Croup — the syndrome arising at infectious and inflammatory diseases of the top airways as a result of the puffiness throat narrowing a gleam. Clinically the croup is shown by a voice osiplost, the barking cough, noisy breath and short wind with the complicated breath. Diagnostics and differential diagnostics of a croup is made on the basis of clinic and history of development of a disease, data of an auskultation of lungs, a laringoskopiya, bacteriological crops, a research of gas composition of blood and so forth. The croup depending on an etiology is treated by antiviral medicines, antibiotics or specific anti-diphtheritic serum. Symptomatic therapy is carried out by anti-spastic, sedative, antihistaminic, protivokashlevy, hormonal and mukolitichesky medicines.
As the croup represents the inflammation of a throat (laryngitis) which is followed by its stenosis, in otolaryngology it also carries the name stenoziruyushchy laryngitis. The croup can be observed at a laryngitis combination to inflammatory process in the departments of airways (tracheitis and bronchitis) located below. Distinguish a true (diphtheritic) croup which develops at diphtheria, and the false croup which is observed at other infectious diseases. Most often the croup is noted at children at the age of 1-6 years. Friable cellulose at children of this age promotes development of the expressed hypostasis, features of an innervation cause emergence of a reflex spasm of guttural muscles, and the cone-shaped shape of a throat and its small size favor to bystry emergence of obstruction. At adults the true croup is, as a rule, observed.
Causes of a croup
The croup has an infectious etiology and can be caused by bacteria or viruses, is more rare — fungal flora. Infectious agents get into a throat in the airborne way through a nasopharynx at inhalation of the infected air. The true croup arises at infection with a diphtheritic stick. The false croup often develops against the background of rhinitis, pharyngitis or laryngotracheitis of virus genesis at a SARS, flu, an adenoviral infection, scarlet fever, measles, chicken pox. The bacterial etiology of a false croup is usually caused by nonspecific microflora: staphylococcus, streptococcus, hemophilic stick. The croup caused by a specific infection at the laryngitis which arose against the background of mycoplasmosis, clamidiosis, syphilis, tuberculosis and so forth is in rare instances observed.
Development of a croup against the background of an infectious disease is promoted by the weakened condition of an organism which is more often observed at the children who had a fruit hypoxia, a patrimonial trauma, rickets; having chronic diseases or diathesis.
The croup results from several components accompanying inflammatory process in a throat: considerable hypostasis of a throat, a reflex spasm of the muscles narrowing a throat, a congestion in its gleam of a dense secret (phlegm) and fibrinozny films. Depending on prevalence of inflammatory damage of the top airways laryngitis, laryngotracheitis can be observed or laringotrakheobronkhit. In all these cases the stenozirovaniye characterizing a croup occurs at the level of subdepository space of a throat as the area of vocal chords is most a bottleneck of respiratory tract.
The obstruction causing a croup leads to difficulty of a breath and reduction of amount of the air getting during a breath into airways. Respectively also the amount of the oxygen coming to an organism decreases that causes development of a hypoxia — oxygen starvation. At the same time the condition of the patient with a croup directly depends on extent of obstruction. At the initial stage difficulty of passing of air to airways is compensated by the strengthened work of respiratory muscles. The expressed narrowing of a throat leads to failure of compensatory mechanisms and emergence of paradoxical breath. The croup in this stage can end with complete cessation of intake of air in airways (asphyxia) and death.
The true croup differs in the fact that in its pathogenesis the leading role belongs to steadily progressing puffiness of a throat while the false croup is characterized by sudden emergence of a reflex spasm of guttural muscles or obturation of a gleam of a throat the dense slime which accumulated in it. Thereof at patients with a diphtheritic croup gradually accruing aggravation of respiratory violations is observed, and at patients with a false croup respiratory obstruction arises pristupoobrazno.
Most in clinical practice division of a croup on true and false is important. The false croup is classified by the cause on bacterial and virus.
The true croup is characterized by staging of a current with consecutive transition from one stage to another. Depending on it allocate: croup of a disfonichesky (catarrhal) stage, grain of a stenotichesky stage and grain of an asfiksichesky stage. The false croup is classified by throat stenosis degree. Distinguish a croup with the compensated stenosis (the I degree), a croup with the subcompensated stenosis (the II degree), a croup with a dekompensirovanny stenosis (the III degree) and a croup in a terminal stage of a stenosis (the IV degree).
Irrespective of an etiology of grain it is shown by cough of the specific "barking" character, noisy breath (stridor), an osiplost of a voice and the general symptomatology. Narrowing of a gleam of a throat causes existence typical for patients with a croup of inspiratory short wind — breath with the complicated breath. The expressed short wind is followed by retraction of mezhreberiya and a jugular pole. At a decompensation of a stenosis of a throat emergence of the mixed inspiratory and expiratory short wind and paradoxical breath is possible. The last is characterized by the fact that the thorax incorrectly participates in the respiratory act: in an exhalation phase it extends, and in the period of a breath decreases.
At patients with a croup air with noise passes through a stenozirovanny throat, causing a stridor. The croup in which pathogenesis throat hypostasis prevails is shown by the whistling breath. At the expressed hyper secretion and a congestion of a phlegm in a throat gleam breath gains the bubbling and rattling character. If the spastic component of obstruction dominates, then the sound characteristic of breath has changeable character. Reduction of intensity of the noise accompanying breath can demonstrate aggravation of a stenosis.
