Viral croup usually has a gradual onset and course. The symptoms often get worse at night. Initially, the child gets a cold with cough, coryza and low-grade fever. In about 12 to 24 hours, the cough becomes croupy (i.e. barky) with inspiratory stridor, causing varying degrees of respiratory distress with retractions and even cyanosis.

The duration of symptoms is usually 3-7 days. Examination reveals hoarse voice, coryza, a normal or minimally inflamed larynx and an increased respiratory rate with prolonged inspiratory phase and stridor.

• Fever

  Accompanying symptoms may include a runny nose, sore throat, and fever. HOME TREATMENT FOR CROUP Mist: Dry air usually makes the cough worse, so keep the child's room humidified. [jeffersandmann.com]

  There can be a low fever too. Spasmodic croup comes on suddenly, often in the middle of the night. Your child might wake up gasping for air. He might also be hoarse, have stridor, and a barky cough. Fever isn’t common with spasmodic croup. [webmd.com]

  Fever Medicine: For fevers above 102° F (39° C), give an acetaminophen product (such as Tylenol). Another choice is an ibuprofen product (such as Advil). Note: Fevers less than 102° F (39° C) are important for fighting infections. [stlouischildrens.org]

  Also, spasmodic croup usually is initiated by a viral infection; however, fever is typically absent. [merckmanuals.com]

• Prisoner of War

  […] were used (Chart entitled "Foreigners and Prisoners of War of the Krupp Concern"; chart entitled "Cast Steel Works, Number of Prisoners of War and Foreigners", not here reproduced.) [jewishvirtuallibrary.org]

  According to conservative estimates, the Krupp enterprises used nearly 100,000 persons in the slave labour programme, about 23,000 of which were prisoners of war. [en.wikipedia.org]

  extermination, enslavement, deportation, imprisonment, torture, and use for slave labor of civilians who came under German control, German nationals, and prisoners of war participating in a common plan or conspiracy to commit crimes against peace. [encyclopedia.ushmm.org]

  Later that year the SS gave him permission to employ 45.000 Russian civilians as forced labour in his steel factories as well as 120.000 prisoners of war in his coalmines. [ww2gravestone.com]

  (viii) The Individual Responsibility of the Accused When dealing with the law protecting prisoners of war, the Tribunal interjected the following remark: “The laws and customs of war are binding no less upon private individuals than upon government officials [casebook.icrc.org]

• Pallor

  Marked sternal retractions, marked tachycardia, pallor, with restlessness, lethargy, or cyanosis. Breath sounds often reduced. [starship.org.nz]

  Child Tripod position Noise Infants grunt to generate auto-CPAP; wheezing can occur with an inhaled foreign body; stridor Ineffective breathing Hypoxaemia and hypercarbia produce tachycardia, sweating, restlessness and confusion, agitation and anxiety, pallor [academic.oup.com]

  In addition to symptoms at the site of infection (sore throat), the patient may experience more generalized symptoms, such as listlessness, pallor, and fast heart rate. These symptoms are caused by the toxin released by the bacterium. [jariboti.pk]

  Grade 3 : respiratory distress, irritability, pallor or cyanosis, tachycardia, and exhaustion. Grade 3 croup is an emergency that necessitates immediate treatment. Your ability to promptly recognize croup and stridor can save a child’s life. [web.archive.org]

  View/Print Table TABLE 5 Indications for Hospitalization of Patients with Croup Actual or suspected epiglottitis Progressive stridor Cyanosis Respiratory distress Depressed sensorium Restlessness Hypoxemia Stridor at rest Pallor Toxic-appearing child [aafp.org]

• Cough

  Clinical presentation (eg, barking cough, inspiratory stridor) Anteroposterior (AP) and lateral neck x-rays as needed Diagnosis of croup is usually obvious by the barking nature of the cough. [merckmanuals.com]

  Cough Medicines Robitussin DM can be used to lessen your child's coughing. Robitussin Pediatric has one-half the dextromethoraphan (cough suppressant) as Adult Robitussin in one teaspoon. [andorrapediatrics.com]

  Case A 2 year old girl presents to the emergency room with fever, cough, runny nose, stridor and difficulty breathing. Temperature is 101, RR 30, there is audible stridor and a barky cough (click on barky cough). [pedclerk.bsd.uchicago.edu]

  Barking cough iStock/stephaniefrey The most obvious sign that your child has croup is the croup cough. “The cough from croup is a very different sounding cough from other coughs. [rd.com]

