approach to Croup

1. Croup
Presented by: Donia Mohammed Abdulazeez
Pediatric resident

2. What Is stridor?
• high-pitched, monophonic sound made when breathing that is best heard
over the anterior neck.
• In all cases, stridor should be differentiated from stertor, which is a lower-
pitched, snoring-type sound generated at the level of the nasopharynx,
oropharynx, and, occasionally, supraglottis.
• Stridor is caused by the oscillation of a narrowed airway, and its presence
suggests significant obstruction of the large airways

4. What is croup?
• The term croup has been used to describe a variety of upper respiratory
conditions in children, including laryngitis, laryngotracheitis,
laryngotracheobronchitis, bacterial tracheitis, or spasmodic croup.

5. Laryngotracheitis (croup)
• It’s an inflammation of the larynx and trachea, it’s characterized by
inspiratory stridor, barking cough, and hoarseness.
• Croup most commonly occurs in children 6 to 36 months of age.
• It is more common in boys, with a male:female ratio of approximately 1.4:1
• Family history of croup is a risk factor for croup and recurrent croup

6. Causes
• Parainfluenza virus type 1 is the most common cause of acute
laryngotracheitis, especially the fall and winter epidemics
• Parainfluenza type 2 sometimes causes croup outbreaks, but usually with
milder disease than type 1.
• Parainfluenza type 3 causes sporadic cases of croup that often are more
severe than those due to types 1 and 2.
• infection caused by parainfluenza virus type 4 is less likely to be associated
with stridor and croup in children.

7. Causes
• Measles
• Influenza virus
• Rhinoviruses, enteroviruses (especially Coxsackie types A9, B4, and B5, and
echovirus types 4, 11, and 21), and herpes simplex virus are occasional causes of
sporadic cases of croup that are usually mild.
• Metapneumoviruses cause primarily lower respiratory tract disease similar to RSV
• Human coronavirus NL63 (HCoV-NL63), first identified in 2004, has been
implicated in croup and other respiratory illnesses
• RSV and adenoviruses are relatively frequent causes of croup.

8. Causes
• Croup also may be caused by bacteria.
• Mycoplasma pneumoniae has been associated with mild cases of croup.
• secondary bacterial infection may occur in children with laryngotracheitis,
laryngotracheobronchitis, or laryngotracheobronchopneumonitis.
• The most common secondary bacterial pathogens include Staphylococcus
aureus, Streptococcus pyogenes, and Streptococcus pneumoniae

9. Clinical features
• The onset of symptoms is usually gradual, beginning with nasal discharge,
congestion, and coryza.
• Symptoms generally progress over 12 to 48 hours to include fever,
hoarseness, barking cough, and stridor.
• Respiratory distress increases as upper airway obstruction becomes more
severe.
• Cough usually resolves within three days; other symptoms may persist for
seven days with a gradual return to normal.

10. Clinical features
• In mild cases, the child is hoarse and has nasal congestion. There is minimal,
if any, pharyngitis.
• As airway obstruction progresses, stridor develops, and there may be mild
tachypnea with a prolonged inspiratory phase.
• The presence of stridor is a key element in the assessment of severity.
• Biphasic stridor at rest is a sign of significant upper airway obstruction.

11. Clinical features
• When airway obstruction becomes severe, suprasternal, subcostal, and
intercostal retractions may be seen. Breath sounds can be diminished.
• Hypoxia and cyanosis can develop, as can respiratory fatigue from sustained
increased respiratory effort. High respiratory rates also tend to correlate with
the presence of hypoxia.

12. History
• Fever – The absence of fever from onset of symptoms to the time of presentation is suggestive of spasmodic croup or
a noninfectious etiology (eg, subglottic cyst, subglottic hemangioma).
• Barking cough – The classic physical finding in a patient with subglottic narrowing is a barky seal-like cough.
• Hoarseness – Hoarseness may be present in croup, particularly in older children, whereas hoarseness is not a typical
finding in epiglottitis or foreign body aspiration.
• Difficulty swallowing – Difficulty swallowing may occur in acute epiglottitis. Rarely, a large, ingested foreign body may
lodge in the upper esophagus, where it distorts and narrows the upper trachea, thus mimicking the croup syndrome
(including barking cough and inspiratory stridor).
• Drooling – Drooling may occur in children with peritonsillar or retropharyngeal abscesses, retropharyngeal cellulitis,
and epiglottitis. In an observational study, drooling was present in approximately 80 percent of children with epiglottitis,
but only 10 percent of those with croup
• Throat pain – Complaints of dysphagia and sore throat are more common in children with epiglottitis than croup
(approximately 60 to 70 percent versus <10 percent)

