Croup Diagnosis and Management

Teaching video link:

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What is croup?
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Croup is a common pediatric respiratory condition characterized by inflammation of the larynx, trachea, and bronchi, often due to viral infections, particularly parainfluenza virus. It typically presents with a barking cough, stridor, hoarseness, and respiratory distress, most commonly in children aged 6 months to 3 years. Symptoms are usually worse at night and can range from mild to severe. Diagnosis is primarily clinical, based on history and physical exam. Mild cases can be managed with supportive care and humidified air. For moderate to severe cases, corticosteroids (e.g., dexamethasone) are first-line treatments, and nebulized epinephrine may be used in severe cases. Monitoring for respiratory fatigue and hypoxia is essential, as some children may require hospitalization. Always ensure proper follow-up care.
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10 Tips for Croup Management: 

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 number 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 number 2: Assessing Severity.
By accurately assessing the severity of croup, healthcare professionals can provide timely and appropriate interventions to manage the condition effectively.

Tip number 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. Adequate hydration is essential, so encourage water intake.

Tip number 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. 

Tip number 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 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.

Tip number 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. Hypoxia in croup is uncommon; consider alternative diagnoses in patients with significant hypoxia.

Tip number 7: No Routine Lab Tests and X-Rays.
Routine laboratory testing, including respiratory viral testing, is not recommended. Similarly, routine imaging such as chest X-ray or lateral neck X-ray is not recommended. 

Tip number 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. 

Tip number 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 number 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.