Joshua Gardner

MS III
USUHS
9 MARCH 2011
 Diagnosis and Management of Croup
◦ Review natural history of viral croup
◦ Distinguish between and review evidence of various
treatment options
 Determining need for outpatient vs inpatient
treatment
◦ Develop a differential diagnosis
◦ Review indications for hospitalization
 J.S. is a 15 mo male who comes in w/ his
very worried mother.
◦ Runny nose started 2 days ago
◦ Temp 100.3 two days ago
◦ Barking cough started 2 days ago
◦ Now making a horrible noise when he takes a
deep breath in
◦ Refuses to lie down
 Received racemic epinephrine & decadron
developed “wheezing”
◦ treated with an albuterol nebulizer x 2
 VS: 97.5F 122 42 O2 sat 99% when quiet
 Gen: alert, sitting in mother’s lap quietly when
you enter, during exam starts to cry you note
inspiratory stridor
 Ears: nl TMs
 Nose: rhinnorhea
 Mouth: no exudate, tonsils normal
 Neck: Mild cervical lymphadenopathy
 Chest: expiratory wheeze, inspiratory sounds
obscured, subcostal retractions worsened w/
crying
 CV: RRR no murmur
 Ext: 2+ cap refill, wwp
 Epiglottitis  Vocal cord paralysis
 Bacterial tracheitis  Smoke inhalation
 Foreign body
 Burns/Thermal
 Subglottic stenosis
injury
 Peritonisillar
 Neoplasm
abscess
 Laryngeal fracture
 Retropharyngeal
abscess
 Diptheria
 Laryngomalacia
Comparison of the Features of Epiglottitis and Croup
Epiglottitis Croup
Age Can occur in infants, older Six months to six years
children, or adults
Onset Sudden Gradual

Location Supraglottic Subglottic

Temp High fever Low-grade fever

Dysphagia Severe Mild or absent

Dyspnea Present Present

Drooling Present Present

Cough Uncommon Chracteristic cough

Position Sitting forward with mouth open Comfortable in different

positions
Radiology Positive thumb sign* Positive steeple sign
Adapted with permission from DeSoto H. Epiglottitis and croup in airway obstruction in children. Anesthesiol Clin North Am 1998;16:85
 Term used to describe the clinical picture of
laryngotracheitis
 A heterogenous group of illnesses affecting

the larynx, trachea, and bronchi

 Viral in origin
 In the past, used to describe bacterial

tracheitis and laryngeal diphtheria

 Annual incidence: 6 cases per 100 children
younger than 6yo
 Affects children 6 mo-12 yo, w/ a peak

incidence at 2 yo
 Boys:Girls 1.5:1
 Fall and winter predominance
 Leading cause of hospitalization in children

younger than 4 yo
 Anatomic narrowing of the airway
◦ i.e. subglottic stenosis or laryngeal web

 Hyperactive airways

 Acquired airway narrowing from respiratory

tract papillomas or post intubation scarring
 Viral: Parainfluenza, Influenza A & B,
Adenovirus, RSV, rhinovirus, enteroviruses,
measles & even Mycoplasma pneumoniae
 Infects nasal and pharyngeal mucosa initially
◦ spreads locally to larynx and trachea
 Spasmodic: viral associated, possibly allergic
reaction to antigens
◦ Sudden onset of stridor overnight in the setting of
mild URI
◦ Recurrent in nature
◦ Non-inflammatory edema
 Symptoms  Signs
◦ 1-4 day Hx of coryzal ◦ Hx consistent w/
illness croup
 Rhinorrhea, low grade ◦ Normal pulse ox
temp & mild tachypnea
◦ Low-grade fever
◦ Hoarseness
◦ “Croupy”/barking
cough
◦ Stridor
◦ Dyspnea/wheeze
 Subglottic  Atelectasis/mucus
narrowing due to plugging
 Ventilation/perfusio
inflammation.
 Cricoid ring allows n mismatch
 Neg intrapleural
fixed area for
pressure
obstruction. ◦ Causing pulmonary
 1mm swelling edema.
causes 65%  Hypoxia/hypercarbi
obstruction in a
infant.
 Plain neck XR: “Steeple sign”
 Larynogoscopy
 
