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COMBATING INFECTION
Viral croup in children
By Janelle Gardner, RN,C, PhD
IT’S A COLD winter night when 12month-old Jacob and his exhausted parents arrive at the ED. Jacob has had
signs of a head cold and a low-grade
fever for 2 days. He’s developed a distinctive barking cough, hoarseness, and
inspiratory stridor. His respiratory rate
is 50 breaths/minute, and the pulse
oximeter reading is 92%. Jacob’s signs
and symptoms suggest croup. What are
the appropriate nursing interventions
for Jacob?
What is croup?
Croup is a generic term applied to a
group of common respiratory illnesses—
mostly seen in children—that result
from edema of the larynx, trachea, and
bronchi. Croup can be categorized as viral or bacterial. In this article, I’ll focus
on viral croup, which is the more common type. Viral croup is also the most
common form of airway obstruction in
children ages 6 months to 6 years and is
one of the leading causes of hospitalization in children under age 4.1
What causes viral croup?
Viral croup is a viral invasion of the upper airway that extends throughout the
larynx, trachea, and bronchi. Caused by
various viruses, most commonly parainfluenza viruses types 1, 2, and 3, it
affects more boys than girls. The peak
season in the United States is late fall,
but it can occur at any time of year. In
most cases, viral croup is mild to moderate in severity, but it can progress to
respiratory failure (see Assessing croup
severity).
The invading virus causes inflammation and edema in the child’s trachea and
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Inflamed
laryngeal
area
Inflamed
subglottic
tissue
Usually worse at night, signs
and symptoms generally peak on
the second or third night.2 The
child may prefer to sit up or be
held upright because he can
breathe more easily in this position. Signs and symptoms may be
more severe in children 3 years of
age and younger.
Assessing the patient
A diagnosis of viral croup usually
rests on patient history and presenting clinical signs and symptoms. However, posterior-anterior
Narrowed
and lateral X-rays of the neck may
trachea
be taken if the diagnosis is in
question. Another reason for taking X-rays is to rule out foreign
body airway obstruction. About
Viral croup causes inflammation and edema of the
50% of children with viral croup
upper respiratory tract.
show a tapered symmetric subglottic narrowing (a “steeple
larynx. The resulting airway obstruction
sign”) on plain neck radiography.1
causes a characteristic barking cough,
Try to keep a child with viral croup
hoarseness, inspiratory stridor, and varycalm because crying and agitation can
ing degrees of respiratory distress.1
exacerbate signs and symptoms. Focus
Respiratory distress is exacerbated by
your physical assessment on the respilarge amounts of thick, tenacious secreratory system.
tions that further obstruct the airway.
Acute airway inflammation in children Maintain, manage, and medicate
When caring for a child with croup,
is dangerous because a child’s larynx is
focus on maintaining his airway. Invery narrow, so even small amounts of
terventions include humidification,
mucus and edema can obstruct it.
medications, and supplemental oxygen.
Inspired humidified air that’s cooler
Identifying viral croup
develops
than body temperature cools and
A child with viral croup first
soothes airway mucosa and triggers
upper respiratory signs and symptoms
vasoconstriction, decreasing edema in
(runny nose, sore throat, low-grade
the respiratory tract. Cool moist air also
fever). Over the next few days, signs
moistens and thins secretions. Conand symptoms progress to those of
trolled delivery of 40% humidity (low
croup.
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COMBATING INFECTION
humidity) or humidity by blow-by is the
most effective technique3 because it lowers anxiety in children who don’t want
to cooperate with oxygen therapy.
Croup tents are seldom used because
they frighten children and make observation more difficult.
For decades, nebulized racemic epinephrine has been the standard medication for children with moderate to severe
croup. Mixed with 0.9% sodium chloride
solution and delivered with humidified
oxygen, it reduces inspiratory stridor and
intercostal retractions within 30 minutes
of treatment. The medication’s effectiveness lasts about 2 hours.1 Common
adverse reactions include tachycardia and
hypertension.
Oral or intramuscular dexamethasone may be ordered to reduce airway
inflammation and edema. It has a long
half-life (24 to 48 hours). Adverse reactions are rare.
