Chapter 23: CROUP

Question 1

What is CROUP?

Answer 1

generic term encompassing a heterogeneous group of illnesses affecting the larynx, trachea, and bronchi
-the lateral walls of the trachea below the level of the vocal cords are marked by swelling and erythema
-described according to the main anatomical area affected
>Epiglottitis, Supraglottitis, Laryngitis, Laryngotracheobronchitis, and Bacterial Tracheitis

Question 2

Most Common Cause of CROUP

Answer 2

-viral agents (parainfluenza viruses (type 1, 2, and 3))
-RSV
>Epiglottitis: Streptococcus pyogenes, S pneumoniae, Staphylococcus aureus
>Bacterial Tracheitis: Haemophilus influenzae, S aureus, Corynebacterium diphtheriae

Question 3

Signs + Symptoms

Answer 3

• explained in terms of the anatomical structure in children
• symptoms r/t the extent of upper airway involvement and the infectious agent responsible
• CROUP can lead to obstruction b/c children have a narrow larynx, such that a decrease in airway diameter causes a decrease in airflow, leading to symptoms of CROUP

Question 4

S/S: Acute laryngotracheitis

Answer 4

• usually viral (parainfluenza, adenovirus, RSV)
• peak age is 3 to 36 months
• gradual, acute onset during the night
• URI symptom
• seal-bark cough
• mild to moderate dyspnea
• symptoms worse at night
• low-grade fever
• respiratory rate less than 50

Question 5

S/S: Spasmodic Croup

Answer 5

• usually viral
• peak age is 3 to 36 months
• generally no preceding illness, though may have coryza (Inflammation and irritation of the mucous membrane of the nose (Rhinitis))
• sudden onset often at night
• fever variable
• barky cough
• hoarseness

Question 6

S/S: Epiglottitis

Answer 6

• usually caused by Haemophilus influenzae type B (Hib)
• peak age 1 to 5 years
• rapid onset
• sore throat
• dysphagia
• anxiety r/t inspiratory distress without significant stridor
• drooling
• muffled speech
• toxic appearance
• tripod positioning
• marked distress
• high fever ranging from 101.8 to 104 Degrees F

Question 7

S/S: Laryngotrachebronchitis

Answer 7

• usually caused by Staphylococcus aureus
• peak age 3 to 36 months
• acute onset
• hoarseness
• barky cough
• inspiratory stridor
• toxic appearance
• purulent sputum
• marked distress
• high fever 102.2 Degrees F

Question 8

S/S: Bacterial Tracheitis

Answer 8

• considered a bacterial complication of a viral disease
• can lead to a life-threatening airway obstruction severe enough to cause respiratory arrest
• preceded by upper airway respiratory tract infection
• croupy cough
• stridor unaffected by position
• toxic appearance
• high fever
• stridor
• hoarseness
• dyspnea
• retractions and nasal flaring
• thick purulent tracheal secretions

Question 9

S/S: Laryngitis

Answer 9

• more common in older children
• usually caused by a virus
• hoarseness
• may have upper respiratory symptoms including coryza, sore throat, and nasal congestion
• malaise
• low-grade fever
• headache
• myalgia

Question 10

Diagnosis

Answer 10

based on signs and symptoms along with history

• because of the severity of the respiratory distress, immediate treatment takes priority over testing
• soft tissue imaging of the neck and chest demonstrate the presentation of subglottic narrowing or “steeple sign”
• if epiglottitis is suspected= blood cultures
• radiograph of the lateral neck may present with the “thumb sign”, which describes x-ray appearance of the epiglottis
• bacterial cause for CROUP, such as bacterial tracheitis or LTB, can be confirmed by elevated white blood cell count, which includes leukocytosis with a left shift
• bacterial tracheitis can be differentiated by epiglottitis by a slower onset, the absence of thumb sign, and classic symptom presented in epiglottitis

Question 11

Prevention

Answer 11

• routine immunization with Hib= primary prevention for epiglottitis
• good hand washing
• proper tissue disposal
• covering of nose and mouth prevents spread

