Difference between revisions of "Croup"

(Differential Diagnosis)
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==Background==
 
==Background==
*Croup = laryngotracheobronchitis
+
*Also known as laryngotracheobronchitis
*Affects 6 mo-3 yr (peak in 2nd year)
+
*Typically affects ages 6 mo-3 yr (peak in 2nd year)
*Fall & winter
+
**Most common in fall & winter
 
*Etiology
 
*Etiology
 
**Parainfluenza (50%), [[Bronchiolitis (RSV)|RSV]], rhinovirus  
 
**Parainfluenza (50%), [[Bronchiolitis (RSV)|RSV]], rhinovirus  
***Consider [[Diphtheria]] if not immunized
+
**Consider [[Diphtheria]] if not immunized
 
*Spasmodic croup
 
*Spasmodic croup
 
**Sudden onset of barking cough/stridor
 
**Sudden onset of barking cough/stridor
Line 12: Line 12:
 
*Must rule-out foreign body
 
*Must rule-out foreign body
  
==Clinical Presentation==
+
==Clinical Features==
*1-2 day of URI followed by barking cough, stridor
+
*1-2 day of URI followed by barking cough and stridor
 
*Low-grade fever
 
*Low-grade fever
 
*NO drooling or dysphagia
 
*NO drooling or dysphagia
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==Differential Diagnosis==
 
==Differential Diagnosis==
 +
*[[Allergic reaction]]
 +
*[[Angioedema]]
 
*[[Asthma]]
 
*[[Asthma]]
 +
*[[Bacterial tracheitis]]
 +
*[[Congestive heart failure]]
 
*[[Croup]]
 
*[[Croup]]
*[[PNA]]
 
*[[Foreign body]]
 
*[[Pertusis]]
 
*[[CHF]]
 
 
*Cystic fibrosis
 
*Cystic fibrosis
*Vascular ring
 
*[[Retropharyngeal abscess]]
 
*Subglottic stenosis
 
*[[Angioedema]]
 
*[[Allergic reaction]]
 
*Tracheomalacia
 
*[[Bacterial tracheitis]]
 
 
*[[Diphtheria]]
 
*[[Diphtheria]]
 
*[[Epiglottitis]]
 
*[[Epiglottitis]]
 +
*[[Foreign body]]
 
*Inhalation injury
 
*Inhalation injury
 
*Laryngeal Fractures
 
*Laryngeal Fractures
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*[[Mononucleosis]] and Epstein-Barr Virus Infection
 
*[[Mononucleosis]] and Epstein-Barr Virus Infection
 
*[[Peritonsillar abscess]]
 
*[[Peritonsillar abscess]]
 +
*[[Pertusis]]
 +
*[[Pneumonia]]
 +
*[[Retropharyngeal abscess]]
 +
*Subglottic stenosis
 +
*Tracheomalacia
 +
*Vascular ring
  
 
==Diagnosis==
 
==Diagnosis==
 +
===Work-up===
 
*Consider CXR if concerned about alternative diagnosis
 
*Consider CXR if concerned about alternative diagnosis
 
**Steeple sign on AP (not Sp, not Sn)
 
**Steeple sign on AP (not Sp, not Sn)
*Consider nasal washings for [[RSV]], parainfluenza, [[influenza]].
+
*Consider nasal washings for [[RSV]], parainfluenza, [[influenza]] serologies.
  
==Treatment==
+
===Evaluation===
===Cool mist===
+
*Often a clinical diagnosis
*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===
+
==Management==
*First line treatment
+
*Cool mist
*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>
+
**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>
===Epinephrine (nebulized)===
+
*Steroids (first line treatment)
*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>
+
**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>
*'''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 (nebulized)
*'''Epinephrine (1:1,000)''': 0.5 mL per kg (maximal dose: 5 mL)  via nebulizer,
+
**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>
 +
**'''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,
  
 
*'''Do NOT''' give albuterol (may worsen edema (vasodilation))
 
*'''Do NOT''' give albuterol (may worsen edema (vasodilation))
  
''Intubation rarely needed but if so the use one half size smaller tube if intubating''
+
''Intubation rarely needed but if so, use tube that is one half size smaller than normal for age/size of pt''
  
 
==Disposition==
 
==Disposition==
===Consider Discharge===
+
*Consider Discharge if:
*3hr since last [[epinephrine]]
+
**3hr since last [[epinephrine]]
*Able to tolerate PO
+
**Able to tolerate PO
*Nontoxic appearance
+
**Nontoxic appearance
  
===Admit===
+
*Admit
*Persistent respiratory symptoms/signs
+
**Persistent respiratory symptoms/signs
*≥2 treatments with [[epinephrine]]
+
**≥2 treatments with [[epinephrine]]
  
 
==See Also==
 
==See Also==
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*[http://www.mdcalc.com/westley-croup-score/ MDCalc - Westley Croup Score]
 
*[http://www.mdcalc.com/westley-croup-score/ MDCalc - Westley Croup Score]
  
==Source==
+
==References==
 
<references/>
 
<references/>
 +
 
[[Category:Peds]]
 
[[Category:Peds]]
 
[[Category:ID]]
 
[[Category:ID]]

Revision as of 07:45, 18 August 2015

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

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)
    • Use in moderate to severe cases based on the croup scores. Use either Racemic or Standard Epinephrine[5]
    • Racemic Epi (2.25%): 0.05 mL per kg (maximal dose: 0.5 mL) of racemic epinephrine 2.25% [6]
    • 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, 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

Bronchiolitis (RSV)

External Links

References

  1. 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.
  2. Klassen TP, et al. Croup. A current perspective. Pediatr Clin North Am. 1999; 46(6):1167–1178.
  3. 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
  4. 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.
  5. 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
  6. 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