Journal of Ayurveda and Integrated Medical Sciences

Introduction

Croup is a common respiratory condition in children, typically caused by a viral infection, most commonly the parainfluenza virus. It causes inflammation and narrowing of the upper airway, primarily the trachea and larynx, which can result in distinctive symptoms like Barking cough, Stridor, hoarseness, labored breathing, Fever. Laryngotracheitis, laryngotracheo-bronchitis, and laryngo-tracheo-broncho-pneumonitis are all included in the spectrum of croup. Croup includes an infection of the upper airway, which becomes narrow, making it harder to breathe. Croup also causes a cough that sounds like barking. It is a self-limited disease that is seen in children less than age of 5 years.

The cough and other signs and symptoms of croup are the result of swelling and irritation around the voice box (larynx), windpipe (trachea) and bronchial tubes (bronchi). When a cough forces air through this narrowed passageway, the swollen vocal cords produce a noise a seal barking. Taking a breath often produces a high-pitched whistling sound called stridor. When the upper airway is infected with the virus that causes croup, tissues around the voice box (larynx) and the windpipe (trachea) will swell. When a cough forces air through this narrowed passageway, it may sound like a seal barking. Croup is usually caused by a viral infection, most often a parainfluenza virus.^[1] A child may get a virus by breathing infected respiratory droplets coughed or sneezed into the air. Virus particles in these droplets may also survive on toys and other surfaces. If your child touches a surface with a virus on it, and then touches the eyes, nose or mouth, an infection may follow. Uncommon complications may include bacterial tracheitis, pneumonia, pulmonary edema, and rarely, death. This activity reviews the evaluation and management of croup and highlights the role of the interprofessional team in improving care for patients with this condition. Ayurveda treats Croup in multiaspect corelating with Kasa and Shwasa Roga. Early intervention is necessary in case of Kasa as it is a potential Nidanarthakara Vyadhi to produce Kshaya.^[2] Croup can be correlated to the description of Kasa in Ayurveda. It is the most frequent symptom of respiratory disease. The main vitiating factors in the Kasa are Kapha and Vata. the increased Kapha forms a sort of Upalepa in Pranavaha Srotas obstructing the normal pathway of Vayu, leading to its vitiation. Kasa

Prodromal symptoms of Kasa

पूर्वरुपं भवेत्तेषां शूकपूर्णगलास्यता । कण्ठे कण्डूश्च भोज्यानामवरोधश्च जायते।। ( माधवनिदान /कास)

Premonitory signs and symptoms of Kasa

1. Sensation as if throat and mouth are filled with Shooka (Thorns)
2. Itching sensation in the throat.
3. Inability to swallow food.

Signs and symptoms of Kasa

Vataja Kasa^[6]

हृत्याश्वोर: शिरः शूलस्वेदभेदकरो भृशम् । शुष्कोर: कण्ठवक्त्रास्यहृष्टलोम्नः प्रताम्यतः ।I११।I निर्घोषदैन्यक्षामस्य दौर्बल्यक्षयमोहकृत् । शुष्ककासः कफं शुष्कं कृच्छ्रान्मुक्त्वाल्पतां व्रजेत् ।। स्निग्धाम्ललवणोष्णैश्च भुक्तमात्रे प्रशाम्यति । ऊर्ध्ववातस्य जीर्णेऽन्ने वेगवान्मारुतो भवेत् ।। (च.चि.१८/९ -११)

Pittaja Kasa^[7]

पीतनिष्ठीवनाक्षत्वं तिक्तास्यत्वं स्वरामयः । उरोधूमायनं तृष्णा दाहो मोहोऽ रुचिर्भमः ।।

प्रततं कासमानश्च ज्योतीषिव च पश्यति । श्लेष्माणं पित्तसंसृष्टं निष्ठीवति च पैत्तिके ।। (च.चि.१८/१३,१४)

Kaphaja Kasa^[8]

मन्दाग्नित्वारुचिच्छार्दपीनसोत्क्लेशगौरवैः । लोमहर्षास्यमाधुर्यक्लेदसंसदनैर्युतम् ।। बहुलं मधुरं स्निग्धं निष्ठीवति घनं कफम् । कासमानो ह्यरुग् वक्षः संपूर्णमिव मन्यते ।। (च.चि.१८/१६-१७)

Kshataja Kasa^[9]

स पूर्व कासते शुष्कं ततः ष्ठीवेत् सशोणितम् । कण्ठेन रुजताऽत्यर्थं विरुग्णेनेव चोरसा ।। सूचीभिरिव तीक्ष्णाभिस्तुद्यमानेन शूलिना । घामका ला दुःखस्पर्शेन शूलेन भेदपीडाभितापिना ।। पर्वभेदज्वरश्वासतृष्णावैस्वर्य पीडितः। पारावत इवाकूजन् कासवेगात्क्षयोद्भवात् ।। (च.चि.१८/१९-२१)