 
 
 
 
 General appearance: agitated, appears to be tiring from
the effort of breathing or has a decreasing level of
consciousness needs to be closely monitored.
 Degree of respiratory distress: stridor at rest, tracheal
tug, chest wall retractions, changing respiratory rate,
and pulse rate indicate treatment is necessary.
 Cyanosis or extreme pallor = immediate treatment
 Oxygen desaturation is a late sign and unreliable for
croup severity.
◦ never a surrogate for clinical examination
 Score < 4, Mild
◦ Trial of humidified air

 Score of > 4, Moderate to Severe

◦ Oxygen
◦ Steroids
◦ Nebulized Racemic Epinephrine

 Score > 8 that did not respond to tx

◦ Candidate for endotrachial intubation
 Humidified Air
◦ Based on historical charm with
no scientific validation
 Oxygen
◦ If O2 saturation < 90 %
 Work through rapidly acting anti-
inflammatory properties or vasoconstrictive
actions in the upper airway
 Dexamethasone: equivalent outcomes with

0.15/kg, 0.3/kg and 0.6/kg

◦ Effective in reducing symptoms within 6 hrs and for
at least 12 hrs after tx
◦ 54 hour half life
 2 mg budesonide neb – onset of action in 30
min
 Nebulized vs oral vs IM
◦ For children with increased WOB
◦ Consider oral or IM over nebulized
 Inpatient vs Outpatient
◦ Depends on VS/PE
 Dose
◦ PO: 0.15mg/kg – lowest known effective dose of
dexamethasone
◦ IM: 0.15-0.6mg/kg IM
 For moderate to severe distress
 0.5 mg/kg to a max dose of 5 mL

◦ 1:1000 Nebulized cocentration

 Decreased stridor/retractions in 30 min
 Duration 2 hrs

◦ Rebound phenomenon
◦ Observe 3-4hrs after administration
 Side effects: tachycardia, HTN
◦ Multiple studies demonstrating safe to d/c pt from
ER if:
 Steroids were given, too.
 No resting stridor 2-4 hrs after tx.
 Otitis media
 Bronchiolitis
 Pneumonia (rare)
 Bacterial tracheitis (rare)
 Croup is a common viral illness in children
 Treatment options include
◦ Steroids – good evidence to support
◦ Epinephrine – years of experience and trials support
its use
◦ Mist – years of use/no data to support
 Evidence supports outpatient treatment in
mild to moderate croup
 Behrman, RE, Kliegman, RM, Jenson, HB Nelson Textbook of Pediatrics, 16th
Ed. W.B. Saunders Co. 2000.
 Cetinkaya F, Tufekei BS, Kutluk GT. A comparison of nebulized budesonide,
and intramuscular, and oral dexamethasone for treatment of croup. Int J
Pediatric Otorhinolaryngology 2004; 68(4): 453-6
 Knutson, D, Aring, A. Viral Croup. American Family Physician 2004; 69:535-
540.
 Luria JW, Gonzalez-del-Rey JA DiGiulio GA, et al. Effectiveness of oral or
nebulized dexamethasone for children with mild croup. Arch Pediatric and
Adolescent Medicine 2001; 155: 1340-5.
 Neto GM, Kentab O, Klassen TP, Osmond MH. A randomized controlled trial
of mist in the acute treatment of moderate croup. Academy of Emergence
Medicine 2002; 9(9): 873-9.
 Rittichier KK, Ledwith CA. Outpatient treatment of moderate croup with
dexamethasone: intramuscular versus oral dosing. Pediatrics 2000; 106(6):
1344-8.