Croup Flashcards
At what ages does Croup typically occur? (TOP)
- 6 months to 3 years
What season does Croup predominantly occur? (TOP)
- Autumn
Does croup affect boys or girls more? (CMAJ)
- Boys
- M:F 1.4:1
What is Croup usually caused by? (TOP)
- Parainfluenza virus
How can Croup be further classified? (TOP)
- Acute laryngotracheobronchitis (included viral prodrome)
- Spasmodic croup (no viral prodrome, can have recurrent episodes)
What symptoms commonly precede symptoms of croup? (TOP)
- Viral Prodrome (24 – 72 hours prior)
- Non-specific cough
- Rhinorrhea
- Fever
Name 8 symptoms of Croup. (TOP)
- Seal-like barky cough
- Hoarseness
- None to moderately high fever (up to 40 degrees C)
- Irritability
- Stridor
- Chest wall indrawing of varying severity
- Absence of drooling
- Non-toxic appearance
When does stridor typically occur for Croup? (TOP)
- Inspiration (can be biphasic – with expiration – with more severe distress)
When do symptoms of Croup typically appear during the day? (TOP)
- Late evening/night and abrupt onset
- Usually improve during the day and often recur again the following night
When do symptoms in children typically resolve by? (TOP/CMAJ)
- 48 hours in 60%
How long can children remain symptomatic with croup in a small percentage of cases? (TOP/CMAJ)
- 5-6 days in less than 2%
What are resolving Croup symptoms usually followed by? (TOP)
- Typical URTI-like symptoms
- Occasionally a secondary bacterial-induced otitis media
Name 5 other potential causes of stridor in children other than Croup. (TOP)
- Bacterial tracheitis
- Epiglottitis
- Foreign body lodged in upper esophagus
- Retropharyngeal or Peritonsillar abscess
- Hereditary angioedema
What is the most common and second most common alternative diagnosis to croup? (TOP)
- Bacterial tracheitis
- Epiglotitis
What is the most frequently isolated bacterial pathogen in bacterial tracheitis? (CMAJ)
- Staphylococcus aureus
How does bacterial tracheitis typically present? (TOP)
- Sudden worsening of symptoms following a mild-to-moderate episode of croup
- Acute onset of high fever
- Toxic appearance
- Poor response to epinephrine
- *Thick tracheal secretions have the potential to cause airway occlusion
How is bacterial tracheitis typically treated? (TOP)
- Broad-spectrum IV antibioitics
- Close monitoring
- Intubation and respiratory support frequently required
What is epiglottitis primarily caused by? (TOP)
- Haemophilus influenza (HIB vaccine)
How does epiglottitis typically present? (TOP)
- Sudden onset of high fever
- Dysphagia
- Drooling
- Toxic appearance
- Anxious
- Sitting forward in a “sniffing position”
- Absence of a barky cough
What is the most crucial aspect of management for epiglottitis? (TOP)
- Intubation (securing the airway)
What are 5 signs of impending respiratory failure in children? (TOP)
- Change in mental status such as fatigue and listlessness
- Pallor or cyanosis
- Dusky appearance
- Decreased retractions or asynchronous chest wall and abdominal movement
- Decreased breath sounds with decreasing stridor
Are laboratory and radiological assessment necessary to diagnose croup? (TOP)
- No
What imaging studies could be ordered to help clarify the diagnosis in children with atypical croup-like symptoms? Describe 4 findings on x-ray suggesting of Croup or other diagnoses. (TOP)
- Lateral and AP soft tissue neck film
- Croup à “Steeple Sign” (cone-shaped narrowing) on AP
- Bacterial Tracheitis à ragged edge or a membrane spanning the trachea
- Epiglottitis à thickening of epiglottis and aryepiglottic folds
- Retropharyngeal abscess à bulging posterior pharynx soft tissues
If ordering radiography in a child with possible croup, what needs to be done? (TOP)
- Child must be monitored closely be personnel with skills and experience in the management of difficult airways
If epiglottitis or bacterial tracheitis is suspected, what test is contraindicated and why? (TOP)
- Lateral and AP soft tissue neck film à manipulation of the neck or agitation to the child may precipitate increased airway obstruction
For children with moderate to severe croup, what should be monitored during assessment? (TOP)
- Pulse oximetry
When should oxygen be administered to children with croup? (TOP)
- Hypoxia (O2 sat < 92%)
- Significant respiratory distress
What are the levels of severity for children with croup? (TOP)
For patients with croup in respiratory distress, what type of oxygen is recommended? (TOP)
