Croup (Laryngotracheobronchitis)To compare the effectiveness of three corticosteroid regimens in children with mild to moderate croup. Double-blinded, randomized comparative trial with parallel over the counter anabolic steroids, conducted in the ED of a paediatric tertiary care hospital. Children aged 6 months to 6 years presenting to the ED orap croup were eligible for oral prednisone dose for croup if their Westley croup score was 2 or more. Primary outcome measures were the magnitude and rate of reduction in Westley croup score, rate of return for medical care with ongoing croup, and further treatment with steroids in the week following index presentation. Secondary outcome measures pdednisone the prednisonr of subjects requiring admission or salvage therapy, such as nebulized adrenaline, during index presentation. A total of 99 oral prednisone dose for croup, aged months, were enrolled mean age: Baseline characteristics of the three groups were similar.
Croup Treatment & Management: Approach Considerations, Corticosteroids, Epinephrine
Croup is a common illness responsible for up to 15 percent of emergency department visits due to respiratory disease in children in the United States. Croup symptoms usually start like an upper respiratory tract infection, with low-grade fever and coryza followed by a barking cough and various degrees of respiratory distress. In most children, the symptoms subside quickly with resolution of the cough within two days.
Croup is often caused by viruses, with parainfluenza virus types 1 to 3 as the most common. However, physicians should consider other diagnoses, including bacterial tracheitis, epiglottitis, foreign body aspiration, peritonsillar abscess, retropharyngeal abscess, and angioedema. Humidification therapy has not been proven beneficial. A single dose of dexamethasone 0. Nebulized epinephrine is an accepted treatment in patients with moderate to severe croup.
Most episodes of croup are mild, with only 1 to 8 percent of patients with croup requiring hospital admission and less than 3 percent of admitted patients requiring intubation. Croup is a syndrome that includes spasmodic croup recurrent croup , laryngotracheitis viral croup , laryngotracheobronchitis, and laryngotracheobronchopneumonitis.
Humidification therapy does not improve croup symptoms in patients with mild to moderate disease in the emergency department setting. A single dose of an oral corticosteroid is effective in patients with mild croup. Nebulized epinephrine improves outcomes in patients with moderate to severe croup. For information about the SORT evidence rating system, go to https: Croup is more common in boys than in girls, usually occurs between six and 36 months of age, and peaks during the second year of life.
Croup is usually caused by viruses, which are detected in up to 80 percent of patients. Bacterial causes are also rare and include diphtheria and Mycoplasma pneumoniae. Etiologies listed in approximate order of frequency. Information from references 3 , 10 , and Allergic factors may play a role in recurrent croup, with the child becoming sensitized to viral antigens. An uncontrolled study of 47 patients with recurrent croup found that treatment of reflux improved respiratory symptoms. Viral croup symptoms usually start like an upper respiratory tract infection, with low-grade fever and coryza followed by a barking cough and various degrees of respiratory distress e.
Croup is a benign condition with a low mortality rate. Croup rarely occurs in children younger than three months. Studies of children presenting to the emergency department with croup symptoms showed that 85 percent had mild croup, 18 and only 1 to 8 percent needed hospital admission.
Recurrent croup is similar to viral croup in presentation, except that it recurs and lacks symptoms of respiratory tract infection. Bacterial tracheitis does not respond to usual croup treatment. Intravenous antibiotics are needed, and intubation may become necessary. Acute epiglottitis typically leads to a more toxic appearance than croup. The classic presentation of epiglottitis is an anxious child with a sore throat who is drooling and sitting or leaning forward; the characteristic barking cough of croup is typically absent.
A retrospective study of patients with croup, epiglottitis, and bacterial tracheitis showed the increasing importance of considering bacterial tracheitis in the differential diagnosis of severe respiratory illness. Hence, physicians should consider bacterial tracheitis when treating patients with severe respiratory symptoms suggestive of croup or epiglottitis.
The differential diagnosis of children with severe respiratory symptoms is summarized in Table 2. Epicutaneous skin testing or radioallergosorbent testing may be performed later. High-grade fever, toxic appearance, copious secretions, productive cough, retractions; no drooling or odynophagia. Lateral neck radiography may be helpful, bacterial culture of tracheal secretions after intubation, WBC count elevated. Staphylococcus aureus , Haemophilus influenzae , group A streptococci. Inferior and medial displacement of the tonsil, contralateral deviation of the uvula, erythema and exudates on the tonsil.
Lateral neck radiography widening of the retropharyngeal soft tissues ; CT with intravenous contrast media is helpful. Generally not indicated, but bronchoscopy especially in children younger than three years and endoscopy may be considered. Same as viral croup, with possible allergic component or gastroesophageal reflux. Information from references 3 , 8 , and 19 through The diagnosis of croup is based on clinical assessment.
