Wednesday, October 7, 2009

Barking and Gasping .... Croup!

My 18 month old son has had a runny nose and mild cold symptoms for about a week, but yesterday he began to cough. We didn’t think much of it, but in the middle of the night he suddenly woke up unable to breathe! He was barking with a harsh, horrible sound, and he couldn’t seem to catch his breath….each time he took a breath in, there was this gasping sound. We were terrified! We ran him into the emergency department, but by the time we got there, he had stopped gasping and was playing with the triage nurse’s stethoscope. They probably think we are idiots…

Nope. We don’t think you are idiots. We think that you made the right call by coming into emergency with a child who was showing signs of upper airway obstruction (barking and gasping when trying to breathe in). We want you to do exactly the same thing, if this happens again. We don’t want you to get into a car accident because of panic, though….if you are so scared that you shouldn’t drive, call an ambulance next time.

This is croup. Croup is a viral infection of the part of the trachea (wind-pipe) just below the vocal cords. Actually, it is a viral infection of the entire trachea, and sometimes even the larger tubes that branch from it into the lungs. But in smaller kids, the symptoms come from the area just below the voice box.

In adults, the narrowest part of the trachea is the vocal cords themselves, so to put this in perspective, if you had this illness, your voice would be gone, you would have that characteristic barky cough, and you would call it “laryngitis”. In a toddler, though, the narrowest part of the trachea is just below the vocal cords; the first symptoms occur when the virus causes swelling in this area and this already narrow, slightly floppy tube sucks in on itself during a big inspiration. The walls of the tube vibrate, making that awful gasping noise which we call “stridor”.

Parents often come in saying that their child “can’t breathe” during these episodes, and that is probably why many are so frightened on arrival. Remember, though, that 
a child who is making noise is breathing. It can’t really be so otherwise. Also, with croup, most children wake up in the middle of the night upset (maybe in pain? … we usually can’t ask them). With the big gulps of air that these kids take while sobbing, the stridor is much more obvious. Once the kid settles down in a parent’s arms, the stridor usually gets better. Taking the child outside into cool air is thought to be helpful, although studies can’t seem to prove this.

What should you do?

  • First: come into the hospital. There are many other things that cause these symptoms (fortunately, rarely) that are very, very dangerous. Be seen! Also, at the hospital, if your child is determined to have croup, a drug called dexamethasone will be offered to you. This medication will decrease the chance of further frightening gasping episodes. We can’t treat the virus directly, but with dex we can diminish the impact it has on your family.

  • Second: don’t worry too much. Croup (if it is croup) is a very safe condition. Virtually no one gets into serious trouble, although a small minority of children with croup will worry even experienced emergency pediatricians.

  • Third: don't worry too little! Despite what you might be told, there is absolutely no way to prove that your child has simple croup. The diagnosis is made based on your doctor's experience, which always means that an error can occur. Watch for the signs of dangerous disease:

    • Increasing pain in the throat. Every child with croup has mild discomfort, but ibuprofen or acetaminophen should take that pain away. Pain that requires more than simple, over the counter medication, or pain that is getting worse should prompt a return to the hospital.

    • Stridor (gasping) that doesn’t settle down in a few minutes. Picking your kid up and cuddling, especially outside in the cool night air, should settle the gasping down fairly quickly. Children who don’t settle should be seen in the emergency department.

    • As always, if you are concerned, as always, come in to be seen.  Don't let a website or blog keep you at home if your child seems more sick than he or she should be.

  • Finally, cough syrups and decongestants are probably useless. Use a humidifier at home (it may help) and ibuprofen or acetaminophen may help, but otherwise, this is a virus, you just have to get through it.
Many kids who get croup as toddlers will get it repeatedly during their pre-school years.  Don't be surprised to see this illness again.

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