Croup (or laryngotracheobronchitis) is a respiratory condition that is usually triggered by an

acute viral infection of the upper airway. The infection leads to swelling inside the throat, which
interferes with normal breathing and produces the classical symptoms of a "barking" cough,
stridor, and hoarseness. It may produce mild, moderate, or severe symptoms, which often worsen
at night. It is often treated with a single dose of oral steroids; occasionally epinephrine is used in
more severe cases. Hospitalization is rarely required.

Croup is diagnosed on clinical grounds once potentially more severe causes of symptoms have
been excluded (i.e. epiglottitis or an airway foreign body). Further investigations—such as blood
tests, X-rays, and cultures—are usually not needed. It is a relatively common condition that
affects about 15% of children at some point, most commonly between 6 months and 5–6 years of
age. It is almost never seen in teenagers or adults.

Once due primarily to diphtheria, this cause is now primarily of historical significance in the
Western world due to the success of vaccination.

Contents
[hide]

 1 Signs and symptoms

 2 Causes
o 2.1 Viral
o 2.2 Bacterial
 3 Pathophysiology
 4 Diagnosis
 5 Prevention
 6 Treatment
o 6.1 Steroids
o 6.2 Epinephrine
o 6.3 Other
 7 Prognosis
 8 Epidemiology
 9 History
 10 References
 11 External links

[edit] Signs and symptoms

Stridor

Inspiratory and expiratory stridor in a 13 month child with croup.

Problems listening to this file? See media help.

Croup is characterized by a "barking" cough, stridor, hoarseness, and difficult breathing which
usually worsens at night.[1] The "barking" cough is often described as resembling the call of a
seal or sea lion.[2] The stridor is worsened by agitation or crying, and if it can be heard at rest, it
may indicate critical narrowing of the airways. As croup worsens, stridor may decrease
considerably.[1]

Other symptoms include fever, coryza (symptoms typical of the common cold), and chest wall
indrawing.[1][3] Drooling or a very sick appearance indicate other medical conditions.[3]

[edit] Causes
Croup is usually deemed to be due to a viral infection.[1][4] Others use the term more broadly, to
include acute laryngotracheitis, spasmodic croup, laryngeal diphtheria, bacterial tracheitis,
laryngotracheobronchitis, and laryngotracheobronchopneumonitis. The first two conditions
involve a viral infection and are generally milder with respect to symptomatology; the last four
are due to bacterial infection and are usually of greater severity.[2]

[edit] Viral

Viral croup/acute laryngotracheitis caused by parainfluenza virus, primarily types 1 and 2, in

75% of cases.[5] Other viral etiologies include influenza A and B, measles, adenovirus and
respiratory syncytial virus (RSV).[2] Spasmodic croup is caused by the same group of viruses as
acute laryngotracheitis, but lacks the usual signs of infection (such as fever, sore throat, and
increased white blood cell count).[2] Treatment, and response to treatment, are also similar.[5]

[edit] Bacterial

Bacterial croup may be divided into laryngeal diphtheria, bacterial tracheitis,

laryngotracheobronchitis, and laryngotracheobronchopneumonitis.[2] Laryngeal diphtheria is due
to Corynebacterium diphtheriae while bacterial tracheitis, laryngotracheobronchitis, and
laryngotracheobronchopneumonitis are usually due to a primary viral infection with secondary
bacterial growth. The most common bacteria implicated are Staphylococcus aureus,
Streptococcus pneumoniae, Hemophilus influenzae, and Moraxella catarrhalis.[2]

[edit] Pathophysiology
The viral infection that causes croup leads to swelling of the larynx, trachea, and large bronchi[4]
due to infiltration of white blood cells (especially histiocytes, lymphocytes, plasma cells, and
neutrophils).[2] Swelling produces airway obstruction which, when significant, leads to
dramatically increased work of breathing and the characteristic turbulent, noisy airflow known as
stridor.[4]
[edit] Diagnosis
The Westley Score: Classification of croup severity[5][6]
Number of points assigned for this feature
Feature
0 1 2 3 4 5
Chest wall
None Mild Moderate Severe
retraction
With
Stridor None At rest
agitation
With
Cyanosis None At rest
agitation
Level of
Normal Disoriented
consciousness
Markedly
Air entry Normal Decreased
decreased