13. Physical examination
• Overall appearance
• Quality of the voice
• A muffled "hot potato" voice is suggestive of epiglottitis, retropharyngeal abscess, or peritonsillar abscess.
• Degree of respiratory distress
• Lung examination – Are there abnormal respiratory sounds during inspiration or expiration?
Inspiratory stridor indicates upper airway obstruction, whereas expiratory wheezing is a sign of lower
airway obstruction. If there is stridor, is it present at rest or only with agitation?. The presence of
crackles (rales) also suggests lower respiratory tract involvement (eg, laryngotracheobronchitis,
laryngotracheobronchopneumonitis, or bacterial tracheitis).
• Assessment of hydration status.

14. Components of the examination that are useful in
distinguishing croup from other causes of acute
upper airway obstruction
• Preferred posture
• Examination of the oropharynx for the following signs:
• Cherry red, swollen epiglottis, suggestive of epiglottitis.
• Pharyngitis, typically minimal in laryngotracheitis, may be more pronounced in epiglottitis or laryngitis.
• Excessive salivation, suggestive of acute epiglottitis, peritonsillar abscess, parapharyngeal abscess or retropharyngeal abscess.
• Tonsillar asymmetry or deviation of the uvula suggestive of peritonsillar abscess.
• Midline or unilateral swelling of the posterior pharyngeal wall suggestive of retropharyngeal abscess.
• Examination of the cervical lymph nodes, which can be enlarged in patients with retropharyngeal or peritonsillar abscesses.
• Other physical findings may be present, depending on the particular inciting virus. As an example, rash, conjunctivitis,
exudative pharyngitis, and adenopathy are suggestive of adenovirus infection.
• Otitis media (acute or with effusion) may be present as a primary viral or secondary bacterial process.

15. **Concerns have been raised about safety of examining the pharynx in children
with upper airway obstruction and possible epiglottitis since such efforts have
been reported to precipitate cardiorespiratory arrest. However, in two series,
each including more than 200 patients with epiglottitis or viral croup, direct
examination of the oropharynx was not associated with sudden clinical
deterioration

16. Westley croup severity score
Clinical feature Assigned score
Level of consciousness
Normal, including sleep = 0
Disoriented = 5
Cyanosis
None = 0
With agitation = 4
At rest = 5
Stridor
None = 0
With agitation = 1
At rest = 2
Air entry
Normal = 0
Decreased = 1
Markedly decreased = 2
Retractions
None = 0
Mild = 1
Moderate = 2
Severe = 3

17. Score Severity Description Management
≤2 Mild
Occasional barky cough, no stridor at rest,
mild or no retractions
Home treatment: Symptomatic care
including antipyretics, mist, and oral fluids
Outpatient treatment: Single dose of oral
dexamethasone 0.6 mg/kg (maximum 10
mg)*
3 to 7 Moderate
Frequent barky cough, stridor at rest, and
mild to moderate retractions, but no or little
distress or agitation
Single dose of oral dexamethasone 0.6
mg/kg (maximum 10 mg)*
Nebulized epinephrine
¶
Hospitalization is generally not needed, but
may be warranted for persistent or worsening
symptoms after treatment with
glucocorticoid and nebulized epinephrine
8 to 11 Severe
Frequent barky cough, stridor at rest, marked
retractions, significant distress and agitation
Single dose of oral/IM/IV dexamethasone
0.6 mg/kg (maximum 10 mg)*
Repeated doses of nebulized
epinephrine
¶
may be needed
Inpatient admission is generally required
unless marked improvement occurs after
treatment with glucocorticoid and nebulized
epinephrine
≥12 Impending respiratory failure
Depressed level of consciousness, stridor at
rest, severe retractions, poor air entry,
cyanosis or pallor
Single dose of IM/IV dexamethasone 0.6
mg/kg (maximum 10 mg)*
Repeated doses of nebulized
epinephrine
¶
may be needed
Intensive care unit admission is generally
required
Consultation with anesthesiologist or ENT
surgeon may be warranted to arrange for
intubation in a controlled setting

