Croup - Laryngotracheitis (6 mo - 6 years) - Curbside
Croup - Laryngotracheitis (6 mo - 6 years)
Editors: Dan Imler, MD
Inclusion Criteria  (Any one criteria present)
  • Clinical symptoms consistent with croup
Exclusion Criteria
  • Toxic appearance
  • History of upper airway anatomical or functional abnormality
  • Hypotonia or neuromuscular disorder

Consider pediatric or pulmonary consult

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Evidence
Total Notes: 13
Evidence

1 Croup

Croup is disease of upper airway inflammation of the larynx and subglottic airway most commonly caused by respiratory viruses (Parainfluenza 1, 2 & 3 are the most commonly isolated viruses). It most commonly occurs in 6 month to 6 year old children and is more common in boys (1.4:1 ratio).

Croup most commonly occurs in the fall - winter (parainfluenza type 1 seasonality). Visits to emergency departments are most common between 11p - 4a however, patient’s arriving earlier in the evening are more likely to be admitted.



References:
  1. Clinical practice. Croup.
    Cherry JD
    N Engl J Med. 2008;358(4):384.
  2. Clinical courses of croup caused by influenza and parainfluenza viruses.
    Peltola V, Heikkinen T, Ruuskanen O
    Pediatr Infect Dis J. 2002;21(1):76.
  3. Human parainfluenza virus-associated hospitalizations among children less than five years of age in the United States.
    Counihan ME, Shay DK, Holman RC, Lowther SA, Anderson LJ
    Pediatr Infect Dis J. 2001;20(7):646.
  4. Respiratory viruses in laryngeal croup of young children.
    Rihkanen H, RönkköE, Nieminen T, Komsi KL, Räty R, Saxen H, Ziegler T, Roivainen M, Söderlund-Venermo M, Beng AL, Anne L, Hovi T, Pitkäranta A
    J Pediatr. 2008;152(5):661.
  5. Croup.
    Bjornson CL, Johnson DW
    Lancet. 2008;371(9609):329.
  6. Croup hospitalizations in Ontario: a 14-year time-series analysis.
    Segal AO, Crighton EJ, Moineddin R, Mamdani M, Upshur RE
    Pediatrics. 2005;116(1):51.
  7. Croup presentations to emergency departments in Alberta, Canada: a large population-based study.
    Rosychuk RJ, Klassen TP, Metes D, Voaklander DC, Senthilselvan A, Rowe BH
    Pediatr Pulmonol. 2010;45(1):83.

2 Clinical presentation

The clinical presentation of croup is dependent on the level of upper airway obstruction caused by airway inflammation. Inspiratory stridor, "barking" cough (more common in children), and hoarseness (more common in adults) are the common symptoms associated with croup. Croup usually begins with URI sx (cough, congestion and rhinorrhea) and then progresses to symptoms of upper airway obstruction as the inflammation worsens. The respiratory distress associated with croup is directly related to the level of obstruction. Most symptoms resolved within 3 days, but may take up to 7 days.



References:
  1. Textbook of Pediatric Infectious Diseases, 7th
    Cherry JD.
    Elsevier Saunders, Philadelphia 2014.p.241.

3 Dexamethasone

Glucocorticoids have repeatedly shown to improve clinical scores of croup, decrease admissions, decrease return visits, decrease time in the ED and hospital and decrease the use of epinephrine in patients with croup. This is likely by decreasing the laryngotracheal edema through their anti-inflammatory actions. Dexamethasone has been the most extensively studied glucocorticoid for croup. Although other steroids may have similar effects, a majority of providers choose dexamethasone due to its multiple routes of administration, prolonged duration of action, few adverse effects and substantial evidence base.

There has been shown to be no difference between the IV, IM and oral use of dexamethasone. It is unclear if nebulized dexamethasone is efficacious, although nebulized budesonide has been shown as efficacious as IV or oral dexamethasone. Dexamethasone + budesonide was shown to be equivalent to dexamethasone alone. A lower dose of dexamethasone (0.15 mg/kg) may be similar to the more commonly used dose (0.6 mg/kg) although a majority of providers still used the higher dose.

Oral dexamethasone is foul tasting and less concentrated so many providers give the IV formulation PO for improve adherence.

There is no evidence that repeat doses of dexamethasone improve outcomes in croup.

Given that mild, moderate and severe patients with croup benefit from glucocorticoids, the Curbside pathway recommends dexamethasone for all patients presenting with symptoms of croup.