The general symptomatology depending on a type of the activator and a condition of reactivity of an organism of the patient with a croup can be expressed in various degree. The diphtheritic croup is characterized by high rise in temperature and considerable intoxication: headache, appetite loss, weakness, fatigue. The false croup caused by an adenoviral or parainfluenzal infection proceeds with a subfebrilny temperature more often. Depending on extent of obstruction of airways at the patient with a croup symptoms of a hypoxia are observed: concern or block, pallor of integuments, perioralny or diffusion cyanosis, the tachycardia which in a decompensation stage is replaced by bradycardia. The current of a croup can be complicated by development of bronchitis, pneumonia, otitis, conjunctivitis, sinusitis, meningitis.
The croup can be diagnosed by the pediatrician, the therapist or the otolaryngologist. At development of bronchopulmonary complications of an infection consultation of the pulmonologist is necessary. The croup at syphilis is diagnosed together with the venereologist, at throat tuberculosis — together with the phthisiatrician. The characteristic clinic, the anamnesis of a disease, these auskultation, laringoskopiya and additional researches allows to diagnose a croup.
At an auskultation in lungs dry rattles of the whistling character are listened. Emergence of damp rattles speaks about aggravation of a disease. The Laringoskopichesky picture allows to define extent of narrowing of a throat and prevalence of process, to reveal fibrinozny films, characteristic of diphtheria. Verification of the activator is carried out at microscopy and a bakposeva of dabs from a pharynx, the PTsR-research, IFA and REEF to diagnostics. For detection of syphilis the RPR test is obligatory. About degree of a hypoxia judge by results of the analysis of gas composition of blood and its acid and main state.
At development of complications depending on their character to the patient carry out a faringoskopiya, an otoskopiya, a rinoskopiya, a X-ray analysis of easy and okolonosovy bosoms, a lyumbalny puncture. Difdiagnostika of a croup is carried out with whooping cough, a foreign matter of a throat, zaglotochny abscess, epiglotity, bronchial asthma, throat tumors, at babies - with a congenital stridor.
Differential diagnosis of a true and false croup
True and false croup arise against the background of the main disease for the 2-3rd day from rise in temperature and emergence of the general symptoms. The similar beginning is replaced by noticeable distinction in the further course of a disease. So, the true croup is characterized by gradual increase in extent of obstruction of a throat and the corresponding gradual development of respiratory violations. In its current allocate the disfonichesky stage proceeding without obstruction signs, stenotichesky and asfiksichesky stages. At a false croup staging of a current is absent, extent of narrowing of a throat changes within a day, the expressed obstruction develops suddenly in the form of an attack (more often at night).
The puffiness of vocal chords accompanying a true croup leads to gradual aggravation of violations of a voice (dysphonia) up to a full aphonia. Lack of strengthening of a voice is characteristic during cough, shout or crying. At approach of an aphonia silent cough and crying is noted. The false croup usually is followed by a voice osiplost, but never leads to an aphonia. Strengthening of a voice at shout and cough remains.
During a laringoskopiya at patients with a true croup catarrhal changes of a mucous throat (hypostasis and hyperaemia), narrowing of its gleam and characteristic diphtheritic raids come to light. Often diphtheritic raids come to light also at survey of a pharynx. They badly act and quite often bare under themselves small ulcer defects. At a false croup the laringoskopiya defines a catarrhal inflammation, a stenosis of a throat and a congestion in it a large amount of dense slime. Existence of easily deleted raid is possible. Finally the bacteriological research of dabs from a pharynx helps to differentiate a true and false croup. Identification of a diphtheritic stick for 100% confirms the diagnosis of a true croup.
Treatment of a croup
Patients with a true croup are without fail hospitalized in an infectious hospital. Their treatment depending on weight of a state is carried out by intramuscular or intravenous administration of anti-diphtheritic serum. Use dezintoksikatsionny treatment: drop introduction of solution of glucose, cocarboxylase, according to indications — glucocorticosteroids (Prednisolonum). At development of the expressed intoxication apply methods of extracorporal haemo correction (discrete and membrane , haemo sorption).
Treatment of a false croup is carried out by antihistaminic, anti-spastic, sedative medicines. At the dry exhausting cough protivokashlevy means (, , , codeine) are shown, at damp cough — mucolytics (, , Ambroxol). In hard cases at sub - and a dekompensirovanny stenosis of a throat purpose of glucocorticosteroids is possible. The croup of a virus etiology is treated by medicines with antiviral effect (interferon alpha 2b, ). To patients with a bacterial croup or threat of secondary infection antibiotic treatment is carried out. Medicine is selected in compliance with results of the antibiotikogramma executed during a bakposev. Inhalation therapy is carried out by alkaline solutions, at symptoms of a hypoxia — oxygenotherapy. The expressed throat stenosis with threat of asphyxia is the indication to tracheotomy.
Specific prevention of diphtheria and true croup is carried out by mass vaccination of children, since three months of life. The false croup has no specific measures of prevention. In its prevention the important part is assigned to increase in protective forces of an organism (healthy nutrition, a hardening and a healthy lifestyle), timely treatment of inflammatory diseases of a nasopharynx and upper respiratory tract infections.