Download An Evidence-Based Approach To The Evaluation And

An Evidence-Based Approach
To The Evaluation And
Treatment Of Croup In Children
Abstract
Croup is a viral childhood infection characterized by the acute onset
of barky cough and stridor that is a common cause of pediatric
presentations to emergency departments and primary care centers. It
is usually a mild, self-limited disease, but, in some rare cases, croup
may lead to upper airway obstruction and respiratory failure. All
children presenting with croup should be treated with oral dexamethasone to reduce the severity of symptoms and rate of revisits or
admissions to the hospital. Children exhibiting signs of upper airway
obstruction should be treated with nebulized epinephrine. There
is no evidence, to date, to show that humidified air or heliox are of
benefit when treating children with croup. Appropriate discharge
instructions should be given to caregivers to prevent unnecessary or
delayed visits to the emergency department. This review focuses on
the clinical evaluation and treatment of children with croup by offering a thorough examination of the recent advances in treatment and
recommendations on the necessity of appropriate disposition and
follow-up.
Editor-in-Chief
Adam E. Vella, MD, FAAP
Associate Professor of Emergency
Medicine, Pediatrics, and Medical
Education, Director Of Pediatric
Emergency Medicine, Mount Sinai
School of Medicine, New York, NY
AAP Sponsor
Martin I. Herman, MD, FAAP, FACEP
Professor of Pediatrics, Attending
Physician, Emergency Medicine
Department, Sacred Heart
Children’s Hospital, Pensacola, FL
Editorial Board
Jeffrey R. Avner, MD, FAAP
Professor of Clinical Pediatrics
and Chief of Pediatric Emergency
Medicine, Albert Einstein College
of Medicine, Children’s Hospital at
Montefiore, Bronx, NY
September 2012
Volume 9, Number 9
Authors
Michelle Clarke, MD
Program Director, Pediatric Emergency Medicine Fellowship
Program, Department of Pediatrics, University of British
Columbia; Staff Physician, Division of Emergency Medicine,
British Columbia Children’s Hospital, Vancouver, BC,
Canada
Jasmine Allaire, MD
Fellow, Pediatric Emergency Medicine, British Columbia
Children’s Hospital, Vancouver, BC, Canada
Peer Reviewers
Stuart Bradin, DO, FAAP, FACEP
Assistant Professor of Pediatric and Emergency Medicine,
Attending Physician, Children’s Emergency Services, The
University of Michigan Health System, Ann Arbor, MI
Mark Silverberg, MD, FACEP
Assistant Professor and Associate Residency Director,
SUNY Downstate Medical Center, Brooklyn, NY
CME Objectives
Upon completion of this article, you should be able to:
1.
Recognize the clinical presentation of viral croup.
2. Identify the common differential diagnoses of cough
and stridor and how they differ from croup.
3. Treat and manage a child who presents with croup.
4. Identify the criteria for admission to the hospital or
discharge home.
Date of original release: September 1, 2012
Date of most recent review: August 15, 2012
Termination date: September 1, 2015
Medium: Print and Online
Method of participation: Print or online answer form and
evaluation
Prior to beginning this activity, see “Physician CME
Information” on the back page.
