Difference between revisions of "Croup"

(Management)
(Text replacement - "3 mg" to "3mg")
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#*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>
 
#*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)
 
#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: 0.15 mg/kg versus 0.3 mg/kg versus 0.6 mg/kg. Pediatr Pulmonol. 1995;20(6):362–368.</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 0.3mg/kg versus 0.6 mg/kg. Pediatr Pulmonol. 1995;20(6):362–368.</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>
 
#*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
 
#*Onset 6 hrs, duration 72 hrs

Revision as of 08:46, 19 July 2016

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

Pediatric stridor

<6mo

  • Laryngotracheomalacia
    • Accounts for 60%
    • Usually exacerbated by viral URI
    • Dx w/ flexible fiberoptic laryngoscopy
  • Vocal cord paralysis
    • Stridor associated w/ feeding problems, hoarse voice, weak and/or changing cry
    • May have cyanosis or apnea if bilateral (less common)
  • Subglottic stenosis
    • Congenital vs 2/2 prolonged intubation in premies
  • Airway hemangioma
    • Usually regresses by age 5
    • Associated w/ skin hemangiomas in beard distribution
  • Vascular ring/sling

>6mo

  • 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
  • Bacterial tracheitis
    • Rare but causes life-threatening obstruction
    • Sx 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

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

  1. Cool mist
    • May provide symptomatic treatment for patients with ongoing stridor[3]
  2. Steroids (first line treatment)
    • Dexamethasone 0.15-0.6mg/kg PO/IM (max 10mg)[4]
    • No differences between intramuscular and oral dexamethasone [5]
    • Onset 6 hrs, duration 72 hrs
  3. Epinephrine (nebulized)
    • Use in moderate to severe cases based on the croup scores. Use either Racemic or Standard Epinephrine[6]
    • Symptomatic relief via local vasoconstriction
    • Racemic Epi (2.25%): 0.05 mL per kg (maximal dose: 0.5 mL) of racemic epinephrine 2.25% [7]
    • 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
  4. 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[8]
  5. 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))

Disposition

  • Consider Discharge if:
    • 3hr since last epinephrine
    • Able to tolerate PO
    • Nontoxic appearance
  • Admit
    • Persistent respiratory symptoms/signs
    • ≥2 treatments with epinephrine

Video

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 0.3mg/kg versus 0.6 mg/kg. Pediatr Pulmonol. 1995;20(6):362–368.
  5. 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.
  6. 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
  7. 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
  8. Moraa I, Sturman N, McGuire T, van Driel ML., Heliox for croup in children., Cochrane Database Syst Rev. 2013 Dec 7;12:CD00682