Croup (Laryngotracheobronchitis): Pediatric Nursing Study Guide

Croup, or laryngotracheobronchitis (LTB), is a common pediatric viral upper-airway infection that produces the classic barking cough and inspiratory stridor. Because a child's airway is small, even mild subglottic swelling can cause significant obstruction — making rapid assessment and stepwise management essential for exam and clinical practice.

Definition

• Croup (LTB) is a viral infection of the upper airway causing inflammation and swelling of the larynx, trachea, and bronchi.
• It causes partial airway obstruction and the classic barking cough.
• Most common in children 6 months to 3 years, peaking in the second year of life; more common in males.

Pathophysiology

• Viral infection causes inflammation and edema of the subglottic area — the narrowest part of the pediatric airway.
• Edema narrows the airway lumen. Because pediatric airways are smaller, a small amount of swelling causes significant obstruction.
• Inspiratory stridor results from partial upper airway obstruction.
• Laryngeal inflammation produces the hallmark barking ("seal-like" or "brassy") cough.

Causes

• Parainfluenza virus is the most common cause (~75% of cases).
• Other viral causes: RSV, influenza A and B, adenovirus, rhinovirus.
• Rare bacterial causes: Mycoplasma pneumoniae, Corynebacterium diphtheriae.
• Seasonal peak: fall and winter.

Clinical Manifestations

• Barking cough — hallmark symptom (seal-like, brassy).
• Inspiratory stridor — high-pitched inspiratory sound indicating upper airway obstruction.
• Hoarseness from laryngeal inflammation.
• Respiratory distress: tachypnea, retractions, accessory muscle use.
• Cyanosis — a late sign of severe obstruction; requires immediate intervention.
• Low-grade fever typical; high fever suggests bacterial superinfection.
• Symptoms characteristically worsen at night.
• Anxiety and agitation worsen obstruction — crying increases airway narrowing.

Severity Assessment: Westley Croup Score

Score-Based Management

• Mild croup: home care with cool mist, fluids, reassurance; keep the child calm.
• Moderate croup: medical evaluation with nebulized epinephrine and corticosteroids.
• Severe croup: hospital admission with nebulized epinephrine, corticosteroids, and oxygen.
• Impending respiratory failure: ICU care with possible intubation and mechanical ventilation.

Medications

• Nebulized epinephrine — for moderate to severe croup. Causes rapid vasoconstriction and reduces airway edema. Onset 10–30 minutes; effects last 1–2 hours. Monitor for rebound worsening.
• Dexamethasone — corticosteroid of choice. Reduces airway inflammation and prevents worsening. Dose: 0.6 mg/kg PO or IM (max 10 mg). Onset 6–12 hours; usually a single dose is sufficient.
• Racemic epinephrine — equivalent in effectiveness to L-epinephrine.
• Heliox (helium–oxygen mixture) — used in severe cases to reduce airway resistance and work of breathing.

Croup vs Epiglottitis

• Croup is viral with gradual onset, barking cough, and hoarseness; child can lie flat.
• Epiglottitis is bacterial with rapid onset, muffled voice, drooling, and tripod positioning; child refuses to lie down.
• Epiglottitis is a medical emergency. Do not examine the throat in suspected epiglottitis — it may precipitate complete airway obstruction.

Nursing Interventions

• Assess respiratory status frequently — monitor stridor, retractions, and work of breathing.
• Monitor for worsening: increased stridor, retractions, or cyanosis indicate deterioration.
• Keep the child calm; allow the parent to hold the child. Crying worsens obstruction.
• Position the child upright to facilitate breathing.
• Administer nebulized epinephrine and corticosteroids as ordered.
• Monitor for rebound worsening 1–2 hours after epinephrine.
• Provide hydration with small, frequent sips of clear fluids.
• Prepare for intubation if the child deteriorates despite treatment.

Exam Traps

• Do not examine the throat in suspected epiglottitis.
• Do not confuse croup (barking cough) with epiglottitis (muffled voice, drooling).
• Do not give sedatives — they worsen airway obstruction.
• Remember that symptoms worsen at night.
• Do not use epinephrine alone — corticosteroids are needed for sustained improvement.
• Do not discharge a child with moderate to severe croup without reevaluation after epinephrine (rebound risk).

Key Takeaways

• Croup is a viral (parainfluenza) infection causing subglottic edema, barking cough, and inspiratory stridor in children 6 months–3 years.
• Use the Westley Croup Score to guide management from home care to ICU.
• Dexamethasone 0.6 mg/kg (max 10 mg) and nebulized epinephrine are the mainstays of pharmacologic treatment.
• After nebulized epinephrine, always monitor for rebound worsening for 1–2 hours before discharge.
• Differentiate croup from epiglottitis — tripod position, drooling, muffled voice, and high fever signal epiglottitis; never inspect the throat.
• Keep the child calm and upright; agitation and crying worsen obstruction.