Course:PostgradFamilyPractice/ExamPrep/99 Priority Topics/Croup

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Croup - Key Features

1. In patients with croup:
a) Identify the need for respiratory assistance (e.g., assess ABCs, fatigue, somnolence, paradoxical breathing, in drawing)
b) Provide that assistance when indicated.

Respiratory compromise evaluation
- Appearance

o Hypoxia: restless or anxious
o somnolent
o Tone - decreased muscle tone, appear limp, weak.
o Interactiveness - does not respond to a caregiver or appropriately resist examination.
o Consolability
o Look/gaze - unresponsive stare suggests an altered mental status.
o Speech/cry - weak cry, a hoarse or muffled voice suggests upper airway obstruction
o Drooling, dysphagia –oropharyngeal or laryngotracheal obstruction.

- Breathing

o increased work of breathing
• Decreased work of breathing may indicate progression toward respiratory failure
o Airway sounds - stridor, snoring, grunting, wheezing
o Positioning - "sniffing position" , tripod position
o Accessory muscle use: supraclavicular, intercostal, and/or substernal groups
• Head bobbing (extension of the head on inhalation and forward movement on exhalation)
• nasal flaring
o Vitals

- Circulation

o Pallor or cyanosis
o Poor capillary refill or cool skin
o Pulsus paradoxus –an exaggeration (greater than 10 mmHg) of the normal decrease in blood pressure during inspiration
• correlates with degree of airway obstruction

- Complete upper airway obstruction: Needle cricothyrotomy
- Foreign body

o Maneuvers should only be used for patients who are unable to phonate
o Back blows/chest thrusts (<1 year of age)
o Abdominal thrusts (≥1 year of age)
o Manual removal with finger sweep
o Laryngoscopy

- Laryngospasm: Positive pressure with a ventilation bag and tight fitting mask
- Soft tissue upper airway obstruction

o Head tilt/chin lift
o Jaw thrust: for patients who may have cervical spine injury
o Nasopharyngeal airway: May be tolerated by a conscious patient
o Oropharyngeal airway: in an unconscious patient

- Respiratory failure

o Bag-mask ventilation
o Endotracheal intubation

- Tension pneumothorax

o Needle thoracentesis
o chest tube placement following emergent decompression

- Cardiac tamponade: Pericardiocentesis

2. Before attributing stridor to croup, consider other possible causes (e.g., anaphylaxis, foreign body (airway or esophagus), retropharyngeal abcess, epiglottitis).

Stridor DDx
- Congenital

o Nasal deformities: Choanal atresia or agenesis, septum deformities, turbinate hypertrophy, vestibular atresia or stenosis.
o Pharynx
• Craniofacial anomalies: Crouzon's, Pierre Robin, Apert's Syndrome.
• Tongue Macroglossia and glossoptosis
o Larynx
• Laryngomalacia: Most common chronic stridor
• Laryngeal webs
• Laryngeal cysts
• Subglottic hemangioma
• Subglottic stenosis
o Trachea
• Tracheal stenosis
• Tracheomalacia

- Bacterial tracheitis

o 6 mo to 8 yo
o S. aureus, Strep pyogenes, S. pneumonia, H. influenzae
o Initially similar to croup (hoarseness, barking cough, stridor)
o High fever, toxic, poor response to epinephrine
o IV antibiotics
o Intubation

- Epiglottitis

o Hemophilus influenza (rare since vaccination)
o 1-8 year old
o High fever, no barky cough, dysphagia, drooling, anxious appearance, sitting forward in sniffing position
o Secure airway

- Laryngeal diphtheria

o Any age
o Gradual onset (2-3 days)
o Hoarseness, barking cough, dysphagia, fever
o Grayish-brown membrane on tonsils
o Inquire about vaccination

- Retropharyngeal abscess

o < 6 yo
o May be preceded by trauma, FB aspiration, URI
o Sore throat, dysphagia, drooling
o Neck pain, stiffness

- Foreign body

3. In any patient presenting with respiratory symptoms, look specifically for the signs and symptoms that differentiate upper from lower respiratory disease (e.g., stridor vs. wheeze vs. whoop).


