REVIEW

CROUP IN CHILDREN
Canadian Medical Associaton Journal
Candice L. Bjornson MD, David W. Johnson MD
October 15, 2013

Pembimbing: dr. Christian Harry, Sp.THT

Disusun oleh: Michael Anthonius Lim

Introduction
Epidemiology
More than 80.000 Canadian children each year 2nd most common
cause of respiratory distress in children
Boys > Girls (1.4:1)
Commonly on young children (6 months 3 years)
Clinical manifestation
Abrupt onset of barky cough, inspiratory stridor, hoarseness, and
respiratory distress
Preceded by 24-72h of nonspecific cough, rhinorrhea, coryza, fever
Often worse at night and can fluctuate rapidly if agitated
60% resolution by 48h
2% persists >5d
Seasonal pattern (late fall) & annual pattern (odd-numbered years)

Introduction
Etiopathogenesis
Viral infection of respiratory tract: Human parainfluenza virus 1 & 3
(mostly), influenza A & B, respiratory syncitial virus, rhinovirus,
coronavirus, human metapneumovirus, adenovirus
Edema & inflammation of the upper airway & laryngeal mucosa
narrowing in subglottic region of the airway
Statistics
2/3 patients have mild symptoms
1-5% patients are admitted to hospital <3% receive intubaton
Death is rare 1 in 30.000 cases

Purpose of review
Address the diagnosis and management of croup in

children, specifically focusing on clinical assessment of

disease severity to guide management decisions

When should croup be suspected?

Child with classic signs & symptoms
Abrupt onset of barky cough, inspiratory stridor, hoarseness
Preceded by 24-72h of nonspecific cough, rhinorrhea, coryza, fever (lowgrade, persistent), malaise, anxiety
Obstruction severe enough respiratory distress
Nasal flaring, chest retraction during inspiration (sternal, intercostal,
supra/infraclavicula), persistent stridor
Obstruction partial total hypoxia, cyanosis, pale
Often worse at night and can fluctuate rapidly if agitated
Diagnosis by history & physical examination alone
<1% children with acute-onset stridor have another diagnosis

Cough in croup

Differential diagnosis
Bacterial tracheitis
Acute, potentially life-threatening
Thick membranous secretion within trachea sudden onset of

stridor and respiratory distress

Pathogen
Staphylococcus aureus, Streptococcus pneumoniae, group A streptococcus,

Moraxella catarrhalis, Haemophilus influenzae, anaerobic bacteria

Consider when
Viral-like respiratory illness not recover, but get worse
Extremely unwell with fever little/no improvement after nebulized epinephrine

Treatment
Monitor airway & prepare for possible ET intubation
Antibiotic broad-spectrum (IV)

Differential diagnosis
Epiglottitis
Uncommon since HiB vaccination
Abrupt onset of dysphagia, drooling, anxiety, fever
No barky cough
Child prefers to sit in an upright posture maintain sniffing position
Risk for progression to complete airway obstruction
Treatment
Monitor airway
Antibiotic broad-spectrum (IV)
ICU

Differential diagnosis
Tracheal or esophageal foreign body
History of ingestion or choking of foreign body
No hoarseness, barky cough, prodromal symptoms
Retropharyngeal or peritonsillar abscess
Stridor, dyspnea, torticollis, dysphagia, neck pain, or stiffness, and
cervical lymphadenopathy
No barky cough
Allergic reaction or acute angioedema
Rapid onset of upper airway obstruction and stridor, signs of allergy
(urticarial skin rash)

What investigation, if any, is needed?

Viral cultures and rapid antigen tests not needed
Radiographic in atypical patients
Frontal: narrowing of the subglottic space (stepple sign)
Absence of this sign doesnt rule out croup

Radiographic investigation
In bacterial tracheitis and epiglottitis can agitate

children and trigger acute airway obstruction

Epiglottitis: abnormally thickened epiglottis and arytenoepiglottic

folds
Retropharyngeal abscess: bulging soft tissue of the posterior
pharyngeal wall
Bacterial tracheitis: irregular tracheal mucosa, or strands projecting
into or across the tracheal lumen

 Score 2

: mild croup
Score 3-5 : moderate croup
Score 6-11 : severe croup
Score 12 : impending respiratory failure

Corticosteroid
Data
Decreased ET intubation by 5x
Reduced length of hospital stay by 1/3
Reduced return medical visits by 1/2
Effects
Reduce respiratory distress within 1h of oral administration
Effects increasing for at least 10h after administration

Mechanism of action
Anti-inflammation reducing edema of laryngeal mucosa

Corticosteroid
Route
Oral: dexamethasone or prednisolone
Nebulized: budesonide
Intramuscular: dexamethasone
Drug of choice: Dexamethasone
Standard-dose (0.6 mg/kg); low-dose (0.15 mg/kg)
Randomized trials no significant differences
Meta-analysis standard-dose > low-dose

Nebulized epinephrine
Data
Clinical improvement in croup score 30m followng administration
Shorter length of stay
Effects
Rapid, short-term relief of severe respiratory distress
Onset of effect within 10m
Effects lasts 1-2h

MoA
Adrenergic reducing vascular permeability on bronchial and
tracheal epithelium, reducing edema of laryngeal mucosa,
increasing respiratory rate

Nebulized epinephrine
Racemic epinephrine 2.25% (0.5 ml in 2.5 ml saline)
L-epinephrine 0.1% (5.0 ml) [1:1000]
Reduction in croup score at 30m no difference
Reduction in croup score at 2h L-epinephrine > racemic
epinephrine
Drug of choice: L-epinephrine

Other pharmacotherapies
Salbutamol (selective 2 agonist)
Unlikely to reverse the narrowing of the upper airway because it
doesnt contain smooth muscle
Antibiotics
Unlikely to shorten the duration of symptoms because croup is
caused by a viral infection
Heliox
Mixture of low-density helium with oxygen (70:30, 80:20)
Thought to decrease airflow turbulence through narrowed airway
decreasing the work of breathing

 Indication of admission
Persistent stridor and chest wall indrawing >4h after treatment with
corticosteroids
Sociodemographic or conditional factors:
Parents dependence on public transport, living a long distance from

medical care and inclement weather

Indication of discharge
No stridor or chest indrawing at rest

Controversies in treatment and gaps in knowledge

Corticosteroid drug of choice for children with croup in

all levels of severity

The most effective dose range?
Benefit of repeated doses in more severe croup?

Epinephrine temporary relief of upper airway

obstruction in more severe cases of croup

Shown to be ineffective and consequently rarely used in acute care

setting

Conclusion
Treatment of all children with croup with corticosteroids
and those with severe respiratory distress with nebulized
epinephrine

Decrease intubations, hospital admissions and return

visits for medical care

Decreasing health care costs while improving childrens

outcomes and lessening the burden of the disease on
childrens families

Thank you