Hark! The Bark of Croup

Croup. Here it comes. Oh, that stop-you-in-your tracks cough makes it that most anomatopoeic of illnesses.

Variously described as barking, brassy, or seal-like, the cough of croup and its accompanying noises are most frequently heard–at a great distance–during the late fall and early winter. Almost always, parents are understandably distressed by croup and seek urgent or emergency care for their charges when they get it. Questions abound: what causes it ? (you might be surprised) have treatments gotten better? (kinda, sorta) And, is it true that a walk outside on a cold night for a croupy kiddo could fix troublesome symptoms? (read on and find out)….

The name “croup” is apt, and is a centuries-old contraction of the words croak and whoop. (Interestingly, and quite of another subject, croup is also the term for the hindquarters of a quadriped–which happily has no clinical significance here). Croup affects the youngest set, ages 6 months to 3 years, most often. However, it does occur occasionally in children up to school age and older. Parents typically describe a few days of mild cough and cold symptoms, with unremarkable runny nose, sore throat, and perhaps a hoarse cry or voice at the start. However, it is when the infection attacks the upper airway on the second or third night (always at night for some reason) of illness in these children that things get exciting.

Croup’s medical aliases– laryngotracheitis or laryngotracheobronchitis –reflect the zip code of a child’s airway affected by the viral infection and inflammation. Parainfluenza virus most often is the culprit here, causing about 80% of cases in kids. The other 20% of viral bad guys causing croup are an infamous lot, including RSV, adenovirus, rhinovirus (the common cold), and influenza (aka the flu). Irritation and swelling of the airway above and below the vocal cords begins as that sore throat or raspy voice, and may progress to that sea-lion’s cough, and perhaps it’s pal, stridor.

Stridor is the hallmark of a more dramatic case of croup, and is caused by noisy turbulence in breathing through a narrow, inflamed airway. Stridor creates a harsh, musical sound, reminiscent of a squeaky wooden drawer being pulled from a jammed position. When taken in combination with the croupy cough, things can get quite symphonic and can seem pretty freaky. Fortunately, the vast majority of croup cases are mild, and stridor may be absent altogether. Parents can be reassured if their child is coughing noisily, but acts playfully, smiles, and can be consoled easily. All that, no stridor? Mild croup.

In moderate or severe cases of croup, stridor may be audible during inspiration and exhalation. As cases become more serious, kids may appear to work harder to breathe, seem cranky and uncomfortable, and show puckering (retracting) between the spaces of their ribs.

Parents will note that stridor often becomes more pronounced (and thus be more distressing) when children breathe more quickly. For this reason, finding ways to keep kids calm (comfort, hugs, and reassuring whispers) during bad croup flares is always a good idea. Medications like acetaminophen (Tylenol) or ibuprofen (Motrin) may help in fever control and for throat discomfort. Steaming up the bathroom with a hot shower may offer some temporary relief.

What’s more, there may be something to this clinical pearl: bundling up and going outside in the winter chill and breathing that cold air for a few minutes may soothe and improve a child’s airway inflammation. ER docs I have worked with insist they have seen multiple cases of kids hacking and barking at home, only to appear much better by the time they reach the hospital after travelling through a December night.

For any family member or caretaker who suspects a case of croup is progressing past the noisy cough stage towards some degree of respiratory distress–or if they are just worried–a STAT checkin with their child’s primary care doc is called for, so to speak. If circumstances allow, and if a child seems more bothered than sick, a phone call may suffice. Having that child within earshot of the clinician on the line to hear some coughing/barking may help clinch the diagnosis and allow for appropriate triage: manage at home? come in tomorrow? go right to the ER?

Treatment for croup has evolved a fair amount in the last twenty years. Some parents today may remember in their childhood that hospitals used to have ‘croup tents’, filled with misty water vapor. These were a mainstay of therapy for croup dating back to the 19th century. However, research by the late 90s proved these devices were not terribly effective for more severe symptoms, and placing children in the plastic-shrouded cribs may have done more to make them anxious and their stridor worse.

In the office or ER, clinicians can usually assess a child quickly and make the croup diagnosis by taking the history and performing an exam. First order of business: determine the severity of the disease. Steroid medications are the first line treatment for children with advancing symptoms of discomfort or distress for croup, and may even be given in milder cases to head off badness. These medications may be administered orally or by injection, and work to reduce the viral inflammation and swelling of the airway. For many, this may do the trick and will work well combined with the comfort and care measures described above. For a few, a checkback and even a second steroid treatment the next day may be recommended.

Children who have more extreme symptoms of cough, stridor, may be given aerosolized treatments of epinephrine. This is dramatic, potent stuff—typically given in an emergency room versus a doctor’s office–and can work in minutes to open things up. Heliox (a blend of oxygen and helium used by scuba divers for deep dives, among other things) has been used for children who have been unresponsive to epinephrine, and tends to be reserved for children admitted to hospital. Fortunately, the effectiveness of these treatments have contributed to faster recoveries and lower rates of hospital admissions for croup over the last decade. That’s nothing to cough at.

Before we wrap up, an important question to consider: Can you get croup again? About 5% of children can have a recurrent episode of croup. Most of these will be another, unfortunate viral illness. Note: a second bout will place a patient on watch to be sure nothing else is going on. Clinician and family may consider if something else is afoot. So-called spasmodic croup, for example, includes a subset of kids who have precipitous bouts of stridor and barking cough absent fever and signs of illness. In short, they customarily awake from sleep in full croupy splendor with little warning. These kids, and others may have other causes at work, including unrecognized allergy, acid reflux disease, or anatomical issues that trigger brassy coughs and noisy breathing. For these children, imaging or the use of special scopes to look at the airway by a specialist may be warranted.

So, my wishes for the best of luck for all of you with a super crouper, the illness with a bark that bites.

photo by jaQinthebox84

diagram link at http://commons.wikimedia.org/wiki/File:Throat_Diagram.svg

Cartoon below by me.

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