  On a cool night it is recommended to crack a window or for increased coughing TAKE CHILD OUTSIDE for at least 20 to 30 minutes. Steam from a hot shower may also calm the cough. [jeffersandmann.com]

• Hoarseness

  Croup manifests as hoarseness, a seal-like barking cough, inspiratory stridor, and a variable degree of respiratory distress. [emedicine.medscape.com]

  METHODS: Children were classified as having recurrent croup if they had had 2 or more episodes of barky cough, inspiratory stridor, and hoarseness. [ncbi.nlm.nih.gov]

  Primary symptoms of croup include a tight, metallic cough (like a barking seal), and a hoarse voice. Accompanying symptoms may include a runny nose, sore throat, and fever. [jeffersandmann.com]

• Inspiratory Stridor

  Similar inspiratory stridor can result from epiglottitis, bacterial tracheitis, airway foreign body, diphtheria, and retropharyngeal abscess. [merckmanuals.com]

  Inspiratory stridor suggests a laryngeal obstruction, whereas expiratory stridor suggests tracheobronchial obstruction. Biphasic stridor indicates either a subglottic or glottic anomaly. [emedicine.medscape.com]

  METHODS: Children were classified as having recurrent croup if they had had 2 or more episodes of barky cough, inspiratory stridor, and hoarseness. [ncbi.nlm.nih.gov]

  Bilateral vocal-cord paralysis produces a high-pitched inspiratory stridor. (Stridor doesn’t occur in unilateral vocal-cord paralysis.) Congenital subglottic stenosis causes stridor that’s commonly biphasic or inspiratory. [web.archive.org]

• Common Cold

  Other croup symptoms are not dissimilar to those of the common cold and upper respiratory infections, so parents should observe their child carefully. [rd.com]

  Many cases come from parainfluenza viruses (the common cold). [healthline.com]

  The largest study (n=1314) reported common cold symptoms lasting 1.8 weeks (SD 1.3) for children aged 7 or younger. 46 Fig 8 Proportion of children with symptoms of common cold. [doi.org]

  “Often trigged by a virus such as the common cold, croup in younger children creates a cough that is described as a seal-like bark, which can be scary for families to hear,” said Dr. [reuters.com]

• Dyspnea

  A nine-month-old girl was admitted to our hospital because of abrupt onset dyspnea and unconsciousness. From clinical and laboratory findings, she was diagnosed as having bacterial croup. [ncbi.nlm.nih.gov]

  Indication for hospitalization Cyanosis Not improving or getting worse Decreased alertness Family anxious about the child's condition No guarantee of follow-up References Ramboud-Cousson, Annie Bacterial Tracheitis among Children Hospitalized for Severe Dyspnea [pedclerk.bsd.uchicago.edu]

  ‘In children, fever associated with dyspnea usually implies an infectious cause, such as pneumonia, croup, or bronchiolitis.’ ‘Bronchiolitis was the most common diagnosis, followed by pneumonia and croup.’ [en.oxforddictionaries.com]

  Other symptoms include dyspnea, hoarseness, stridor, and wheezing. 1 Symptoms are worse at night, peak between 24 and 48 hours, and generally resolve within one week. 5, 10 Agitation and crying tend to aggravate symptoms, and children often prefer to [aafp.org]

• Overeating

  Physical examination revealed decreased breath sounds over left lower chest. Chest x-ray disclosed segmental atelectasis over left lower chest and a mass shadow over mediastinum. [ncbi.nlm.nih.gov]

  Contagiousness The virus that causes croup is contagious to other children as long as your child has a fever over 101 degrees. [andorrapediatrics.com]

  The Krupp family no longer has a direct say over the steel group. [telegraph.co.uk]

• Tachycardia

  Tachycardia and other adverse effects may occur. This drug is recommended mainly for patients with moderate to severe croup. [merckmanuals.com]

  Marked sternal retractions, marked tachycardia, pallor, with restlessness, lethargy, or cyanosis. Breath sounds often reduced. [starship.org.nz]

  Nebulised epinephrine may result in dose-related adverse effects including tachycardia, arrhythmias and hypertension and its benefit may be short-lived. [ncbi.nlm.nih.gov]

