Croup
Background
- Also known as laryngotracheobronchitis
- Typically affects ages 6 mo-3 yr (peak in 2nd year)
- Most common in fall & winter
- Etiology
- Parainfluenza (50%), RSV, rhinovirus
- Consider Diphtheria if not immunized
- 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 Features
- 1-2 day of URI followed by barking cough and 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
- Allergic reaction
- Angioedema
- Asthma
- Bacterial tracheitis
- Congestive heart failure
- Croup
- Cystic fibrosis
- Diphtheria
- Epiglottitis
- Foreign body
- Inhalation injury
- Laryngeal Fractures
- Laryngomalacia
- Mononucleosis and Epstein-Barr Virus Infection
- Peritonsillar abscess
- Pertusis
- Pneumonia
- Retropharyngeal abscess
- Subglottic stenosis
- Tracheomalacia
- Vascular ring
Pediatric stridor
<6 Months Old
- Laryngotracheomalacia
- Accounts for 60%
- Usually exacerbated by viral URI
- Diagnosed with flexible fiberoptic laryngoscopy
- Vocal cord paralysis
- Stridor associated with feeding problems, hoarse voice, weak and/or changing cry
- May have cyanosis or apnea if bilateral (less common)
- Subglottic stenosis
- Congenital vs secondary to prolonged intubation in premies
- Airway hemangioma
- Usually regresses by age 5
- Associated with skin hemangiomas in beard distribution
- Vascular ring/sling
>6 Months Old
- Croup
- viral laryngotracheobronchitis
- 6 mo - 3 yr, peaks at 2 yrs
- Most severe on 3rd-4th day of illness
- Steeple sign not reliable- diagnose clinically
- Epiglottitis
- H flu type B
- Have higher suspicion in unvaccinated children
- Rapid onset sore throat, fever, drooling
- Difficult airway- call anesthesia/ ENT early
- H flu type B
- Bacterial tracheitis
- Rare but causes life-threatening obstruction
- Symptoms of croup + toxic-appearing = bacterial tracheitis
- Foreign body (sudden onset)
- Marked variation in quality or pattern of stridor
- Retropharyngeal abscess
- Fever, neck pain, dysphagia, muffled voice, drooling, neck stiffness/torticollis/extension
Diagnosis
Work-up
- Consider CXR if concerned about alternative diagnosis
- Steeple sign on AP (not Sp, not Sn)
- Consider nasal washings for RSV, parainfluenza, influenza serologies.
Evaluation
- Often a clinical diagnosis
Management
- Cool mist
- May provide symptomatic treatment for patients with ongoing stridor[3]
- Steroids (first line treatment)
- Epinephrine (nebulized)
- Use in moderate to severe cases based on the croup scores. Use either Racemic or Standard Epinephrine[6]
- Symptomatic relief via local vasoconstriction
- Racemic Epi (2.25%): 0.05 mL per kg (maximal dose: 0.5 mL) of racemic epinephrine 2.25% [7]
- Epinephrine (1:1,000): 0.5 mL per kg (maximal dose: 5 mL) via nebulizer
- Watch child 2-3 hrs after administration to ensure no return of stridor at rest
- Heliox
- Mixture of helium and oxygen (with not less than 20% oxygen)
- Low viscosity and low specific gravity facilitates laminar airflow through the respiratory tract.
- Currently there is a lack of evidence to establish the effect of heliox inhalation in the treatment of croup in children[8]
- Intubation
- Rarely needed but if so, use tube that is one half size smaller than normal for age/size of pt
- Do NOT give albuterol (may worsen edema (vasodilation))
Disposition
- Consider Discharge if:
- 3hr since last epinephrine
- Able to tolerate PO
- Nontoxic appearance
- Admit
- Persistent respiratory symptoms/signs
- ≥2 treatments with epinephrine
Video
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See Also
External Links
References
- ↑ 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.
- ↑ Donaldson D, Intramuscular versus oral dexamethasone for the treatment of moderate-to-severe croup: a randomized, double-blind trial. Acad Emerg Med. 2003 Jan;10(1):16-21.
- ↑ 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
- ↑ Moraa I, Sturman N, McGuire T, van Driel ML., Heliox for croup in children., Cochrane Database Syst Rev. 2013 Dec 7;12:CD00682