Croup:

Not all that barks is

viral!
Craig Dobson, MD
CPT, MC, USAR

NCC Pediatrics

Definitions
Croup- term used to describe the
clinical picture of laryngotracheitis.
Hoarse

voice
Barking cough
Inspiratory stridor
Possible respiratory distress

Epidemiology
Peak fall & winter.
Range primarily 1-6 years
Incidence 5/100 of children between
age 1-2 years
Males > females

Etiologies
Parainfluenza, types 1,2,3
Contribute

65% of cases.

Influenza A & B
Adenovirus
RSV
Rarely mycoplasma.

Pathogenesis
Subglottic narrowing due to
inflammation.
Cricoid ring allows fixed area for
obstruction.
1mm swelling causes 65% obstruction
in infant.

Pathogenesis
Atelectasis/mucus plugging
Ventilation/perfusion mismatch
Negative intrapleural pressure may lead
to varying degrees of pulmonary
edema.
Hypoxia/hypercarbia
Air

hunger
Anxiety/Lethargy/Obtundation.

Clinical history
Parents usually report viral URI
symptoms 12-48hrs prior to cough.
Fever, Barking cough,Stridor
Typical course 3-5 days.

Worry if
Drooling
Dyphagia
Toxic

appearance
Stridor without cough or without fever
Incomplete immunizations

Badness mimicking
croup
Epiglottis
Dysphagia
Odynophagia
Drooling
Tripoding/sword-swallowing
Pt

resists lying on back

Prefers leaning forward
Stat

to OR for evaluation/intubation

Badness Mimicking
Croup, cont.
Bacterial tracheitis
More common in order children to teens
Staph aureus/Diphtheria
Fever/ resp distress/Dysphagia/Odynophagia
Worsening over hours
Difficult to distinguish from epiglottis
Doesnt matter, management is same:

OR intubation
Abx, worry more about Staph coverage if child is older.

Badness Mimicking
Croup, cont.
Bacterial superinfection of Croup
Symptoms

5-7 days
Worsening quickly over hours
Increasingly high fevers
Toxic appearance

Badness Mimicking
Croup, cont.
Retropharyngeal/peritonsilar abscess
Fever
Odynophagia
Prodrome

of sore throat
Often swollen, tender ant. cerv. Nodes.
Resistence to neck movement

Badness Mimicking
Croup, cont.
Neoplasm
Foreign body
Afebrile
Toddlers

most at risk
Often no history of aspiration

Trauma
History/physical

exam.

Badness Mimicking
Croup, cont.
Angioneurotic edema
Recurrent
Lip

swelling

Spasmotic croup (well, not really

badness)
Recurrent
Nighttime

Laboratory tests
No value.. nough said.
Agitation for sticking child for ABG will
worsen childs symptoms.
You still need IV access, though, sorry.

Radiographic findings
Steeple sign
Lateral neck films if unsure of ruling out
retropharyngeal abscess
Fluouroscopy if still unsure
Still this is a clinical diagnosis
If any airway worries, no radiographs
Example radiograph

Management of Croup
Do I need an artificial airway!!!!
Cool mist
No

literature to support efficacy

Multiple studies demonstrating that it may
worsen situation
Bronchospasm
Hypothermia

in young infants
Tent obscures close observation of pt.

Epinephrine
Mechanism- constricts arterioles to airway
thus reducing further edema.
Waiisman, et al. Prospective RCT comparing
L-epi and RE in treatment of laryngotracheitis.
Pediatrics. 1992.
Demonstrated reduced croup score by 30min,
lasts usually 2hrs.
Dose 0.5cc of 2.25% racemic solution
No difference found L- epi using 5cc of 1:1000
conc.

Epi, cont.
Rebound phenomenon
Bunk

It just wears off in 2hours usually.

Multiple studies demonstrating safe to d/c
pt from ER if:
Steroids

were given, too.

No resting stridor 2-4 hrs after tx.

Corticosteroids
Roid controversy. getting clearer.
Ausejo, M. Glucocorticoids for croup. Cochrane
Database of Systemic Reviews Jan 2000.
Repeated with identical results by Moyer in
Pediatrics, March 2000.

Metanalysis (N=2221 patients)

Improved Croup score at 6 and 12 hrs, not 24 after
dexamethasone or budesonide neb.
Decr. need for epi nebs by 9%.
Decr. Emergency Room stay (-11hrs).
Decr. Hospital stay (-16hrs).

Corticosteroids, cont.
Kairys, et al. Steroid treatment of
laryngotracheitis. Pediatrics. 1989.
First

meta-analysis of randomized trials.

Demonstrated reduction in intubation from
1.27% (no steroids) to 0.17% steroids.
No difference in inhaled budesonide versus
IM dex.

Corticosteroids, cont
Ritticher and Ledwith. Outpatient
treatment of moderate croup with
dexamethasone: Intramuscular versus
oral dosing. Pediatrics. 2000
ER

patients sent home.

No statistical difference in later
interventions.
Power to detect at least 10% difference.

Corticosteroids, cont.
Klassen, et al. Nebulized budesonide
and oral dexamethasone treatment for
croup. JAMA. 1998
Oral

dexamethasone/Inhaled budesonide
Both treatments
No difference in groups
Budesonide much more expensive.

Corticosteroids
A moment on dosage:
Most

studies 0.6mg/kg (IM or PO)

Malhotra and Krilov. Viral Croup. PIR, 2001
Lower

doses of 0.15mg/kg and 0.3mg/kg

shown to be equally effective.

Heliox
Weber, JE. A randomized comparison of
Heliox and racemic epinephrine for the
treatment of moderate to severe croup.
Pediatrics. 2001
N=29
Similar

improvement in both groups.

No significant difference in croup score,
oxygen sat, respiratory rate or heart rate.

Where to now?
Still unanswered questions:
Should

you re-dose dexamethasone since

the duration is pharmacologically is 48hrs,
but benefit was only demonstrated though
12hrs?
What about heliox and epi together?
Should any patient with croup symptoms
be given steroids?