Croup: Difference between revisions
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==Background== | ==Background== | ||
* | *Also known as laryngotracheobronchitis | ||
* | *Typically affects ages 6 mo-3 yr (peak in 2nd year) | ||
* | **May affect older children | ||
**Most common in fall & winter | |||
***Consider | ===Etiologies=== | ||
*Parainfluenza (50% - 75%) | |||
*[[Influenza]] A and B (usually more severe clinical picture) | |||
*[[RSV]] | |||
**[[Rhinovirus]] | |||
**Consider [[Diphtheria]] if not immunized | |||
*Spasmodic croup | *Spasmodic croup | ||
**Sudden onset of barking cough/stridor | **Sudden onset of barking cough/stridor | ||
**No viral prodrome, unlike | **No viral prodrome, unlike typical croup | ||
**Difficult to differentiate from croup | **Difficult to differentiate from typical croup | ||
*Must rule | *Must rule out [[foreign body]] | ||
==Clinical Features== | |||
*1-3 days of [[URI]] symptoms, followed by barking [[cough]], hoarse voice, and [[stridor]] | |||
*Low-grade [[fever]] | |||
*NO drooling or dysphagia | |||
*Duration 4 - 7 days | |||
**Usually most severe on days 3-4 | |||
===Mild<ref>Rose, E. (2018) Pediatric respiratory emergencies: Upper airway obstruction and infections. Rosen's Emergency Medicine (9th ed.) Philadelphia, PA: Elsevier/Saunders</ref>=== | |||
*85% of cases | |||
*Intermittent barking [[cough]] | |||
*[[Stridor]] with agitation | |||
*Mild [[Shortness of breath (peds)|tachypnea]] | |||
*Mild [[tachycardia]] | |||
===Moderate<ref>Rose, E. (2018) Pediatric respiratory emergencies: Upper airway obstruction and infections. Rosen's Emergency Medicine (9th ed.) Philadelphia, PA: Elsevier/Saunders</ref>=== | |||
*Fussy but alert, interactive, consolable by parents | |||
*[[Stridor]] at rest | |||
*Worsening stridor with agitation | |||
*Increased [[Shortness of breath (peds)|work of breathing]] | |||
===Severe<ref>Rose, E. (2018) Pediatric respiratory emergencies: Upper airway obstruction and infections. Rosen's Emergency Medicine (9th ed.) Philadelphia, PA: Elsevier/Saunders</ref>=== | |||
*[[Hypoxia]] | |||
*Less than 1% of cases | |||
==Differential Diagnosis== | |||
{{Pediatric stridor DDX}} | |||
{{Pediatric SOB DDX}} | |||
==Evaluation== | |||
===Work-up=== | |||
[[File:Croup steeple sign.jpg|thumb|The steeple sign as seen on an AP neck X-ray (dedicated neck film not typically indicated).]] | |||
*Consider CXR if concerned about alternative diagnosis | |||
**In typical cases, imaging is not needed and does not change management | |||
**Steeple sign on AP XR (not specific or sensitive) | |||
*Consider nasal pharyngeal swab | |||
==Diagnosis== | ===Diagnosis=== | ||
*Clinical | |||
**Steeple sign unreliable | |||
====Westley Croup Score<ref>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.</ref><ref>Klassen TP, et al. Croup. A current perspective. Pediatr Clin North Am. 1999; 46(6):1167–1178.</ref>==== | |||
''Helps to stratify patients into mild moderate and severe and guide treatment'' | |||
{| class="wikitable" | |||
|+ '''Westley score: Classification of croup severity''' | |||
|- | |||
! rowspan="2" |Feature | |||
! colspan="6" |Number of points assigned for this feature | |||
|- | |||
!0 | |||
!1 | |||
!2 | |||
!3 | |||
!4 | |||
!5 | |||
|- | |||
| Chest wall retraction | |||
| style="width:50px;"|None | |||
| style="width:50px;"|Mild | |||
| style="width:50px;"|Moderate | |||
| style="width:50px;"|Severe | |||
| style="width:50px;"| | |||
| style="width:50px;"| | |||
|- | |||
| [[Stridor]] | |||
| None | |||
| With agitation | |||
| At rest | |||
| | |||
| | |||
| | |||
|- | |||
| Cyanosis | |||
| None | |||
| | |||
| | |||
| | |||
| With agitation | |||
| At rest | |||
|- | |||
| Level of consciousness | |||
| Normal | |||
| | |||
| | |||
| | |||
| | |||
| Disoriented | |||
|- | |||
| Air entry | |||
| Normal | |||
| Decreased | |||
| Markedly decreased | |||
| | |||
| | |||
| | |||
|} | |||
'''Assessment''' | '''Assessment''' | ||
*<2 Very mild | *<2 Very mild | ||
*2- | *2-6 Mild to moderately severe | ||
* | *7-11 Severe croup | ||
*≥ 12 Respiratory failure | |||
