Croup

1. In patients with croup,
   1. Identify the need for respiratory assistance (e.g., assess ABCs, fatigue, somnolence, paradoxical breathing, in drawing)
   2. Provide that assistance when indicated.
2. Before attributing stridor to croup, consider other possible causes (e.g., anaphylaxis, foreign body (airway or esophagus), retropharyngeal abcess, epiglottitis).
3. In any patient presenting with respiratory symptoms, look specifically for the signs and symptoms that differentiate upper from lower respiratory disease (e.g., stridor vs. wheeze vs. whoop).
4. In a child presenting with a clear history and physical examination compatible with mild to moderate croup, make the clinical diagnosis without further testing (e.g., do not routinely X-ray).
5. In patients with a diagnosis of croup, use steroids (do not under treat mild-to-moderate cases of croup).
6. In a patient presenting with croup, address parental concerns (e.g., not minimizing the symptoms and their impact on the parents), acknowledging fluctuating course of the disease, providing a plan anticipating recurrence of the symptoms.

General Overview

• Affects 6mo-3yo
• Symptoms last 3-7 days
• Parainfluenza Type 1 and 3

Diagnosis

• Barky cough
• Stridor
• In-drawing suprasternal/intercostal
• Distress, agitation, lethargy
• Cyanosis

Differential Diagnosis

• Bacterial tracheitis - 1-3d of URTI symptoms before worsening stridor, dyspnea, high fever, toxic, poor response to nebulized epinephrine and steroids
  • Neck XR (lateral or AP) - Steeple sign as seen in Croup
  • Endoscopy to confirm diagnosis and remove pseudomembranous exudates
    • Airway, O2
    • IV antibiotics to cover S aureus, GAS, S pneumo, H influenzae, M catarrhalis (Ceftriaxone or Cefotaxime +/- MRSA coverage)
    • ICU
• Retro/parapharyngeal/peritonsillar abscess - High fever, neck pain, torticollis, drooling, respiratory distress, stridor
  • Neck XR (lateral) - bulging posterior pharynx (abnormal if >7mm at C2, >14mm at C6)
    • CT ideally
    • Intubation
    • Consider I&D
    • IV antibiotics
• Epiglottitis - Absence of barky cough, fever, drooling, toxic, sitting forward in "sniffing" position
  • Neck XR (lateral) - thumb sign
  • Direct laryngoscopy in OR
    • Intubation (ideally in OR)
    • IV corticosteroids
    • IV antibiotics (Ceftriaxone or Cefotaxime +/- MRSA coverage)
    • Supportive care, ICU
• Aspiration or ingestion of foreign body - Croup cough, choking episode, wheezy, hoarseness, biphasic stridor, decreased air entry
• Allergic reaction (anaphyaxis or angioneurotic eddema) - Rapid onset, wheezing, stridor, urticarial rash

Treatment

• Dexamethasone 0.6mg/kg PO or IM (max 10mg) x 1
  • Onset 2h, acts 24-48h
• If moderate-severe
  • Nebulized epinephrine over 15 minutes (Racemic 0.5mL or L-epinephrine 5mL of 1:1000)
    • Onset 10-30mins, acts up to 2h
      • Can discharge after observing up to 4h if given epinephrine and dexamethasone
• No evidence for Heliox (or helium-oxygen mixture), antibiotics, short-acting beta-2-agonist bronchodilators
• Usual return to care instructions
  • Fever persists x 48h, fluid intake/output inadequate, fatigue/lethargy, fearful symptoms (resp distress, unable to talk, drools), does not improve after 3-4d