Adult Onset Croup

Croup is a common disease in children.  While rare, can still occur in adults, yet when it does it is more severe, often requiring care in intensive care units. 

Croup is caused by inflammation and swelling around the vocal cords, and can cause a harsh barky cough, and may also lead to breathing difficulty if the air passages becomes partially blocked.  If severe, it may lead to death.  

The simplest treatment for croup may be to place the child in a hot, steamy bathroom. This tends to ease some of the swelling.  Another treatment may be to go outside in the cool, fresh air.  However, when these simple treatments don't work, a visit to a physician, or an emergency room, may be required. In some instances, a stay in a hospital may be required.  Death, however, from croup is rare.

The cause of croup is most often a virus, but occasionally it can be caused by a bacteria.  Croup is contagious, as the germs that cause it may be exhaled and transferred through the air in droplets.  The best way to prevent the spread of it is to wash your hands frequently, clean up surfaces touched by those who are infected, and to cover your mouth when you sneeze or cough.  

While croup is a lot less common in adults than it is in children, it is possible for a rare form of croup to affect adults, so it is best to take precautions to avoid contracting croup, even if you are an adult. Here are some everyday tips on how to keep your lungs clean: http://www.healthcentral.com/copd/cf/slideshows/9-ways-to-keep-your-airways-clear-and-lungs-clean

I found a really nice case study on adult croup by Karger: Medical and Scientific Publishers, "Adult Croup: A Rare but More Severe Condition."  Basically, 11 cases of adult croup were reviewed. All required a stay in the hospital ranging anywhere from 3-35 days. While ten of the patients required care in an intensive care unit, none of them died. So, adult onset croup tends to be more severe than child onset croup, although it is not deadly if treated properly.

It's also interesting to note that the presumed reason croup is more common in children is because they have narrower airways than adults. Because their airways are narrow, even slight inflammation may partially block their air passages, causing the symptoms of croup (harsh voice, barky cough, shortness of breath, fever, etc.)

Usually when adults get the same virus, they simply get a common cold. However, in some instances, the inflammation may become so severe that it causes adult croup.
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High & low humidity both bad for asthma

I remember when I was a kid -- like say 10-years-old or so -- and having an asthma attack, and my dad taking me into a bathroom that was full of hot steam. Sometimes he'd have me sit in there for what seemed like a long, long time.

It never worked. In fact, every time I remember my dad doing this with me -- every time in the middle of the night -- I ended up in the emergency room anyway. I do remember feeling more refreshed when I walked out of the bathroom, but I was still short-of-breath.

I also have vague memories of a humidifier in my bedroom. My mom would set that up whether I was having a bout of asthma or not. Despite her efforts to set this up, it never seemed to do anything for my breathing. If asthma was going to occur, it was going to occur.

My parents did this because they were told by my pediatrician that humidity was good for breathing. It was common knowledge back then for doctors to recommend humidity for asthma.

I was discussing this with Jane Sage today, and she said she used to set up ice tents on asthma children routinely. She said scientists and doctors honestly believed they were doing something to help asthmatics.

It was a fallacy. We know that now. Steam works well for inflammation of the upper airway, or croup, but it does not work for asthma.

Many times a mom woke up because her child had a harsh barky cough, or croupy (stridor) expiration, and the child was working hard to breath as a result. A trip to the bathroom usually
worked wonders, and prevented many trips to the hospital. Steam can be soothing to the upper airway.

Cool mists work well for croup too, but not for asthma. If the mom of the croupy child decides to come to the hospital, and it's the middle of winter or a rainy day, the child is usually cured even before she arrives at the hospital.

And, if this croupy child did get admitted, he would be placed either in a cool mist tent or set up with a cool mist aerosol. Now we just use a cool mist aerosol in stead of the tent.

But this therapy seldom works for asthma. In fact, steam, or cool mist tents, or aerosols, have a tendency to make asthma worse. It makes the air thicker, and the patient has a more difficult time inhaling it in.

Still, I have asthma mom's and asthma dad's ask me on a regular basis if they should set up humidifiers for their asthma children, and each time I have to correct the old fallacy that humidity is good for asthma.

That in mind, allow me to introduce you to RT Cave Rule #19:

RT Cave Rule #19: Humidity or cool mists may work wonders for croup, but can make the air difficult to breath for asthmatics. In the hospital, cool mist therapy can be used for croup patients, but not for asthma.

And this is one of the reasons that dehumidifiers and air conditioners can be of benefit for asthmatics (and COPD patients) because they remove the humidity from the air and make it lighter and, thus, easier to breath.

