CROUP

In Croup there is a noise which comes from the throat on breathing in called stridor. This sounds alarming, it usually happens in the "small hours" and so often wakes the patient (usually aged less than five) and his/her parents from sleep.

Some points:

• Firstly, croup is common and is usually much more alarming than it is dangerous.
• Secondly, croup is due to a viral infection which inflames the lining of the wind-pipe. It is very like laryngitis in the adult but because the tubes are so much narrower the small degree of swelling causes the wind-pipe to act a bit like an organ-pipe. Antibiotic treatment is not very useful in this condition therefore.
• Thirdly, in croup although breathing may be very noisy it is usually not causing  to much difficulty to the child and so the child will not be blue or gasping for breath - if they are then this could be an emergency so call 999 for an ambulance.
• Fourthly, the child  usually responds within 10 minutes or so to being sat up in a steamy atmosphere - if they don't then call for further advice.
• Fifthly the child isn't usually too unwell in themselves. If they are very hot and unwell with a muffled voice, very sore throat and difficulty swallowing then this could be the much rarer condition called epiglottitis. This can be extremely serious and you should get in touch with the duty doctor straight away expressing your concerns. 

What to do?

• Don't panic! It's rarely as bad as it sounds. Check that despite their breathing being very noisy that they are actually breathing without too much effort, that their lips are pink and that they are not very hot and unwell. If all this is all satisfactory then take them into the bathroom or kitchen and get the atmosphere really steamy with the shower, kettle or hot tap - they don't need to be too near the source of the steam! In simple croup the response is usually rapid and fairly dramatic and if it is you can safely settle the child down with perhaps some paracetamol.
• If their condition is not satisfactory at the outset or they don't respond to the steam or rapidly deteriorate again then you need to seek advice. If the colour is poor (blue) or there is real breathing difficulty or they are drooling because they can't swallow then it would be appropriate to call an ambulance.

What else could it be?

• Asthma. Usually there is a history - either in the child themselves, a parent or a brother or sister - and so you are likely to recognise the child as being the same or different to your previous experience of asthma. The stridor of croup is much harsher than the wheeze of asthma and it is mainly on the in-breath whereas the asthma wheeze is on the out-breath. Croup usually responds very rapidly to steam in a way that asthma doesn't - equally asthma inhalers don't work for croup although the child may start to improve through sitting up and being reassured and comforted.
• Foreign bodies. If you think that this is a real possibility then you must take it seriously and respond accordingly using first aid principles for choking if that is necessary - i.e.:
  • Very small children that can be safely turned upside down should be and if this alone does not dislodge the foreign body then a firm blow to the back of the chest should be applied.
  • In everyone else Pawlik's manoeuvre should be used: from behind grasp the patient around the trunk at the lower chest level, make your right hand into a fist and grasp it with your left. Now using a short sharp firm movement squeeze the patient's lower chest.
• Epiglottitis. This is increasingly rare nowadays because of the protective effects of the Hib vaccine against the bacterium haemophilus. The epiglottis sits behind the tongue and doesn't not usually have much of a job to do nor does it announce its presence. In epiglottitis the organ is infected by the haemophilus bacterium and so it swells up and can obstruct breathing. Usually the patient is quite unwell with a temperature, very sore thoat and difficulty swallowing as well as breathing. Whereas in croup the voice is rather harsh and hoarse (just like adult laryngitis) in epiglottitis the voice is said to be muffled. Epiglottitis is potentially very serious and is not entirely confined to young children so if you think that this may be the problem it is important to seek urgent advice.

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