Croup is a clinical diagnosis.[4] The first step is to exclude other obstructive conditions of the
upper airway, especially epiglottitis, an airway foreign body, subglottic stenosis, angioedema,
retropharyngeal abscess, and bacterial tracheitis.[2][4]

A frontal X-ray of the neck is not routinely performed,[4] but if it is done, it may show a
characteristic narrowing of the trachea, called the steeple sign. The steeple sign is suggestive of
the diagnosis, but is absent in half of cases.[3]

Other investigations (such as blood tests and viral culture) are discouraged as they may cause
unnecessary agitation and thus worsen the stress on the compromised airway.[4] While viral
cultures, obtained via nasopharyngeal aspiration, can be used to confirm the exact cause, these
are usually restricted to research settings.[1] Bacterial infection should be considered if a person
does not improve with standard treatment, at which point further investigations may be indicated.
[2]

Severity

The most commonly used system for classifying the severity of croup is the Westley score. It is
primarily used for research purposes rather than in clinical practice.[2] It is the sum of points
assigned for five factors: level of consciousness, cyanosis, stridor, air entry, and retractions.[2]
The points given for each factor is listed in the table to the right, and the final score ranges from
0 to 17.[6]

 A total score of ≤ 2 indicates mild croup. The characteristic barking cough and
hoarseness may be present, but there is no stridor at rest.[5]
 A total score of 3–5 is classified as moderate croup. It presents with easily heard stridor,
but with few other signs.[5]
 A total score of 6–11 is severe croup. It also presents with obvious stridor, but also
features marked chest wall indrawing.[5]
  A total score of ≥ 12 indicates impending respiratory failure. The barking cough and
stridor may no longer be prominent at this stage.[5]

85% of children presenting to the emergency department have mild disease; severe croup is rare
(<1%).[5]

[edit] Prevention
Many cases of croup have been prevented by immunization for influenza and diphtheria. At one
time, croup referred to a diphtherial disease, but with vaccination, diphtheria is now rare in the
developed world.[2]

[edit] Treatment
Children with croup are generally kept as calm as possible.[4] Steroids are given routinely, with
epinephrine used in severe cases.[4] Children with oxygen saturations under 92% should receive
oxygen,[2] and those with severe croup may be hospitalized for observation.[3] If oxygen is
needed, "blow-by" administration (holding an oxygen source near the child's face) is
recommended, as it causes less agitation than use of a mask.[2] With treatment, less than 0.2% of
people require endotracheal intubation.[6]

[edit] Steroids

Corticosteroids, such as dexamethasone and budesonide, have been shown to improve outcomes
in children with all severities of croup.[7] However, significant relief is often not obtained for up
to six hours after administration, and lasts for only about 12 hours.[7] While effective when given
orally, parenterally, or by inhalation, the oral route is preferred.[4] A single dose is usually all that
is required, and is generally considered to be quite safe.[4] Dexamethasone at doses of 0.15, 0.3
and 0.6 mg/kg appear to be all equally effective.[8]

[edit] Epinephrine

Moderate to severe croup may be improved temporarily with nebulized epinephrine.[4] While
epinephrine typically produces a reduction in croup severity within 10–30 minutes, the benefits
last for only about 2 hours.[4][1] If the condition remains improved for 2–4 hours after treatment
and no other complications arise, the child is typically discharged from the hospital.[4][1]

[edit] Other

While other treatments for croup have been studied, none have sufficient evidence to support
their use. Inhalation of hot steam or humidified air is a traditional self-care treatment, but clinical
studies have failed to show effectiveness[2][4] and currently it is rarely used.[9] The use of cough
medicines, which usually contain dextromethorphan and/or guiafenesin, are also discouraged.[1]
While breathing heliox (a mixture of helium and oxygen) to decrease the work of breathing has
been used in the past, there is very little evidence to support its use.[10] Since croup is usually a
viral disease, antibiotics are not used unless secondary bacterial infection is suspected.[1] In cases
of possible secondary bacterial infection, the antibiotics vancomycin and cefotaxime are
recommended.[2] In severe cases associated with influenza A or B, the antiviral neuraminidase
inhibitors may be administered.[2]

