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Not all that barks is

             Craig Dobson, MD
              CPT, MC, USAR
             NCC Pediatrics
Croup- term used to describe the
clinical picture of laryngotracheitis.
 Hoarse voice
 Barking cough

 Inspiratory stridor

 Possible respiratory distress
Peak fall & winter.
Range primarily 1-6 years
Incidence 5/100 of children between
age 1-2 years
Males > females
Parainfluenza, types 1,2,3
   Contribute 65% of cases.
Influenza A & B
Rarely mycoplasma.
Subglottic narrowing due to
Cricoid ring allows fixed area for
1mm swelling causes 65% obstruction
in infant.
Atelectasis/mucus plugging
Ventilation/perfusion mismatch
Negative intrapleural pressure may lead
to varying degrees of pulmonary
 Air hunger
 Anxiety/Lethargy/Obtundation.
      Clinical history
Parents usually report viral URI
symptoms 12-48hrs prior to cough.
Fever, “Barking cough,”Stridor
Typical course 3-5 days.
              Worry if

 Drooling
 Dyphagia

 Toxic appearance

 Stridor without cough or without fever

 Incomplete immunizations
    Badness mimicking
 Dysphagia
 Odynophagia

 Drooling

 Tripoding/sword-swallowing
      Pt resists lying on back
      Prefers leaning forward

   Stat to OR for evaluation/intubation
    Badness Mimicking
                Croup, cont.
Bacterial tracheitis
   More common in order children to teens
   Staph aureus/Diphtheria
   Fever/ resp distress/Dysphagia/Odynophagia
   Worsening over hours
   Difficult to distinguish from epiglottis
   Doesn‟t matter, management is same:
        OR intubation
        Abx, worry more about Staph coverage if child is older.
    Badness Mimicking
        Croup, cont.
Bacterial superinfection of Croup
 Symptoms 5-7 days
 Worsening quickly over hours

 Increasingly high fevers

 Toxic appearance
    Badness Mimicking
         Croup, cont.
Retropharyngeal/peritonsilar abscess
 Fever
 Odynophagia

 Prodrome of sore throat

 Often swollen, tender ant. cerv. Nodes.

 Resistence to neck movement
    Badness Mimicking
           Croup, cont.
Foreign body
 Afebrile
 Toddlers most at risk

 Often no history of aspiration

   History/physical exam.
    Badness Mimicking
         Croup, cont.
Angioneurotic edema
 Recurrent
 Lip swelling

Spasmotic croup (well, not really
 Recurrent
 Nighttime
     Laboratory tests
No value….. „nough said.

Agitation for sticking child for ABG will
worsen child‟s symptoms.
You still need IV access, though, sorry.
Radiographic findings
Steeple sign
Lateral neck films if unsure of ruling out
retropharyngeal abscess
Fluouroscopy if still unsure
Still this is a clinical diagnosis
If any airway worries, no radiographs
Example radiograph…
Management of Croup
Do I need an artificial airway!!!!
Cool mist
 No literature to support efficacy
 Multiple studies demonstrating that it may
  worsen situation
     Bronchospasm
     Hypothermia in young infants

     Tent obscures close observation of pt.
Mechanism- constricts arterioles to airway
thus reducing further edema.
Waiisman, et al. Prospective RCT comparing
L-epi and RE in treatment of
laryngotracheitis. Pediatrics. 1992.
   Demonstrated reduced croup score by 30min,
    lasts usually 2hrs.
   Dose 0.5cc of 2.25% racemic solution
   No difference found L- epi using 5cc of 1:1000
               Epi, cont.
Rebound phenomenon
 Bunk… It just wears off in 2hours usually.
 Multiple studies demonstrating safe to d/c
  pt from ER if:
     Steroids were given, too.
     No resting stridor 2-4 hrs after tx.
„Roid controversy…. getting clearer.
   Ausejo, M. Glucocorticoids for croup. Cochrane
    Database of Systemic Reviews Jan 2000.
   Repeated with identical results by Moyer in
    Pediatrics, March 2000.
        Metanalysis (N=2221 patients)
        Improved Croup score at 6 and 12 hrs, not 24 after
         dexamethasone or budesonide neb.
        Decr. need for epi nebs by 9%.
        Decr. Emergency Room stay (-11hrs).
        Decr. Hospital stay (-16hrs).
Corticosteroids, cont.
Kairys, et al. Steroid treatment of
laryngotracheitis. Pediatrics. 1989.
 First meta-analysis of randomized trials.
 Demonstrated reduction in intubation from
  1.27% (no steroids) to 0.17% steroids.
 No difference in inhaled budesonide versus
  IM dex.
 Corticosteroids, cont
Ritticher and Ledwith. Outpatient
treatment of moderate croup with
dexamethasone: Intramuscular versus
oral dosing. Pediatrics. 2000
 ER patients sent home.
 No statistical difference in later
 Power to detect at least 10% difference.
Corticosteroids, cont.
Klassen, et al. Nebulized budesonide
and oral dexamethasone treatment for
croup. JAMA. 1998
 Oral dexamethasone/Inhaled budesonide
 Both treatments

 No difference in groups

 Budesonide much more expensive.
A moment on dosage:
 Most studies 0.6mg/kg (IM or PO)
 Malhotra and Krilov. Viral Croup. PIR, 2001
       Lower doses of 0.15mg/kg and 0.3mg/kg
        shown to be equally effective.
Weber, JE. A randomized comparison
of Heliox and racemic epinephrine for
the treatment of moderate to severe
croup. Pediatrics. 2001
 N=29
 Similar improvement in both groups.

 No significant difference in croup score,
  oxygen sat, respiratory rate or heart rate.
      Where to now?
Still unanswered questions:
 Should you re-dose dexamethasone since
  the duration is pharmacologically is 48hrs,
  but benefit was only demonstrated though
 What about heliox and epi together?

 Should any patient with croup symptoms
  be given steroids?

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