Introduction

What is croup?

Croup is a respiratory condition characterised by a distinctive barking cough, often compared to the sound of a seal. It primarily affects the larynx, trachea, and bronchi, leading to inflammation and swelling in these areas. The condition is commonly caused by viral infections, particularly the parainfluenza virus, but can also be due to other respiratory viruses such as adenovirus, respiratory syncytial virus (RSV), and influenza.¹

Importance for the elderly

While croup is most commonly seen in young children, it can occur in the elderly, who may experience more severe complications due to their age and potential comorbidities. The elderly have a higher risk of complications from croup, including severe airway obstruction, secondary bacterial infections like pneumonia, and exacerbation of underlying chronic conditions such as chronic obstructive pulmonary disease (COPD) and heart disease. Their immune response can be less robust, making it harder to fight off the viral infections that cause croup.²

Causes and effects

Causes

The primary cause of croup is viral infection, with the most common culprit being the parainfluenza virus. Other viruses that can cause croup include influenza A and B, respiratory syncytial virus (RSV), adenovirus, and rhinovirus.³

Effects

The viral infection leads to inflammation, causing swelling and narrowing of the airways, which results in the hallmark symptoms of croup: a barking cough, stridor (a high-pitched wheezing sound caused by disrupted airflow), and respiratory distress. In severe cases, the swelling can significantly obstruct the airway, leading to severe breathing difficulties and hypoxia.³

Symptoms

Common signs

The most characteristic symptom of croup is a barking cough, which sounds similar to a seal's bark. Along with the barking cough, individuals with croup often experience hoarseness, as the larynx gets affected. Stridor, a high-pitched wheezing sound during inhalation, is another common sign. It indicates a significant narrowing of the airways, particularly in the laryngeal and tracheal regions.⁴

Severity in the elderly

In the elderly, croup symptoms can be more severe due to several factors. Older adults are more likely to have weakened immune systems, making it harder for their bodies to fight off the viral infection causing croup. Additionally, they may have pre-existing respiratory conditions, such as COPD or cardiovascular issues, that can exacerbate the symptoms. As a result, elderly patients may experience more intense respiratory distress, a higher likelihood of developing secondary infections like pneumonia, and an increased risk of complications such as significant airway obstruction and hypoxia.⁴

Diagnosis

Methods

Diagnosis of croup primarily involves a clinical examination, where a healthcare provider assesses the patient's symptoms and listens for the characteristic barking cough and stridor. The patient's medical history and recent exposure to respiratory infections are also considered. In some cases, imaging studies such as a neck X-ray may be performed to rule out other conditions and confirm the diagnosis. The classic finding on an X-ray is the "steeple sign", which shows subglottic narrowing of the trachea.^4,5

Challenges

Diagnosing croup in the elderly can be challenging due to its symptoms overlapping with other respiratory conditions such as epiglottitis, tracheitis, bronchitis, and asthma. Additionally, elderly patients may have chronic respiratory conditions like COPD or heart failure, which can complicate the clinical picture. These overlapping symptoms can make it difficult to distinguish croup from other conditions, necessitating a thorough and careful diagnostic approach.⁵

Complications

Respiratory issues

In the elderly, croup can lead to severe respiratory complications. The inflammation and swelling of the airways can cause significant obstruction, making it difficult for patients to breathe. This can result in hypoxia (low oxygen levels) and respiratory distress. Additionally, the elderly are at higher risk for secondary bacterial infections such as pneumonia. Pneumonia can further complicate the clinical course, leading to prolonged illness, increased morbidity, and a higher risk of hospitalisation and mortality.⁶

Systemic impacts

The systemic impacts of croup in the elderly can be significant. Severe respiratory distress and hypoxia can put considerable strain on the cardiovascular system, potentially exacerbating pre-existing heart conditions such as heart failure or coronary artery disease. 

Additionally, elderly patients often have chronic conditions like COPD or diabetes, which can be worsened by the stress of a severe respiratory infection. The overall frailty and reduced physiological reserve in elderly patients make them more vulnerable to the systemic impacts of croup, leading to a higher risk of severe outcomes.

Treatment

Standard care

The standard treatment for croup includes the administration of corticosteroids, such as dexamethasone or prednisolone, which help reduce inflammation and swelling in the airways.^7,9 Nebulised adrenaline is often used in more severe cases to provide rapid relief of airway obstruction by decreasing mucosal oedema through vasoconstriction. 

