Croup occurs as a result of an upper airway infection. The infection causes swelling around the larynx, trachea, and bronchi.

In all forms of croup, mucosal inflammation and edema cause narrowing of the airway

Air is usually much drier at night, and as the child lies down, blood flow to the respiratory systems changes. These factors likely explain why symptoms are usually worse during this time and may recur for several nights.

Crying aggravates the airway obstruction associated with croup.

Retractions and flaring are NEGATIVE.

4L of oxygen maximum by nasal cannula.

Drooling indicates being unable to swallow.

Croup refers to a group of conditions characterized by inspiratory stridor, a harsh (brassy or croupy) cough, hoarseness, and varying degrees of respiratory distress. Croup is a viral infection of the upper airway.

Laryngotracheobronchitis, the most common form of croup, usually affects infants and toddlers; it is one cause of airway obstruction in children ages 6 months to 6 years.

In all forms of croup, mucosal inflammation and edema cause narrowing of the airway. This narrowing is more dangerous in infants and young children than in adults because of their small airway diameter and flexible larynx, which is more susceptible to spasm.

Symptoms are usually worse at night and better in the day; they may recur for several nights. Croup usually lasts 3 to 4 days.

Assessment

A nursing history typically reveals a recent upper respiratory tract infection. Assess the child for inspiratory stridor, barking cough, hoarseness, and increased heart and respiratory rates. Record any signs of respiratory distress, such as the use of accessory muscles; substernal, intercostal, and suprasternal retractions; nasal flaring; restlessness and irritability; and pallor or cyanosis. Cyanosis, increased heart rate and respiratory rate, extreme restlessness, or evidence of fatigue or listlessness are signs of hypoxia and should be reported to the physician immediately (Nierengarten, 2015). The lungs should be auscultated for adventitious breath sounds or areas of decreased breath sounds. Temperature and hydration status should also be assessed.

Labs

A croup score is often used to describe the severity of respiratory distress. Arterial blood gas values or pulse oximetry readings may be monitored to detect decreased PaO2 levels.

Manifestations

Croup often begins at night and may be preceded by several days of symptoms of upper respiratory tract infection. The child with laryngotracheobronchitis may have a gradual onset and a fever along with other signs and symptoms; occasionally the fever is as high as 40° C (104° F). Children with spasmodic croup do not have a fever. Other manifestations include the following:

• The sudden onset of a harsh, metallic barky cough; sore throat; inspiratory stridor; and hoarseness

• The use of accessory muscles (substernal, intercostal, suprasternal retractions) to breathe

• Frightened appearance

• Agitation

• Cyanosis

Therapeutic Management

The goal of treatment is to maintain a patent airway. Children with acute spasmodic croup can usually be cared for at home. Treatment for acute spasmodic croup includes a calm approach and increased oral fluid intake if the child is not in respiratory distress. Taking the child out into the cool, humid night air may relieve mucosal swelling (Roosevelt, 2016).

Crying aggravates the airway obstruction. The child should be kept as quiet as possible because crying can aggravate laryngospasm and increase hypoxia. Children who develop stridor at rest, cyanosis, severe agitation, fatigue, moderate to severe retractions, or are unable to take oral fluids should be seen in the emergency department. For mild croup, oral dexamethasone in a single dose of 0.15 to 0.6 mg/kg or inhaled budesonide decreases airway inflammation and reduces the necessity for hospitalization for many children.

For children with more severe symptoms (progressively worsening stridor, cyanosis, decreased oxygen saturation, retractions), hospitalization is necessary. Humidified oxygen and intravenous (IV) fluids are given until respiratory distress subsides and the child can take adequate fluids by mouth. Sedatives are contraindicated because they depress respirations and could mask restlessness, an early sign of hypoxia.

Medicine

Croup symptoms can reoccur after approximately 2 hours, so children who receive epinephrine should be observed in the emergency department for at least 3 hours after treatment and should not be discharged if stridor or retractions are present. Antibiotics are not indicated unless a bacterial infection is present. Acetaminophen is given to reduce fever.

Interventions

Facilitate airway clearance - The nurse monitors the child's breathing continuously for signs and symptoms of increased respiratory distress (increased respiratory rate, stridor at rest, nasal flaring, retractions, cyanosis, changes in level of consciousness or increased irritability, decreased or adventitious breath sounds, tachypnea). A child with respiratory distress should never be left alone.

Fluid Balance - Tachypnea causes insensible water loss, and difficulty swallowing leads to decreased intake. Therefore, the nurse monitors the child's hydration status with intake and output and urine specific gravity measurements. Check mucous membranes, skin turgor, and presence of tears. Weigh the child daily on the same scale and at the same time of day. Offer the child clear, room temperature liquids as tolerated when the child no longer exhibits signs of respiratory distress. Observe the child's ability to swallow because tachypnea and laryngospasm often cause dysphagia. IV fluids are administered in the acute phase of croup because oral fluids are contraindicated in the setting of severe respiratory distress that heightens the risk for aspiration. The child's temperature is taken every 4 hours, and acetaminophen is administered as ordered.

Decreasing Fear - Caring for a child in the hospital is exhausting for parents, and fatigue magnifies feelings of anxiety and helplessness. Therefore, provide parents with breaks as needed and assure them that their child will be cared for in their absence. Allow the child to keep a favorite toy or blanket and use developmentally appropriate communication techniques (e.g., play, puppets) when explaining treatments and procedures. Allow the child and parents to ask questions and to discuss fears and concerns, because croup symptoms can be frightening and parents sometimes feel guilty for not having brought the child in for treatment sooner.

	Created by Kalyn S almost 7 years ago

Nursing Note on Respiratory Alterations, created by Kalyn S on 05/03/2018.

Respiratory Alterations