Medicine, University of Medicine and Association, Hawaii and Pacific
Brent R. King, MD, FACEP, FAAP,
Ghazala Q. Sharieff, MD, FAAP,
Dentistry of New Jersey; Director,
Island Region
FAAEM
FACEP, FAAEM
Pediatric Emergency Medicine,
Professor
of
Emergency
Medicine
Associate Clinical Professor,
Andy Jagoda, MD, FACEP
Children’s Medical Center, Atlantic Professor and Chair, Department
and Pediatrics; Chairman,
Children’s Hospital and Health
Health System; Department of
Department of Emergency Medicine,
Center/University of California;
of Emergency Medicine, Mount
Emergency Medicine, Morristown
The University of Texas Houston
Director of Pediatric Emergency
Sinai School of Medicine; Medical
Memorial Hospital, Morristown, NJ
Medical
School,
Houston,
TX
Medicine, California Emergency
Director, Mount Sinai Hospital, New
Physicians, San Diego, CA
Ran D. Goldman, MD
York, NY
Robert Luten, MD
Associate Professor, Department
Madeline Matar Joseph, MD, FAAP,
of Pediatrics, University of Toronto;
FACEP Division of Pediatric Emergency
Professor of Emergency Medicine
Medicine and Clinical Pharmacology
and Pediatrics, Assistant Chair
and Toxicology, The Hospital for Sick
of Pediatrics, Department of
Children, Toronto, ON
Emergency Medicine; Chief,
Mark A. Hostetler, MD, MPH Pediatric Emergency Medicine
Clinical Professor of Pediatrics and Division, Medical Director, Pediatric
Emergency Medicine, University
Emergency Department, University
of Arizona Children’s Hospital
of Florida Health Science Center,
Division of Emergency Medicine,
Jacksonville, FL
Phoenix, AZ
Anupam Kharbanda, MD, MS
Alson S. Inaba, MD, FAAP, PALS-NF
T. Kent Denmark, MD, FAAP, FACEP Pediatric Emergency Medicine
Attending Physician, Kapiolani
Medical Director, Medical Simulation
Medical Center for Women &
Center, Professor, Emergency
Children; Associate Professor of
Medicine, Pediatrics, and Basic
Pediatrics, University of Hawaii
Science, Loma Linda University
John A. Burns School of Medicine,
School of Medicine, Loma Linda, CA
Honolulu, HI; Pediatric Advanced
Michael J. Gerardi, MD, FAAP,
Life Support National Faculty
FACEP
Representative, American Heart
Clinical Assistant Professor of
Research Director, Associate
Fellowship Director, Department
of Pediatric Emergency Medicine,
Children's Hospitals and Clinics of
Minnesota, Minneapolis, MN
Professor, Pediatrics and
Gary R. Strange, MD, MA, FACEP
Emergency Medicine, University of
Professor and Head, Department
Florida, Jacksonville, FL
of Emergency Medicine, University
of Illinois, Chicago, IL
Garth Meckler, MD, MSHS
Associate Professor and
Fellowship Director, Pediatric
Emergency Medicine, Oregon
Health & Science University,
Portland, OR
Christopher Strother, MD
Assistant Professor, Director,
Undergraduate and Emergency
Simulation, Mount Sinai School of
Medicine, New York, NY
Joshua Nagler, MD
Assistant Professor of Pediatrics,
Harvard Medical School; Pediatric
Emergency Medicine Fellowship
Director, Division of Emergency
Medicine, Children's Hospital,
Boston, MA
Research Editor
Steven Rogers, MD
Tommy Y. Kim, MD, FAAP, FACEP
Assistant Professor, University of
Assistant Professor of Emergency
Connecticut School of Medicine,
Medicine and Pediatrics, Loma
Attending Emergency Medicine
Linda Medical Center and Children’s Physician, Connecticut Children’s
Hospital, Loma Linda, CA
Medical Center, Hartford, CT
Vincent J. Wang, MD, MHA
Associate Professor of Pediatrics,
Keck School of Medicine of the
University of Southern California;
Associate Division Head,
Division of Emergency Medicine,
Children's Hospital Los Angeles,
Los Angeles, CA
Accreditation: EB Medicine is accredited by the ACCME to provide continuing medical education for physicians. Faculty Disclosure: Dr. Clarke, Dr. Allaire, Dr. Bradin, Dr. Silverberg, Dr. Vella, and
their related parties report no significant financial interest or other relationship with the manufacturer(s) of any commercial product(s) discussed in this educational presentation.
Commercial Support: This issue of Pediatric Emergency Medicine Practice did not receive any commercial support.
