CROUP (English. croup, from the Scottish croup to croak) — the term applied to designation of the clinical symptom complex which is characterized by the hoarse voice barking cough and complicated by breath.
The term «grain» has also other value. In pathoanatomical understanding — this fibrinous inflammation of a mucous membrane of a trachea, a gut, a bladder, etc., at Krom loss of fibrin happens only within an epithelial cover (unlike a diphtheritic inflammation when fibrinous exudate penetrates also subepithelial fabric).
Many authors distinguish true and false To. also connect true To. with the inflammatory process in a throat caused only by a diphtheritic stick, and false To. — with inflammatory process in a throat of not diphtheritic etiology (e.g., To. at flu, acute respiratory diseases, measles, chicken pox and other infectious and noninfectious diseases). Some authors to false To. carry only acute subdepository laryngitis which is characterized by considerable hypostasis of a mucous membrane under voice folds. In modern literature the term «grain» designate an inflammation of a throat and trachea of various etiology with the diverse morphological changes which are followed by difficulty of breath owing to spasmodic narrowing (stenosis) of a throat. Considering convention of the concepts «true» and «false», it is more correct to define To. as wedge, symptom complex by the form basic disease: To. diphtheritic, clumsy, influenzal etc.
To. it is known long ago; Hippocrates called To. «an epidemic inflammation of a neck». K. Galen described the patients with the complicated breath and swallowing who are coughing up films. In 1658 the London doctor Bennet described a case To. with allocation of films at cough. Bretonno (R. of F. Bretonneau) in 1821 described filmy To. also suggested to call its «diphtheria».
Diphtheritic To. is one of a wedge, forms of diphtheria. In an etiology To. at other diseases (flu, a parainfluenza, adenoviral infections, measles, scarlet fever, etc.), in addition to the activator of a basic disease, the large role is played accompanying, by hl. obr. coccal, flora.
the Greatest number of diseases To. it falls on autumn and spring months, i.e. on that time when diseases of flu and acute respiratory viral infections meet more often.
Get sick To. more often children aged from one year up to 3 — 4 years. In the second half of 20 century diphtheritic To., as well as in general diphtheria, almost does not meet; in children's incidence the greatest value has To. at flu and acute respiratory infections (adenoviral, parainfluenza, etc.).
For diphtheritic To. formation of fibrinous films in a throat is characteristic (see fig. 4). At extended To. these films can be also in a trachea, sometimes in bronchial tubes.
At flu and acute respiratory diseases of change in a throat and trachea can vary from simple mucoserous or serous and purulent Qatar to necrotic - hemorrhagic and even fibrinous (see. Inflammation ). In a throat find in mild cases only reddening of a mucous membrane, narrowing of a glottis as a result of hypostasis of subdepository space.
At a lung clumsy To., developing usually in an onset of the illness, only Qatar in the field of voice folds with more or less expressed inflammatory infiltration and hypostasis is observed.
For clumsy To. in the late period of measles necrotic changes in a mucous membrane of a throat, trachea, sometimes bronchial tubes are typical; at the same time quite often the necrosis happens quite deep so ulcers With a necrotic bottom are formed.
In development of the stenotic breath arising at To. various etiology, the main role is played by the reflex spasm of muscles of a throat which is shown a smykaniye of voice and predoor folds (see. Laryngospasm ). The spasm of muscles of a throat arises owing to the irritation of a mucous membrane of a throat and a trachea caused by inflammatory process and the tearing-away fibrinous films or the formed crusts. Also the necroses and ulcers increasing irritability of a mucous membrane during the passing of a current of air can be the cause of a spasm. In favor of the neurogenic and reflex theory of stenotic breath at To. tells also that circumstance that quite often at the child sharply expressed stenosis bringing to is observed asphyxia (see), and at a pathoanatomical research find only an insignificant film in the field of voice folds or the small site of a necrosis which in itself could not interfere with normal respiration mechanically in any way.
Clinical manifestations and the diagnosis
Typical a wedge, manifestations diphtheritic To. the afonichny voice, the rough barking cough and a stenosis of respiratory tracts (noisy breath, retraction of intercostal spaces of a thorax, tension of auxiliary respiratory muscles) are hoarse, sometimes.