References:
  1. Steroid treatment of laryngotracheitis: a meta-analysis of the evidence from randomized trials.
    Kairys SW, Olmstead EM, O'Connor GT
    Pediatrics. 1989;83(5):683.
  2. Glucocorticoids for croup.
    Russell KF, Liang Y, O'Gorman K, Johnson DW, Klassen TP
    Cochrane Database Syst Rev. 2011 Jan 19;(1):CD001955.
  3. Placebo-controlled trial of prednisolone in children intubated for croup.
    Tibballs J, Shann FA, Landau LI
    Lancet. 1992;340(8822):745.
  4. A randomized trial of a single dose of oral dexamethasone for mild croup.
    Bjornson CL, Klassen TP, Williamson J, Brant R, Mitton C, Plint A, Bulloch B, Evered L, Johnson DW, Pediatric Emergency Research Canada Network
    N Engl J Med. 2004;351(13):1306.
  5. Nebulized budesonide and oral dexamethasone for treatment of croup: a randomized controlled trial.
    Klassen TP, Craig WR, Moher D, Osmond MH, Pasterkamp H, Sutcliffe T, Watters LK, Rowe PC
    JAMA. 1998;279(20):1629.
  6. Budesonide offers no advantage when added to oral dexamethasone in the treatment of croup.
    Geelhoed GC
    Pediatr Emerg Care. 2005;21(6):359.
  7. Textbook of Pediatric Emergency Medicine, 6th
    Harper MB, Fleisher GR.
    Lippincott Willams & Wilkins, Philadelphia 2010.p.887.
  8. Croup.
    Johnson D
    Clin Evid. 2005 Dec;(14):310-27.
  9. Bioavailability of oral dexamethasone.
    Duggan DE, Yeh KC, Matalia N, Ditzler CA, McMahon FG
    Clin Pharmacol Ther. 1975;18(2):205.
  10. Effectiveness of oral or nebulized dexamethasone for children with mild croup.
    Luria JW, Gonzalez-del-Rey JA, DiGiulio GA, McAneney CM, Olson JJ, Ruddy RM
    Arch Pediatr Adolesc Med. 2001;155(12):1340.
  11. Outpatient treatment of croup with nebulized dexamethasone.
    Johnson DW, Schuh S, Koren G, Jaffee DM
    Arch Pediatr Adolesc Med. 1996;150(4):349.
  12. A comparison of nebulized budesonide, and intramuscular, and oral dexamethasone for treatment of croup.
    Cetinkaya F, Tüfekçi BS, Kutluk G
    Int J Pediatr Otorhinolaryngol. 2004;68(4):453.

4 Severity assessment

In 1978 Westley et al. developed a validated croup score to determine the severity of symptoms. Other clinical scores have been subsequently developed, but none have been validated in the clinical setting. Children with moderate to severe scores (greater than 3 on the Westley scale) will likely benefit from nebulized racemic epinephrine. Curbside uses a modified version of the Westley score (listed below) to determine the need for epinephrine.

Stridor  
   None 0
   With agitation 1
   At rest 2
Retractions  
   None 0
   Mild 1
   Moderate 2
   Severe 3
Air entry  
   Normal 0
   Decreased 1
   Markedly decreased 2
Cyanosis  
   None 0
   With agitation 4
   At rest 5
Level of consciousness  
   Normal, including sleep 0
   Disoriented 5


References:
  1. Nebulized racemic epinephrine by IPPB for the treatment of croup: a double-blind study.
    Westley CR, Cotton EK, Brooks JG
    Am J Dis Child. 1978;132(5):484.
  2. Croup.
    Bjornson CL, Johnson DW
    Lancet. 2008;371(9609):329.
  3. Clinical practice. Croup.
    Cherry JD
    N Engl J Med. 2008;358(4):384.

5 Nebulized racemic epinephrine

Nebulized racemic epinephrine causes rapid improvement in most cases of moderate to severe croup by constricting the arterioles in the upper airway causing fluid resorption and improvement of airway edema. Due to the nature of fluid dynamics, even a slight improvement in the diameter of the airway can cause large effects in the flow of air. The max effect of epinephrine appears around 20 - 30 minutes and resolves by ~120 minutes. Because of this, racemic epinephrine does not alter the natural course of croup, but simply provides symptomatic relief. There is no evidence that the patients have worsening croup scores after the epinephrine effect resolves, but simply return to their previous baseline.

Dexamethasone + nebulized epinephrine has been shown to decreased duration of hospitalization.

In several studies the evidence does not favor racemic epinephrine or L-epinephrine, or Intermittent Positive Pressure Breaths (IPPB) over simple nebulization.



