It was a cold and crisp December night, the kind of night that you'd swear that you could see a million stars. The moon was full and seemed to fill the nighttime sky. Mr. Jones stared at the dying embers in the fireplace as he fiddled with the belt of his bathrobe. His wife was on the phone with the doctor. They hesitated to call because it was so late, 1 AM, but they were terribly worried about their 19 month old daughter Ann. She woke up, or better yet, woke them up at 11 PM with a horrible cough and trouble breathing. It came on so suddenly.
Mr. Jones was mesmerizes by the smoldering ashes thinking how just a few hours earlier Ann was perfectly fine as they played by the fire. She went to bed at her usual time, * PM, with not a trace of even a cold. Now she struggled to get air in her lungs, and when she coughed she sounded like a seal. Her voice was hoarse and it looked painful for her to try to talk. A tremendous sense of relief came over him when his wife got through to the doctor on call.
Ann, as it turned out, had "croup" which is a viral infection that is usually caused by the parainfluenza virus. It is more accurately known as laryngo-tracheo-bronchitis (LTB). There are other viruses that can cause a croup-like picture, but the classic croup seen in the winter is caused by parainfluenza. Croup is typically seen in the winter months, and tends to occur in mini-epidemics. Physicians who treat children will often say when they see their first case of croup, that there are bound to be more in the office during the next couple of weeks.
Croup may or may not cause a fever. The symptoms of croup invariably come on very rapidly, usually late at night. To better understand what happens during a bout of croup, refer to Fig. 1. This shows the anatomy of the upper respiratory tract: the larynx (voicebox), the trachea (windpipe), and the major bronchi. Croup causes inflammation of these specific parts, but does NOT affect the lungs.
Because the larynx is swollen and inflamed, the child's voice is hoarse. When they cough, they sound like a seal, or the bark of a dog. Inflammation of the trachea produces a harsh, raspy noise when they take a breath in known as stridor. This is not to be confused with a wheeze from asthma which is the noise that an asthmatic makes when they breathe out. In croup, the bronchi too become swollen and inflamed. This irritates the bronchi and causes the cough seen in croup. Generally speaking, as badly as a patient with croup can sound, the lungs are NOT affected and they are not likely to have a pneumonia.
Since croup is caused by a virus, antibiotics are not usually indicated. The treatment is symptomatic, meaning that one should do what it takes to make the child comfortable. It is important to give plenty of fluids, run a vaporizer or a humidifier to keep the air from drying out, something for fever and cough if needed. What may give dramatic relief of the symptoms is to dress the child warmly and go outside in the night air for 10-15 minutes. Some books recommend taking them in the bathroom and running the hot water in the shower to create a steam room. All too often, however, you merely run out of hot water before there is any appreciable relief.
An interesting observation about croup is that it is predictably better in the morning or light of day. It is not uncommon to see an exhausted parent in the office who has been up all night with their croupy child...who seems perfectly fine in the office. The parent apologetically states that they feel silly for being in the office with this "happy child" who was so miserable the night before. That parent can almost be sure that the child will be croupy again tonight. As with most viral infections, croup lasts a few days. It is important that they know that they are not out of the woods just yet.
In evaluating a child with croup, it is critical to establish that they do not have epiglottis. This is a medical emergency as epiglottis is a rapidly progressing, life-threatening illness. Epiglottis is a bacterial infection of the epiglottis which is a flap that covers and protects the windpipe. When we swallow, it prevents food or fluid from entering the lungs. Epiglottis causes swelling and inflammation of this flap which can become so red and swollen that it blocks the windpipe and prevents air from getting into the lungs. This infection is caused by a bacteria, Hemophilus influenza, and like croup it comes on very rapidly. A child with epiglottis is very ill appearing with a high fever, hoarse voice, barky cough, severe stridor and difficulty swallowing. By choice they prefer to sit up and lean forward to try to keep their airway open. Because of the difficulty in swallowing, they often times appear to "drool". Thankfully, because of the H. flu vaccine that is given during the first year of life, the incidence of epiglottis has fallen dramatically, although it should always be on the mind of a physician who is treating a "croupy" child.
As a rule, parents should contact their doctor whenever their child has croup if they have ANY questions. It is important to at least touch base and be sure that they are doing the correct things. The physician can determine if and when the child should be seen or taken to the office or emergency room. This is what happened in the Jones' case. After a detailed history over the phone, the doctor determined that Ann had croup and he instructed the parents to take her outside for 15 minutes, and then call him back. Remarkably, she improved dramatically. She was like a different child, running around and drinking a sipper cup of juice. As instructed, they got the humidifier out of the closet and turned down the thermostat to a cool 68 degrees. They promised to call him the next morning with an update, and had an uneventful night. As predicted, she was fine the next day, but sure enough, at around midnight the next night she was as croupy as the night before. This time however, they were prepared.