Croup Syndrome Nursing Care Planning and Management: Study Guide

Croup is inflammation and swelling of the upper airway, hitting the vocal cords and the subglottic region, most often in children 6 months to 3 years. The picture is unmistakable: a harsh barking cough, inspiratory stridor, and a scared child and parent. Most croup is mild and self-limiting, but your assessment exists to catch the child whose airway is closing. The single most important thing you do is gauge the degree of airway obstruction, and you do it without agitating the child, because crying tightens a narrow airway and drives up oxygen demand.

What is Croup Syndrome?

Croup is a common, primarily pediatric viral respiratory illness and the most common cause of hoarseness, cough, and acute stridor in febrile children. Its alternative names, acute laryngotracheitis and acute laryngotracheobronchitis, point to where it lands: the larynx and trachea, sometimes extending to the bronchi. The name comes from the Anglo-Saxon kropan or the old Scottish roup, meaning to cry out in a hoarse voice.

Pathophysiology

The viruses spread by direct inhalation of a cough or sneeze, or by contaminated hands touching the eyes, nose, or mouth. The nose and nasopharynx are the entry ports; infection then spreads to the larynx and trachea. Inflammation and edema of the subglottic larynx and trachea, especially near the cricoid cartilage, are the clinically significant lesion. Histologically the area is edematous with cellular infiltration in the lamina propria, submucosa, and adventitia. This narrowing produces the seal-like barky cough, turbulent airflow, stridor, and chest-wall retractions, while edema-limited vocal cord mobility causes the hoarseness.

Statistics and Incidences

Croup is the most common pediatric cause of acute stridor, accounting for about 15% of annual clinic and emergency department visits for pediatric respiratory tract infections. It is mainly a disease of infants and toddlers, peaking at 6 months to 36 months (3 years). In North America incidence peaks in the second year of life, at about 5 to 6 cases per 100 toddlers. It is uncommon after age 6 years but can occur in preteens, adolescents, and rarely adults. The male-to-female ratio is about 1.4:1. It occurs most often in late fall and early winter but can present any time of year, and about 5% of children have more than 1 episode.

Causes

Parainfluenza viruses (types 1, 2, 3) cause about 80% of cases, with types 1 and 2 accounting for nearly 66%. The bacterial pathogen Mycoplasma pneumoniae has been identified in a few cases.

Clinical Manifestations

Croup usually starts with nonspecific respiratory symptoms. It may be preceded by coryza and hoarseness, or by no apparent respiratory signs during the evening. Fever is generally low grade (38 to 39°C) but can exceed 40°C. Within 1 to 2 days the characteristic hoarseness, barking cough, and inspiratory stridor develop, often suddenly, with variable respiratory distress. Symptoms worsen at night, and most ED visits occur between 10 pm and 4 am. Spasmodic (recurrent) croup typically presents at night with sudden croupy cough and stridor.

Assessment and Diagnostic Findings

Croup is primarily a clinical diagnosis based on history and exam. Pulse oximetry is usually within the normal range but helps assess the need for supplemental oxygen and detect worsening compromise (tachypnea, falling saturations). Radiographs can help confirm the diagnosis but are not required in uncomplicated cases.

Medical Management

Treatment depends on the degree of respiratory distress. Corticosteroids reduce laryngeal mucosal edema and the need for salvage nebulized epinephrine, and are warranted even in mild symptoms. Children given nebulized racemic epinephrine in the ED should be observed for at least 3 hours afterward, because of rebound bronchospasm, worsening distress, or persistent tachycardia; discharge only if they are clinically stable with good air entry, baseline consciousness, no stridor at rest, and have received corticosteroids. Heliox, a mix of helium and oxygen (with not less than 20% oxygen) delivered by nasal cannula, mask, or hood, has low viscosity and specific gravity that promote laminar airflow, easing the work of breathing and reducing distress.

Pharmacologic Management

The mainstays are corticosteroids and nebulized epinephrine; steroids help in severe, moderate, and mild croup. Corticosteroids decrease airway edema through their anti-inflammatory effect and have been shown to reduce hospitalization rates by 86% and, in mild disease, return visits to the ED. Epinephrine stimulates alpha and beta2 receptors, constricting precapillary arterioles to decrease airway edema; because of tachycardia and hypertension risk, it is reserved for moderate to severe disease.

Nursing Management

In mild croup the child may have only a croupy cough and need parental guidance and reassurance, given alertness, minimal distress, good oxygenation, and stable fluid status.

Nursing Assessment

Determining the degree of airway obstruction is the most important part of assessment. Begin while taking the history, observing the child seated on the parent's lap at a non-threatening distance; much can be learned without disturbing the child. Assess respiratory rate, accessory muscle use, tracheal tug, and the presence or absence of central cyanosis. A child who is agitated, tired from the effort of breathing, or showing a decreasing level of consciousness needs close monitoring. Stridor at rest, tracheal tug, chest-wall retractions, and changing respiratory and pulse rates indicate treatment is needed.

Nursing Diagnosis

• Ineffective airway clearance related to thick, tenacious mucus and swelling or spasm of the epiglottis.
• Deficient fluid volume related to decreased ability or aversion to swallowing, fever, and increased respiratory losses.

Nursing Care Planning and Goals

The child maintains a clear, open airway with normal breath sounds, rate, and depth and can clear secretions after treatments and deep breaths; demonstrates increased air exchange; identifies methods to enhance secretion removal and the significance of sputum changes (color, character, amount, odor); and avoids factors that impair airway clearance. The child stays normovolemic, evidenced by systolic BP greater than or equal to 90 mm Hg (or baseline), no orthostasis, HR 60 to 100 beats/min, urine output greater than 30 mL/hr, and normal skin turgor, and the family verbalizes the causative factors and behaviors needed to correct fluid deficit.

Nursing Interventions

Use humidified air. Cool mist from a humidifier, or sitting with the child in a bathroom (not the shower) filled with steam from running hot water, helps minimize symptoms.

Treat fever with an antipyretic such as acetaminophen or ibuprofen.

Encourage fluids. Push oral intake; frozen juice popsicles ease throat soreness.

Teach caregivers to avoid smoking in the home, since smoke worsens the cough.

Elevate the head. An infant can sit in a car seat and an older child can be propped on an extra pillow; do not use pillows with infants younger than 12 months.

Decrease anxiety. Keep young children comfortable in a parent's arms and avoid unnecessary painful interventions, because crying raises oxygen demand and respiratory muscle fatigue can worsen the obstruction.

Monitor vital signs. Watch heart rate (tachycardia), respiratory rate (tachypnea), respiratory mechanics (sternal retractions), and pulse oximetry (hypoxia).

Cool mist was historically the mainstay (hospitals kept "croup rooms"), on the theory that mist moistens secretions, lowers their viscosity, and soothes inflamed mucosa.

Evaluation

Goals are met when the child maintains a clear, open airway with normal breath sounds and respirations and clears secretions; demonstrates increased air exchange; identifies methods to enhance secretion removal and the significance of sputum changes; avoids factors that impair clearance; stays normovolemic (systolic BP greater than or equal to 90 mm Hg or baseline, no orthostasis, HR 60 to 100 beats/min, urine output greater than 30 mL/hr, normal skin turgor); and the family verbalizes the causes and behaviors needed to correct fluid deficit.

Documentation Guidelines

Document breath sounds, presence and character of secretions, and accessory muscle use; the plan of care and teaching plan; responses to interventions and actions performed; progress toward desired outcomes; and modifications to the plan of care.