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
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)
- Dexamethasone 0.15-0.6mg/kg PO/IM (max 10mg)[4]
- Epinephrine (nebulized)
- Do NOT give albuterol (may worsen edema (vasodilation))
Intubation rarely needed but if so, use tube that is one half size smaller than normal for age/size of pt
Disposition
- Consider Discharge if:
- 3hr since last epinephrine
- Able to tolerate PO
- Nontoxic appearance
- Admit
- Persistent respiratory symptoms/signs
- ≥2 treatments with epinephrine
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.
- ↑ 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