Domino_5-Minute Clinical Consult, 33e

Croup (Laryngotracheobronchitis)

First Line • Corticosteroids: Oral corticosteroids should be used in patients with any severity. They provide faster resolution and decrease hospital admission by decreasing laryngeal mucosa edema. – Dexamethasone is the preferred corticosteroid due to its easy single dosing and ability to give orally, intramascularly, and intravenously. It is also the least expensive steroids. Optimal dosage is unclear, but 0.6 mg/kg is the most commonly used range—maximum of 16 mg. – Other steroids (betamethasone, budesonide, prednisolone) are beneficial. In randomized trials comparing prednisolone to dexamethasone, the latter is more commonly used in the emergency department, but they have no difference in efficacy in the community. • Nebulized epinephrine; racemic or L-epinephrine (equal efficacy and side effect profiles); reserved for moderate-to-severe cases with stridor at rest – Racemic epinephrine is dosed at 0.05 mL/kg of 2.25% (max of 0.5 mL) solution nebulized in normal saline to total volume of 3 mL. – L-epinephrine is dosed at 0.5 mL/kg (max of 5 mL) of a 1:1,000 via nebulizer. Onset of action is within 1 to 5 minutes, and duration is of ap proximately 2 hours. Repeat as necessary as long as side effects are tolerated. Observe the child for 2 hours to ensure no recurrence after epinephrine wears off. • Antitussives and decongestants are not recommended. • Antibiotics when suspecting a primary or secondary bacterial infection • Oxygen as needed • Humidified air without clinical benefit in croup (2) SURGERY/OTHER PROCEDURES • Intubation is rarely required; tube 0.5 to 1.0 mm smaller than normal • Intubation may be required for fatigue due to work of breathing or obstruction. ADMISSION, INPATIENT, AND NURSING CONSIDERATIONS • Outpatient care for mild cases • In most cases, observation in the emergency room after medical management is sufficient. • Admission criteria: poor response to therapy or recurrent stridor at rest after epinephrine wears off, increased oxygen requirement, pneumonia, or other serious conditions • Discharge criteria – At least 2 hours since last epinephrine – Received dose of steroids – No stridor at rest, no difficulty breathing – Able to tolerate oral fluids – Normal air entry, color, and consciousness – Has home management and outpatient follow up established DIET • Cool, liquid diet is better tolerated. • Frequent small feedings PATIENT EDUCATION • Croup is usually a self-limited and mild disease, but some will need hospital care. • Avoid agitation, which may worsen symptoms; use antipyretics as needed. Keep hydrated with liquids, ice pops, etc. ONGOING CARE

• Emergency ambulance for cyanosis, lethargy, strug gling to breathe, drooling and unable to swallow • It is contagious in the first few days; good hand hygiene is very important. • The cough may linger for a few weeks. • Parents of patients with COVID-19–related croup should be counseled on quarantine guidelines. PROGNOSIS • Prognosis is usually good. The few cases that are severe respond to intensive respiratory management. • Recurrence is rare in viral-mediated disease. If croup recurs, consider an anatomic, allergic, or obstructive etiology. COMPLICATIONS • Subglottic stenosis in intubated patients • Bacterial tracheitis • Cardiopulmonary arrest • Pneumonia (2) REFERENCES 1. Hanna J, Brauer PR, Morse E, et al. Epidemiological analysis of croup in the emergency depart ment using two national datasets. Int J Pediatr Otorhinolaryngol . 2019;126:109641. 2. Smith DK, McDermott AJ, Sullivan JF. Croup: diagnosis and management. Am Fam Physician . 2018;97(9):575–580. 3. Venn AMR, Schmidt JM, Mullan PC. Pediatric croup with COVID-19. Am J Emerg Med . 2021;43:287.e1–287.e3. ADDITIONAL READING Quraishi H, Lee DJ. Recurrent croup. Pediatr Clin North Am . 2022;69(2):319–328.

• If imaging were to be done, posteroanterior and lateral neck films will show funnel-shaped subglottic region with normal epiglottis: “steeple” or “pencil point” sign (present in 40–60% of children with croup). – A steeple sign can be seen in patients without croup warranting other considerations. – Monitor all patients during imaging as airway obstruction may occur rapidly. • When suspecting an alternative diagnosis, the following findings can be appreciated: – Retropharyngeal abscess: bulging of posterior pharyngeal wall – Epiglottitis: thumb sign, which is a thickened epiglottis • Polymerase chain reaction testing from nasopharyn geal mucosa is used when SARS-CoV-2 is suspected as the cause of croup (3). Initial Tests (lab, imaging) Radiographic imaging is not routinely indicated. CT of the neck can be considered for patients with suspected abscess, tumor, or foreign body aspiration (2). Follow-Up Tests & Special Considerations Recurrent croup needs evaluation to check for other underlying predisposing conditions (e.g., asthma, gas troesophageal reflux, anatomical airway abnormalities). Diagnostic Procedures/Other Laryngoscopy should be reserved for atypical presen tations or when alternate diagnosis is suspected (2). Specifically, those that are hospitalized but not intubated or those with a history of intubation and , 36 months of age. TREATMENT • Treatment is supportive; severity of illness may dictate additional measurements. • Outpatient patients with severe croup or impending respiratory failure should be transported via ambu lance to the nearest hospital for management. • The limited experience with COVID-19 croup sug gests cases can present with severe pathology and may not improve as rapidly as with typical croup. GENERAL MEASURES • Symptomatic treatment • Minimize lab tests, imaging, and procedures that upset the child; agitation worsens tachypnea and can be detrimental. • Pulse oximetry and oxygen should be administered for hypoxemia or respiratory distress. • Frequent clinical checks may be more sensitive in identifying worsening disease. • Heliox is a helium and oxygen mixture used for respiratory conditions, and it improves airflow resis tance by decreasing gas density; data are limited on its benefits for croup (2)[B]. MEDICATION Treatment is based on Wesley Croup Severity Score: mild (0 to 2): give 1 dose of dexamethasone; moder ate to severe ( $ 3): give nebulized epinephrine in addition to dexamethasone.

C

CODES

ICD10 • J05.0 Acute obstructive laryngitis [croup] • J20.9 Acute bronchitis, unspecified • J38.5 Laryngeal spasm CLINICAL PEARLS

• Croup outbreaks are most common in fall and winter seasons in ages 6 months to 3 years. • Inspiratory stridor is the clinically evident and should raise suspicion of croup. • Symptoms often occur at night. • Clinical diagnosis, medical management, and stabilization of the patient take priority over lab testing or radiographic images. • Recurrence requires further evaluation. • Consider other diagnoses in acute presentations with a toxic appearance: epiglottitis, abscess, and bacterial tracheitis. • Be aware of severity if the child becomes less noisy; less air movement can be sign of respiratory failure. • Foundation of treatment is corticosteroid; supple mental oxygen as needed and epinephrine for moderate-to-severe cases

Copyright © 2025 Wolters Kluwer. Unauthorized reproduction of the article is prohibited.

227