Croup, also known as laryngotracheobronchitis, is a viral illness that typically occurs during late fall to early winter. The most common pathogen associated with croup is the parainfluenza virus. Other viruses, such as RSV, influenza A and B, Mycoplasma pneumoniae, and various respiratory viruses, can also cause the condition.
Tip 1: Recognizing Croup
Croup is a viral infection affecting the upper airway, leading to inflammation and swelling, causing the acute onset of fever, barking cough, inspiratory stridor, and a hoarse voice.
It primarily affects children between six months and three years of age.
The natural course of croup tends to worsen at night, and in most cases, symptoms typically resolve after about three days.
Tip 2: Assessing Severity
By accurately assessing the severity of croup, healthcare professionals can provide timely and appropriate interventions to manage the condition effectively.
Mild cases of croup are characterized by a barking cough and hoarse voice.
There is no stridor present at rest, and if stridor occurs, it is only mild and heard during agitation or activity.
The work of breathing is either absent or mild in these cases.
For moderate cases, patients have stridor at rest, along with tachypnea.
The work of breathing is moderate, and there might be signs of anxiety and agitation. Patients may also experience difficulty talking or feeding.
Severe cases present with stridor at rest and exhibit severe work of breathing or signs of respiratory distress.
Patients may self-position in a way that provides relief, such as tripoding or head extension. Additionally, they may have altered mental status and be unable to talk or feed.
Tip 3: Supportive Care
Supportive care is the cornerstone of croup management.
Using a cool-mist humidifier at home in the child's bedroom may help soothe the airway.
There is no supporting evidence for added benefit of cool mist in hospital setting.
Adequate hydration is essential, so encourage water intake.
Tip 4: Single Dose Oral Dexamethasone
Oral dexamethasone is the recommended glucocorticoid for croup management in the emergency department.
The standard dose is 0.6 mg/kg, with a maximum dose of 16 mg, given as a single dose, regardless of severity.
In cases where oral administration is not feasible, alternative routes like IV, IM, or nebulization (use budesonide) may be used.
There are no conclusive studies recommending one specific drug, dose, or route for treating croup.
In severe or atypical cases, pediatric subspecialists may be consulted to consider the possibility of repeat steroid doses.
Tip 5: Nebulized Epinephrine
Nebulized racemic epinephrine helps reduce airway swelling and improve breathing.
In situations where racemic epinephrine is not available, nebulized L-epinephrine can serve as a suitable alternative, even in settings such as EMS vehicles.
The clinical effect of nebulized racemic epinephrine becomes apparent approximately 30 minutes after treatment. It's clinical benefits tend to diminish at around 120 minutes.
L-epinephrine may have a longer half-life than the racemic form.
The dose of nebulized racemic epinephrine (2.25%) is 0.5 milliliter fixed dose. Reduce the dose to 0.25 milliliter if the body weight is less than 5 kg.
The dose of nebulized L-epinephrine (1 to 1000) is 0.5 milliliter per kilogram, up to 5 milliliter maximum.
Nebulized epinephrine should be used with caution, as it can cause tachycardia and hypertension. Monitor the child closely after administration.
Tip 6: Oxygen Therapy and SpO2
Oxygen therapy may be required for children with severe croup and respiratory distress. Initiate supplemental oxygen for saturations less than 90% in room air.
Continuous pulse oximetry is not routinely recommended.
Consider continuous monitoring for unstable patients or those receiving numerous repeated doses of racemic epinephrine.
Hypoxia in croup is uncommon; consider alternative diagnoses in patients with significant hypoxia.
Tip 7: No Routine Lab Tests and X-Rays
Routine laboratory testing, including respiratory viral testing, is not recommended.
However, if there is a suspicion of impending respiratory failure, arterial blood gas testing should be considered.
Similarly, routine imaging such as chest X-ray or lateral neck X-ray is not recommended.
Nevertheless, imaging may be considered in instances of atypical presentation or when there is suspicion of alternative diagnoses, such as pneumonia or retropharyngeal abscess.
Tip 8: No Routine Antibiotics
Routine antibiotics are not recommended.
However, antibiotics may be considered in cases of atypical presentation or when there is suspicion of alternative diagnoses, such as pneumonia or bacterial tracheitis.
Tip 9: Admission Criteria
Admission criteria for croup include: persistent stridor at rest after Dexamethasone & racemic epinephrine, inadequate hydration, need for supplemental oxygen, atypical presentations, concerns for alternative diagnoses, escalating stridor at rest, or need for emergency intubation, such as cyanosis or hypoxemia despite supplemental oxygen, bradypnea or poor respiratory effort, along with altered mental status.
Tip 10: Hospital Discharge Criteria
Hospital discharge criteria for croup include: no or minimal stridor at rest, able to talk and feed without difficulty, and maintain adequate hydration.
Discharge may be considered if more than two hours have passed since the last racemic epinephrine treatment and more than twelve hours have passed since the need for supplemental oxygen.
However, it is advisable to postpone discharge until after one night free of croup-related events or symptoms, unless the respiratory exam is completely normal.
Take Home Message
In conclusion, croup management involves accurate diagnosis, supportive care, and appropriate use of medications such as oral dexamethasone and nebulized epinephrine.
Remember to consider the child's severity, provide necessary oxygen therapy if needed, and reassess their condition before discharge.
By following these evidence-based guidelines, we can ensure the best outcomes for our young patients with croup.