Kshayaja Kasa^[10]

१. स गात्रशूलज्वरदाहमोहान् प्राणक्षयं चोपलभ्येत कासी। शुष्यान्विनिष्ठीवति दुर्बलस्तु प्रक्षीणमांसो रुधिरं सपूयम् ।। तं सर्वलिंग भृशदुश्चिकत्स्यं चिकित्सितज्ञाः क्षयजं वदन्ति।।

२. दुर्गन्धं हरितं रक्तं ष्ठीवेत् पूयोपमं कफम् । स्थानादुत्कासमानश्च हृदयं मन्यते च्युतम् ।। अकस्मादुष्णशीतार्तो बह्वाशी दुर्बलः कृशः । स्निग्धाच्छमुखवर्णत्वक् श्रीमद्दर्शनलोचनः ।। पाणिपादतलैः श्लक्ष्णैः सततासूयको घृणी । ज्वरो मिश्राकृतिस्तस्य पार्श्वरुक् पीनसोऽरुचिः ।। भिन्नसंहतवर्चस्त्वं स्वरभेदोऽ निमित्ततः । इत्येष क्षयजः कासः क्षीणानां देहनाशनः ।। (च.चि. १८/२५)

Lakshana

• Shwasa

• Rule out other obstructive conditions in nasal cavity
• Characteristic narrowing of the trachea in 50% of cases, known as the steeple sign, because of the subglottic stenosis, which resembles a steeple can rarely be diagnosed by X-ray.
• Blood tests and viral culture are advised against, as they may cause unnecessary agitation and lead to further airway swelling and obstruction, viral cultures.

Symptoms of Croup^[12]

Treatment of Croup^[13]

Treatment depends on the severity based on the Westley croup score. Children with mild croup defined as Westley croup score less than 2 are given a single dose dexamethasone. Children with moderate to severe croup defined as a Westley croup score greater than 3 are given nebulized epinephrine in addition to dexamethasone.^[14]

Steroids - Corticosteroids, such as dexamethasone, results in faster resolution of symptoms, decreased return to medical care, and decreased length of stay. Dexamethasone is superior to budesonide for improving symptom scores, but there is no difference in readmission rates.^[15]

Epinephrine - For moderate to severe cases, nebulized racemic epinephrine has been found to improve symptom scores at 30 minutes, but the benefits may wear off after 2 hours. Current recommendations advocate for a prolonged period of observation in patients receiving racemic epinephrine. If symptoms do not worsen after 4 hours of observation, consider discharge home with close follow-up.^[16]

Oxygen - Deliver oxygen by "blow-by" administration as it causes less agitation than the use of a mask or nasal cannula.

necessary in case of Kasa as it is a potential Nidanarthakara Vyadhi to produce Kshaya. Croup can be correlated to the description of Kasa in Ayurveda. It is the most frequent symptom of respiratory disease. The main vitiating factors in the Kasa are Kapha and Vata. The vitiated Kapha forms a sort of Upalepa in Pranavaha Srotas obstructing the normal pathway of Vayu, leading to its vitiation. Kasa may develop as an independent disease. Due to the causative factors, Pranavata combined with Kapha leaves its path and begins to move in the upward direction, giving rise to breathing difficulty, cough etc. It can be treated by various Kasa Shwasahara Kalpas and Panchakarma procedures like Dashamoola Niruha Basti is best in Vata Kapha Roga Chikitsa, Mrudu Vamana, Mrudu Virechana, Karpooradi Taila application on chest region during breathing difficulty. Croup is a viral upper respiratory infection, in children. It is characterized by the abrupt onset of barky cough, inspiratory stridor, hoarseness and respiratory distress. Oral corticosteroids reduce the severity and duration of respiratory distress, the need for hospital admission, airway intubations and repeat health care visits. For children with severe respiratory distress, nebulized epinephrine givers rapid but temporary relief. Most children, including many with severe respiratory distress, can be easily treated. There is always a scope of research considering to present scenario.

References

1. Buttaravoli PM, et al., editors. Laryngotracheobronchitis (croup). In: Minor Emergencies. 4th ed. Elsevier; 2022. Available from: https://www.clinicalkey.com. Accessed May 9, 2022.

2. Kashinath Shastri P, Chaturvedi GN. Hindi commentary on Charaka Samhita of Agnivesha revised by Charaka and Dridbala, nidansthan 8/19, p666, Edition 2009. Varanasi: Chaukhambha Bharti Academy; 2009.

3. Astanga Sangraha. Atrideva Gupta, Editor. Varanasi: Chaukhamba Krishnadas Academy; 2005; Nidanasthana 3/43.

4. Sharma RK, Dash B. Caraka Samhita, English translation. Varanasi: Chowkhamba Sanskrit Series Office; 2009. Reprint edition; Volume IV; p.128.