Question 12

Nursing Care

Answer 12

-depend on causative organism
-goal of CROUP treatment is maintaining the airway and providing adequate respiratory exchange
-nurse stays at the child’s side to reduce child and parent anxiety, observes for worsening symptoms, and helps the child maintain a position that supports maximum airway and respiratory exchange
-Key areas: maintaining the airway, providing rest and humidification, monitoring fluid balance, and administering medications as prescribed
>changes in condition are based on observations and assessment of the child’s response to therapy, and careful observation of the child’s response to his or her surroundings (changes in level of consciousness)

Question 13

Key Areas of Nursing Responsibility

Answer 13

• maintaining the airway
• provide rest and humidification
• monitoring fluid balance
• administering medications as prescribed

Question 14

Medical Care

Answer 14

-mild cases of CROUP are treated with cool mist
-high-humidity cool air vaporizer may be used at home in child’s room
-oxygen hoods for infants
-oxygen tents for toddlers
>cool mist is thought to moisten airway secretions to facilitate clearance, soothe inflamed mucosa, and provide comfort and reassurance to the child, thereby lessening anxiety
-Nebulized racemic epinephrine (Micronefrin or Vaponefrin) or l-epinephrine are equally effective to cause mucosal vasoconstriction and decrease subglottic edema, relieving symptoms; treatment indicated for those with moderate to severe stridor at rest or when stridor does not respond to cool mist
-Corticosteroids (IM dexamethasone, and nebulized budesonide)= decrease the edema in the laryngeal mucosa through their anti-inflammatory action
-Antibiotic therapy indicated for epiglottitis and bacterial tracheitis (combinations of ampicillin and sulbactam); antibiotics not used in viral croup

Question 15

Education/ Discharge

Answer 15

• use of cool-mist humidification; use of a steamy bathroom to help modify respiratory symptoms
• is hospitalized and discharged on medications, instructed on compliance, proper administration, and dosage
• instructed on symptoms and potential side effects of medications
• symptoms of worsening condition (increased respiratory distress, restlessness, and confusion)

Question 16

Nursing Diagnoses for Upper Respiratory Disorders

Answer 16

• risk for ineffective airway clearance r/t excessive secretions, inflammation, or obstruction in the airway
• risk for ineffective breathing pattern r/t tracheobronchial inflammation or obstruction
• risk for imbalanced nutrition: less than body requirements r/t discomfort with swallowing

Question 17

Treatment for Mild Cases of Croup

Answer 17

• cool mist
• high-humidity, cool air vaporizer
• oxygen hoods
• oxygen tents

Question 18

Treatment for Those with Moderate to Severe Stridor at rest or when Stridor does not Respond to Cool Mist

Answer 18

-Nebulized racemic epinephrine (Micronefrin or Vaponefrin)
-l-epinephrine
>cause mucosal vasoconstriction and decrease subglottic edema, relieving symptoms

Question 19

ATI: Croup Syndromes: Bacterial Epiglottitis (Acute Supraglottitis)

Answer 19

• medical emergency

- usually caused by Haemophilus influenza

Question 20

ATI: Croup Syndromes: Bacterial Epiglottitis (Acute Supraglottitis): Expected Findings

Answer 20

• absence of cough
• drooling
• agitation
• sitting upright with chin pointing out, mouth opened, and tongue protruding (tripod Position)
• Dysphonia (thick, muffled voice and froglike croaking sound)
• Dysphagia (difficulty swallowing)
• Inspiratory Stridor (noisy inspirations)
• suprasternal and substernal retractions
• sore throat
• high fever
• restlessness

Question 21

ATI: Croup Syndromes: Bacterial Epiglottitis (Acute Supraglottitis): Diagnostic Procedures

Answer 21

-Lateral neck radiograph: of the soft tissues

Question 22

ATI: Croup Syndromes: Bacterial Epiglottitis (Acute Supraglottitis): Nursing Care

Answer 22

• protect airway
• AVOID throat culture or using a tongue blade
• prepare for intubation
• provide humidified oxygen
• monitor continuous oximetry
• administer corticosteroids, and IV fluids as prescribed
• administer antibiotic therapy starting with IV, then transition to oral to complete a 10-day course as prescribed
• Droplet Isolation Precautions for first 24 hours after IV antibiotics initiated