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Author: Germaine L Defendi, MD, MS, FAAP; Chief Editor: Russell W Steele,
MD more...
Updated: Jun 17, 2015


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Croup is a common, primarily pediatric viral respiratory tract illness. As its alternative
names, laryngotracheitis and laryngotracheobronchitis, indicate, croupgenerally
affects the larynx and trachea, although this illness may also extend to the bronchi. It
is the most common etiology for hoarseness, cough, and onset of acute stridor in
febrile children. Symptoms of coryza may be absent, mild, or marked. The vast
majority of children with croup recover without consequences or sequelae; however,
it can be life-threatening in young infants. (See Etiology, Epidemiology, Prognosis,
Clinical, and Treatment.)
Croup manifests as hoarseness, a seal-like barking cough, inspiratory stridor, and a
variable degree of respiratory distress. However, morbidity is secondary to
narrowing of the larynx and trachea below the level of the glottis (subglottic region),
causing the characteristic audible inspiratory stridor (see the image below).

Child with croup. Note the steeple or pencil sign of

the proximal trachea evident on this anteroposterior film. Courtesy of Dr. Kelly Marshall, CHOA at Scottish Rite.

(See Prognosis, Clinical, and Workup.)

Stridor[1] is a common symptom in patients with croup. The acute onset of this
abnormal sound alarms parents enough to prompt an urgent care or emergency
department (ED) visit. Stridor is an audible harsh, high-pitched, musical sound on
inspiration produced by turbulent airflow through a partially obstructed upper airway.
This partial airway obstruction can be present at the level of the supraglottis, glottis,
subglottis, and/or trachea. During inspiration, areas of the airway that are easily
collapsible (eg, supraglottic region) are suctioned closed because of negative
intraluminal pressure generated during inspiration. These same areas are forced
open during expiration.
Depending on timing within the respiratory cycle, stridor can be heard on inspiration,
expiration, or in both (biphasic; inspiratory and expiratory). Inspiratory stridor
suggests a laryngeal obstruction, whereas expiratory stridor suggests
tracheobronchial obstruction. Biphasic stridor indicates either a subglottic or glottic
anomaly. An acute onset of marked inspiratory stridor is the hallmark of croup;
however, there also may be less audible expiratory stridor. (See Clinical.)
Young infants who present with stridor require a meticulous evaluation to determine
the etiology and, most importantly, to exclude rare life-threatening causes. Although
croup is usually a mild, self-limited disease, upper airway obstruction may result in
respiratory distress and even death. (See Prognosis, Clinical, and Workup.)

Patient education
For patient education information, see the Lung Disease and Respiratory Health
Center, as well as Croup.

Viruses causing acute infectious croup are spread through either direct inhalation
from a cough and/or sneeze or by contamination of hands from contact with fomites,
with subsequent touching the mucosa of the eyes, nose, and/or mouth. The most
common viral etiologies are parainfluenza viruses. The type of parainfluenza (1, 2,
and 3) causing outbreaks varies each year.
The primary ports of entry are the nose and nasopharynx. The infection spreads and
eventually involves the larynx and trachea. Although the lower respiratory tract may
also be affected, some practitioners consider laryngotracheobronchitis a separate
entity, with bacterial secondary infection as the potential cause.
Inflammation and edema of the subglottic larynx and trachea, especially near the
cricoid cartilage, are most clinically significant. Histologically, the involved area is
edematous, with cellular infiltration located in the lamina propria, submucosa, and
adventitia. The infiltrate contains lymphocytes, histiocytes, plasma cells, and
neutrophils. Parainfluenza virus activates chloride secretion and inhibits sodium
absorption across the tracheal epithelium, contributing to airway edema. The
anatomical area impacted is the narrowest part of the pediatric airway; accordingly,
swelling can significantly reduce the diameter, limiting airflow. This narrowing results
in the seal-like barky cough, turbulent airflow and stridor, and chest wall retractions.
Endothelial damage and loss of ciliary function occur. A mucoid or fibrinous exudate
partially occludes the lumen of the trachea. Decreased mobility of the vocal cords
due to edema leads to the associated hoarseness.
In severe disease, fibrinous exudates and pseudomembranes may develop, causing
even greater airway obstruction. Hypoxemia may occur from progressive luminal
narrowing and impaired alveolar ventilation and ventilation-perfusion mismatch.
Spasmodic croup (laryngismus stridulus) is a noninfectious variant of the disorder,
with a clinical presentation similar to that of the acute disease but with less coryza.
This type of croup always occurs at night and has the hallmark of reoccurring in
children; hence it has also been called recurrent croup. In spasmodic croup,
subglottic edema occurs without the inflammation typical in viral disease. Although
viral illnesses may trigger this variant, the reaction may be of allergic etiology rather
than a direct result of an infectious process.

Parainfluenza viruses (types 1, 2, 3) are responsible for as many as 80% of croup
cases, with parainfluenza types 1 and 2, accounting for nearly 66% of cases. Type 3
parainfluenza virus causes bronchiolitis and pneumonia in young infants and

children. Type 4, with subtypes 4A and 4B, are not as well understood and tend to
be associated with milder clinical illness.
Differing parainfluenza serotypes play a more prominent role in the infectious
process as related to the patients age. Infection with type 3 occurs most often in
infants and is the etiology of lower respiratory tract illness; by age 1 year, 50% of
infants have acquired this infection. Respiratory infections in children aged 1-5 years
are most often due to type 1, less so with type 2.[2]
Other infectious causes of croup include the following:

Respiratory syncytial virus (RSV)
Human bocavirus
Coronavirus [3]
Metapneumovirus [4]
Influenza A and B
Rarer causes - Measles virus, herpes simplex virus, varicella
Influenza A is associated with severe respiratory disease as it has been detected in
children with marked respiratory compromise. The bacterial pathogen, Mycoplasma
pneumoniae, has also been identified in a few cases of croup. [5] Prior to 1970,
diphtheria was a common cause of crouplike symptoms. The vaccine has eliminated
this infection with no cases reported in the United States in over 20 years.
Next Section: Epidemiology


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