2007.
(2) Roosevelt GE. Acute inflammatory upper airway
obstruction( Croup, Epiglottitis, Laryngitis, and
Bacterial tracheitis). In : Kleigman MR, Berham ER,
Jenson BH, Stanton FB, editors. Nelson’s Textbook of
Paediatrics.19th ed. Elsevier; 2011.
SUGGESTED READING
(3) Webb JKG.Diseases of the respiratory system.
Diarrhoeal diseases. In: Stanfield P, Brueton
M, Chan M, Parkin M, Waterston T, editors.
Diseases of Children in the Subtropics and
Tropics. 4th ed. Educational Low priced books.
(5) Internet.

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CROUP

Stridor None Mild Moderate at Severe on

Retraction None Mild moderate Severe,

Air Entry Normal Mildly Moderately Markedly

Mucosal Normal Normal (o- Normal (o- Dusky or

moderate and 9 – 15 is severe.

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