- Caused by the oscillation of a narrowed airway
- Suggests significant obstruction of large airways
- Stridor from extrathoracic area is more pronounced during inspiration
- Stridor caused by obstruction at the glottis (vocal cords) may occur during inspiration only, or during both inspiration and expiration
- Originates in the intrathoracic airways more pronounced on exhalation


- Occur during inspiration or expiration
- Can originate from airways of any size
- Stridor refers to a monophonic wheeze that is loudest over the central airways

4. In a child presenting with a clear history and physical examination compatible with mild to moderate croup, make the clinical diagnosis without further testing (e.g., do not routinely X-ray).

- Aka laryngotracheobronchitis
- Parainfluenza
- Most commonly 6 mo to 3 years
- Autumn/winter months generally
- Abrupt onset of barmy cough
- Inspiratory stridor, hoarseness, respiratory distress
- Severity

o Mild: occasional barky cough, no stridor at rest, no to mild suprasternal/intercostal indrawing
o Moderate: frequent barky cough, stridor, suprasternal/sternal wall retraction at rest, no or little distress or agitation
o Severe: occasional expiratory stridor, marked sternal wall retractions, significant distress and agitation
o Impending respiratory failure: lethargy, or decr LOC, dusky appearance on RA

- With or without antecedent upper respiratory symptoms of cough, rhinorrhea and fever
- Symptoms occur in evening
- Seal like barmy cough
- Inspiratory stridor
- Hoarseness
- No to moderate fever
- Symptoms fluctuate worse when child agitated
- Majority symptoms resolve within 48 hrs
- Resolution of croup symptoms, children may have typical URTI like symptoms

- Febrile, tachy, tachypnea
- O2 sats in severe cases
- Seal like barmy cough
- Hoarse voice
- Stridor (mostly inspiratory)
- Intercostal retractions
- No drooling
- Nontoxic
- Impending respiratory failure

o Change in mental status
o Pallor
o Dusky
o Decreased retractions
o Decreased breath sounds, decreasing stridor

5. In patients with a diagnosis of croup, use steroids (do not under treat mild-to-moderate cases of croup)

- Comfortable
- Do not agitate
- Oxygen if respiratory distress/hypoxia (<92%)

o Blow by : hose with end open held near nose/mouth

- Epinephrine

o Severe respiratory distress (sternal wall indrawing and agitation)
• Improvement occurs within minutes
• Wears off after 1 hr
o Racemic 0.5mL of 2.25% soln diluted into 3mL of NS or sterile H2O via nebulizer
o L Epinephrine 1:1000 sol’n via nebulizer
o May be repeated as necessary

- Dexamethasone

o For all children, regardless of severity
o Improvement after 2-3 hrs
o Persist 24-48 hrs
o Single dose - No evidence to support multiple doses
o 0.6 mg/kg po/IM
o Po is well absorbed, reaches peak serum levels as rapidly as IM
• Both equivalent results
o Reduces
• Rate/duration of intubation
• Rate/duration of hospitalization
• Rate of return to medical care
• Duration of symptoms in children with mild, moderate, severe symptoms

- Admission

o Respiratory compromise after >4 hrs with corticosteroids
o Relative
• Patient living long distance away or inadequate transportation
• Inadequate observation or f/u
• Significant parental anxiety
• Recurrent ED visits within 24 hrs

- Discharge from ED

o Mild symptoms
o 2 hrs after epinephrine

6. In a patient presenting with croup, address parental concerns (e.g., not minimizing the symptoms and their impact on the parents), acknowledging fluctuating course of the disease, providing a plan anticipating recurrence of the symptoms.

- Symptoms worse at night
- Discharge instructions

o Provide humidified air, Steamed bathroom environment
o Avoid irritants (Smoke)
o Return if signs of Respiratory distress
o Symptoms lasts 3-5 days, up to 10 days

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