Laboratory studies are seldom needed for diagnosis of croup. Viral cultures and rapid antigen testing have minimal impact on management and are not routinely recommended. Radiography and laryngoscopy should be reserved for patients in whom alternative diagnoses are suspected. Randomized controlled trials have demonstrated that a single dose of oral, intramuscular, or intravenous dexamethasone improves symptoms and reduces return visits and length of hospitalization in children with croup of any severity.
In patients with moderate to severe croup, the addition of nebulized epinephrine improves symptoms and reduces length of hospitalization. Croup is a common respiratory illness of the larynx, trachea, and bronchi that leads to inspiratory stridor and a barking cough. A community-based randomized trial of children with mild to moderate croup found no difference in symptom scores between a single dose of dexamethasone and three daily doses of prednisolone.
In patients with more than two croup episodes per year, clinically significant bronchoscopy findings are associated with risk factors such as prior intubation, age younger than three years, and prematurity. Although gastroesophageal reflux disease and asthma are highly prevalent in patients with recurrent croup, neither is associated with significant bronchoscopy findings. Enlarge Print. Diagnosis of croup is based on clinical findings of barking cough, stridor, and hoarseness. Diagnostic testing is typically not necessary.
Humidified air inhalation does not improve symptoms in patients with moderate croup. Croup is typically self-limited in immuno-competent children, occurring predominantly during the fall and winter.
It is more common in boys than in girls 1. Although the incidence of croup is highest between six months and three years of age, it can occur in children up to six years of age, or earlier than six months in atypical cases. In patients with recurrent croup more than two episodes per year , clinically significant bronchoscopy findings are associated with risk factors such as prior intubation, prematurity, and age younger than three years.
Outcomes are favorable; croup has a mortality rate of less than 0. Viral infection of the subglottic region and laryngeal mucosa causes inflammation and edema, which significantly decrease air movement and lead to respiratory distress and stridor.
Viral croup often presents similarly to an upper respiratory infection, with 12 to 72 hours of low-grade fever and coryza. Narrowing of the larynx leads to stridor, increased respiratory rate, respiratory retractions, and a barking cough. Symptoms may be exacerbated by emotional distress, are worse at night, and peak between 24 and 48 hours. Croup typically resolves spontaneously within 48 hours to one week; however, the abrupt onset and harsh cough can be concerning. Many patients will also have dyspnea and fever, 5 , 6 but the absence of fever should not reduce suspicion for croup.
Respiratory rate is often increased in patients with croup. Clinicians should use age-appropriate rates; for patients six months to three years of age, a normal rate is 20 to 30 breaths per minute.
Additionally, patients can present with tachycardia. If pulse oximetry is performed, low oxygen levels may be noted in patients with more severe cases.
Visual inspection can reveal clues to the severity of illness. Retractions and nasal flaring may indicate more severe cases. Although cyanosis is absent in most patients with croup, its presence suggests severe disease. The most common auscultatory finding is overt inspiratory stridor in the neck. If wheezing is present, it is typically mild; substantial wheezing should prompt evaluation for alternate diagnoses. Rhonchi may be present but are not typical. Rales are generally not present in croup, so this finding should prompt further evaluation.
Differentiating croup from other acute illnesses can be challenging. Specifically, distinguishing it from epiglottitis is important because the treatment and prognosis of these conditions are substantially different.
Acute onset of dysphagia, odynophagia, drooling, high fever, anxiety, and muffled voice. Information from references 2 , 5 , 6 , 14 , and 16 through Laboratory studies are seldom needed to diagnose croup. Viral cultures and rapid antigen testing should be reserved for patients in whom initial treatment is ineffective.
Lymphocytosis may suggest a viral etiology. However, this finding is neither specific nor sensitive for croup and may be present in patients with epiglottitis, bacterial tracheitis, neoplasm, or thermal injury. Laryngoscopy should be reserved for atypical presentations or when alternate diagnoses are suspected. Management of croup is based on the severity of illness.
Although a scoring system is not necessary, the most widely studied and commonly used is the Westley Croup Score Table 2. Figure 1 provides an outpatient management algorithm for children with croup. Placing the child in a comfortable position may help improve the evaluation and treatment process.
Nebulized racemic epinephrine by IPPB for the treatment of croup: a double-blind study. Am J Dis Child. Croup: an overview. Am Fam Physician. Oxygen should be administered to children with hypoxemia or severe respiratory distress. Heliox is a helium and oxygen mixture used for respiratory conditions that theoretically improves airflow resistance by decreasing gas density helium is a low-density gas. Data are limited on the benefit of heliox in the treatment of croup, and based on a Cochrane review of three conflicting trials, it is not recommended.