== | ==Management== | ||
# | [[File:VEP Croup Care Pathway 2019.png|thumb|VEP Croup Care Pathway]] | ||
## | #Cool mist | ||
# | #*Humidified air may provide symptomatic treatment for patients with ongoing stridor<ref>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</ref> | ||
#Steroids (first line treatment) | |||
#*[[Dexamethasone]] 0.15-0.6mg/kg PO/IM (max 10mg)<ref>Geelhoed GC, Macdonald WB. Oral dexamethasone in the treatment of croup: 0.15mg/kg versus 0.3mg/kg versus 0.6mg/kg. Pediatr Pulmonol. 1995;20(6):362–368.</ref><ref>Bjornson, C.L., Klassen, T.P., Williamson, J., Brant, R., Mitton, C., Plint, A., Bulloch, B., Evered, L. and Johnson, D.W. (2004) ‘A Randomized trial of a single dose of oral dexamethasone for mild Croup’, New England Journal of Medicine, 351(13), pp. 1306–1313.</ref> | |||
#*No differences between intramuscular and oral dexamethasone <ref>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.</ref> | |||
#*Onset 6 hrs, duration 72 hrs | |||
#*Recent study showing non-inferiority of low dose (0.15mg/kg) dexamethasone and prednisolone at 1mg/kg<ref>Prednisolone versus dexamethasone for croup: a randomized controlled trial Parker CM, Cooper MN. Pediatrics. 2019;144(3):e20183772.</ref>. | |||
#[[Epinephrine]] (nebulized) | |||
#*Use in moderate to severe cases based on the croup scores. Use either Racemic or Standard Epinephrine<ref>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</ref> | |||
#*Symptomatic relief via local vasoconstriction | |||
#*'''Racemic Epi (2.25%)''': 0.05 mL per kg (maximal dose: 0.5 mL) of racemic epinephrine 2.25% <ref>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</ref> | |||
#*'''[[Epinephrine]](1:1,000)''': 0.5 mL per kg (maximal dose: 5 mL) via nebulizer | |||
#*Onset up to 30 min, duration 2 hrs | |||
#*Watch child 2-3 hrs after administration to ensure no return of stridor at rest | |||
#[[Intubation]] | |||
#*Rarely needed but if so, use tube that is one half size smaller than normal for age/size of patient | |||
===Contraindicated=== | |||
*'''Do NOT''' give albuterol (may worsen edema (vasodilation)) | |||
== | ===No Evidence=== | ||
*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<ref>Moraa I, Sturman N, McGuire T, van Driel ML., Heliox for croup in children., Cochrane Database Syst Rev. 2013 Dec 7;12:CD00682</ref> | |||
==Disposition== | ==Disposition== | ||
===Consider Discharge if=== | |||
*3hr since last [[epinephrine]] | |||
*Able to tolerate PO | |||
# | *Nontoxic appearance | ||
===Admit=== | |||
*Persistent respiratory symptoms/signs | |||
*≥2 treatments with [[epinephrine]] | |||
==Video== | |||
{{#widget:YouTube|id=Z01e1bJ9p-g}} | |||
==See Also== | ==See Also== | ||
[[Bronchiolitis (RSV)]] | *[[Bronchiolitis (RSV)]] | ||
*[[Prehospital protocol croup]] | |||
==External Links== | |||
*[http://www.mdcalc.com/westley-croup-score/ MDCalc - Westley Croup Score] | |||
==References== | |||
<references/> | |||
[[Category:Pediatrics]] | |||
[[Category: | |||
[[Category:ID]] | [[Category:ID]] |
Revision as of 16:22, 1 July 2020
Background
- Also known as laryngotracheobronchitis
- Typically affects ages 6 mo-3 yr (peak in 2nd year)
- May affect older children
- Most common in fall & winter
Etiologies
- Parainfluenza (50% - 75%)
- Influenza A and B (usually more severe clinical picture)
- RSV
- Rhinovirus
- Consider Diphtheria if not immunized
- Spasmodic croup
- Sudden onset of barking cough/stridor
- No viral prodrome, unlike typical croup
- Difficult to differentiate from typical croup
- Must rule out foreign body
Clinical Features
- 1-3 days of URI symptoms, followed by barking cough, hoarse voice, and stridor
- Low-grade fever
- NO drooling or dysphagia
- Duration 4 - 7 days
- Usually most severe on days 3-4
Mild[1]
- 85% of cases
- Intermittent barking cough
- Stridor with agitation
- Mild tachypnea
- Mild tachycardia
Moderate[2]
- Fussy but alert, interactive, consolable by parents
- Stridor at rest
- Worsening stridor with agitation
- Increased work of breathing
Severe[3]
- Hypoxia
- Less than 1% of cases
Differential Diagnosis
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