18. Imaging
• In children with croup, a posterior-anterior chest radiograph demonstrates
subglottic narrowing, commonly called the "steeple sign". The lateral view may
demonstrate overdistention of the hypopharynx during inspiration and subglottic
haziness .The epiglottis should have a normal appearance.
• In contrast, the lateral radiograph in virtually all children with epiglottitis
demonstrates swelling of the epiglottis, sometimes called the "thumb sign"
• The lateral radiograph in children with bacterial tracheitis may demonstrate only
nonspecific edema or intraluminal membranes and irregularities of the tracheal wall

20. Laboratory study
• Laboratory studies, which are rarely indicated in children with croup, are of limited
diagnostic utility, but may help guide management in more severe cases.
• Blood tests
• WBC count can be low, normal, or elevated; WBC counts >10,000 cells/microL are common.
Neutrophil or lymphocyte predominance may be present on the differential. The presence of a large
number of band-form neutrophils is suggestive of primary or secondary bacterial infection. Croup is
not associated with any specific alterations in serum chemistries.
• Microbiology
• Confirmation of etiologic diagnosis is not necessary for most children with croup, since croup is a self-
limited illness that usually requires only symptomatic therapy. When an etiologic diagnosis is necessary,
viral culture and/or rapid diagnostic tests that detect viral antigens are performed on secretions from
the nasopharynx or throat.

23. Differential diagnosis
• Acute epiglottitis
• rare in the era of vaccination against Haemophilus
influenzae type b, is distinguished from croup by the
absence of barking cough and the presence of anxiety
that is out of proportion to the degree of respiratory
distress. Onset of symptoms is rapid, and because of the
associated bacteremia, the child is highly febrile, pale,
toxic, and ill-appearing. Because of the swollen epiglottis,
the child will have difficulty swallowing and is often
drooling. The children usually prefer to sit up and seldom
have observed cough.

24. Differential diagnosis – acute epiglottitis
• Maintenance of the airway is the first priority for patients with epiglottitis.
• For patients who are not maintaining their airway as indicated by drooling, "sniffing", or "tripod" posture , and severe
respiratory distress, the physician should first proceed with bag-valve-mask (BVM) ventilation with 100 percent oxygen.
• children younger than six years of age with epiglottitis undergo endotracheal intubation as described for oxygenating
patients who cannot maintain their airway
• empiric combination therapy with a third-generation cephalosporin (eg, ceftriaxone or cefotaxime) AND an
antistaphylococcal agent (eg, vancomycin or as determined by the local prevalence and sensitivities of MRSA isolates)
• Bronchodilators and parenteral glucocorticoids have both been used as adjunctive treatments for patients with epiglottitis,
but these agents are not routinely necessary
• All patients with epiglottitis should be monitored in an intensive care unit.
• Intubation for two to three days is usually necessary before extubation can be safely accomplished

25. Differential diagnosis
• Bacterial tracheitis
• Bacterial tracheitis may present as a primary or secondary infection.
• In primary infection, there is acute onset of symptoms of upper airway obstruction with fever and toxic appearance.
• In secondary infection, there is marked worsening during the clinical course of viral laryngotracheitis, with high fever, toxic
appearance, and increasing respiratory distress secondary to tracheal obstruction from purulent secretions.
• In both of these presentations, signs of lower airway disease, such as crackles and wheezes, may be present. However, the upper
airway obstruction is the more clinically significant manifestation
• generally occurs during the first six years of life but may occur at any age.
• Although uncommon, it is among the most frequent pediatric airway emergencies requiring admission to an ICU.
• The cornerstones of treatment for bacterial tracheitis are maintenance of the airway, fluid resuscitation (if needed), and
administration of appropriate antimicrobial agents. Some children require emergent or urgent evaluation of the airway via
endoscopy. This procedure generally is best performed in the operating room, intensive care unit, or equivalent setting

26. Suggested intravenous antimicrobial
treatment regimens for bacterial tracheitis
in children
For patients without hypersensitivity to penicillin or cephalosporin
Vancomycin*
¶
OR
40 to 60 mg/kg per day in three to four divided doses
Maximum daily dose 4 g
Clindamycin
40 mg/kg per day in three divided doses
Maximum daily dose 2.7 g
PLUS
Ceftriaxone
Δ
OR
50 to 100 mg/kg per day once daily or in two divided doses
Maximum daily dose 2 g
Cefotaxime
¶Δ
OR
150 to 200 mg/kg per day in four divided doses
Maximum daily dose 10 g
Ampicillin-sulbactam
¶ 150 to 200 mg/kg (of ampicillin component) per day in four divided doses
Maximum daily dose 8 g

