May 20, 2019

Episode 163.0 – Croup

6 minutes

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

Download

One Comment

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

There is limited evidence to support the role of heliox in croup,

NB: Pt may require higher levels of oxygen than the 20-30% mixture may provide

Intubation

Anticipate edema narrowing the airway

Consider starting with a tube that is 0.5 to 1 mm smaller than size typically used

Disposition:

Patients without stridor at rest or respiratory distress can be generally discharged from the ED

If epinephrine is given, patients should be monitored for 2-4 hours for reemergence of symptoms as the medication wears off

Take Home Points

Croup usually affects children within the age range of 6 months to 36 months with the most common cause being parainfluenza virus

Given the symptom overlap, we must consider more concerning diagnoses, including bacterial tracheitis, in these patients, especially if they are ill appearing or traditional therapies are ineffective

All patients benefit from a one-time dose of dexamethasone and, if racemic epinephrine is given, the patient should be observed for at least 3 hours

If intubation is required, anticipate a narrowed airway

Parent Article: https://coreem.net/core/croup/ by Dr. Pankow

...more

View all episodes

By Core EM

4.5

237237 ratings