Pediatric Shortness of Breath
Pulmonary/airway
- Airway obstruction
- Structural
- Infectious
- Other
Cardiac
- Congenital heart disease
- Vascular ring
- Cardiac tamponade
- Congestive Heart Failure (peds)
- Myocarditis (peds)
Other diseases with abnormal respiration
- Normal neonatal periodic breathing (misinterpreted by caregivers as abnormal)
- Brief resolved unexplained event
- Anemia
- Abdominal distension (e.g. SBO, liver failure
- Neonatal abstinence syndrome
- Decreased perfusion states
- Metabolic acidosis
- CO Poisoning
- Diaphragm injury
- Renal Failure
- Electrolyte abnormalities
- Organophosphate toxicity
- Tick paralysis
- Fever (Peds)
- Panic attack
- Porphyria
Evaluation
Work-up
- Consider CXR if concerned about alternative diagnosis
- In typical cases, imaging is not needed and does not change management
- Steeple sign on AP XR (not specific or sensitive)
- Consider nasal pharyngeal swab
Diagnosis
- Clinical
- Steeple sign unreliable
Westley Croup Score[4][5]
Helps to stratify patients into mild moderate and severe and guide treatment
Feature | Number of points assigned for this feature | |||||
---|---|---|---|---|---|---|
0 | 1 | 2 | 3 | 4 | 5 | |
Chest wall retraction | None | Mild | Moderate | Severe | ||
Stridor | None | With agitation | At rest | |||
Cyanosis | None | With agitation | At rest | |||
Level of consciousness | Normal | Disoriented | ||||
Air entry | Normal | Decreased | Markedly decreased |
Assessment
- <2 Very mild
- 2-6 Mild to moderately severe
- 7-11 Severe croup
- ≥ 12 Respiratory failure
Management
- Cool mist
- Humidified air may provide symptomatic treatment for patients with ongoing stridor[6]
- Steroids (first line treatment)
- Dexamethasone 0.15-0.6mg/kg PO/IM (max 10mg)[7][8]
- No differences between intramuscular and oral dexamethasone [9]
- Onset 6 hrs, duration 72 hrs
- Recent study showing non-inferiority of low dose (0.15mg/kg) dexamethasone and prednisolone at 1mg/kg[10].
- Epinephrine (nebulized)
- Use in moderate to severe cases based on the croup scores. Use either Racemic or Standard Epinephrine[11]
- Symptomatic relief via local vasoconstriction
- Racemic Epi (2.25%): 0.05 mL per kg (maximal dose: 0.5 mL) of racemic epinephrine 2.25% [12]
- Epinephrine(1:1,000): 0.5 mL per kg (maximal dose: 5 mL) via nebulizer
- Onset up to 30 min, duration 2 hrs
- Watch child 2-3 hrs after administration to ensure no return of stridor at rest
- Intubation
- Rarely needed but if so, use tube that is one half size smaller than normal for age/size of patient
Contraindicated
- Do NOT give albuterol (may worsen edema (vasodilation))
No Evidence
- 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[13]
Disposition
Consider Discharge if
- 3hr since last epinephrine
- Able to tolerate PO
- Nontoxic appearance
Admit
- Persistent respiratory symptoms/signs
- ≥2 treatments with epinephrine
Video
{{#widget:YouTube|id=Z01e1bJ9p-g}}
See Also
External Links
References
- ↑ Rose, E. (2018) Pediatric respiratory emergencies: Upper airway obstruction and infections. Rosen's Emergency Medicine (9th ed.) Philadelphia, PA: Elsevier/Saunders
- ↑ Rose, E. (2018) Pediatric respiratory emergencies: Upper airway obstruction and infections. Rosen's Emergency Medicine (9th ed.) Philadelphia, PA: Elsevier/Saunders
- ↑ Rose, E. (2018) Pediatric respiratory emergencies: Upper airway obstruction and infections. Rosen's Emergency Medicine (9th ed.) Philadelphia, PA: Elsevier/Saunders
- ↑ 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: 0.15mg/kg versus 0.3mg/kg versus 0.6mg/kg. Pediatr Pulmonol. 1995;20(6):362–368.
- ↑ Bjornson, C.L., Klassen, T.P., Williamson, J., Brant, R., Mitton, C., Plint, A., Bulloch, B., Evered, L. and Johnson, D.W. (2004) ‘A Randomized trial of a single dose of oral dexamethasone for mild Croup’, New England Journal of Medicine, 351(13), pp. 1306–1313.
- ↑ 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.
- ↑ Prednisolone versus dexamethasone for croup: a randomized controlled trial Parker CM, Cooper MN. Pediatrics. 2019;144(3):e20183772.
- ↑ 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