• Blister

  […] week in the ICU at Cedars Sinai Hospital with epiglottitis.[15][16][17] George Washington is thought to have died of epiglottitis.[18] The treatments given to George Washington, such as severe bloodletting, an enema, vinegar, sage, molasses, butter, blistering [en.wikipedia.org]

• Confusion

  Laryngeal foreign bodies may present with less severe symptoms compared to lower respiratory tract foreign bodies, resulting in misdiagnosis, confusion and delay. [ncbi.nlm.nih.gov]

  Croup is not to be confused with Whooping Cough, a much rarer disease characterized by coughing fits. We are always happy to evaluate children with croup but it can be managed well at home in most cases with rest, time an a little TLC. [unionvillepediatrics.com]

  Conditions that may be confused with Croup Epiglottitis can occur in children ages 2 to 6 years. This type of croup is rare but very serious, and sometimes fatal, and is caused by a bacterium called Hemophilus influenza type b (Hib). [healthcentral.com]

Diagnosis is usually made on the basis of complete history and clinical examination. Usually, baseline investigations such as complete blood count are of no great significance as the results are non-specific.

Procedures: Laryngoscopy may be required in when any uderlying anatomic or congenital anomaly is suspected. Bronchoscopy is indicated in cases of recurrent croup when other respiratory disorders have to be ruled out [5].

Radiography: Plain X-ray films can help confirm the diagnosis of croup. The posterolateral and lateral neck films show funnel-shaped subglottic region with normal epiglottis. This is known as Steeple's sign and is present in 40 to 60% of the cases [6]. It is also known as hour-glass or pencil point sign.

• Staphylococcus Aureus

  Staphylococcus aureus was isolated from tracheal secretions. Bacterial tracheitis is an infrequent cause of non-menstrual toxic shock syndrome. [ncbi.nlm.nih.gov]

  Unusually, it may be caused by bacteria, for example Staphylococcus aureus. There is a characteristic inspiratory stridor caused by laryngeal oedema and thick tenacious secretions that block the trachea and airways. [gpnotebook.co.uk]

  Bacterial tracheitis is an infection of the tracheal mucosa (usually Staphylococcus aureus or Streptococci) which results in copious secretions and mucosal necrosis. [clinicalguidelines.scot.nhs.uk]

• Streptococcus Pneumoniae

  Most common bacteria implicated are Staphylococcus aureus, Streptococcus pneumoniae, Hemophilus influenzae, and Moraxella catarrhalis Swelling produces airway obstruction which causes dramatically increased WOB, and stridor (turbulent, noisy airflow) [autoprac.com]

  The most frequent organism is Staphylococcus aureus, followed by group A streptococcus, Moraxella catarrhalis, Streptococcus pneumoniae, Haemophilus influenzae and anaerobes. [patient.info]

  Other Causes of Epiglottitis Bacteria Streptococcus groups A, B, and C, Nontypeable Haemophilus influenzae, Streptococcus pneumoniae, Klebsiella pneumoniae, Staphylococcus aureus, Haemophilus parainfluenza, Neisseria meningitidis Viruses Varicella zoster [atsu.edu]

  백일해는 이전에 백신을 맞은 성인에서도 급성 기관지염의 원인이 될 수 있고, 최근의 보고에 의하면 1주 이상의 기침환자에서 백일해 감염의 빈도는 12~32% 정도 이다. 10-12 만성기관지염의 급성악화와 관련된 균인 Streptococcus pneumonia, Moraxella catarrhalis, Haemophilus influenzae 등도 급성 기관지염에서의 역할이 제시되기는 했지만, 13 만성기관지염의 급성악화는 급성기관지염과는 다른 [hira.or.kr]

The treatment depends upon the severity of symptoms and degree of the respiratory distress. For mild disease, reassurance in addition to maintenance of oxygenation and fluid homeostasis is sufficient.

Children that present with significant respiratory distress and stridor may require 100% oxygen supplementation and ventilator support.

• Mist therapy: It is given by hot steam from a vaporizer or cold steam from a nebulizer [7].
• Oxygen (cold and humidified) must be provided. Pulse oxymetry and arterial blood gas analysis are important in assessing the adequacy of air exchange.
• Nebulizer recemic epinephrine (2.5% solution) if available may improve air exchange [8].

• Dexamethasone (0.3-0.5 mg/kg administered once and repeated in 2 hours) shortens the course of illness but should be used with caution to prevent the occurrence of side effects [9] [10].

• Antibiotics are used only if there is suspicion of secondary bacterial infections.

