5 Essential Steps to Managing Croup

Podcast

Episode 9: 5 Essential Steps to Managing Croup

Show Notes

 Background

Croup, a.k.a. laryngotracheitis is a common viral illness seen predominantly in children and affecting the upper respiratory tract.  While typically mild, croup has the potential to become life-threatening in some cases.  By causing subglottic edema, croup narrows the upper airway, sometimes causing respiratory distress.  In extreme circumstances, respiratory arrest may result.

Identifying Croup

  • Signs and Symptoms

    • Onset typically occurs over 1-2 days with general upper respiratory tract infection s/s
      • Runny Nose
      • Cough
      • Sore Throat
      • etc.
    • Low-grade fever MAY be present, yet absence does not exclude diagnosis
    • Seal-like barking cough (this is the hallmark of croup)
      • See video and audio clips above
    • Inspiratory stridor (moderate to severe cases)
    • Respiratory distress (moderate to severe cases)
    • Symptoms seem to spike at night
      • Most ED visits for croup occur between the hours of 2200-0400
    • Steeple Sign on AP chest film
    • Children with mild to moderate croup may appear to be completely normal, with no obvious illness until you hear them cough or cry.  They may be happy, running about and playing as normal.
    • Pay attention to the caretaker’s description of the child’s problem.
  • Differential Diagnoses

    • Epiglottitis
      • Onset much faster (several hours), drooling, child will look very sick
    • Foreign Body Obstruction
      • Sudden onset, lack of URI s/s
    • Bacterial Tracheitis
      • Child will look very sick, painful swallowing
    • Diptheria
      • Child will look very sick, white to gray pseudomembrane
      • ASK ABOUT VACCINATION Hx

Remain Alert for Signs of Impending Respiratory Arrest

  • Increased Lethargy
  • Decreased Muscle Tone
  • Decreased Level of Consciousness
  • Cyanosis (Very Late Sign- Badness)

Essential Management Steps

#1 Keep the Patient Calm

  • Even children with moderate croup may initially appear asymptomatic
  • Avoid agitating the child while conducting assessments and administering treatments. (Get Creative)
  • Utilize parents to comfort and reassure the child as much as possible.

#2 Monitor with Pulse Oximetry and Capnography

  • Monitor for hypercapnia due to CO2 retention
  • Administer oxygen as needed, humidified if possible.

#3 Manage Airway Restriction with Nebulized Epinephrine

  • Used for treatment of moderate to severe cases.
  • Standard L-Epinephrine (1:1000) up to 5 mg nebulized, has been shown to be just as safe as, and possibly more effective than racemic epinephrine.
  • Add Epinephrine (1:1000) to small volume nebulizer and adjust oxygen flow to a low to medium flow rate about 8 liters per minute.
    • While the 1:1000 concentration of epinephrine has been sufficiently documented as safe and effective, consult your local protocols for specific recommendations.
  • Albuterol is NOT an appropriate treatment for croup.
  • Nebulized saline (cool mist) has not been shown to significantly improve croup symptoms.



#4 Reduce Inflammation with Corticosteroids

  • A single dose of dexamethasone is preferred
  • Prednisolone or methylprednisolone may also be used
  • These interventions take time, usually about an hour, to have any effect

#5 Treat Fever with Antipyretics

  • If the patient is febrile, management with antipyretics such as acetaminophen or ibuprofen is indicated.
  • While most children with croup present with a low-grade fever (38-39C), or afebrile, higher fevers (40C+) may occur.


Thanks for listening/reading, please take a moment to follow the site via email, so you don’t miss any future episodes!  You can also follow me on Twitter, Facebook, and Instagram, so you can let me know what you think of the show & the site!  Many of the posts and podcast episodes come from your suggestions, so I would love to hear those as well!  Until next time, stay safe & treat aggressively!

Owen Wood



References

Bjornson C, Russell KF, Vandermeer B, Durec T, Klassen TP, Johnson DW. Cochrane Review: Nebulized epinephrine for croup in children. Evidence-Based Child Health: A Cochrane Review Journal. 2012;7(4):1311–1354.

Croup. Background, Epidemiology. 2017 Nov 15 [accessed 2017 Dec 28]. https://emedicine.medscape.com/article/962972-overview

Diphtheria – Infectious Diseases. Merck Manuals Professional Edition. [accessed 2017 Dec 28]. https://www.merckmanuals.com/professional/infectious-diseases/gram-positive-bacilli/diphtheria

Eghbali A, Sabbagh A, Bagheri B, Taherahmadi H, Kahbazi M. Efficacy of nebulized L-epinephrine for treatment of croup: a randomized, double-blind study. Fundamental & Clinical Pharmacology. 2015;30(1):70–75.

Hansen M, Meckler G, Lambert W, Dickinson C, Dickinson K, Guise J-M. Paramedic assessment and treatment of upper airway obstruction in pediatric patients: an exploratory analysis by the Childrens Safety Initiative-Emergency Medical Services. The American Journal of Emergency Medicine. 2016;34(3):599–601.

Hansen M, Meckler G, Lambert W, Dickinson C, Dickinson K, Guise J-M. Paramedic assessment and treatment of upper airway obstruction in pediatric patients: an exploratory analysis by the Childrens Safety Initiative-Emergency Medical Services. The American Journal of Emergency Medicine. 2016;34(3):599–601.

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