- Blow-by humidified oxygen (administration of oxygen through a plastic hose with the end opening held near the child’s nose and mouth)
Is there any benefit to mist therapy or humidifiers for children with croup? (TOP)
- No
What is the evidence for mist therapy for croup? (TOP)
- Systematic review found no significant difference in croup score following humidified air
- RCT published in JAMA 2006
- Randomized 140 children with moderate to severe croup in an ED
- Humidified ‘blow-by’ oxygen (placebo – ambient humidity equal to room air) vs 40% humidified oxygen vs 100% humidified oxygen
- No significant benefit to humidity (croup score, admission to hospital, need for additional medical care, treatment with epinephrine or dexamethasone
Why are mist tents in particular not recommended? (TOP)
- Uncomfortable wet, cold, “caged” environment
- Separate the child from their parents which results in agitating the child
- If improperly cleaned between use may disperse contaminants into the child’s room
What is the evidence for antitussives and decongestants for children with croup? (TOP)
- No evidence, should NOT be recommended
Is there a benefit for beta-2 agonists for treating croup? (TOP)
- No (Croup upper airway disease, no physiological basis)
For patients with croup and severe respiratory distress (i.e. marked sternal wall indrawing and agitation), what can be given for the temporary relief of symptoms of airway obstruction? (TOP)
- Epinephrine (L-epinephrine = racemic epinephrine)
- Racemic epinephrine 2.25% (0.5 mL in 2.5 mL saline)
- No longer available in North America
- L-epinephrine 1:1000 (5 mL)
- Racemic epinephrine 2.25% (0.5 mL in 2.5 mL saline)
How long does it take to see a benefit with epinephrine for croup, how long does the improvement typically las, and how long until the effects dissipate? (TOP)
- Within 10 minutes can see benefit (improvement in croup score on systematic review 30 minutes following administration)
- Lasts for more than an hour
- Dissipates within 2 hours
Do patients with croup treated with epinephrine develop a ‘rebound effect’ after 2 hours? (TOP)
- No
For patients that receive nebulized epinephrine for croup, do they require admission to hospital? (TOP)
- No – but should NOT be discharged home before 2 hours after treatment
Should repeat doses of epinephrine be used in patients with croup? Why or why not? (TOP)
- No (one paper reported on a child receiving 3 nebulizations within one hour developed ventricular tachycardia and had a myocardial infarction)
What should all children diagnosed with croup be administered as treatment? (TOP)
- Dexamethasone (Oral preferred to IM except in very severe croup)
What is the dose of dexamethasone to treat croup? (TOP)
- Dexamethasone 0.6 mg/kg PO/IM once
- Can consider lower dose of 0.15 mg/kg PO/IM (TFP)
- May repeat in 6 to 24 hours
When does clinical improvement begin for croup after treatment with dexamethasone? (TFP)
- Improvement within 1 to 3 hours
What is the NNT for benefit with dexamethasone for croup symptoms? (TFP)
- Significant improvement in croup symptoms at 6 hours (NNT = 5)
- Fewer return visits to emergency and/or (re)admissions (NNT = 17)
How long do patients with croup that are treated with dexamethasone have improved symptoms? (TOP)
- 24 to 48 hours
How long should children with croup receiving corticosteroids be observed before the decision is made whether to admit to hospital? (CMAJ)
- 4 hours
What are 2 relative contraindications to dexamethasone treatment in patients with croup? (TOP)
- Known immune deficiency
- Recent exposure to varicella
What % of patients with croup receiving oral dexamethasone vomit? (TOP)
- < 5%
When would nebulized budesonide be given for croup? (TOP)
- Persistent vomiting
- Severe respiratory distress
- Mixed with epinephrine and administered simultaneously (2 mg budenoside nebulized with epinephrine)
Why is budesonide not routinely used to treat croup? (TOP)
- No more effective than dexamethasone
- More traumatic to administer
- Substantially more expensive
Name 1 indication for admission for croup and 3 relative indications for admission. (TOP)
- Significant respiratory distress persisting for 4 or more hours after treatment with corticosteroids
- Sternal wall indrawing
- Easily audible stridor at rest
- *Lack of timely access to care, risk of no observation and follow-up
- *Significant parental anxiety
- *Multiple ED visits within 24 hours
