Pediatrics 4: Laryngotracheal Bronchitis (Croup) Portal
PEDS: Because this entire portal pertains only to pediatric patients, the convention of underlining has been omitted.
Croup most commonly affects children ages 3 months to 5 years, with it being more prevalent in children from 1 to 3 years of age. Croup typically starts with a mild, barking cough associated with low-grade fever. The symptoms may progress over 1 to 2 days to increasing inspiratory stridor, nasal flaring, and rising temperatures to 104°F. In severe cases, the patient develops severe rib retractions with inspiratory and expiratory stridor, agitation, and fatigue. Severe hypoxia, weakness, and exhaustion may cause a rising pulse and eventually death from hypoventilation.
Croup is most often caused by viruses. Parainfluenza viruses are most common; adenoviruses, respiratory syncytial, and influenza are also potential causative agents. Occasionally bacterial tracheitis complicates viral croup.
Acute epiglottitis due to Hemophilus influenza type B may occasionally be confused with viral croup. A lateral x-ray of the nasopharynx and upper airway may be helpful to differentiate.
Children with suspected croup who demonstrate progressive stridor, restlessness, temperatures > 102.2°F (39°C), increasing respiratory distress, pallor, or depressed sensorium need to be hospitalized for close observation and possibly treated with intubation or tracheostomy.
To administer oxygen, hold an oxygen mask near the face, but do not agitate the child. For patients who are not being intubated, avoid sedation.
Give racemic epinephrine by aerosol (2.25% solution diluted 1:8 with water) in doses of 2 to 4 mL for 15 minutes either with or without positive pressure ventilation. This provides some transient relief of symptoms. Closely observe a child who has not been intubated.
Orotracheally intubate patients who demonstrate progressive respiratory distress despite epinephrine. Prepare equipment before laying the child flat. If the child is too agitated and alert to allow this, follow RSI Algorithm. (See Vol I—ACUTE CARE PORTALS.) If no IV access is available, consider IO administration. Warning: Remember if using ketamine that it may increase the risk of bronchospasm in young children with upper respiratory illness. Also administer dexamethasone 0.6 mg/kg IM. Following intubation, confirm correct placement with a CO2 detector or an esophageal intubation detector (not in infants). (See Vol II—AIR SKILLS 1 Aids to Intubation.)
If orotracheal intubation is unsuccessful, tracheostomy may be necessary.
Corticosteroids aid resolution. Administer dexamethasone 0.3 to 0.6 mg/kg IM or PO.
Obtain blood and tracheal cultures before beginning antibiotic therapy in children who appear toxic.
Consider bacterial complications, such as epiglottitis or bacterial tracheitis, especially in children with high fevers.