Depending on expressiveness distinguish a stenosis of I, II and III degrees. During To. at diphtheria allocate three periods, or stages: the first — catarral, or a stage of croupous cough, the second — a stenosis and the third — asphyxia. There are no sharp borders between stages, one passes into another gradually and imperceptibly. Duration of stages is also strictly not determined. More detailed a wedge, a picture diphtheritic To. — see. Diphtheria .
Presents the greatest difficulties for diagnosis To. at flu and acute respiratory viral diseases which is one of frequent and quite often initial displays of a disease; in some cases a syndrome To. joins flu or an acute respiratory disease several days later after an onset of the illness. At these diseases a syndrome To. it is usually shown suddenly (unlike diphtheritic To., at Krom, as a rule, develops gradually), begins more often at night. The child was before going to bed healthy in the evening or it had a small cold; at night he suddenly wakes up from a fit of coughing, it has a complicated breath at once; he is frightened, rushes about in a bed, cyanosis of a nasolabial triangle quickly develops. It is important to note that the voice at the same time happens hoarse or siplovaty, but during shout ringing notes, unlike diphtheritic are almost always listened To., at Krom the voice becomes hoarse in the beginning, and by the time of development of a stenosis, as a rule, afonichny (except for exceptional cases when films are located in subdepository space). Cough at flu and acute respiratory diseases in the beginning dry, but very quickly, by the end of the first days, is humidified that usually does not happen at diphtheritic K.
Techeniye K. at a parainfluenza and an adenoviral infection usually easier, than at flu; sharply developed stenosis at the same time quickly weakens or completely passes in several hours after use of thermal procedures (hot general and foot baths, warm drink, hot-water bottles to legs, mustard plasters on area of a throat). In some cases the phenomena of a stenosis can repeat in the next night, but also safely pass, as well as for the first time.
To. at flu often proceeds more hard; sharply developed stenosis can quickly, progress within several hours. In some cases the current of a stenosis at flu has wavy character — amplifies, decreases even within a day, proceeding from 7 to 10 days. Weight and duration influenzal To. depend not only on expressiveness of necrotic process in a throat, a trachea and bronchial tubes, but also on quite often joining pneumonia. To establish an etiology of an acute respiratory disease, against the background of to-rogo there was a syndrome To., it is possible only at the accounting of all a wedge, displays of a disease, and also results virusol, and serol, researches on respiratory group of viruses (see. Virologic researches , Serological researches ).
Presents not smaller difficulties for diagnosis sometimes clumsy K. Koreva K. can be early if it develops in the period a prodrome measles (see); at the same time the heavy stenosis usually is not observed and by the time of emergence of rash it considerably weakens. Proceeds late clumsy more hard To., appearing during pigmentation. At the same time changes in a throat and a trachea have necrotic character and a current of a stenosis happens same long more often, and is frequent also wavy, as well as at influenzal To. Diagnosis late clumsy To. in former years especially was at a loss the fact that during pigmentation of rash owing to easing immunobiol, conditions of an organism the diphtheritic infection could join. It must be kept in mind it and now. Though diphtheria in the second half of 20 century meets exclusively seldom, the contact with the diphtheritic bacillicarrier is possible.
Diagnosis To. at to scarlet fever (see), to chicken pox (see), aphthous stomatitis (see), at the milkwoman (see. Candidiasis ) does not present special difficulties. The main symptoms of these diseases and a wedge, manifestations To. in most cases allow to be guided correctly concerning its etiology.
The complicated breath arising sometimes at retropharyngeal abscess (see), differs from To. the fact that at the child the ringing voice always remains it only becomes muffled (with a nasal shade), but the aphonia and rough cough at the same time never happens. Detection of protrusion of a back wall of a throat at faringoskopiya (see), quite often fluctuating at a palpation, gives the chance to make the correct diagnosis.
At acute hypostasis of a throat (see. Throat ), caused by a burn (alkali or other substances), the stenosis develops very quickly, within several hours after a burn. Hypostases of a throat of an allergic origin are possible at serum disease (see) or idiosyncrasies (see).
At papilloma of a throat the course of a disease long, before emergence of a stenosis passes half a year or year; the complicated breath is more expressed during sleep and is not followed by concern, as at To. other etiology.
