15.8 Croup

Croup, more formally known as laryngotracheobronchitis, is a respiratory disorder that leads to inflammation of the trachea, larynx, and bronchi. Typically, croup is caused by the parainfluenza virus, but it can also be caused by the influenza virus, adenovirus, and respiratory syncytial virus. Croup is less commonly caused by bacterial infections. Croup affects children in the age ranges of six months to three years old, with boys being affected more often than girls. Most cases of croup are mild, but it does have the potential to become a severe infection requiring hospitalization.^[1]

Pathophysiology

When a client becomes infected with parainfluenza virus, the larynx, trachea, and bronchi begin to swell due to the influx of white blood cells to the area. This swelling leads to partial obstruction of the airway and the symptoms associated with croup.^[2]

Assessment (Recognizing Cues)

Physical Exam

Initially, the client may present with signs of an upper respiratory infection. Common signs and symptoms are a barking cough, hoarseness, difficulty breathing, and fever that are often worse at night. Symptoms of croup last up to seven days, with the most severe symptoms typically occurring on Days 3 or 4 of the illness duration. If swelling worsens in the larynx, trachea, and bronchi, a high-pitched sound can occur as the client breathes through an obstructed airway, called stridor. Stridor is a characteristic symptom of severe croup. View the video in the following box to hear the sound of stridor.

The client may also exhibit an elevated heart rate, elevated respiratory rate, nasal flaring, retractions, and cyanosis. See Figure 15.7^[4] for an image showing retractions in an infant.

Complications of croup are uncommon, but in severe cases may include pneumonia, pulmonary edema (excess fluid in the lungs), bacterial  tracheitis (infection of the trachea), or respiratory failure.^[5]

The severity of croup can be determined by using the Westley scoring system, although this system is primarily used for research and not clinically. Scoring is based on several factors, including chest wall retractions, the presence of stridor, reductions in air entry, the presence of cyanosis, and level of consciousness. See Table 15.8 for criteria related to the Westley scoring system. A Westley score of 2 or less means that croup is mild, scores of 3 to 5 indicate moderate croup, and scores of 6 to 11 indicate severe croup. A score over 12 suggests that respiratory failure is likely.^[6]

Table 15.8. Westley Scoring System

Common Laboratory and Diagnostic Tests

Croup is a clinical diagnosis, but tests may be done to rule out other conditions that present in a similar manner. Additionally, nasal secretions can be tested for parainfluenza virus or other causative factors. Although not routinely ordered, an X-ray of the neck can show narrowing of the trachea that is consistent with croup.^[7]

Nursing Diagnosis (Analyzing Cues)

Nursing priorities for clients with croup include symptom management, airway management, and preventing the spread of illness to others.

Nursing diagnoses for clients with croup are created based on the specific needs of the client, their signs and symptoms, and the etiology of the disorder. These nursing diagnoses guide the creation of client-specific care plans that encompass client outcomes and nursing interventions, as well the evaluation of those outcomes. These individualized care plans then serve as a guide for client treatment.

Possible nursing diagnoses for clients with croup are as follows^[8]:

• Ineffective airway clearance r/t airway inflammation
• Ineffective breathing pattern r/t disease process
• Anxiety r/t shortness of breath
• Risk for fluid volume deficit r/t poor oral intake

Outcome Identification (Generate Solutions)

Outcome identification encompasses the creation of short- and long-term goals for the client. These goals are used to create expected outcome statements that are based on the specific needs of the client. Expected outcomes should be specific, measurable, and realistic. These outcomes should be achievable within a set time frame based on the application of appropriate nursing interventions.

Sample expected outcomes for the described nursing diagnoses are listed below:

• The client will exhibit a patent airway and no signs of respiratory distress during the course of the illness.
• The client will demonstrate an appropriate respiratory rate for their age within four hours of seeking medical treatment.
• The client will demonstrate a calm demeanor within fifteen minutes of medical treatment.
• The client will exhibit blood pressure and heart rate within normal limits for age, moist mucous membranes, urine output appropriate for their age, and non-sunken fontanels for infant clients during the course of the illness.

Interventions (Generate Solutions & Take Action)

Medical Interventions

Specific medical interventions for croup depend on the severity of the disorder. Clients with mild croup may be prescribed dexamethasone to reduce swelling. Clients with moderate to severe croup may be prescribed epinephrine via nebulizer to help open airways, in addition to dexamethasone. If symptoms do not improve within four hours of seeking medical attention, hospital admission is warranted. Clients with decreased oxygen saturation will receive oxygen therapy, and severe cases may require intubation and mechanical ventilation. Antibiotics are only prescribed if secondary bacterial infection is suspected. If croup is severe and linked to influenza, antiviral medications may be used. Clients are discharged from the hospital when they no longer require nebulized epinephrine, can tolerate oral intake, and are available for close follow-up appointments with the health care provider.^[9]

Nursing Interventions

Registered nurses plan interventions based on the expected outcomes of the client. Prior to implementation, the nurse must determine if all previously planned interventions are still suitable based on the current situation of the client.

When caring for a client with croup, nursing interventions can be divided into nursing assessments, nursing actions, and client teaching that are described in the following subsections^[10],[11]

Nursing Assessments

• Assess the respiratory system, including the use of accessory muscles or the presence of nasal flaring, retractions, and/or cyanosis. As croup progresses, upper airway obstruction may lead to a reduction in oxygenation or respiratory distress.
• Monitor the client’s vital signs. Elevated heart rate and/or respiratory rate based on normal age ranges can indicate a reduction in oxygenation.
• Assess the client’s level of consciousness because confusion, restlessness, or irritability can indicate inadequate oxygen to the brain.
• Assess for the presence of anxiety in the client or their parents/caregivers to determine if health teaching about coping strategies are needed.

Nursing Actions

• Encourage increased oral fluid intake and administer IV fluids if prescribed. Fluids will prevent dehydration and may help liquefy secretions.
• Encourage the client to remain in the semi-Fowler’s position or higher, as this can allow for optimal lung expansion.
• Encourage the use of a humidifier or steam from a hot shower to help clear mucus from the airway.
• Administer humidified oxygen per provider order, as this will increase oxygen levels without drying out the airways.
• Administer dexamethasone, epinephrine, and antipyretics per provider order.
• Provide the client with a calm and quiet environment to reduce anxiety. Anxiety can increase respiratory rate, which may worsen symptoms.
• Encourage adequate rest to promote healing, decrease fatigue, and prevent respiratory distress. Cluster cares to allow for rest with fewer interruptions.
• Provide suctioning as needed to remove secretions and prevent airway compromise.

Client Teaching

• Teach the client and their parents/caregivers about the disease, signs and symptoms, and treatment. Health teaching can reduce anxiety.
• Educate the client and caregivers about relaxation techniques, such as deep breathing or visualization, to reduce anxiety.
• Educate caregivers about the need to avoid anything that leads to the child crying, as crying can lead to coughing and further airway obstruction.
• Educate the client and their caregivers about proper handwashing and respiratory etiquette to help prevent the spread of infection to others.

Evaluation (Evaluate Outcomes)

Evaluation of client outcomes refers to the process of determining whether or not client outcomes were met by the indicated time frame. This is done by reevaluating the client as a whole and determining if their outcomes have been met, partially met, or not met. If the client outcomes were not met in their entirety, the care plan should be revised and reimplemented. Evaluation of outcomes should occur each time the nurse assesses the client, examines new laboratory or diagnostic data, or interacts with another member of the client’s interdisciplinary team.