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 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 Read More