This is my opinion of course. As you will read in a moment, there has been much scientific research on humidity and asthma.

According to Sue Hare and Joe Buchdahl, co-coordinators of the Atmosphere,Climate and Environment Information Programme (see article here, or related article here), areas on the planet that had a relative humidity lower than 50% had fewer "rates of asthma." This problem may be exacerbated in big cities, "because the urban 'heat island' effect caused by asphalt and concrete trapping heat at night."

The report also states that "for every 10% increase in indoor humidity was associated with a 2.7% increase in the prevalence of asthma."

While they may not have had access to these expensive studies, this is also one of the reasons why asthmatics, like Teddy Roosevelt for example, used to report finding relief moving to areas like Arizona where the air is dry all the time.

However, moving to Arizona is no longer recommended, as the increased levels of smog may offset the benefits of the dry air.

Now we have plenty of scientific evidence to support the claim that dry air is better for asthma.

Scientists, according to American Academy of Allergy, Asthma and Immunology (aaaai.org), have determined that high humidity levels have a tendency to be harboring grounds for fungus and molds that might bother asthmatics. Plus, when the humidity is greater than 50%, the amount of dust mites in the air is increased. For this reason alone, humidity is no longer recommended for asthmatics by pediatricians.

Likewise, if you have ever been in a hospital, you probably noticed how dry it is in these places. Noses get dry, hands get chapped and start to crack (especially in the winter months). The reason is because the humidity of hospitals is kept low as to not create a harboring ground for fungus, molds and dust mites.

That's also why the air is cranked up in the summer months too. Sure, you may be cold, but this is good for disease control, and great for asthmatics.

As per The American Lung association, "Air-conditioning can help. It allows windows and doors to stay closed. This keeps some pollen and mold spores outside. It also lowers indoor humidity. Low humidity helps to control mold and dust mites."

On the other hand, also according to aaaai.org, if the relative humidity is less than 15%, this may trigger an excessive cough for asthmatics. Thus, it is recommended for "asthmatic patients to aim for a 'happy medium' relative humidity in their homes, monitoring their home humidity regularly with a reliable gauge."

The Center for Disease Control and Prevention recommends humidity be set between 35% and 50%.

I suppose you could use a convenient humidity monitor (like this). (I am not endorsing this product, I just coincidentally found it while doing my research tonight. In fact, I didn't even know it existed until a few moments ago.)

Personally, I do not have an air conditioner at home, nor do I control my humidity, but often times in the dog days of summer I wish I could afford it.

Likewise, working in the nice cool, clean air environment of a hospital was one of the best incentives of me deciding to be an RT.

(Allergy Be Gone has an excellent related article. This is also where I got that cool picture from.)

Monday's class: My response to your queries

This post is my weekly attempt to answer Internet search engine queries that lead someone to clicking onto my medblog.

I know that most people click on my site and leave two minutes later frustrated that my site is not what they were looking for. When, in actuality, if they would have hung around a bit, had a cup of coffee with me, they may have found the answer they were looking for.

This is what I'm going to make an effort to do every Monday.