Case Presentation
A previously healthy 2-year-old boy presents to your ED
on an early winter evening after the sudden onset of a
barking cough and trouble breathing. His parents are concerned because of a “whistling” sound he is making when
he cries. He has had rhinorrhea and a low-grade fever for
the past 36 hours. Upon arrival at triage, he is mildly
tachypneic with a respiratory rate of 32 breaths per minute. His oxygen saturation is 94% on room air, his axillary temperature is 38.4oC, and his heart rate is 135 beats
per minute. On examination, he is restless, fussy, and
unable to settle down on his mother’s lap. You can clearly
hear inspiratory stridor punctuated by a barking cough,
and you notice moderate intercostal retractions. The rest
of your physical exam is within normal limits. What are
your first steps towards treating this child? What clinical
criteria will you use to discharge this patient home? What
discharge instructions will you give the parents?
Introduction
Croup is a common childhood viral illness. Clinically, it is manifested by the sudden onset of a barky
cough, hoarseness, and inspiratory stridor which
may lead to obstruction and, rarely, to respiratory
failure. It typically affects young children between 6
months and 3 years of age and is seen predominantly in boys. It is the most prevalent cause of hoarseness, cough, and acute onset of stridor in the febrile
child. While croup can be seen year-round, there
is a clear seasonal pattern in North America, with
affected children presenting most commonly between the months of November and February. This
has been attributed to the biennial peak in human
parainfluenza virus epidemics in November. Children may acutely become symptomatic at night and
improve during daytime hours. This is often frightening for caretakers, as the distress can be quite dramatic. Although croup is typically a self-limited viral
illness that normally resolves over 2 to 5 days, it can
require admission to the hospital and, rarely, to the
intensive care unit (ICU). The majority of children
recover with no complications; however, in very
rare instances, it can be life-threatening. The routine
use of corticosteroid therapy in the last 30 years has
revolutionized the treatment of croup, resulting in
a dramatic decrease in the number of admissions to
the ICU and the need for invasive therapy such as
intubation and mechanical ventilation.1,2
This issue of Pediatric Emergency Medicine
Practice focuses on the evaluation and treatment of
children with croup by offering a thorough review
of the recent advances in treatment. It will provide
updated information to the emergency clinician and
guidelines on management for primary care providers, who often see these patients early in their illness.
Adequate first-line care and follow-up instructions
Pediatric Emergency Medicine Practice © 20122
may prevent unnecessary or delayed visits to emergency departments (EDs), alleviate burden on the
healthcare system, and minimize stressful situations
for caretakers.
Critical Appraisal Of The Literature
A literature review was carried out with PubMed
and Ovid MEDLINE® for articles on croup, acute
laryngotracheitis, and acute laryngotracheobronchitis with limits on all child: 0-18 years. Pertinent,
well-designed randomized controlled trials were
included as well as commonly referenced and
older publications on the topic. A search in the
Cochrane Database of Systematic Reviews yielded
3 important publications relating to the treatment
of croup.1-3 One relevant review was not included
in this issue as it had been withdrawn from the
Cochrane Library because the authors were unable
to update it.4 The website of the Canadian Pediatric
Society (http://www.cps.ca/) and the American
Academy of Pediatrics (AAP) (http://www.aap.