A child with mild croup who responds
well to treatment may be sent home from
the ED after 3 or 4 hours of observation.
If signs and symptoms of respiratory distress persist after initial treatment, he’ll be
admitted to the hospital for further observation and management.
Keeping an eye on croup
When a child has been diagnosed with
croup, monitor him closely and quickly
identify any alterations in airway patency. Follow these guidelines.
• Monitor him for tachypnea and tachycardia, which signal the child’s increasing respiratory effort.
• Assess his breath sounds and monitor
for retractions, nasal flaring, stridor, and
cyanosis.
• Use a cardiac monitor and pulse
oximeter for continuous monitoring.
• Position the child for comfort and remember that a need to move to a more
upright position may indicate increased
respiratory distress.
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ASSESSING CROUP SEVERITY
Level of severity
Characteristics
Mild
• Occasional barking cough
• Limited or no stridor at rest
• Mild or no suprasternal or intercostal retractions
• Frequent barking cough
• Easily audible stridor at rest
• Suprasternal and sternal wall retractions at rest
• Little to no distress or agitation
• Frequent barking cough
• Prominent inspiratory and occasionally expiratory stridor
• Marked sternal wall retractions
• Significant distress and agitation
• Barking cough (often not prominent)
• Audible stridor at rest (occasionally hard to hear)
• Sternal wall retractions (may not be marked)
• Lethargy or decreased level of consciousness
• Often dusky complexion without supplemental oxygen
Moderate
Severe
Impending
respiratory failure
Adapted from Bjornson CL, Johnson DW, Croup—treatment update, Pediatric Emergency Care, December 2005.
What parents need to know
Viral croup usually runs its course in 3
to 7 days. Give parents the following advice to keep their child comfortable at
home.
• Hold your child in an upright position, which can help him breathe more
easily. Hold him in your lap or place
him in a favorite chair or infant seat.
• Moist air seems to help. Run hot water
in the bathtub with the door closed and
hold your child while he breathes in the
humidified air.
• A walk in cool nighttime air can help
too. Dress your child warmly and take a
short walk with him.
• Try to keep your child calm and relaxed; crying or becoming agitated will
make breathing more difficult.
• Administer a fever reducer such as
ibuprofen or acetaminophen as directed
by the health care provider.
• If he doesn’t respond to treatments or
his signs and symptoms get worse, call
your health care provider immediately.
How’s Jacob?
Jacob was diagnosed with viral croup and
admitted to the hospital. Intravenous flu-
ids were administered to prevent dehydration, and supplemental oxygen with
humidity was administered via a blow-by
for hypoxemia. Jacob received oral dexamethasone and humidified racemic epinephrine. He was monitored closely, his
signs and symptoms improved, and he
was discharged after 48 hours. ‹›
REFERENCES
1. Knutson D, Aring A. Viral croup. American Family Physician. 69(3):535-540, February 2004.
2. Dykes J. Managing children with croup in emergency departments. Emergency Nurse. 13(6):14-19,
October 2005.
3. Scolnik D, et al. Controlled delivery of high vs.
low humidity vs. mist tent for croup in emergency
departments: A randomized controlled trial. The
Journal of the American Medical Association.
295(11):1274-1280, March 15, 2006.
RESOURCES
Ball JW, Bindler RC. Child Health Nursing: Partnering with Children and Families. Prentice Hall, 2006.
Bjornson CL, Johnson DW. Croup—treatment
update. Pediatric Emergency Care. 21(12):863-870,
December 2005.
Bjornson CL, Johnson DW. Pediatric practice. That
characteristic cough: When to treat croup and what
to use. Patient Care for the Nurse Practitioner.
7(1):13, January 2004.
Mayo Clinic. Croup. http://www.mayoclinic.com/
health/croup/DS00312/DSECTION=1.
Nursing2008 Drug Handbook, 28th edition. Lippincott Williams & Wilkins, 2008.
Web site last accessed on March 3, 2008.
Janelle Gardner is a professor at California State
University’s School of Nursing in Chico.
www.nursing2008.com