1. vomiting bipap: This is a good question and something that was covered extensively in RT school. There are two types of masks patients can wear who are using BiPAP. There is a nasal mask, and a full face mask. If the patient is wearing a nasal mask, then there's no problem. However, in the hospital setting we use full face masks probably 90% of the time. And, if someone is throwing up with a mask on their face, their risk of aspiration (inhaling the vomit into the lungs and risking pneumonia) increases big time. Take the mask off if a patient is vomiting. If the patient is in the hospital and is on BiPAP to prevent him from needing a vent, intubation might need to be considered to protect the airway.
2. giving mucomyst without a bronchodilator: Mucomyst has the ability to break up thick secretions and making them easier to spit up (theoretically). It can cause bronchospasm, and should always be given with a bronchodilator, such as Albuterol.
3. vaponephrine dose for kids: At Shoreline we use 0.5cc Vaponephrine on all kids. It's safe. I have rarely ever notices an increase in heart rate as a result of this medicine, and usually if the heart rate does increase, it's because of the kid crying because he's annoyed by the RT.
4. efficacy of albuterol with chf: I've repeated this many times on this blog, but Albuterol will do nothing for CHF unless -- UNLESS -- the patient also has an underlying bronchospasm component. If you want to try one treatment to see if it does anything, go for it.
5. is a nurse above a respiratory therapist: Absolutely not. We are a team. Now, RNs are know to have a little more respect in society, but that is slowly changing. The reason is that nurses have been around since the Civil War, and RTs are only just getting started. RNs also get paid more than RTs, but that's only because of the nursing shortage and, partially, because of the respect thing. But, all in all, we are a team.
6. azthmacort: I took asthma cort for about 15 years, and never had much success with it. The main reason for this was compliance, as I was prescribed to use it four times a day. I think it's better to use a steroid inhaler that allows you to use it twice a day to increase compliance. I have better success with Flovent or Advair, but there are other options.
7. barriers to being a good respiratory therapist: Lack of respect I think is the main barrier. And lack of protocols that allow us to really excell at providing the best care to our patients at the least cost to the hospitals. However, due to lack of respect by doctors, many hospitals still do not have respiratory therapy or patient driven protocols. That's a shame, I think, and is the biggest barrier in my mind.
8. albuterol blow-by neonates: I find that most babies do not tolerate masks, however the results of using a mask may vary from patient to patient. If the child is sick enough, he or she might not care. Also, a blowby may result in the loss of 80% or more of the medicine to the atmoshphere. That said, giving a blowby is often better than doing nothing for a child who is having true bronchospasm.
9. should i give my daughter albuterol for croup: Only if there is underlying bronchospasm. Albuterol does absolutely nothing for croup.
10. cpap therapy for copd how it works: CPAP works to improve oxygenation. It helps a patient oxygenate better, and thus allows more oxygen to get into the bloodstream.
11. congestive heart failure croupiness: We hear this a lot in CHF patients. And, more often than not, RNs and RTs mistake this for a wheeze and recommend or order breathing treatments. Actually, this is caused due to increased secretions or fluid in the upper airway, and will not go away with a treatment. I would say that abaout 80% of CHF patients, patients with pulmonary edema, will have this harsh, upper airway, stridorous, croupy sound. This is something they should teach in school, but I'm not sure they do.
12. what is my internet time: Huh?
13. extra shift incentive pay respiratory: What do you mean by extra shift? Do you mean overtime. We get paid overtime for anything over 40 hours just like everybody else.
14. bad experiences with advair: Some people have bad experiences with Advair mostly becaue it has Serevent in it, which can make a person shakey and irritable. I would recommend weaning yourself onto the Advair slowly, instead of starting right out taking it twice a day. I'm patenting that idea. I recently wrote a post about this, check it out by clicking here.
15. stridor and aerosol therapy: See my answer to question #9.
16. duoneb and hyperkalemia: It would be the equivelent of taking an asprin for a heart attack. Need I say more.
17. why respiratory therapists are disrespected: I tried to explain this in my answer to #7 above. Maybe one of my fellow bloggers can word it better than me with a comment.
18. my doctor gave me potassium after an asthma attack why and what does potassium do f: Hopefully he gave potassium because lab results showed hyperkalemia, not because of some frivolous idea that one treatment of Albuterol will decrease Potassium. However, for a further answer, see #16 above.
19. definite sign of impending alcoholism: Okay, sorry sir or maam, but you had to read all of the above to learn that I do not have an answer to this question. Now, I could gather a pretty good educated guess, but I'm pretty sure you'd rather hear from a professional in that area rather than a lowly RT.
20. respiratory therapist 12 hours: I do not know of any hospitals where the RT does not work less than 12 hour shifts.
21. does albuterol breathing treatments make baby sleepy: Actually, it can be soporiphic. I know for it fact it puts some babies and even some adults asleep. Ah, maybe this gives me another idea for an 'olin.

If you have a question I have not addressed here, or if you want an answer right now, feel free to contact us anytime and we'll get you an answer ASAP. You can contact us at Freadom1776@yahoo.com, or RTcave@yahoo.com.

That concludes today's class.

Your Respiratory Therapy Search Engine Queries: Here are the responses from the RT Cave

I don't really spend a lot of time checking my stat counter, but about once a week I check it out for fun just to see who's been clicking on my blog. One of my favorite things to do while I'm there is click on "Recent Keyword Activity."

This is where my stat counter records what was typed into a search engine, such as Google or Yahoo, that led someone to clicking on my website. A few of the searches have nothing to do with respiratory, such as "Scratchy Neck," but the majority are respiratory related.

As I glance through the list, I wonder if that person had his question or concern answered. And, I think, they should just email me and I'd give them a legitimate reply, or at least I could tell them I don't know.

