Back to Basics: Croup

Croup (laryngotracheitis) 
-          Ages 6 months – 3 years
-          Parainfluenza virus
-          Peak Fall/Early winter
-          URI prodrome
-          Barking cough, hoarse voice
-          Symptoms most severe on 3rd-4th day -  can develop varying degrees of airway obstruction over 12-48h
-          Inspiratory stridor
Differential Diagnosis:
-          Epiglottitis
-          Tracheitis
-          Retropharyngeal abscess
-          Foreign body aspiration
-          Allergic reaction
-          Rare: diphtheria; < 6 mos consider vascular slings/rings, airway hemangioma, laryngomalacia, subglottic stenosis, vocal cord paralysis
-          Mild – no stridor at rest, +/- stridor and mild retractions when agitated
-          Moderate – stridor at rest + mild retractions, little to no signs of agitation or distress
-          Severe – stridor at rest + severe retractions, agitation and signs of respiratory distress
-          Impending respiratory failure – decreased breath sounds, altered mental status, inspiratory and expiratory stridor, cyanosis
Diagnostic Studies:
-          ***Clinical diagnosis***
-          Classic finding of PA Neck XR with “Steeple Sign” due to subglottic narrowing due to edema
Options include steroids, nebulized racemic epinephrine, and respiratory support
-          Mild – 1x dose dexamethasone (IM or PO), supportive care at home
-          Moderate to severe – steroids + racemic epi (can repeat as frequently as q20 minutes PRN)
-          Discharge: non-toxic, tolerates PO, watch and reassess after 3 hours if received racemic epi
-          Admission: persistent stridor at rest, tachypnea, accessory muscle use, hypoxia, or requirement of >2 treatments with racemic epi
Malhotra A, Krilov R. "Viral Croup." Pediatrics in Review. 2001; 22;5. DOI: 10.1542/pir.22-1-5.

Mapelli E, Sabhaney V. "Stridor and Drooling in Infants and Children." Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8eEds. Judith E. Tintinalli, et al. New York, NY: McGraw-Hill, 2016, pg 800-801.