The prognosis of croup is excellent. Almost all of the cases of croup recover completely without any sequel of complications. Most of the patients can even get treated in the outpatient settings, whereas few of the cases might require hospitalization. Although the overall mortality rate in not exactly known, however a 10-year study shows the mortality rate to be less than 0.5% in intubated patients [4].

About 80% of the total cases of croup are caused by Parainfluenza viruses (type 1, 2 and 3), out of which about 66% of the cases are caused by types 1 and 2. Parainfluenza type 3 virus mostly causes bronchiolitis and pneumonia in young infants. Not much is known about parainfluenza type 4 virus. It may be the cause of minor childhood illness.

The remaining 20% of the cases of croup are caused by adenovirus, respiratory syncytial virus (RSV), enterovirus, coronavirus, rhinovirus, reovirus, influenza virus A and B and metapneumovirus [1] [2]. Other rare causes of croup are measles virus, herpes simplex virus and varicella virus.

These viruses can spread through inhalation of infectious agents in the cough or sneeze of an infected person. They can also spread by contamination of hands with fomites or through touching of mucosa of eyes, mouth and/or nose.

Croup is primarily a disease of infants and younger children and is the most common cause of acute stridor in this age group. It is slightly more common in the male gender, the male-to-female ratio being 1.5:1.

It is common in children aged 7 months to 3 years. After 6 years of age, the occurrence of croup is very rare [3].

In North America, the peak incidence is in the second year of life affecting 5-6 cases per 100 children.

The common ports of entry of the virus are nose and nasopharynx. From there, the virus then spreads to the larynx and trachea resulting in inflammation and edema in these areas. The inflammatory infiltrate contains lymphocytes, histiocytes, plasma cells and neutrophils. An increased chloride secretion and decreased sodium absorption results in edema, thus narrowing the lumen of the air passages by accumulation of fibrinous exudates.

Endothelial damage and loss of ciliary function occurs which decreases the mobility of vocal cords thus resulting in hoarseness.

As croup is a contagious disease, contact with the affected individuals must be made as minimally as possible.

• Proper hand washing technique must be taught to the children and have them wash their hands more often to avoid the spread from one child to another.
• Children should increase their fluid intake.
• Exposure to respiratory irritants (such as smoke) should be avoided.
• Treatment should be promptly obtained when the respiratory symptoms appear.
• Hygienic conditions must be ensured.
• Covering the mouth while coughing or sneezing helps prevent the spread to other children.

Croup or laryngotracheobronchitis is a common respiratory tract viral illness affecting the pedriatic population. It generally affects the larynx and trachea; and sometimes even the bronchi.

In febrile children, the presence of hoarseness, barking cough or acute inspiratory stridor is usually indicative of croup. Older children usually recover fully without any complications. In infants however, this might be a life-threatening condition.

Croup refers to infection of the airways that causes them to swell up. It is caused by a virus and usually affects male children under the age of 4 years. Symptoms are more common in winter months. The child develops flu-like symptoms with cough that sounds like a bark. Croup is usually not fatal and almost all children recover from it.

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3. Sobol SE, Zapata S. Epiglottitis and croup. Otolaryngologic clinics of North America. Jun 2008;41(3):551-566, ix.
4. Segal AO, Crighton EJ, Moineddin R, Mamdani M, Upshur RE. Croup hospitalizations in Ontario: a 14-year time-series analysis. Pediatrics. Jul 2005;116(1):51-55.
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6. Huang CC, Shih SL. Images in clinical medicine. Steeple sign of croup. The New England journal of medicine. Jul 5 2012;367(1):66.
7. Moore M, Little P. Humidified air inhalation for treating croup: a systematic review and meta-analysis. Family practice. Sep 2007;24(4):295-301.
8. Bjornson C, Russell KF, Vandermeer B, Durec T, Klassen TP, Johnson DW. Nebulized epinephrine for croup in children. The Cochrane database of systematic reviews. 2011(2):CD006619.
9. Bjornson CL, Klassen TP, Williamson J, et al. A randomized trial of a single dose of oral dexamethasone for mild croup. The New England journal of medicine. Sep 23 2004;351(13):1306-1313.
10. Cetinkaya F, Tufekci BS, Kutluk G. A comparison of nebulized budesonide, and intramuscular, and oral dexamethasone for treatment of croup. International journal of pediatric otorhinolaryngology. Apr 2004;68(4):453-456.