The reason I think this way is that some of these questions could only possibly be answered by an RT. So, with that in mind, I have listed some of the "recent keyword activity," and my humble responses.

1. "blowing into computer for respiratory": Um, I have no clue.


2. "Itchy neck pain": Um, how did that cause Google to link you to me.


3. "Duoneb pediatrics": Some studies show it works well in ER. Other than that I'd recommend just Albuteral. Personally, though, I don't see what it would hurt.


4. "Doctor doesn't believe in Peek flow meters: The doctor is a fool to disregard the benefits of a peek flow meter. It's a great tool to use in asthmatics to measure the effect of a breathing treatment, and to be an adequate tool to determine when to use a rescue inhaler, go to the doctor, or come here to the ER.


5. "Persistent croup": You can try the shower. You can taking the child outside in the cool air because many times it goes away on the way to the hospital. But don't be afraid to come in and get checked out. That's why we are here.


6. "Will Ventolin harm you if taken unprescribed": NO. However, I would not recommend it. If you have a need for Ventolin, you should go see your doctor.


7. "Does Albuterol Help Crackles?": No. The medicine particle size is too large to even get down in to the colapsed alveoli, and even if it did it wouldn't be able to re inflate it. But this is a great question, because often doctors prescribe Albuterol for this.


8. "Needle shot stings": Yes.


9. "How to write BiPap orders": With a pen in the doctors order section. It works best if you write the doctor's name followed by your signature. Plus I'd write "RT to set up BiPap to patient tolerance." Seriously, every patient is different, and every patient tolerates BiPap differently. That's how we write the order where I work.


10. "House filled with smoke from fireplace fever coughing": I would recommend not having the fire in the fireplace if it causes you to have trouble breathing due to it. It may cause you to cough, but it will not cause the fever. However, if you do have a respiratory illness, it may exacerbate your problem. Also note that it is not uncommon for smoke to bother people with respiratory illnesses.


11. "Respiratory therapy one treatment at a time": I would recommend it, but sometimes you will have no choice. If your patient takes nebs at home, or if the nebs are not indicated, then you should be okay doing more than one treatment at a time, just make sure you are only one or two rooms away. This is where it really comes in handy to know your patient. However, if you are new at this, or not sure, then you should definitely do one at a time.


12. "I hate respiratory therapists": What's your point.


13. "Breathing treaments for pneumonia": Same as for the question on atelectasis above: Albuterol does not get down to the alveoli. Besides, Albuterol relaxes bronchiolar muscles, and there are no bronchiolar muscles in the alveoli anyway. However, if the pneumonia causes bronchospasm, the treatment might work. Usually the first treatment in ER does the trick. If I were a doctor, I'd order Albuterol Q4 prn for these patients so we can give a treatment if indicated.


14. "Coughing spasms albuterol": If it's caused by bronchospasm then Albuterol is a good idea, othersise what's the point. Albuterol will not cause someone to stop coughing if it is not caused by bronchospasm. Personally, I'd try one and see what happens. It's a safe medicine.


15. "COPD on BiPAP": It works. And if it keeps them off the vent, you'll be happy and so will the patient. I've kept many patients off the vent by using a BiPaP. The big problem here is patient compliance. You will have to do a good job of explaining and be very patient with the patient.
    
16. "How long are patients intubated for": Depends on how long it takes them to recover. Depends on how sick they are. Many times, with the new microprocessor ventilators, it takes only one or two days. But every patient is different. If you are the family of someone currently on a vent, you should talk to the RT for an explanation.


17. "Do you give breathing treatment for cough congestion?": Yes, many doctors do. But Albuterol is technically speaking indicated for bronchospasm only.


18. "Where should one live with asthma": While there was once an advantage to living in dry areas like Arizona, research shows that this is no longer a benefit due to air polution.


19. "Why do people need to be intubated": I like to tell people that they, or family member, need to be intubated to get over the hump when they are really having trouble breathing. It allows their lungs to rest. Unlike in the movies, it is also indicated when someone goes into cardiac arrest. It is also done during certain surgeries, if someone is comatose to prevent aspiration, bronchoscopy, or you can check Wikipedia for more information.


20. "Tips for being a great respiratory therapist: Be patient. Don't be afraid to let other people take credit for your ideas. Do your homework. Most important, have fun with your patients and enjoy your job.

Well, I could go on, but I figure I had best stop at 20. There were many that I chose not to list here just because I saw via the stat counter that the person was linked to one of my articles where I know they would have found the answer if they read it.

Perhaps I'll make this a regular feature on this blog.