org/) were consulted for guidelines, but none were
found. The only document concerning croup from
these organizations that was written for professionals is a position statement from the Canadian
Pediatric Society dating back to 1992 on steroid administration for patients admitted to the hospital.5
The AAP website yielded several patient education
sheets but no official guidelines or clinical decision
algorithms. Additionally, the most often referenced
guidelines on diagnosis and management of croup
in the literature, published in 2007 by the Alberta
Medical Association, were reviewed.6
The literature on croup underwent a drastic
update in the early 1990s with the introduction of
corticosteroids, which were first used in hospitalized patients and then in ambulatory patients. The
literature predating this introduction focused mostly
on management of severe cases of upper airway
obstruction from croup and on distinguishing this
entity from other common childhood illnesses in the
preimmunization period that cause upper airway
obstruction (most notably, epiglottitis caused by
Haemophilus influenzae type b). Several small underpowered studies demonstrated a small benefit in
improvement of symptoms and a reduction in the
rate of intubation with the treatment of hospitalized patients with upper airway obstruction using
corticosteroids.7-12 These results were largely ignored
by most of the pediatric medical community until
1989, when Kairys et al published a meta-analysis
based on 10 randomized trials with a total of 1286
patients that supported the use of corticosteroids to
lower the morbidity associated with croup.13 Based
on these results, appropriately powered randomized controlled trials showing the effectiveness and
safety of corticosteroids in croup were conducted.
www.ebmedicine.net • September 2012
Recently updated meta-analyses confirmed these
results. More-recent studies have focused on determining the best administration modality and
dosage to maximize effectiveness while minimizing
harm to the patient. Multiple randomized controlled
trials are currently trying to determine whether a
lower corticosteroid dose is as effective as the one
traditionally recommended. There are also several
newer modalities, such as heliox, under investigation for the treatment of more-severe cases of croup.
With the widespread use of corticosteroids, the rates
of hospitalization and of admission to the ICU for
croup have steadily decreased in the past 2 decades,
limiting research in this area.2
following the epidemics of human parainfluenza
virus, and has biennial peaks in rates in November
during odd years and February in even years.17-18
Although less frequent, croup may also occur with
infection by influenza A and B, respiratory syncytial
virus, adenovirus, coronavirus, human metapneumovirus, and Mycoplasma pneumoniae.21,22 Sporadic
cases have also been identified with infectious
agents such as enterovirus and mumps, and croup
is a known complication of measles.23 Fungi and
mycobacteria are extremely rare primary causes
of laryngotracheobronchitis, and, when identified,
should raise the suspicion of underlying immunodeficiency and prompt appropriate investigations.
Immunosuppression may also occur with repeated
treatments of corticosteroids or prophylaxis with
antibiotics and may lead to opportunistic infections
such as Candida or herpes simplex virus.24
The symptoms of croup are caused by infiltration of the subglottic region of the larynx by an infectious pathogen. This infiltration causes erythema,
edema, and glandular hypersecretion of the subglottic mucosa. Because this narrowest part of the
pediatric airway is bound by a complete ring of cartilage and cannot expand outward to accommodate
for narrowing of the airway, obstruction may occur
quickly with even the smallest amount of swelling.
Poiseuille’s law states that the increase in airway
resistance is inversely proportional to the fourth
power of the radius. This phenomenon explains
why even a minimal amount of airway edema may
lead to an exponential rise in airway obstruction,
especially in the young infant or toddler. In bacterial
croup, pseudomembranes and fibrinous exudates
may accumulate within the airway and cause further
obstruction. The characteristic stridor of croup is
caused by the passage of turbulent air through the
narrowed airway at the level of the supraglottis,
glottis, subglottis, or trachea and—depending on its
timing with the respiratory cycle—may be inspiratory, expiratory, or biphasic.25
Epidemiology, Etiology, And Pathogenesis
The term croup encompasses a spectrum of disease
involving the upper airway and sometimes (although rarely) extending into the lung parenchyma
(laryngotracheitis, laryngotracheobronchitis, laryngotracheobronchopneumonitis). Acute laryngotracheitis is the most common presentation of these
illnesses and is usually infectious in nature. In medical textbooks and review articles, differentiation
is typically made between acute laryngotracheitis
and recurrent croup that is associated with airway
hyperreactivity (spasmodic croup).14-15 Both of these
entities are usually caused by the same pathogens,
and their clinical management is similar. Acute bacterial laryngotracheobronchitis is bacterial tracheitis,
and it is commonly due to infection with Staphylococcus aureus or H influenzae.16
Males have a predominance over female patients
on both visit and admission rates by a ratio of 3:2.17
Children aged 1 year old usually have the highest
rate of visits to the ED and have the highest rate of
admission to the hospital.17-18 Mortality quoted in
a study from 1991 prior to the widespread use of
corticosteroids was estimated to be less than 0.5%.19
More-recent extrapolations estimate the mortality
rate now to be about 1 in 30,000 cases, which makes
it an even more unlikely event.13,33
According to a large Canadian population-based
study, viral croup accounts for 3% to 5% of total visits to EDs.17 This study demonstrates that although
the number of cases presenting to the ED increased
over the 6 years studied (from April 1999 to May
2005), there has been a steady decrease in the number of patients needing admission to hospitals and
ICUs. The authors hypothesize that this is due to the
introduction of evidence-based treatment, such as
corticosteroids.