Abrupt onset of barking cough, hoarseness, and inspiratory stridor is highly suggestive of croup. Diagnosis also involves closely assessing the severity of croup by evaluating respiratory status and rate, retractions, stridor, heart rate, use of accessory muscles, and mental status. Laboratory and imaging evaluation are not essential, but may be used to rule out other illnesses in selected patients with an atypical or severe presentation.
Although chest radiography cannot diagnose croup, it can rule out other pulmonary conditions when the diagnosis is unclear in a child with stridor. Therefore, physicians should consider the risk and expense of radiography versus its possible benefit before ordering the test. Lateral neck radiography may be considered if the diagnosis is in doubt because it could help detect epiglottitis thickened epiglottis , retropharyngeal abscess widening of the retropharyngeal soft tissues , and bacterial tracheitis thickened trachea.
In a series of 30 patients who underwent endoscopy for recurrent croup, one-third had airway disorders such as subglottic edema, stenosis, or cyst.
Figure 1 is an algorithm for outpatient management of croup based on illness severity. Positioning the child so that he or she is comfortable is appropriate because no particular position has been shown to be more beneficial in the assessment. Oxygen should be administered when the child is hypoxic or in severe respiratory distress.
Heliox, a helium-oxygen mixture, has been used to reduce airflow resistance and turbulence. Although case reports have been encouraging, a systematic review found insufficient evidence that heliox is beneficial for croup. Information from references 25 through Humidification therapy has long been used as a treatment for croup. However, it has not been shown to reduce croup severity, hospitalization, additional medical care, or epinephrine and corticosteroid use in patients with mild to moderate illness in the emergency department—even if delivered with a particle size that could reach the larynx.
Heated humidification should not be used because of the risk of scalding the child. Use of croup tents should be avoided so that the child can stay in the lap of a parent or caregiver, and to avoid hindering the clinical assessment e. Corticosteroid therapy benefits patients with croup presumably by decreasing edema in the laryngeal mucosa, and is usually effective within six hours of treatment.
Corticosteroid therapy decreases the need for additional medical care, hospital stays, and intubation rates and duration. A recent randomized controlled trial found that a single dose of an oral corticosteroid benefited children with mild croup. The optimal type of corticosteroid, route of administration, and dose are unclear.
Oral and intramuscular administration provide similar degrees of benefit, and both are equivalent or superior to inhaled corticosteroids. However, the addition of inhaled corticosteroids to either systemic therapy does not provide further benefit. In very sick children who need a parenteral route, intravenous administration may be better than intramuscular administration because the intravenous line could also be used for resuscitation and other therapies as needed.
Intramuscular corticosteroids are typically used when intravenous and oral administration are not feasible. Based on expert opinion and consensus, dexamethasone is the recommended corticosteroid for treatment of croup because of its longer half-life a single dose provides anti-inflammatory effects over the usual symptom duration of 72 hours. However, no randomized controlled trials have compared multiple versus single dosing.
If continued therapy is required, other causes for airway obstruction or respiratory distress should be considered. No adverse effects have been associated with appropriate corticosteroid therapy in patients with croup. The risks of single-dose corticosteroids are very low, but should be considered in children with diabetes mellitus, children exposed to varicella virus, and children at risk of bacterial superinfection i.
A number of small randomized controlled trials have shown that nebulized epinephrine is an effective treatment for moderate to severe croup, with benefits such as reduction in croup severity, various objective pathophysiologic measures, and need for intubation. Using a nebulizer is equally as effective as using intermittent positive pressure ventilation. With either form of epinephrine, therapeutic benefit usually occurs within the first 30 minutes.
Because this benefit typically lasts up to two hours, it may be best to evaluate for disposition several hours following the last epinephrine treatment. The rapid action of epinephrine paired with the later onset and sustained action of corticosteroid treatment justifies the consideration of dual therapy. Already a member or subscriber? Reprints are not available from the authors.
Knutson D, Aring A. Croup hospitalizations in Ontario. N Engl J Med. Effect of weather conditions on acute laryngotracheitis. Guideline for the diagnosis and management of croup. Accessed June 16, Sobol SE, Zapata S. Otolaryngol Clin North Am. Respiratory viruses in laryngeal croup of young children [published correction appears in J Pediatr. Malhotra A, Krilov LR. Viral croup [published correction appears in Pediatr Rev. A cotton rat model of human parainfluenza 3 laryngotracheitis: Correlating the clinical course of recurrent croup with endoscopic findings.
Ann Otol Rhinol Laryngol. The need for intubation in serious upper respiratory tract infection in pediatric patients a retrospective study. Croup presentations to emergency departments in Alberta, Canada.
Evidence based guideline for the management of croup. The assessment and management of croup. The viral aetiology of croup and recurrent croup.