Episode 163.0 – Croup

A look at one of the most common and potentially concerning upper respiratory infections in children.

Host:

Brian Gilberti, MD

https://media.blubrry.com/coreem/content.blubrry.com/coreem/Croup.mp3

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Tags: Airway, Infectious Diseases, Pediatrics

Show Notes

Background

* Croup is a viral infection starts in the nasal and pharyngeal mucosa but spreads to the larynx and trachea

* Subglottic narrowing from inflammation

* Dynamic obstruction

* Barking cough

* Inspiratory stridor

* Causes:

* Parainfluenza virus (most common)

* Rhinovirus

* Enterovirus

* RSV

* Rarely: Influenza, Measles

* Age range: 6 months to 36 months

* Seasonal component with high prevalence in fall and early winter

* Differential

* Bacterial tracheitis

* Acute epiglottitis

* Inhaled FB

* Retropharyngeal abscess

* Anaphylaxis

Presentation & Diagnosis

* Classically a prodrome of nonspecific symptoms for 1-3 days with low grade fevers, congestion, runny nose.

* Symptoms reach peak severity on the 4th day

* “Steeple sign” on Xray (subglottic narrowing) present in only 50% of patients with croup

* Assess air entry, skin color, level of consciousness, for tachypnea, if there are retractions / nasal flaring (if present at rest or with agitation) & coughing

* “Westley Croup Score” (https://www.mdcalc.com/westley-croup-score)

* Chest wall retractions

* Stridor

* Cyanosis

* Level of consciousness

* Air entry

Management

* Mild Croup

* Occasional barking cough, but no stridor at rest and mild to no retractions

* Tx: Single dose of dex

* Has been shown to improve severity and duration of symptoms

* Route is not particularly important, whether it’s PO, IV or IM

* Chosen route should aim to minimize agitation in the patient that might worsen their condition

* May be managed at with supportive care

* Humidifiers (NB: there isn’t good evidence supporting the use of humidifiers)

* Antipyretics

* PO fluids

* Moderate Group

* May have stridor at rest, mild-moderate retractions but no AMS and will not be in distress.

* Tx: Dex + Racemic Epinephrine

* Racemic epinpehrine will start to work in about 10 minutes

* Effects last for more than an hour

* Severe group

* Receives the same initial therapy as the moderate group with dex and race epi

* Pts with worrisome signs: stridor at rest, marked retraction, cyanosis and/or lethargy

* Heliox (a combinations of 70-80% helium + 20-30% oxygen) may be attempted...