References:
  1. Viral croup: current diagnosis and treatment.
    Kaditis AG, Wald ER
    Pediatr Infect Dis J. 1998;17(9):827.
  2. Nebulized racemic epinephrine by IPPB for the treatment of croup: a double-blind study.
    Westley CR, Cotton EK, Brooks JG
    Am J Dis Child. 1978;132(5):484.
  3. Inhalation of racemic adrenaline in the treatment of mild and moderately severe croup. Clinical symptom score and oxygen saturation measurements for evaluation of treatment effects.
    Kristjánsson S, Berg-Kelly K, WinsöE
    Acta Paediatr. 1994;83(11):1156.
  4. Treatment of laryngotracheobronchitis (croup). Use of intermittent positive-pressure breathing and racemic epinephrine.
    Taussig LM, Castro O, Beaudry PH, Fox WW, Bureau M
    Am J Dis Child. 1975;129(7):790.
  5. Radiographic tracheal diameter measurements in acute infectious croup: an objective scoring system.
    Corkey CW, Barker GA, Edmonds JF, Mok PM, Newth CJ
    Crit Care Med. 1981;9(8):587.
  6. A randomized double-blind, placebo-controlled trial of dexamethasone and racemic epinephrine in the treatment of croup.
    Kuusela AL, Vesikari T
    Acta Paediatr Scand. 1988;77(1):99.
  7. Nebulized epinephrine for croup in children.
    Bjornson C, Russell K, Vandermeer B, Klassen TP, Johnson DW
    Cochrane Database Syst Rev. 2013;10:CD006619.
  8. Racemic epinephrine in the treatment of croup: nebulization alone versus nebulization with intermittent positive pressure breathing.
    Fogel JM, Berg IJ, Gerber MA, Sherter CB
    J Pediatr. 1982;101(6):1028.
  9. Prospective randomized double-blind study comparing L-epinephrine and racemic epinephrine aerosols in the treatment of laryngotracheitis (croup).
    Waisman Y, Klein BL, Boenning DA, Young GM, Chamberlain JM, O'Donnell R, Ochsenschlager DW
    Pediatrics. 1992;89(2):302.

6 Clinical reassessment

Nebulized racemic epinephrine has a rapid onset of action between 5 - 10 min. By the time the nebulized treatment is complete most patients will begin to have some effect from the medication. If a patient arrives with severe signs of croup and does not improve with a nebulized dose, transfer to an ICU and evaluation of other causes of upper airway obstruction (foreign body, epiglottitis, bacterial tracheitis, etc.) should be considered.



References:
  1. Nebulized racemic epinephrine by IPPB for the treatment of croup: a double-blind study.
    Westley CR, Cotton EK, Brooks JG
    Am J Dis Child. 1978;132(5):484.
  2. Prospective randomized double-blind study comparing L-epinephrine and racemic epinephrine aerosols in the treatment of laryngotracheitis (croup).
    Waisman Y, Klein BL, Boenning DA, Young GM, Chamberlain JM, O'Donnell R, Ochsenschlager DW
    Pediatrics. 1992;89(2):302.

7 Epinephrine duration

Multiple studies have shown that croup scores return to their baseline ~120 min after nebulized epinephrine and that epinephrine does not alter the longer term progression of disease. Patients who are being discharged who have received nebulized epinephrine should be observed for at least 2 hours to ensure that their symptoms do not return.



References:
  1. Nebulized racemic epinephrine by IPPB for the treatment of croup: a double-blind study.
    Westley CR, Cotton EK, Brooks JG
    Am J Dis Child. 1978;132(5):484.
  2. Taussig LM, Castro O, Beaudry PH, Fox WW, Bureau M
    Treatment of laryngotracheobronchitis (croup). Use of intermittent positive-pressure breathing and racemic epinephrine.
    Am J Dis Child. 1975;129(7):790.
  3. Nebulized epinephrine for croup in children.
    Bjornson C, Russell K, Vandermeer B, Klassen TP, Johnson DW
    Cochrane Database Syst Rev. 2013;10:CD006619.

8 Cool mist

There have been several randomized trials that have shown no effect of mist therapy in the treatment of croup. Although deliver of nebulized treatments and oxygen should be humidified, there is no role for mist therapy as a primary treatment modality.



References:
  1. Treatment of croup. A critical review.
    Skolnik NS
    Am J Dis Child. 1989;143(9):1045.
  2. A randomized controlled trial of mist in the acute treatment of moderate croup.
    Neto GM, Kentab O, Klassen TP, Osmond MH
    Acad Emerg Med. 2002;9(9):873.
  3. Controlled delivery of high vs low humidity vs mist therapy for croup in emergency departments: a randomized controlled trial.
    Scolnik D, Coates AL, Stephens D, Da Silva Z, Lavine E, Schuh S
    JAMA. 2006;295(11):1274.