[edit] Prognosis
Viral croup is usually a self-limited disease, but can very rarely result in death from respiratory
failure and/or cardiac arrest.[1] Symptoms usually improve within two days, but may last for up to
seven days.[5] Other uncommon complications include bacterial tracheitis, pneumonia, and
pulmonary edema.[5]

[edit] Epidemiology
Croup affects about 15% of children, and usually presents between the ages of 6 months and 5–6
years.[4][2] It accounts for about 5% of hospital admissions in this population.[5] In rare cases, it
may occur in children as young as 3 months and as old as 15 years.[5] Males are affected 50%
more frequently than are females, and there is an increased prevalence in autumn (fall).[2]

[edit] History
The word croup comes from the Early Modern English verb croup, meaning "to cry hoarsely";
the name was first applied to the disease in Scotland and popularized in the 18th century.[11]
Diphtheritic croup has been known since the time of Homer's Ancient Greece and it was not until
1826 that viral croup was differentiated from croup due to diphtheria by Bretonneau.[12] Viral
croup was thus called "faux-croup" by the French, as "croup" then referred to a disease caused by
the diphtheria bacteria.[9] Croup due to diphtheria has become nearly unknown due to the advent
of effective immunization.[12]

Clinical Manifestations
Signs & Symptoms
Chest Pain
Chest pain, substernal/midline
Non-Pleuritic Chest Pain
Vomiting
Allergic Barking Cough
Chest pain/non-cardiac
Cough
Cough Acute
Cough Dry Non-productive
Cough Whooping Quality
Noisy Breathing
Noisy Breathing Child
 Prolonged expiratory phase
Pursed lips breathing
Retraction of intercostal muscles
Burning/Raw throat feeling
Constriction throat/Pharyngeal dystonia
Difficulty speaking/phonating
Dysphonia
Hoarseness
Laryngeal pain/Aphonia
Larynx Pain
Neck/throat pain/anterior
Odd sounding voice/husky
Stridor (Inspiratory noise)
Stridor infant Child
Voice Alteration
Voice Alteration in Children
Voice change/disturbance/Unusual
Voice/phonation problems
Fever
Fever Febrile Possible
Flu-Like Syndrome
High body temperature
Clinical Presentation & Variations
Presentation/Wheeze Cough Dyspnea Infant
Disease Progression
Course/Acute
Course/Acute only
Laboratory Tests
Abnormal Lab Findings (Non Measured)
Acute inflammatory markers elevated (Lab)
Right Shift (Viral) Differential Smear (Lab)
Diagnostic Test Results
Other Tests & Procedures
PFT/FEV1 decreased
Associated Diseases & Rule outs
Rule Outs
Tracheitis, acute
Asthma Children
Associated Disease & Complications
Acute respiratory failure/Respiratory arrest
Airway obstruction
Airway obstruction/Children
Apnea
Asphyxia/suffocation
Laryngeal stridor
Laryngitis, acute
 Respiratory failure/Pulmonary insufficiency
Upper airway obstruction
Disease Mechanism & Classification
Specific Agent
AGENT/Virus (category)
Class
CLASS/Bronchus involvement/disorder (ex)
CLASS/Laryngeal disorder (ex)
CLASS/Trachea disorder/lesion (ex)
CLASS/Tracheonasal/larynx/pharynx (category)
Pathophysiology
Pathophysiology/Upper airway narrowing
Process
PROCESS/Acute infection (ex).
PROCESS/Infected organ/abscess (category)
PROCESS/Infection/agent specific (category)
PROCESS/Inflammatory/infection (ex)
Synonyms
Synonym
Acute laryngotracheobronchitis, Acute Obstructive Laryngitis, Acute obstructive
laryngitis (croup), croup, Croup (disorder), Croup syndrome,
LARYNGOTRACHEOBRONCHITIS ACUTE, Synonym/Croup
Treatment
Drug Therapy - Indication
RX/Antibiotic
RX/Ephedrine
Definition
Be the first to add a definition for Laryngotracheobronchitis, acute
External Links Related to Laryngotracheobronchitis, acute
Google
Wikipedia
Merck
Images
PubMed (National Library of Medicine)
NGC (National Guideline Clearinghouse)
Medscape (eMedicine)
Harrison's Online (accessmedicine)
NEJM (The New England Journal of Medicine)