Supportive care is also crucial and includes ensuring adequate hydration, maintaining a calm environment to minimise respiratory effort, and providing supplemental oxygen if necessary. These treatments help alleviate symptoms and improve breathing.⁵

Adjustments for the elderly

In elderly patients, treatment for croup requires special considerations. Due to the higher risk of severe complications, close monitoring is essential. This includes frequent assessments of respiratory status, oxygen saturation and overall clinical condition. Elderly patients are more likely to have comorbidities that can complicate the course of illness, so careful monitoring for adverse effects of medications, such as corticosteroids, is necessary. 

In many cases, hospitalisation may be warranted to provide intensive monitoring and support, manage complications promptly, and ensure the best possible outcomes. Hospitalised patients may require intravenous fluids, more aggressive respiratory support, and possibly antibiotics if a secondary bacterial infection is suspected.^5,6

Prevention

Measures

Preventing croup, particularly in the elderly, involves a combination of vaccinations and general health maintenance. Vaccinations against influenza and pneumococcus are crucial as they can prevent some of the viral infections that lead to croup and reduce the risk of secondary bacterial infections like pneumonia. 

Additionally, maintaining overall health through proper management of chronic conditions (e.g. COPD, diabetes, heart disease), good nutrition, regular physical activity, and avoiding smoking can help strengthen the immune system and reduce the likelihood of severe respiratory infections.

Early detection

Early detection of croup in the elderly can significantly improve outcomes by allowing for prompt treatment. Educating caregivers and healthcare providers about the signs and symptoms of croup is essential. Caregivers should be aware of the characteristic barking cough, stridor, and signs of respiratory distress. They should also understand the importance of seeking medical attention early, especially if the elderly patient has underlying health conditions that could complicate the illness. 

Additionally, caregivers should be informed about preventive measures, such as vaccinations and maintaining good respiratory hygiene, to minimise the risk of infections that can lead to croup.¹⁰

Case examples

Management stories

A 72-year-old woman with a history of COPD presented with a barking cough, hoarseness, and difficulty breathing. She was diagnosed with croup based on clinical examination and a neck X-ray showing the classic steeple sign. Treatment included administration of oral dexamethasone and nebulised adrenaline, along with supportive care involving oxygen therapy and hydration. 

Her symptoms improved significantly within 24 hours, and she was monitored closely for potential complications due to her underlying COPD. After a few days of treatment and observation, she was discharged with instructions for follow-up care and preventive measures, including vaccination against influenza and pneumococcus.

Lessons from complications

An 80-year-old man with a history of heart disease and diabetes developed severe croup symptoms, including stridor and respiratory distress. Despite initial treatment with corticosteroids and nebulised adrenaline, his condition worsened, leading to significant airway obstruction and hypoxia. He was admitted to the intensive care unit (ICU) for advanced airway management and mechanical ventilation. 

This case highlights the importance of early and aggressive intervention in elderly patients with croup, especially those with significant comorbidities. It underscores the need for vigilant monitoring and the potential necessity for intensive care support to manage severe complications effectively.⁸

Summary 

Croup is a respiratory condition characterised by a distinctive barking cough, primarily caused by viral infections like the parainfluenza virus. Although it is common in children, the elderly can also be severely affected due to their higher risk of complications. These complications arise from viral infections that cause inflammation and swelling in the larynx, trachea, and bronchi, leading to symptoms such as a barking cough, stridor, and respiratory distress. In elderly individuals, these symptoms can be more severe due to weakened immune systems and pre-existing conditions like COPD and heart disease, which increase the risk of respiratory distress and secondary infections. 

Diagnosis typically involves a clinical examination and sometimes imaging, such as a neck X-ray, to identify the "steeple sign." However, diagnosing croup in the elderly can be challenging due to symptom overlap with other conditions like bronchitis and asthma. 

Severe respiratory issues, including significant airway obstruction and pneumonia, are common complications in the elderly, as are systemic impacts like cardiovascular strain and exacerbation of chronic conditions. Standard treatment includes corticosteroids, nebulised adrenaline, and supportive care, with close monitoring and potential hospitalisation for elderly patients. 

Prevention involves vaccinations against influenza and pneumococcus, managing chronic conditions, and maintaining good health practices. Early detection through caregiver education is crucial for prompt treatment.