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


Management
- 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).

Stridor

- 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


Wheeze

- 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).

Definition
- 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


History
- 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

Physical
- 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)

Treatment
- 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

Study Guide

Croup

Resources