To., caused by tuberculosis or syphilis of a throat, meets very seldom. These diseases have the features, and at the correct assessment their wedge, symptoms establishment of the reason To. comes easy.
Sometimes for To. accept an attack bronchial asthma (see). The complicated breath at a foreign body in respiratory tracts (see. Foreign bodys ) it is also quite often treated as manifestation To. The careful analysis of anamnestic data (acute development of suffocation in the healthy child at a foreign body) and a wedge, displays of a disease (goose breathing with the complicated exhalation at bronchial asthma) helps with diagnosis.
It is necessary to remember about laryngospasm (see) which is observed at the children of early age suffering rickets (see) and spasmophilia (see), and also about inborn stridor (see) when noisy breath with a special additional sound on a breath is observed, but the voice remains ringing; this state is shown usually in the first months of life.
In all cases at establishment of the reason of stenotic breath it is necessary to exclude first of all diphtheritic To., since at it timely administration of antidiphtherial serum can warn at the child asphyxia and need of an operative measure.
One of the most frequent complications at To. is focal pneumonia (see). At pneumonia the phenomena of a stenosis and air hunger amplify that promotes bystry approach of asphyxia.
At treatment of the patient To. it is necessary to proceed first of all from an etiology and it is obligatory to consider a wedge, a current, a form and a stage To. At diphtheritic To. treatment is directed to elimination of specific intoxication, antidiphtherial serum in the corresponding dosage, depending on weight of a condition of the patient is entered. If antidiphtherial serum was entered late and stenotic breath keeps without weakening within several hours, the child becomes extremely uneasy, there are expressed symptoms of respiratory insufficiency (cyanosis of a nasolabial triangle, pallor, perspiration of a head, loss of pulse wave on a breath, etc.), then is shown intubation (see) or tracheotomy (see).
Treatment diphtheritic is detailed To. — see. Diphtheria .
Treatment To. at acute respiratory viral diseases more difficult since there is no specific therapy; at influenzal To. it is recommended to apply anti-influenza gamma-globulin intramusculary (see. Flu ). Considering the frequency of developing of pneumonia at To. any etiology (especially at flu and acute respiratory diseases), it is recommended to apply antibiotics.
Lech. actions at To. shall be directed to any etiology to elimination of a stenosis; as in a pathogeny of stenotic breath various factors play a role, to lay down. actions shall be complex. First of all it is necessary to organize the correct leaving and the guarding mode eliminating all moments promoting traumatizing a nervous system of the child, his excessive excitement; to create conditions which would promote a long dream of the child. The child with the phenomena of a stenosis demands special service and observation from personnel; it needs to be placed in separate chamber where there is a good aeration, toys for derivation of the child. It is necessary to allow mother to care of the small child. Thermal procedures are shown: a hot general bathtub (t ° 38 °) for 7 — 10 min. or foot baths, ozokeritovy «boots», warm drink (tea, milk with soda), mustard plasters on a thorax, steam inhalations with solution of soda, ephedrine. Antihistaminic and sedative drugs (Dimedrol, Pipolphenum, Seduxenum) are obligatory. If the thermal and distracting procedures do not render the expressed effect and the stenosis progresses, it is necessary to give periodically warm moistened oxygen. During the strengthening of the phenomena of a stenosis (when the stenosis of the II degree develops) use of Prednisolonum inside at the rate of 1 — 2 mg on 1 kg of body weight of the child is recommended, Pipolphenum and Seduxenum are entered intramusculary. According to indications the straight line is made laringoskopiya (see) under a mask ftorotanovy anesthesia, in time the cut is deleted by crusts and grease a mucous membrane of a throat with solution of ephedrine and peach-kernel oil. At a stenosis of the III degree Prednisolonum is entered intramusculary, but if all above-mentioned actions were not effective and there were symptoms of asphyxia, the nazotrakhealny intubation or the Tracheostomy is shown.
The forecast is usually favorable, depends on a basic disease and timeliness of the begun treatment.
Bibliography: Nisevich N. I., Kazarin V. S. and Pashkevich G. S. A croup at children, M., 1973, bibliogr.; Rose trees S. N. Krup at children, M., 1956.
See also bibliogr, to St. Diphtheria .