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Croup, Emergency Medicine

Basics

Description

- Viral infection of the upper respiratory tract - Most commonly presents in children 6 mo-3 yr: - Laryngotracheitis/laryngotracheobronchitis - Inspiratory stridor owing to extrathoracic airway obstruction - Expiratory wheeze suggests lower airway involvement. - Inflammatory edema of subglottic region - Narrowest part of pediatric airway

- Retractions: - 0 = None - 1 = Mild - 2 = Moderate - 3 = Severe

- Air entry: - 0 = Normal - 1 = Decreased - 2 = Severely decreased

  • Viral infection of the upper respiratory tract
  • Most commonly presents in children 6 mo-3 yr:Laryngotracheitis/laryngotracheobronchitisInspiratory stridor owing to extrathoracic airway obstructionExpiratory wheeze suggests lower airway involvement.Inflammatory edema of subglottic regionNarrowest part of pediatric airway
  • May progress to respiratory failure

Etiology

  • Parainfluenza types 1, 2, and 3
  • Human coronavirus NL63
  • Influenza A and B
  • Adenoviruses
  • Respiratory syncytial virus
  • Measles
  • Mycoplasma pneumoniae
  • Herpes simplex

Diagnosis

Signs and Symptoms

History

  • Nonspecific upper respiratory prodrome with or without fever
  • Duration of illness
  • History of tracheal intubation
  • Possibility of foreign body aspiration
  • Previous episodes
  • History of wheeze
  • Immunization status (Haemophilus influenzae type b [HIB]; diphtheria, pertussis, and tetanus [DPT]), influenza

Physical Exam

  • Rarely toxic appearing
  • Cyanosis (not present in majority of patients. If present, suggests severe disease)
  • Prefer upright position
  • Quality of cry/voice
  • Drooling/trismus/limited neck extension
  • Mental status
  • Stridor at rest, increased work of breathing
  • Hydration status
  • Westley croup score (max. total points: 17):Stridor (inspiratory or biphasic):0 = None1 = Audible with stethoscope at rest2 = Audible without stethoscope at restRetractions:0 = None1 = Mild2 = Moderate3 = SevereAir entry:0 = Normal1 = Decreased2 = Severely decreasedCyanosis:0 = None4 = With agitation5 = At restLevel of consciousness:

Diagnosis Tests & Interpretation

Lab

  • Continuous pulse oximetry
  • Other tests are not routinely indicated.

Imaging

Anteroposterior (AP) and lateral neck radiographs: пїЅ

  • Steeple sign indicates narrowing of subglottic trachea.
  • Imaging not routinely indicated, unless atypical presentation or clinical course
  • Subject to misinterpretation and should not be used as sole means to exclude epiglottitis
  • Should not delay definitive visualization and intubation in OR in child with concern for epiglottitis or bacterial tracheitis
  • Monitor child during imaging, if done.

Differential Diagnosis

  • Infection:Bacterial tracheitisRetropharyngeal or parapharyngeal abscessEpiglottitisPeritonsillar abscessDiphtheria
  • Foreign body (airway or esophageal)
  • Angioedema
  • Congenital airway anomaly:Laryngomalacia, tracheomalacia, laryngeal cleft
  • Acquired subglottic stenosis
  • Vocal cord paralysis
  • Thermal or chemical injury to upper airway
  • Hemangioma
  • Laryngeal papillomatosis
  • Vocal cord dysfunction (VCD) (adolescents)

Treatment

Pre-Hospital

  • Allow child to maintain position of comfort.
  • Defer interventions that may distress child such as:
  • If severe distress:Immediate nebulized epinephrine

Initial Stabilization/Therapy

  • Nebulized racemic epinephrine or l-epinephrine if distress or stridor at rest:l-epinephrine containing only the active isomer; has been shown to be therapeutically equivalent to racemic epinephrine
  • Oxygen (via blow-by) for suspected or documented hypoxia suggesting severe disease
  • Mist therapy often used, but no evidence for efficacy
  • Dexamethasone:Reduces need for intubation, shortens length of stay, and reduces admissions and return visits and may have effects within 30 minEffective even in mild croup (Westley croup score ≤2)
  • If poor response to nebulized racemic epinephrine or l-epinephrine:Consider trial of heliox:Heliox, when available, has been used to decrease the work of breathing in patients with an incomplete response to epinephrine.
  • If impending or existing respiratory failure despite aforementioned therapy:Tracheal intubation by most experienced person availableUse uncuffed endotracheal tube (ETT) 0.5-1 mm smaller than usual size.
  • If epiglottitis or foreign body suspected:Ideally, to OR for inhalational anesthesia, direct laryngoscopy, and intubationSurgeon standing by for emergent tracheostomy

