What is Croup Syndrome?

Croup is a respiratory condition characterized by a distinctive brassy cough, which may be accompanied by inspiratory stridor, hoarseness, or respiratory distress. It includes conditions such as acute epiglottitis, laryngitis, laryngotracheobronchitis, and spasmodic laryngitis. The symptoms typically include a harsh cough and noisy breathing, often improving within hours but recurring over subsequent days. In most cases, the illness follows a benign course, with complete recovery. Humidifying the room can provide symptomatic relief.

Differential Diagnosis

Croup syndromes must be distinguished from other respiratory conditions such as:

• Diphtheritic croup

• Measles-associated respiratory complications

• Angioneurotic edema

• Retropharyngeal abscess

• Aspiration of a foreign body

Management of Croup

Acute Epiglottitis

Patients with epiglottitis require immediate hospitalization. The management includes:

• Administration of humidified oxygen via hood (face masks are generally not well tolerated).

• Close monitoring for signs of respiratory failure, as oxygen therapy can mask cyanosis.

• Avoidance of sedatives and unnecessary throat examinations to prevent laryngeal spasm.

• Intravenous fluids to maintain hydration.

• Intravenous third-generation cephalosporins such as cefotaxime or ceftriaxone (100 mg/kg/day) to treat bacterial infection.

• Endotracheal intubation or tracheostomy in cases of worsening airway obstruction despite antibiotic therapy.

Laryngotracheobronchitis (Infectious Croup)

Patients should be assessed based on general appearance, stridor, oxygen saturation, and respiratory distress severity.

Mild Cases:

• Managed on an outpatient basis with symptomatic treatment for fever.

• Encouragement of fluid intake.

• Educating parents about possible disease progression and when to seek medical attention.

Moderate Cases:

• Require hospitalization.

• Nebulized epinephrine (1:1000 dilution, 0.1-0.5 mL/kg, max 5mL) for immediate symptom relief.

• A single dose of intramuscular dexamethasone (0.3-0.6 mg/kg) within 24 hours.

• Inhalation of budesonide (1 mg twice daily for two days) for effective symptom control.

Severe Cases:

• Require urgent hospitalization.

• Oxygen therapy.

• Administration of epinephrine and steroids as per moderate case management.

• Short-term mechanical ventilation in cases of respiratory failure.

Epiglottitis

Epiglottitis, also known as supraglottitis, is primarily caused by Haemophilus influenzae type B. It begins as a mild upper respiratory infection but rapidly progresses within hours. It is a bacterial form of croup. Symptoms include:

• High fever

• Difficulty in swallowing

• Inability to speak (aphonia)

• Sitting in a characteristic "tripod position" with the neck extended and drooling of saliva

• Severe respiratory distress with suprasternal and subcostal retractions

• Fatigue, leading to a decrease in stridor intensity

A cautious direct laryngoscopy reveals an intensely inflamed, swollen epiglottis. Injudicious throat examinations can trigger fatal reflex laryngeal spasms, so emergency resuscitation equipment should be readily available during assessment. 

Laryngitis and Laryngotracheobronchitis (Infectious Croup)

These conditions are almost always viral in origin, commonly caused by parainfluenza virus type 1. Other causative viruses include:

• Respiratory syncytial virus (RSV)

• Parainfluenza types 2 and 3

• Influenza virus

• Adenovirus

• Rhinovirus

The illness usually starts with mild cold symptoms before progressing to:

• A brassy cough

• Inspiratory stridor

• Suprasternal and sternal retractions

• Restlessness and anxiety due to hypoxemia

• Cyanosis in severe cases

• Diminished breath sounds as airway obstruction worsens

Spasmodic Croup

Spasmodic croup primarily affects children aged 1-3 years. Unlike infectious croup, it often occurs without a preceding cold. The child may wake suddenly in the early morning hours with a characteristic cough and difficulty breathing.

Prevention and Vaccination

• Hib Vaccine: Routine immunization against Haemophilus influenzae type B can significantly reduce the incidence of epiglottitis.

• Influenza Vaccine: Annual flu shots help prevent viral infections that may lead to croup.

• General Hygiene: Regular handwashing and avoiding exposure to infected individuals can reduce transmission risks.

Conclusion

Early recognition and appropriate management of croup and its subtypes are crucial for preventing complications and ensuring complete recovery. In cases of severe respiratory distress, immediate medical intervention is essential to secure the airway and provide adequate oxygenation. Preventive measures, including vaccination and good hygiene, play a key role in reducing the incidence of croup-related illnesses.