Croup is most often caused by a variety of viruses. Human parainfluenza viruses, especially type
I and III, are the most common infectious agents, accounting for close to 80% of cases.20 In the Northern
Hemisphere, croup follows a clear seasonal pattern,
September 2012 • www.ebmedicine.net
Differential Diagnosis
Most children presenting with the classic “barky”
cough and stridor have croup. Nonetheless, other
potentially more serious entities may manifest as
stridor and present similarly to croup. Emergency
clinicians need to stay vigilant to identify and treat
these children appropriately. (See Table 1, page 4.)
Common causes of acute febrile stridor are bacterial tracheitis, epiglottitis, and retropharyngeal
abscess. Acute afebrile stridor may be due to foreign body aspiration, spasmodic croup, thermal or
caustic injury to the airway, or angioneurotic edema.
Patients with accidental or intentional strangulation
may also present with stridor. Emergency clinicians
should inspect the neck for external signs of injury
3
Pediatric Emergency Medicine Practice © 2012
and consider the possibility of nonaccidental injury
if other aspects of the history are suspicious. Chronic
stridor is usually caused by laryngomalacia, vascular anomalies, or adenotonsillar hyperplasia.26-27
Bacterial tracheitis is an acute infectious illness
that causes subglottic edema and accumulation of
purulent secretions in the larynx.16 The primary bacterial infection is characterized by high fever, toxic
appearance, and acute onset of stridor that does not
respond well to usual therapy, especially nebulized
epinephrine. The infection may also be superinfection sequelae of viral croup. Common pathogens
include Group A streptococcus, Streptococcus pneumoniae, S aureus and H influenzae. Early differentia-
tion of bacterial tracheitis from croup is important,
as the management of the two are very different.
Management of bacterial tracheitis includes intravenous (IV) antibiotics and usually mandates hospital
admission. Some patients may require intubation
and ventilatory support.
