Difference between revisions of "Croup"

(Background)
(Treatment)
Line 54: Line 54:
  
 
==Treatment==
 
==Treatment==
#Cool mist
+
===Cool mist===
#Steroids
+
*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>
##Give to all pts with croup
+
===Steroids===
###Dexamethasone 0.15-0.6mg/kg PO/IM (max 10mg)
+
*First line treatment
#Epinephrine (nebulized)
+
*Dexamethasone 0.15-0.6mg/kg PO/IM (max 10mg)<ref>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.</ref>
##Give for moderate-severe cases
+
===Epinephrine (nebulized)===
##Racemic epinephrine decreases the need for intubation, and should be tried before intubation.
+
*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>
#Do NOT give albuterol (may worsen edema (vasodilation))
+
*'''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>
#Intubation rarely needed
+
*'''Epinephrine (1:1,000)''': 0.5 mL per kg (maximal dose: 5 mL)  via nebulizer,
##Use one half size smaller tube if intubating
+
 
 +
*'''Do NOT''' give albuterol (may worsen edema (vasodilation))
 +
 
 +
''Intubation rarely needed but if so the use one half size smaller tube if intubating''
  
 
==Disposition==
 
==Disposition==

Revision as of 14:47, 1 December 2014

Background

  • Croup = laryngotracheobronchitis
  • Affects 6 mo-3 yr (peak in 2nd year)
  • Fall & winter
  • Etiology
    • 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

Diagnosis

  1. 1-2 day of URI followed by barking cough, stridor
  2. Low-grade fever
  3. NO drooling or dysphagia
  4. Duration = 3-7d, most severe on days 3-4

Croup Score

  • Inspiratory stridor
    • None (0 points)
    • When agitated (1 points)
    • On/off at rest (2 points)
    • Continuous at rest (3 points)
  • Retractions
    • None (0 points)
    • Mild (1 points)
    • Moderate (2 points)
    • Severe (3 points)
  • Air entry
    • Normal (0 points)
    • Decreased (1 points)
    • Moderately decreased (2 points)
    • Severely decreased (3 points)
  • Cyanosis
    • None (0 points)
    • When crying (2 points)
    • At rest (3 points)
  • Alertness
    • Alert (0 points)
    • Restless, anxious (2 points)
    • Depressed (3 points)

Assessment

  • <2 Very mild
  • 2-9 Mild to moderately severe
  • >9 Severe croup

Work-Up

  1. Consider CXR if concerned about alternative dx
    1. Steeple sign on AP (not Sp, not Sn)
  2. Consider nasal washings for RSV, parainfluenza, influenza.

Treatment

Cool mist

  • May provide symptomatic treatment for patients with ongoing stridor[1]

Steroids

  • First line treatment
  • Dexamethasone 0.15-0.6mg/kg PO/IM (max 10mg)[2]

Epinephrine (nebulized)

  • Use in moderate to severe cases based on the croup scores. Use either Racemic or Standard Epinephrine[3]
  • Racemic Epi (2.25%): 0.05 mL per kg (maximal dose: 0.5 mL) of racemic epinephrine 2.25% [4]
  • 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

  1. Consider discharge if:
    1. 3hr since last epinephrine
    2. Able to tolerate PO
    3. Nontoxic appearance
  2. Admit:
    1. Persistent respiratory sx/signs
    2. ≥2 tx with epinephrine

External Links

See Also

Bronchiolitis (RSV)

Source

  • Tintinalli
  • Rosen
  • 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