Croup

We all enjoy treating “fixable” problems. If you can couple that with simple diagnosis and the ability to bill Critical Care time (ok, perhaps that last criteria is a bit too jaded for our newest of residents), then you have a fun condition to manage in the ED. Croup fits all of those criteria perfectly. You are often able to make the diagnosis before you even enter the patient’s room by hearing the barking from down the hall. Most often you are able to administer simple and effective therapies and can see clinical improvement. Occasionally, the presenting symptoms are severe enough, and your time commitment long enough, to warrant critical care billing. Man that is fun! But, you should always be mindful that not everyone plays by the same rules and, occasionally, croup may actually require Critical Care Admission.

Basics

1. Ages: 6mos – 6yrs (peak at 2yrs)
2. Parainfluenza is the most common etiology, but it can be any virus really

Presentation

1. Typically have 1-3 days of URI symptoms and then develop Harsh, Barking cough
2. With or without stridor
3. Diagnosis is clinical (another positive of this condition!)

Management

1. Croup Scores
   1. Useful in research to ensure comparability…
   2. I’m not smart enough to remember them… so I prefer the following:
      1. MILD CROUP= Barky Cough, No Stridor
         1. Decadron (0.6mg/kg po once, 0.15mg/kg has also shown benefit)
         2. The steroid will NOT necessary improve the condition, but can prevent it from progressing – so be very clear with the family to manage expectations.
      2. MODERATE CROUP= Barky Cough, Stridor with agitation/excitement
         1. Decadron – can decrease symptoms and improve stridor.
         2. Observation – this is to define whether the stridor is ever at rest… when you first evaluate the child, he/she is likely not at rest as you either excite or agitate them (maybe that’s just me). So reassess the patient at rest. No stridor at rest? No Racemic Epi needed.
         3. Inform family that cough will last for even several weeks and that the stridor may recur during episodes of agitation/excitement.
      3. SEVERE CROUP= Barky cough, Stridor AT REST!
         1. Decadron
         2. Racemic Epinephrine – will work faster than the steroids, but has short half-life.
         3. Ideally, one dose of Racemic Epi will improve patient long enough for steroids to start to work and both alleviate Stridor at Rest.
         4. Requires Observation to determine duration of efficacy. If patient does not require any more Racemic Epi after 2 hours, then the patient can be safely discharged home.
         5. If the patient requires more Racemic Epi, then admission for further management is warranted.
2. OTHER THERAPIES
   1. Cool Mist – never proven to be effective (but little downside)
   2. Heliox – helps alleviate the turbulent airflow created by the supraglottic edema and, thus, improves stridor and decreases work of breathing.
   3. BiPap – anytime that you are dealing with increased work of breathing, consider BiPap. This hasn’t been specifically proven to work for severe croup… but it still may help.
   4. Intubation – there will be some that require an ETT… anticipate a difficult airway (have all of your back-up plans) and use 1-1.5 smaller size ETT than normal.
3. Consider:
4. If the patient is not responding like you thought he/she should have, then it is time to readdress the diagnosis and consider others like:
   1. Bacterial Tracheitis (see separate Morsel on this!)
   2. Foreign Body Aspiration
   3. Epiglottitis (may present atypically now with HiB vaccination)

Admit

1. Stridor at rest despite racemic Epi
2. Persistent respiratory distress
3. Dehydration
4. Poor social situation.

Bjornson CL, Johnson DW. Croup. Lancet. 2008; 371: 329-339.

Cherry JD. Croup. NEJM. 2008; 358: 384-391.