9 Respiratory Viral PCR

Many different viruses may cause croup. Identification of the exact pathogen is unlikely to improve the outcomes of patients given the clinical diagnosis and clinical management of the patient. Therefore, guidelines commonly do not advocate for the use of viral or other laboratory studies in the management of croup. The exception to this may be for influenza testing for prophylaxis or for cohorting of admitted patients.



References:
  1. Evidence based guideline for the management of croup.
    Mazza D, Wilkinson F, Turner T, Harris C; Health for Kids Guideline Development Group.
    Aust Fam Physician. 2008 Jun;37(6 Spec No):14-20.

10 Radiographs

Both chest x-rays and neck x-rays are rarely useful in the diagnosis and treatment of croup. CXR may demonstrate a "steeple sign", representing the subglottic narrowing. The lateral neck view may demonstrate hypopharynx overdistention during inspiration.

X-rays may be useful to evaluate for other diagnosis that may present with airway obstruction such as foreign body aspiration or epiglottitis.



References:
  1. The usefulness of lateral neck roentgenograms in laryngotracheobronchitis.
    Mills JL, Spackman TJ, Borns P, Mandell GA, Schwartz MW
    Am J Dis Child. 1979;133(11):1140.
  2. Evidence based guideline for the management of croup.
    Mazza D, Wilkinson F, Turner T, Harris C; Health for Kids Guideline Development Group.
    Aust Fam Physician. 2008 Jun;37(6 Spec No):14-20.

11 Bacterial tracheitis

Bacterial tracheitis may mimic some of the initial symptoms of croup or present as a secondary superinfection imposed upon croup. The provider must play close attention to identify this critical disorder. Symptoms which should prompt concern for bacterial tracheitis include: high fevers, toxic appearance, and increasing respiratory distress secondary from purulent secretions. Early antibiotics, ICU admission and airway stabilization are often required for this disease process.



References:
  1. Differentiation of epiglottitis from laryngotracheitis in the child with stridor.
    Mauro RD, Poole SR, Lockhart CH
    Am J Dis Child. 1988;142(6):679.
  2. Bacterial tracheitis in children.
    Kasian GF, Bingham WT, Steinberg J, Ninan A, Sankaran K, Oman-Ganes L, Houston CS
    CMAJ. 1989;140(1):46.
  3. Bacterial tracheitis.
    Jones R, Santos JI, Overall JC Jr
    JAMA. 1979;242(8):721.
  4. Bacterial tracheitis reexamined: is there a less severe manifestation?
    Salamone FN, Bobbitt DB, Myer CM, Rutter MJ, Greinwald JH Jr
    Otolaryngol Head Neck Surg. 2004;131(6):871.

12 Epiglottitis

Epiglottitis may mimic some of the symptoms of croup and needs to be identified immediately to provide relevant care. Epiglottitis often presents with high fevers, toxic appearance, acute upper airway obstruction (tripod posture), dysphagia, drooling, and distress. The severity and drooling symptoms are less common in bacterial tracheitis, but can occur. Immediate airway intervention and antibiotics are often necessary in epiglottitis.



References:
  1. Airway infectious disease emergencies.
    Rafei K, Lichenstein R
    Pediatr Clin North Am. 2006;53(2):215.
  2. An update on inflammatory disorders of the pediatric airway: epiglottitis, croup, and tracheitis.
    Stroud RH, Friedman NR
    Am J Otolaryngol. 2001;22(4):268.
  3. Emergency department management of acute respiratory infections.
    Ward MA
    Semin Respir Infect. 2002;17(1):65.
  4. Acute epiglottitis: analysis of factors associated with airway intervention.
    Katori H, Tsukuda M
    J Laryngol Otol. 2005;119(12):967.

13 Spasmodic croup

Spasmodic croup is similar to Laryngotracheitis however its key differentiating feature is that it ONLY occurs at night. It often occurs multiple times per night or on multiple nights for several nights in a row. Often it resolves prior to reaching care or when the child becomes less anxious. Commonly spasmodic croup requires no intervention although steroids and racemic epinephrine may improve symptoms. Spasmodic croup may have a genetic component and has been related in families with atopy.



References:
  1. Textbook of Pediatric Infectious Diseases, 7th
    Cherry JD.
    Elsevier Saunders, Philadelphia 2014.p.241.
  2. Recurrent croup.
    Hide DW, Guyer BM
    Arch Dis Child. 1985;60(6):585.
  3. Viral croup: current diagnosis and treatment.
    Kaditis AG, Wald ER
    Pediatr Infect Dis J. 1998;17(9):827.