Croup

ALERTS

• Epiglotitis
• Bacterial tracheitis
• Peritonsilar/Retropharyngeal abscess
• Foreign body
• Anaphylaxis/allergic reaction
• Upper airway injury
• Congenital anomalies

AGE OR PREGNANCY CONSIDERATIONS

• ≤ 4years = Typical presentation
• Chronic croup can remain in older children

DIFFERENTIAL DIAGNOSIS

• Epiglotitis
• Peritonsilar/Retropharyngeal abscess
• Laryngomalacia
• Foreign body
• Anaphylaxis/allergic reaction
• Upper airway injury

EVALUATION

HISTORY

• Onset and timing of cough, presence of stridor and hoarseness, level of distressed breathing, presence of drooling, alleviating factors, associated symptoms (fever, congestion, coryza).
• Progression of symptoms since onset
• Nocturnal worsening of symptoms
• History of croup
• History of wheezing/RAD/Asthma
• History of congenital airway anomalies
• Irritability, poor feeding/hydration – Infants/young children
• Recent exposures – daycare

PHYSICAL EXAM

• HEENT – Uvula position, peritonsilar/retropharyngeal space
• Respiratory – RR, O2 saturation
• Cardiovascular – HR, hydration, perfusion
• Neuro – mental status, irritability

Diagnostic findings

• HEENT – congestion, coryza
• Respiratory – tachypnea, hypoxia if severe
• CV – tachycardia, decreased perfusion
• Neuro – fussiness

Concerning Findings

• Stridor at rest
• Drooling
• Anxious appearance/distress

DIAGNOSTIC TESTS & INTERPRETATION

Lab Tests

• RSV
• Influenza
• Parainfluenza

Imaging

• AP/Lateral neck films – “steeple sign”
• Neck CT – if concern for abscess
• Additional Chest films – if concern for foreign body

Diagnostic Testing

• N/A

MANAGEMENT

TRANSFER/ADMISSION CONSIDERATIONS

• Severe distress/anxious appearance
• Toxic appearance
• Persistent hypoxia
• Airway foreign body

CROUP

TREATMENT

First Line

• • Dexamethasone PO/IM
  • Nebulized Racemic Epinephrine
    • Must monitor and reassess 2 hours after administration for rebound edema

Second Line

• • • Prednisone

Supportive

• • • Humidified air/Cool air (saline neb, steamy shower, outside air)
    • Fever relief

Complementary & Alternative Therapies

FOLLOW UP

Outpatient Referral

• • • PCP in 24 hours
    • ENT if chronic severity

Written instructions should include:

Anticipatory Guidance

• • • Importance of increased fluids
    • Use of humidified air/cool air

Activity, Diet

• • • Activity as tolerated
    • Increase fluids

Signs and Symptoms to return

• • • Drooling
    • Stridor at rest
    • Wheezing/respiratory distress
    • Persistent fever
    • Lethargy

PROGNOSIS, COMPLICATIONS

• • • Self-limited illness
    • Typically responds well to steroids
    • Can progress to respiratory emergency in severe cases
    • Can exacerbate asthma in predisposed patients

PERITONSILLAR/RETROPHARYNGEAL ABSCESS

TREATMENT

First Line

• • • Ampicillin-sulbactam or Clindamycin IV
    • Followed by Augmentin or Clindamycin PO

Second Line

• • • Vancomycin IV – if suspected MRSA in setting of prominant Clindamycin resistance
    • Followed by Linezolid or Bactrim

Supportive

• • • Fever and/or pain relief
    • Push fluids/IV hydration

Surgery / Other Procedures

• • • Incision & Drainage or Needle Aspiration

FOLLOW UP

Outpatient Referral

• • • PCP in 24 hours
    • ENT if recurrent or if complications

Written instructions should include:
Anticipatory Guidance

• • • Importance of increased fluids
    • Fever and pain relief

Activity, Diet

• • • Activity as tolerated
    • Increase fluids

Signs and Symptoms to return

• • • Drooling
    • Persistent fever on antibiotics
    • Lethargy
    • Decreased urine output

PROGNOSIS, COMPLICATIONS

• • • Typically responds well to I&D/aspiration and antibiotics
    • Can progress to bacteremia
    • Risk of dehydration

REFERENCES

Fleisher G, Ludwig S. (Eds.). Textbook of Pediatric Emergency Medicine. 6th ed. Philadelphia, PA: Lippincott, 2010.

Hay, W., Levin, M., Deterding, R., Abzug, M. (Eds.). Current Diagnosis & Treatment – Pediatrics. 22nd ed. New York: McGraw Hill, 2014.

Engorn, B. & Flerlage, J. (Eds.). (20th ed., 2015). The Harriet Lane Handbook. Philadelphia: Saunders.

Textbook of Pediatrics. 19th ed. Philadelphia, PA: Saunders Elsevier, 2011.

Wald, E (2014). Peritonsillar cellulitis and abscess. Retrieved February 10, 2015 from Up To Date.

SEE ALSO (TOPIC, ALGORITHM, ELECTRONIC MEDIA ELEMENT)

CODES

ICD9

PUBLISHER WILL ENTER

Snomed

PUBLISHER WILL ENTER

CME/REVIEW QUESTIONS

• 1. Name 2 potentially emergent differential diagnoses to consider when making the diagnosis of croup.
  2. What are the monitoring and reassessment requirements with the use of nebulized epinephrine for the acute management of severe croup?
  3. Give one criteria for transfer or admission when treating croup.