1. A nurse is assessing a child with croup. Which clinical sign would indicate worsening respiratory distress?

a) Mild inspiratory stridor and barking cough
b) Intercostal retractions with nasal flaring
c) Clear lung sounds with occasional coughing
d) Slight hoarseness with no respiratory difficulty

Answer: b) Intercostal retractions with nasal flaring

2. A child with croup is prescribed nebulized epinephrine. What is the nurse's priority assessment after administration?

a) Respiratory rate and effort
b) Urine output
c) Level of consciousness
d) Capillary refill time

Answer: a) Respiratory rate and effort

3. Which nursing intervention is most important when caring for a child with moderate croup?

a) Encouraging frequent sips of cold water
b) Placing the child in a high-Fowler's position
c) Administering antibiotics as prescribed
d) Performing chest physiotherapy every 2 hours

Answer: b) Placing the child in a high-Fowler's position

4. A nurse is providing discharge teaching to the parents of a child with mild croup. Which statement by a parent indicates a need for further teaching?

a) "We should keep a cool mist humidifier in the room."
b) "If my child starts drooling and has difficulty breathing, I should take them to the emergency room immediately."
c) "We can give cough syrup to help with the barking cough."
d) "If symptoms get worse at night, we should take our child to a steamy bathroom or outside for cool air."

Answer: c) "We can give cough syrup to help with the barking cough."

Rationale: Cough syrups are not recommended as they may not be effective and can pose a choking risk.

5. A nurse is assisting a paediatrician in assessing a child suspected of acute epiglottitis. What action should the nurse avoid?

a) Keeping emergency airway equipment ready
b) Monitoring oxygen saturation continuously
c) Using a tongue depressor to check the throat
d) Keeping the child in an upright position

Answer: c) Using a tongue depressor to check the throat

Rationale: This can cause laryngospasm and airway obstruction.

6. A nurse is caring for a child with severe croup in the emergency department. Which intervention should be performed first?

a) Administer humidified oxygen
b) Encourage oral fluid intake
c) Teach parents about home management
d) Start intravenous antibiotic therapy

Answer: a) Administer humidified oxygen

7. The nurse is evaluating the response to treatment in a child with moderate croup receiving dexamethasone. Which finding indicates improvement?

a) Increased stridor at rest
b) Decreased respiratory rate and effort
c) Cyanosis of lips and fingers
d) Increased work of breathing with nasal flaring

Answer: b) Decreased respiratory rate and effort

8. Which position is best for a child experiencing respiratory distress due to croup?

a) Supine with the head slightly elevated
b) Prone with a pillow under the chest
c) Sitting upright or in the parent's arms
d) Trendelenburg position

Answer: c) Sitting upright or in the parent's arms

9. A nurse is providing health education to a parent about preventing croup. Which statement should be included?

a) "Ensure your child receives the Hib vaccine as scheduled."
b) "Avoid giving your child cold fluids during winter."
c) "Keep your child indoors at all times during flu season."
d) "Give over-the-counter cough suppressants regularly."

Answer: a) "Ensure your child receives the Hib vaccine as scheduled."

10. Which of the following is a priority nursing intervention for a child with spasmodic croup?

a) Encouraging deep breathing exercises
b) Providing comfort and reducing anxiety
c) Giving oral rehydration therapy
d) Administering broad-spectrum antibiotics

Answer: b) Providing comfort and reducing anxiety

Rationale: Anxiety can worsen respiratory distress in croup.

11. A child with croup is prescribed nebulized epinephrine. The nurse should explain to the parents that the expected effect of the medication is:

a) Reduction in airway swelling and improved breathing
b) Decrease in mucus production
c) Increase in energy and appetite
d) Prevention of bacterial infection

Answer: a) Reduction in airway swelling and improved breathing

12. A nurse is caring for a child with severe croup who is experiencing respiratory distress. Which finding would indicate a need for intubation?

a) Stridor at rest despite treatment
b) Barking cough with mild nasal congestion
c) Increased heart rate but normal oxygen saturation
d) Fever with mild inspiratory stridor

Answer: a) Stridor at rest despite treatment

13. The nurse is teaching a mother how to recognize signs that her child's croup is worsening. Which symptom requires immediate medical attention?

a) Hoarseness and mild barking cough
b) Stridor only when crying
c) Retractions and cyanosis
d) Occasional nighttime cough

Answer: c) Retractions and cyanosis

14. Which nursing intervention is appropriate when caring for a child with mild croup at home?

a) Encouraging exposure to dry, warm air
b) Using a cool-mist humidifier in the child’s room
c) Keeping the child in a supine position
d) Giving antihistamines for symptom relief

Answer: b) Using a cool-mist humidifier in the child’s room

15. A nurse is reviewing the signs of mild, moderate, and severe croup. Which of the following symptoms would indicate moderate croup?

a) Noisy breathing only while crying, no retractions
b) Stridor at rest, suprasternal retractions, and tachypnea
c) Severe respiratory distress with cyanosis
d) Normal oxygen saturation with occasional barking cough

Answer: b) Stridor at rest, suprasternal retractions, and tachypnea

References

1. Ghai OP. Essential Paediatrics. 10th ed. New Delhi: CBS Publishers; 2022.

2. Hockenberry MJ, Wilson D. Wong’s Essentials of Paediatric Nursing. 11th ed. St. Louis: Elsevier; 2021.

#CroupSyndrome #RespiratoryCare #PediatricNursing #NursingQuiz #NCLEXPrep #AIIMSNursing #HealthcareEducation #EmergencyCare #NursingExam #AirwayManagement