An 11-month old male born at full term arrives to your ED. He is up to date on vaccinations. Mom reports 3 days of fever, rhinorrhea, and cough. You hear his barking cough in the waiting room. On exam, you hear a high-pitched sound upon inspiration at rest. Mom mentions that baby seemed to get better while outside in the cold air waiting for the ambulance. The patient appears to have increased work of breathing but is not hypoxic on the monitor. His CXR is shown below. What is the best treatment for the patient at this time?

Case courtesy of Dr Liam Pugh, Radiopaedia.org, rID: 53949

A. Albuterol-ipratropium nebulization

B. Amoxicillin 

C. Dexamethasone and racemic epinephrine

D. Dexamethasone only 

C. Dexamethasone and racemic epinephrine. This infant has croup, otherwise known as laryngotracheobronchitis. It is caused by parainfluenza virus most commonly in the colder months for children under the age of 3. This is a clinical diagnosis however it is associated with the classic “steeple sign” of supraglottic tracheal narrowing on CXR. Because this patient has stridor at rest, he needs racemic epinephrine nebulization in addition to 0.6 mg/kg oral dexamethasone. Beta agonists may actually worsen airway edema and should not be used. This patient should then be observed for return of stridor for 2 hours after initial racemic epinephrine administration. If the patient’s respiratory status further declines and intubation is required, note that a smaller than calculated ETT size may be needed.

Smith, D., McDermott, A., and Sullivan, J. (2018). Croup: Diagnosis and Management. American Family Physician, 1;97(9):575-580. <https://www.aafp.org/afp/2018/0501/p575.html>

For further review of croup, see this prior EM Daily post: https://emdaily.cooperhealth.org/content/back-basics-croup