‘Tis The Season Of The Barking Cough

It was a case of Physician Heal Thyself, or in this pediatrician’s case, Heal Thine Own. One midnight in Baltimore, I was on duty in the Pediatric ED when my wife called: our son awoke struggling to breathe, such that he couldn’t even talk.  Miles away, I could only help over the phone.  I gave the standard pediatrician’s advice for croup : take him outside, keep him upright.  His breathing subsided, everyone calmed down, and I called in a prescription to the 24 hour pharmacy.  Croup can be scary, yet easily managed.  This week’s guest columnist, Dr. Leslie Sizemore, a family practice resident at the University Hospital and Clinics here in Lafayette, explains:

In the fall physicians prepare for the typical fall and winter illnesses. Everyone thinks of influenza virus (“the flu”) but we also worry about RSV, mycoplasma (“walking pneumonia”), common cold, and the ever recognizable croup.

What is croup?  Croup starts like any cold- dry cough, runny nose, hoarseness, and sometimes fever.  The characteristic “barking cough” comes about 12-48 hours later. The barking lasts about 3 days but the rest of the cold may take around 7 days to resolve. Sometimes croup comes on suddenly at night, with a previously well child awakening with the barking cough and shortness of breath.

Croup is caused by inflammation at the top of your windpipe, called the trachea, just below your vocal cords.  When these pipes get inflamed, they swell and the breathing space gets narrower.  The smaller space compresses the air during cough, making that strange cough like a barking seal.  If the swelling worsens, the child gets stridor, which is a high pitched whistling sound when breathing in.  When the airway is narrow enough to make stridor, kids really starting struggling to breathe.

We see croup mostly in the fall, October being the peak month.  This coincides with a peak in parainfluenza virus, the most common cause of croup.  Croup is mostly seen in kids age 6 months to 3 years, and is unusual beyond age 6.  Viruses that cause croup are spread by close contact, just like any cold.

Most cases of croup are mild with occasional barking cough, hoarseness, and maybe a little stridor when crying.  It is the more severe cases we worry about, when the swelling of the windpipe gets worse.  Then the child has that whistling stridor sound even at rest. These children need to get seen immediately.  If the airway gets too narrow the child may no longer be able to breath.  The good news is that less than 5% of kids with croup get put in the hospital, so these bad cases are rare.

How do we treat this nasty illness?  Since it is caused by a virus, we all know that antibiotics won’t help, since they don’t kill viruses.  We treat the symptoms while the child’s immune system gets rid of the virus.  We treat the airway inflammation with anti-inflammatory medicine- steroids.  This can be done in two ways: the child can be given a one-time shot, or be given three days of a liquid steroid by mouth. We all know which one the kid would prefer!

If the child is having stridor, we give them a breathing treatment with a medicine called epinephrine.  The breathing treatment, or nebulizer, is that pipe commonly used by asthmatics that turns medicine into a mist that is inhaled.  But instead of the albuterol that kids with asthma need, we put in epinephrine.

The epinephrine relaxes the muscles that line the windpipe.  We give this medicine only in the Emergency Department, not at home.  This is because the child needs to be watched for several hours after the treatment.  Sometimes kids who get the epinephrine treatment have “rebound,” where the stridor comes back within an hour, sometimes coming back worse.

For the other croup symptoms, you treat them like any other cold.  Give Tylenol or ibuprofen for fever and throat soreness.  Run a vaporizer by the bed for moist air to lubricate those inflamed airways.  Prop up the child’s head to help minimize gagging on secretions.  Give plenty of fluids, and in a few days your child should get better and go on about his business, no longer imitating a barking seal.