Ed Treatment/Procedures

See "Initial Stabilization."пїЅ пїЅ

Medication

  • Racemic epinephrine 2.25%: 0.25-0.5 mL nebulized in 2.5 mL NS
  • l-epinephrine 1:1,000: 5 mL (5 mg) nebulized
  • Dexamethasone: Single dose of 0.6 mg/kg (max. 10 mg) PO (use crushed tablet) or IV preparation (4 mg/mL) PO with flavored syrup. Equally effective when given PO, IV, or IM. Lower doses may be effective.
  • Heliox (70% helium: 30% oxygen mixture administered via face mask or tent house)
  • Antibiotics: Not indicated

Follow-Up

Disposition

Admission Criteria

  • Young infants, pre-existing upper airway obstruction
  • Persistent or recurrent stridor at rest unresponsive to nebulized epinephrine, or recurring during 2-3 hr observation
  • Pediatric intensive care unit:Persistent severe obstructionNeed for frequent epinephrine treatments and/or helioxTracheal intubation with assisted ventilation

Discharge Criteria

  • Normal oxygenation in room air
  • No stridor at rest after brief observation
  • Children initially given epinephrine who no longer have stridor at rest should be observed for a min. of 2-3 hr
  • Reliable caretaker, communication, and transport

Issues for Referral

  • Concern for underlying anatomic abnormality (young age, history of intubation, frequent recurrence)
  • Infants <1 year with stridor unassociated with laryngotracheobronchitis may require endoscopic evaluation

Follow-Up Recommendations

  • Most children with croup do not require specific follow-up.
  • Patients who have had prolonged stridor, or acute worsening of stridor should seek care with their primary care physician or return to the ED.

Pearls and Pitfalls

  • Beware young infants with stridor
  • High incidence of congenital abnormalities
  • Mild and early epiglottitis or bacterial tracheitis may mimic croup

Additional Reading

  • Bjornson пїЅC, Russell пїЅKF, Vandermeer пїЅB, et al. Nebulized epinephrine for croup in children. Cochrane Database Syst Rev. 2011;16(2):CD006619.
  • Cherry пїЅJD. Clinical practice. Croup. NEJM. 2008;358:384-391.
  • Cooper пїЅT, Kuruvilla пїЅG, Persad пїЅR, et al. Atypical croup: Association with airway lesions, atopy, and esophagitis. Otolaryngol Head Neck Surg. 2012;147(2):209-214.
  • Dobrovoljac пїЅM, Geelhoed пїЅGC. How fast does oral dexamethasone work in mild to moderately severe croup? A randomized double-blinded clinical trial. Emerg Med Australas. 2012;24(1):79-85.
  • Russell пїЅKF, Liang пїЅY, O'Gorman пїЅK, et. al. Glucocorticoids for croup. Cochrane Database Syst Rev. 2011;19(1):CD001955.
  • Scolnik пїЅD, Coates пїЅAL, Stephens пїЅD. Controlled delivery of high vs. low humidity vs. mist therapy for croup in emergency departments. JAMA. 2006;295:1274-1280.
  • Sung пїЅJY, Lee пїЅHJ, Eun пїЅBW, et. al. Role of human coronavirus NL63 in hospitalized children with croup. Pediatr Infect Dis J. 2010;29(9):822-826.
  • Zoumalan пїЅR, Maddalozzo пїЅJ, Holinger пїЅLD. Etiology of Stridor in infants. Ann Otolaryng, Rhinology, Laryngology. 2007;116(5):329-334.

See Also (Topic, Algorithm, Electronic Media Element)

Epiglottitis пїЅ

Codes

ICD9

  • 464.4 Croup
  • 464.20 Acute laryngotracheitis without mention of obstruction

ICD10

  • J04.2 Acute laryngotracheitis
  • J05.0 Acute obstructive laryngitis [croup]

SNOMED

  • 71186008 Croup (disorder)
  • 275495004 Acute fibrinous laryngotracheobronchitis (disorder)
  • 232430006 Recurrent allergic croup (disorder)