Corticosteroids should be used in patients with croup of any severity. Treatment with dexamethasone results in faster resolution of symptoms and decreased return to medical care. A Cochrane review showed improved symptom scores at six and 12 hours after treatment with a corticosteroid dexamethasone, budesonide [Rhinocort], or methylprednisolone. There is no statistically significant difference between corticosteroids and epinephrine, although patients treated with corticosteroids require less epinephrine.
Dexamethasone is the preferred corticosteroid because it is given as a single dose and can be given orally, intramuscularly, or intravenously. Although the optimal dose is unclear, 0. Compared with prednisolone, dexamethasone use in the emergency department or hospital may decrease rates of return visits or readmissions.
Epinephrine is thought to improve symptoms in patients with croup through arteriole vasoconstriction in the upper airway mucosa, which eventually leads to decreased edema. Epinephrine is typically used in conjunction with corticosteroids because it has a quick onset of action but a short half-life, whereas corticosteroids have a slower onset of action but a longer half-life. These treatments do not have any affect on a patient with bacterial epiglottitis.
The steeple sign seen in an anteroposterior neck radiograph is characteristic of viral croup. Viral cultures usually are not obtained. Clinical Features. Viral Croup. Parainfluenza virus. Haemophilus influenzae type b. Age of patient. Onset of disease. Abnormal chest sounds. Bark-like cough, stridor. Muffled, guttural cough. Difficult, with drooling. Anxious, distressed, toxic. Response to racemic. Usually good;. Less air hunger and.
Usually poor;. Little to no effect on air hunger and restlessness. Steeple sign in. Thumb sign in lateral radiograph. Epiglottitis- Stridor is a late sign - Act on clinical suspicion based on the history.
Once stridor develops, you may only have minutes to act. Suspect epiglottitis in children with a sore throat and unusual symptoms e,g. Suspect any patient with a severe sore throat and no evidence of tonsillitis or pharyngitis on examination. Examination of the larynx can irritate the patient and cause airway closure and asphyxiation. Equipment for an emergency tracheostomy should be available during examination of a patient suspected of having epiglottitis.
If the patient has bacterial epiglottitis, the etiologic agent should be determined. H influenzae type b, the most common cause of epiglottis, does not grow on blood agar, therefore, throat swabs and smears should be cultured on blood agar and chocolate agar plates.
In epiglottitis, H influenzae is often in the bloodstream; therefore blood cultures are helpful. A leukocytosis can be seen in the complete blood count CBC. A positive thumb sign on lateral radiographs of the neck is diagnostic of epiglottitis. Therapy and Prevention. Acute laryngitis is a self-limiting infection, and symptomatic therapy usually is all that is necessary.
Treatment of viral croup requires maintenance of an adequate airway as follows. Proper care and handling of the patient with epiglottitis can determine whether the patient lives or dies. Children should be sedated when being intubated to prevent them from pulling out the tube. The Hib vaccine is the capsular type b polysaccharide conjugated to the diphtheria toxoid, and it has drastically reduced the incidence of epiglottitis in the US.
A child who has not received the Hib vaccine and who is exposed to a patient with epiglottitis should receive chemoprophylaxis with rifampin. Young children are most susceptible to viral croup, which typically occurs in children 6 months to 3 years of age, with the mean age being 18 months.
It causes swelling of the trachea , voice box and bronchi. As a result, it obstructs breathing. When breathing, it produces a high-pitched whistling sound as well. Moreover, barking cough is characteristic of croup. Fever can also be developed due to croup.
Croup is a common and primarily pediatric illness that occurs in younger children. Children between 6 months and 3 years of age are more susceptible to croup.
Croup starts with a typical cold and shows inflammation. Symptoms of croup last for two-three days. Generally, symptoms worsen at night. Croup is not a serious illness. It can be treated at home. It can be prevented by taking precautions such as washing hands frequently, keeping children away from sick people and encouraging kids to sneeze into the elbow. Epiglottis is the flap at the base of the tongue.
It prevents food from entering the trachea. Epiglottitis is a life threatening condition or illness caused due to inflammation and swelling of the epiglottis. The infective agent of epiglottitis is Haemophilus influenza. It occurs due to other bacteria as well. It is a rare condition. But it is a potentially life-threatening infection. This infection causes rapid swelling of the epiglottis.
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