28. Differential diagnosis
• Retropharyngeal abscess
• Most retropharyngeal abscesses occur in children between two and four years of age.
• Early in the disease process, the findings may be indistinguishable from those of uncomplicated
pharyngitis. As the disease progresses, symptoms include fever, dysphagia and drooling, unwillingness
to move neck, muffled or "hot potato" voice, and inspiratory stridor.
• Peritonsillar abscess
• Peritonsillar abscess generally arises as a complication of tonsillitis or pharyngitis. Its incidence peaks in
children older than 10 years of age, when streptococcal pharyngitis becomes more common.
• The typical clinical presentation is a severe sore throat (usually unilateral), fever, muffled or "hot
potato" voice, sometimes with inspiratory stridor, drooling, trismus, or neck swelling

29. • Foreign body aspiration
• If an inhaled foreign body lodges in the larynx, it will produce hoarseness and stridor.
If a large foreign body is swallowed, it may lodge in the upper esophagus, resulting in
distortion of the adjacent soft extrathoracic trachea, producing a barking cough and
inspiratory stridor. Ingestion of a non-obstructive but subsequently erosive foreign
bodies such as a button battery may produce stridor more remote from the time of
ingestion that persist or recur.

30. Outpatient management
• children with mild croup who are seen in the outpatient setting be treated
with a single dose of oral dexamethasone (0.15 to 0.6 mg/kg, maximum dose
10 mg)
• Treatment with nebulized epinephrine is not typically necessary for
management of mild croup.
• Children with mild croup who are tolerating fluids and have not received
nebulized epinephrine can be sent home after specific follow-up

31. Home treatment
• The caregivers of children with mild croup who are managed at home should be instructed
in provision of supportive care including mist, antipyretics, and encouragement of fluid
intake.
• In acute situations and for short periods of time, caregivers may try sitting with the child in
a bathroom filled with steam generated by running hot water from the shower to improve
symptoms. This may help reassure parents that "something" is being done to reverse the
symptoms, and anecdotal evidence supports some benefit with this measure.
• Exposure to cold night air also may lessen symptoms of mild croup, although this has never
been systematically studied. If parents or caregivers wish to use humidifiers at home, only
those that produce mist at room temperature should be used to avoid the risk of burns from
steam or the heating element.

32. Management of moderate-severe croup
• administration of dexamethasone (0.6 mg/kg, maximum of 10 mg) in all
children with moderate to severe croup.
• Dexamethasone should be administered by the least invasive route possible
• The oral preparation of dexamethasone (1 mg/mL) has an unpleasant taste.
The IV preparation is more concentrated (4 mg per mL) and can be given
orally mixed with syrup.
• A single dose of nebulized budesonide (2 mg [2 mL solution] via nebulizer)
is an alternative option, particularly for children who are vomiting

33. Management of moderate-severe croup
• In addition to dexamethasone, it’s recommended to use nebulized epinephrine in all
patients with moderate to severe croup:
• Racemic epinephrine is administered as 0.05 mL/kg per dose (maximum of 0.5 mL) of a
2.25 percent solution diluted to 3 mL total volume with normal saline. It is given via
nebulizer over 15 minutes.
• L-epinephrine is administered as 0.5 mL/kg per dose (maximum of 5 mL) of a 1:1000
dilution. It is given via nebulizer over 15 minutes.
• Patients should be observed for three to four hours after initial treatment. The need
for additional intervention and/or admission to the hospital is determined chiefly by
the response to therapy with corticosteroids and nebulized epinephrine.

34. Inpatient management
Respiratory care — Respiratory support for children hospitalized with croup may include the
following:
• Nebulized epinephrine − Repeated doses of nebulized epinephrine may be warranted for children
with moderate to severe distress. It is not always required; one study of 365 hospitalizations for
croup found that only 49 percent required additional nebulized epinephrine during the inpatient stay
. Nebulized epinephrine can be repeated every 15 to 20 minutes. However, children who require
frequent doses of epinephrine (eg, more frequently than every one to two hours) should
be admitted/transferred to an intensive care unit for close cardiopulmonary monitoring.
• Supplemental oxygen − Oxygen should be administered to children who are hypoxemic (oxygen
saturation of <92 percent in room air). Supplemental oxygen should be humidified to decrease
drying effects on the airways, since drying may impede the physiologic removal of airway secretions
via mucociliary and cough mechanisms.

