Croup: Difference between revisions
| Line 39: | Line 39: | ||
*2-9 Mild to moderately severe | *2-9 Mild to moderately severe | ||
*>9 Severe croup | *>9 Severe croup | ||
==Differential Diagnosis== | |||
==Differential Diagnosis== | |||
*[[Asthma]] | |||
*[[Croup]] | |||
*[[PNA]] | |||
*[[Foreign body]] | |||
*[[Pertusis]] | |||
*[[CHF]] | |||
*Cystic fibrosis | |||
*Vascular ring | |||
*[[Retropharyngeal abscess]] | |||
*Subglottic stenosis | |||
*[[Angioedema]] | |||
*[[Allergic reaction]] | |||
*Tracheomalacia | |||
*[[Bacterial tracheitis]] | |||
*[[Diphtheria]] | |||
*[[Epiglottitis]] | |||
*Inhalation injury | |||
*Laryngeal Fractures | |||
*Laryngomalacia | |||
*[[Mononucleosis]] and Epstein-Barr Virus Infection | |||
*[[Peritonsillar abscess]] | |||
==Diagnosis== | ==Diagnosis== | ||
Revision as of 04:33, 6 May 2015
Background
- Croup = laryngotracheobronchitis
- Affects 6 mo-3 yr (peak in 2nd year)
- Fall & winter
- Etiology
- Parainfluenza (50%), RSV, rhinovirus
- Consider Diphtheria if not immunized
- Parainfluenza (50%), RSV, rhinovirus
- Spasmodic croup
- Sudden onset of barking cough/stridor
- No viral prodrome, unlike standard croup
- Difficult to differentiate from croup
- Must rule-out foreign body
Clinical Presentation
- 1-2 day of URI followed by barking cough, stridor
- Low-grade fever
- NO drooling or dysphagia
- Duration = 3-7d, most severe on days 3-4
Westley Croup Score[1][2]
Helps to stratify patients into mild moderate and severe and guide treatment
| Parameter | 0 Point | 1 Point | 2 Points | 3 Points |
|---|---|---|---|---|
| Inspiratory stridor | None | When agitated | On/off at rest | Continuous at rest |
| Retractions | None | Mild | Moderate | Severe |
| Air Entry | Normal | Decreased | Mod decreased | Severely decreased |
| Cyanosis | None | When crying | At rest | |
| Alertness | Alert | Restless, anxious | Depressed |
Assessment
- <2 Very mild
- 2-9 Mild to moderately severe
- >9 Severe croup
Differential Diagnosis
Differential Diagnosis
- Asthma
- Croup
- PNA
- Foreign body
- Pertusis
- CHF
- Cystic fibrosis
- Vascular ring
- Retropharyngeal abscess
- Subglottic stenosis
- Angioedema
- Allergic reaction
- Tracheomalacia
- Bacterial tracheitis
- Diphtheria
- Epiglottitis
- Inhalation injury
- Laryngeal Fractures
- Laryngomalacia
- Mononucleosis and Epstein-Barr Virus Infection
- Peritonsillar abscess
Diagnosis
- Consider CXR if concerned about alternative diagnosis
- Steeple sign on AP (not Sp, not Sn)
- Consider nasal washings for RSV, parainfluenza, influenza.
Treatment
Cool mist
- May provide symptomatic treatment for patients with ongoing stridor[3]
Steroids
- First line treatment
- Dexamethasone 0.15-0.6mg/kg PO/IM (max 10mg)[4]
Epinephrine (nebulized)
- Use in moderate to severe cases based on the croup scores. Use either Racemic or Standard Epinephrine[5]
- Racemic Epi (2.25%): 0.05 mL per kg (maximal dose: 0.5 mL) of racemic epinephrine 2.25% [6]
- Epinephrine (1:1,000): 0.5 mL per kg (maximal dose: 5 mL) via nebulizer,
- Do NOT give albuterol (may worsen edema (vasodilation))
Intubation rarely needed but if so the use one half size smaller tube if intubating
Disposition
Consider Discharge
- 3hr since last epinephrine
- Able to tolerate PO
- Nontoxic appearance
Admit
- Persistent respiratory symptoms/signs
- ≥2 treatments with epinephrine
See Also
External Links
Source
- ↑ Westley CR, et al. Nebulized racemic epinephrine by IPPB for the treatment of croup: a double-blind study. Am J Dis Child. 1978; 132(5):484-487.
- ↑ Klassen TP, et al. Croup. A current perspective. Pediatr Clin North Am. 1999; 46(6):1167–1178.
- ↑ Scolnik D, Coates AL, Stephens D, Da Silva Z, Lavine E, Schuh S. Controlled delivery of high vs low humidity vs mist therapy for croup in emergency departments. JAMA. 2006;295(11):1274–1280
- ↑ Geelhoed GC, Macdonald WB. Oral dexamethasone in the treatment of croup: 0.15 mg/kg versus 0.3 mg/kg versus 0.6 mg/kg. Pediatr Pulmonol. 1995;20(6):362–368.
- ↑ Adair JC, Ring WH, Jordan WS, Elwyn RA. Ten-year experience with IPPB in the treatment of acute laryngotracheobronchitis. Anesth Analg. 1971;50(4):649–55
- ↑ Westley CR, Cotton EK, Brooks JG. Nebulized racemic epinephrine by IPPB for the treatment of croup: a double-blind study. Am J Dis Child. 1978;132(5):484–487