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Emergent Management of Croup (Laryngotracheobronchitis)

  • Author: Lonnie King, MD; Chief Editor: Kirsten A Bechtel, MD  more...
 
Updated: Nov 02, 2015
 

Overview

Laryngotracheobronchitis (ie, croup) is a viral infection of the upper respiratory tract that causes varying degrees of airway obstruction but that,[1] with aggressive emergent management, only infrequently requires hospital admission.[2]  Although the disease is most often self-limited, it occasionally is severe and can in rare cases be fatal. A barking cough, stridor, and fever are characteristic symptoms; laryngotracheobronchitis is the most common cause of stridor in children.[3, 4, 5] (See the image below.)

Child with croup. Note the steeple or pencil sign Child with croup. Note the steeple or pencil sign of the proximal trachea evident on this anteroposterior film. Courtesy of Dr. Kelly Marshall, CHOA at Scottish Rite.

 

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Emergency Care

Prehospital care

Avoid actions that may agitate the child with laryngotracheobronchitis and lead to worsened respiratory distress. Transport the child in a parent's lap and give oxygen as tolerated, usually via a blow-by technique.

Emergency department care

Goals of emergency department (ED) care are to reduce respiratory distress, monitor for worsening condition, and consider or evaluate for other etiologies of stridor. Evidence-based guidelines have been established for the management of laryngotracheobronchitis.[6]

Make the child as comfortable as possible, and avoid agitating the patient with unnecessary procedures and examinations. Humidified air or mist therapy may be used, but both have unproven efficacy.[7] Provide oxygen (humidified) to all hypoxic patients.

L -epinephrine (1:1000) is as effective as racemic epinephrine. Nebulized epinephrine has proven to significantly reduce symptoms of laryngotracheobronchitis within 30 minutes of administration. (Epinephrine therapy does not indicate the need for admission.)[8]

Rebound stridor after epinephrine therapy has been described in patients with laryngotracheobronchitis, but it appears to be less of a problem if corticosteroid therapy is initiated early in the ED course.

Dexamethasone has been shown to reduce symptoms in patients with moderate to severe laryngotracheobronchitis (0.6 mg/kg IM, not to exceed 10 mg). The intravenous formulation of dexamethasone may be administered orally as it is readily bioavailable from the GI tract.[9] Some authorities recommend a repeat dose of dexamethasone in 6 hours.[10, 11]  Prednisolone (2 mg/kg/dose/day for a total of 3 days) may be an alternative if dexamethasone is not available.[12]

Nebulized budesonide (2 mg) has been shown in several studies to be equivalent to oral dexamethasone. Inhaled dexamethasone is also used, when budesonide is unavailable.[13]

Always consider other causes of stridor, such as foreign bodies, bacterial tracheitis, and epiglottitis. Be sure to observe patients for an adequate period before ED discharge and to document satisfactory pulse oximetry.

Consultation with an otorhinolaryngologist and anesthesia prior to rapid sequence induction (RSI) may be necessary if the patient is exhibiting rapid deterioration that might suggest an alternative diagnosis.

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Contributor Information and Disclosures
Author

Lonnie King, MD Consulting Staff, Department of Emergency Medicine, Children's Healthcare of Atlanta at Scottish Rite

Lonnie King, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Emergency Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Wayne Wolfram, MD, MPH Professor, Department of Emergency Medicine, Mercy St Vincent Medical Center; Chairman, Pediatric Institutional Review Board, Mercy St Vincent Medical Center, Toledo, Ohio

Wayne Wolfram, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Pediatrics, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Kirsten A Bechtel, MD Associate Professor of Pediatrics, Section of Pediatric Emergency Medicine, Yale University School of Medicine; Co-Director, Injury Free Coalition for Kids, Yale-New Haven Children's Hospital

Kirsten A Bechtel, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Additional Contributors

Jerry R Balentine, DO, FACEP, FACOEP Vice President, Medical Affairs and Global Health, New York Institute of Technology; Professor of Emergency Medicine, New York Institute of Technology College of Osteopathic Medicine

Jerry R Balentine, DO, FACEP, FACOEP is a member of the following medical societies: American College of Emergency Physicians, New York Academy of Medicine, American College of Osteopathic Emergency Physicians, American Association for Physician Leadership, American Osteopathic Association

Disclosure: Nothing to disclose.

References
  1. Johnson DW. Croup. Clin Evid (Online). 2009 Mar 10. 2009:[Medline].

  2. Narayanan S, Funkhouser E. Inpatient hospitalizations for croup. Hosp Pediatr. 2014 Mar. 4 (2):88-92. [Medline]. [Full Text].

  3. Miller EK, Gebretsadik T, Carroll KN, Dupont WD, Mohamed YA, Morin LL, et al. Viral Etiologies of Infant Bronchiolitis, Croup, and Upper Respiratory Illness during Four Consecutive Years. Pediatr Infect Dis J. 2013 May 20. [Medline].

  4. Atkinson PR, Boyle AA, Lennon RS. Weather factors associated with paediatric croup presentations to an Australian emergency department. Emerg Med J. 2013 Apr 4. [Medline].

  5. Rankin I, Wang SM, Waters A, Clement WA, Kubba H. The management of recurrent croup in children. J Laryngol Otol. 2013 May. 127(5):494-500. [Medline].

  6. [Guideline] Mazza D, Wilkinson F, Turner T, Harris C. Evidence based guideline for the management of croup. Aust Fam Physician. 2008 Jun. 37(6 Spec No):14-20. [Medline].

  7. Petrocheilou A, Tanou K, Kalampouka E, Malakasioti G, Giannios C, Kaditis AG. Viral croup: diagnosis and a treatment algorithm. Pediatr Pulmonol. 2014 May. 49 (5):421-9. [Medline].

  8. Bjornson C, Russell KF, Vandermeer B, Durec T, Klassen TP, Johnson DW. Nebulized epinephrine for croup in children. Cochrane Database Syst Rev. 2011 Feb 16. 2:CD006619. [Medline].

  9. Chou JW, Decarie D, Dumont RJ, et al. Stability of dexamethasone in extemporaneously prepared oral suspensions. J Can Pharm Hosp. 2001. 54:97-103.

  10. Bjornson CL, Klassen TP, Williamson J, et al. A randomized trial of a single dose of oral dexamethasone for mild croup. N Engl J Med. 2004 Sep 23. 351(13):1306-13. [Medline].

  11. Beigelman A, Chipps BE, Bacharier LB. Update on the utility of corticosteroids in acute pediatric respiratory disorders. Allergy Asthma Proc. 2015 Sep. 36 (5):332-8. [Medline]. [Full Text].

  12. Garbutt JM, Conlon B, Sterkel R, Baty J, Schechtman KB, Mandrell K, et al. The comparative effectiveness of prednisolone and dexamethasone for children with croup: a community-based randomized trial. Clin Pediatr (Phila). 2013 Nov. 52 (11):1014-21. [Medline].

  13. Fitzgerald D, Mellis C, Johnson M, Allen H, Cooper P, Van Asperen P. Nebulized budesonide is as effective as nebulized adrenaline in moderately severe croup. Pediatrics. 1996 May. 97 (5):722-5. [Medline].

 
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Child with croup. Note the steeple or pencil sign of the proximal trachea evident on this anteroposterior film. Courtesy of Dr. Kelly Marshall, CHOA at Scottish Rite.
 
 
 
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