35. Inpatient management
• Heliox − Heliox is a mixture of helium (70 to 80 percent) and oxygen (20 to 30 percent). Heliox may decrease the work of
breathing in children with croup by reducing turbulent airflow. A meta-analysis of three trials concluded that while there is
evidence to suggest a short-term benefit of heliox, a larger trial is needed before recommendations regarding the use of heliox in
children with croup can be made . While the evidence from these trials does not suggest a large benefit from Heliox to support its
routine use in the management of croup, in patients with severe symptoms who are at risk for respiratory failure, it may be used
in an attempt to avoid the need for intubation. An important limitation of heliox use is the low fractional concentration of
inspired oxygen (FiO2) in the gas mixture, which may not be adequate for children with hypoxia.
• Intubation − The need for intubation should be anticipated in children with progressive respiratory failure so that the procedure
can be performed in a controlled setting if possible. Intubation can be challenging due to the narrowed subglottic airway and
should be performed with the assistance of a skilled provider (ie, an anesthesiologist or otolaryngologist). Neuromuscular
blocking agents should be avoided unless the ability to provide bag-mask ventilation has been demonstrated. An endotracheal
tube that is 0.5 to 1 mm smaller than would typically be used should be placed
• Endotracheal intubation is rarely required for management of croup. In a large study at one institution, less than 1 percent of
children admitted to the hospital for croup required intubation

36. Inpatient management
• Mist − Humidified air is frequently used in the treatment of croup, although a
meta-analysis of three trials evaluating the use of humidified air in croup found only
marginal improvement in croup scores. Mist therapy may provide a sense of
comfort and reassurance to both the child and family; however, if the child is
instead agitated by the mist, it should be discontinued.
• Infection control — Children who are admitted to the hospital with croup should
be managed with contact precautions (ie, gown and gloves for contact), particularly
if parainfluenza or respiratory syncytial virus is the suspected etiology. If influenza
is suspected, droplet isolation measures (ie, respiratory mask within three feet) also
should be followed.

37. Discharge criteria
• No stridor at rest
• Normal pulse oximetry in room air
• Good air exchange
• Normal color
• Normal level of consciousness
• Demonstrated ability to tolerate fluids by mouth
** Symptoms of croup resolve in most children within three days, but may persist for up to one
week. Approximately 8 to 15 percent of children with croup require hospital admission, and among
those, less than 1 percent require intubation. Mortality is rare, occurring in <0.5 percent of
intubated children

39. Complications
• Complications of croup are uncommon.
• Children with moderate to severe croup are at risk for hypoxemia (oxygen saturation <92 percent
in room air) and respiratory failure.
• Other complications include pulmonary edema, pneumothorax, and pneumomediastinum. These
complications can be anticipated and managed by aggressive monitoring and intervention in the
medical setting. Out-of-hospital cardiac arrest and death also have been reported.
• Secondary bacterial infections may arise from croup. Bacterial tracheitis, bronchopneumonia, and
pneumonia occur in a small number of patients. In most instances, the child has been relatively
stable or beginning to improve after several days of illness, but then suddenly worsens, with
higher or recurrent fever, increased (and potentially productive) cough, and/or respiratory
distress.

40. Laryngotracheobronchitis (LTB)
• LTB occurs when inflammation extends into the bronchi, resulting in lower airway
signs (eg, wheezing, crackles, air trapping, increased tachypnea) and sometimes more
severe illness than laryngotracheitis alone.
• This term commonly is used interchangeably with laryngotracheitis, and the entities
are often indistinct clinically.
• Further extension of inflammation into the lower airways results in
laryngotracheobronchopneumonitis, which sometimes can be complicated by
bacterial superinfection.
• Bacterial superinfection can be manifest as pneumonia, bronchopneumonia, or
bacterial tracheitis.

41. • Spasmodic croup
• Spasmodic croup is characterized by the sudden onset of inspiratory stridor at night, short duration
(several hours), and sudden cessation
• This is often in the setting of a mild upper respiratory infection, but without fever or inflammation.
• Although the initial presentation can be dramatic, the clinical course is usually benign. Symptoms are
almost always relieved by comforting the anxious child and administering humidified air. Rarely,
children may benefit from treatment with corticosteroids and/or nebulized epinephrine
• Laryngitis
• Laryngitis refers to inflammation limited to the larynx and manifests itself as hoarseness. It usually
occurs in older children and adults and, similar to croup, is frequently caused by a viral infection

42. Thank you
Any questions?