Croup Review by MikeJenny


  A Review
 Kimberly A. Dovin, MD
Swedish Family Medicine
     April 27, 2004
          Objectives - Goals
• Diagnosis and Management of Croup
  – Review natural history of viral croup
  – Distinguish between and review evidence of
    various treatment options
• Determining need for outpatient vs inpatient
  – Develop a differential diagnosis
  – Review indications for hospitalization
                  Case #1
• T.T. is a 27mos male who comes in w/ his
  very worried mother.
  – Runny nose started 2 days ago
  – Temp 100.3 yesterday
  – Barking cough started this AM
  – Now making a horrible noise when he takes a
    deep breath in
  – Refuses to lie down
                Case # 1 Continued
• VS: 99.8F 120 22 O2 sat 96% when quiet
• Gen: alert, sitting in mother’s lap quietly when you enter,
  sees you and starts to cry  you note inspiratory stridor
• Ears: nl TMs
• Nose: rhinnorhea
• Mouth: no exudate, tonsils normal
• Neck: cervical LAD
• Chest: expiratory wheeze, inspiratory sounds obscured,
  subcostal retractions worsened w/ crying
• CV: RRR no murmur
• Ext: 2+ cap refill, wwp
• “A generic term”
• A heterogenous group of illnesses affecting
  the larynx, trachea, and bronchi
• Viral origin
• Characteristic cough, inspiratory stridor,
• Annual incidence: 6 cases per 100 children
  younger than 6yoa
• Affects children 6mos-12yoa, peak
  incidence at 2yoa
• Boys:Girls 1.5:1
• Fall and winter predominance
• Leading cause of hospitalization in children
  younger than 4yoa
• $56 million annually
         The Usual Suspects
• Viral: Parainfluenza, Influenza A & B,
  Adenovirus, RSV, rhinovirus, enteroviruses,
• Spasmodic: viral associated, possibly
  allergic reaction to antigens
               Clinical Course
• Symptoms                   • Signs
  – 12-72hr prodrome of        – Hx consistent w/ croup
    fever/coryza               – Normal pulse ox
  – Hoarseness                 – Low-grade fever
  – “Croupy”/barking cough
  – Stridor
  – Dyspnea/wheeze
               Differential Dx
• Epiglottitis             •   Vocal cord paralysis
• Bacterial tracheitis     •   Smoke inhalation
• Foreign body             •   Burns/Thermal injury
• Subglottic stenosis      •   Neoplasm
• Peritonisillar abscess
                           •   Laryngeal fracture
• Retropharyngeal
• Diptheria
• Laryngomalacia
• Plain neck XR: “Steeple sign”
• CT: supected other causes
• Larynogoscopy
•   Serial observation
•   Mist therapy
•   Steroids
•   Epinephrine
        Indications to Hospitalize
•   Actual/expected epiglottitis
•   Cyanosis
•   Depressed sensorium
•   Hypoxemia
•   Pallor
•   Progressive stridor
•   Resp distress
•   Restlessness
•   Toxic-appearing
Comparison of the Features of Epiglottitis and Croup
                     Epiglottitis                                              Croup
Age                  Can occur in infants, older                               Six months to six years
                     children, or adults
Onset                Sudden                                                    Gradual

Location             Supraglottic                                              Subglottic

Temp                 High fever                                                Low-grade fever

Dysphagia            Severe                                                    Mild or absent

Dyspnea              Present                                                   Present

Drooling             Present                                                   Present

Cough                Uncommon                                                  Chracteristic cough

Position             Sitting forward with mouth open                           Comfortable in different
Radiology            Positive thumb sign*                                      Positive steeple sign
Adapted with permission from DeSoto H. Epiglottitis and croup in airway obstruction in children. Anesthesiol Clin North Am 1998;16:855
          Management: Steroids 1
• 1970 – the debate begins!
• “With the battle won, what remains are
  largely minor skirmishes…”1
  – Nebulized vs oral vs IM
  – Inpatient vs outpatient
  – Dose
  1J.   Paton, Royal Hospital for Sick Children, Glasgow, Scotland
       Management: Steroids 2
• BMJ 1999, meta-analysis: Steroids improve sx
  within 6hrs for up to 12hrs
• Nebulized vs Oral: 1999 & 2004 RCTs,
  equivalent; 2002 oral significantly better.
• Oral vs IM: 2000 Randomized, uncontrolled,
• Dose: equivalent outcomes with 0.15/kg, 0.3/kg
  and 0.6/kg dexamethasone
       Management: Steroids 3
• Nebulized vs oral vs IM
   – For children with increased WOB
   – Might consider oral or IM over nebulized
• Inpatient vs Outpatient
   – Either – depends on VS/PE
• Dose
   – PO: 0.15mg/kg – lowest known effective dose of
   – IM: 0.15-0.6mg/kg IM
      Management: Epinephrine
•   For moderate to severe distress
•   5ml 1:1000 Nebulized racemic epinephrine
•   Decreased stridor/retractions in 30min
•   Duration 2 hrs
    – Rebound phenomenon
    – Observe 3-4hrs after administration
• Side effects: tachycardia, HTN
        Case #1 – Follow-up
• You decide to give T.T. a dose of
  dexamethasone in the clinic at 0.3mg/kg
• Advise mother to check in on him during
  the night and gave warning signs
• Suggest taking him out into the air or
  running a hot shower might help
                Case #1a
• T.T. returns to your clinic in 2 days. His
  mother says that the cough is tapering and
  he is sleeping better through the night.
  However, he has been tugging at his ear all
  day long and complaining of pain.
• PE: notable for a erythematous TM on left
  w/ decreased mobility and obscured
•   Otitis media
•   Bronchiolitis
•   Pnemonia (rare)
•   Bacterial tracheitis (rare)
Case #1a Follow-up

• Croup is a common viral illness in children
• Treatment options include
  – Steroids – good evidence to support
  – Epinephrine – years of experience and trials
    support its use
  – Mist – years of use/no data to support
• Evidence supports outpatient treatment in
  mild to moderate croup
•   Behrman, RE, Kliegman, RM, Jenson, HB Nelson Textbook of Pediatrics, 16th Ed.
    W.B. Saunders Co. 2000.
•   Cetinkaya F, Tufekei BS, Kutluk GT. A comparison of nebulized budesonide, and
    intramuscular, and oral dexamethasone for treatment of croup. Int J Pediatric
    Otorhinolaryngology 2004; 68(4): 453-6
•   Knutson, D, Aring, A. Viral Croup. American Family Physician 2004; 69:535-540.
•   Luria JW, Gonzalez-del-Rey JA DiGiulio GA, et al. Effectiveness of oral or nebulized
    dexamethasone for children with mild croup. Arch Pediatric and Adolescent
    Medicine 2001; 155: 1340-5.
•   Neto GM, Kentab O, Klassen TP, Osmond MH. A randomized controlled trial of
    mist in the acute treatment of moderate croup. Academy of Emergence Medicine
    2002; 9(9): 873-9.
•   Rittichier KK, Ledwith CA. Outpatient treatment of moderate croup with
    dexamethasone: intramuscular versus oral dosing. Pediatrics 2000; 106(6): 1344-8.

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