Croup

Revision as of 04:15, 6 May 2015 by Rossdonaldson1 (talk | contribs) (Disposition)

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

Clinical Presentation

Helps to stratify patients into mild moderate and severe and guide treatment

Westley Croup Score[1][2]

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

Diagnosis

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

Treatment

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 the use one half size smaller tube if intubating

Disposition

Consider Discharge

  • 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

Source

  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