Epiglottitis remains a critical component to the
differential diagnosis of the acute onset of fever and
stridor; however, since the introduction of universal
immunization against H influenzae type b, its incidence
has dramatically decreased in the pediatric population. Nonetheless, its accompanying high mortality
still makes it a diagnosis that cannot be delayed or
missed. Culprit pathogens now include nontype b
Table 1. Differential Diagnosis Of Stridor
Diagnosis
Clinical Presentation
Physical Examination
Diagnostic Investigations
Management
Bacterial tracheitis
Prodromal upper respiratory
viral illness, high fever,
acute-onset stridor
Toxic appearance, varying
degree of respiratory
distress, poor response to
epinephrine
Complete blood count, blood
and tracheal secretion
cultures
IV antibiotics; may require
intubation and mechanical
ventilation
Epiglottitis
High fever, dysphonia,
refusal to eat, dysphagia,
sore throat, vomiting,
absence of cough
Toxic appearance, drooling,
tripod stance, obtundation
Direct visualization of
edematous epiglottis by
laryngoscopy, “thumb print”
sign on lateral neck x-ray
Airway management by
highly skilled physicians
(ENT, anesthesiologist), IV
antibiotics
Viral croup (laryngotracheitis)
Low grade fever, +/- prodromal upper respiratory tract
illness, barky “seal-like”
cough, inspiratory stridor,
onset during night
Respiratory distress, audible
stridor, agitation
Clinical diagnosis; “steeple
sign” on anteroposterior
neck x-ray
Nebulized epinephrine,
corticosteroids; may require
intubation and mechanical
ventilation
Retropharyngeal/peritonsillar abscess
Fever, odynophagia, neck
pain or torticollis, drooling,
general malaise
Enlarged cervical lymph
nodes, tender neck to palpation, limitations of neck
movements
Swelling of retropharyngeal
space on lateral neck x-ray,
CT scan
IV antibiotics, surgical
management (drainage,
tonsillectomy) by ENT
specialist
Diphtheria
Low-grade fever, upper
respiratory tract illness,
sore throat, odynophagia,
recent travel to endemic
area
Pharyngeal pseudomembrane, enlarged cervical
lymph nodes, swelling of
neck (“bull neck”), skin
lesions
Throat culture positive for
Corynebacterium diphtheriae
Diphtheria antitoxin, antibiotics; may require intubation
and mechanical ventilation
Foreign body aspiration
Sudden episode of choking
on food or small object,
cough, stridor/wheezing
Diminished air entry, stridor/
wheezing
Lateral decubitus chest x-ray
or inspiratory/expiratory
chest x-ray, bronchoscopy
(rigid or flexible)
Bronchoscopy and foreign
body removal
Laryngomalacia
Progressively worsening
stridor associated with
crying/feeding or position
(supine), possible feeding
intolerance
Positional, inspiratory stridor;
otherwise unremarkable
physical examination
Laryngoscopy or bronchoscopy, chest x-ray +/- barium
esophagography to rule
out extrinsic compression
of airway by structural
anomalies
Conservative or surgical
(laryngoplasty or epiglottopexy)
Angioneurotic edema
Positive family history; rapidonset swelling of face,
limbs, or larynx without
discoloration; abdominal pain precipitated by
trauma/emotional stress
Angioedema, stridor, shock,
absence of urticaria and
pruritus
C1 esterase inhibitor level
and function, complement
levels
Epinephrine (IV or IM),
fluid resuscitation, C1
inhibitor concentrate (rarely
available); may require
intubation and mechanical
ventilation
Abbreviations: CT, computed tomography; ENT, ear, nose, and throat; IM, intramuscular; IV, intravenous.
Pediatric Emergency Medicine Practice © 20124
www.ebmedicine.net • September 2012
Emergency Department Evaluation
H influenzae strains, several streptococcus strains,
S aureus, and Pasteurella multocida.28 Clinically, children
with epiglottitis will have a toxic appearance and high
fever and will present with drooling, a preference to
sit in a tripod stance, refusal of food, dysphagia, and
dysphonia. Croup can be distinguished by its viral
prodrome of upper respiratory symptoms, barky
cough, and chest retractions.29 These children are
typically not ill-appearing. The most experienced and
skilled clinicians should be consulted to secure the
airway in these patients, as ventilatory support for
respiratory failure is often required.
Retropharyngeal abscess is a rare cause of
stridor. These patients usually present with fever;
neck pain; marked decreased range of motion of
the neck, sometimes accompanied by meningismus; and, rarely, with respiratory distress. Radiographic evaluation is often required to confirm
diagnosis. Parenteral antibiotics, hospitalization,
and concurrent ear, nose, and throat (ENT) consultation for potential surgical management are
mainstays of therapy.
Afebrile and chronic causes of stridor will typically have a pertinent clinical history and physical
signs to support their diagnoses. Patients with foreign body aspiration may present with a history of
sudden choking or coughing. Often, however, this
diagnosis is delayed because an acute event may
not be witnessed. Structural anomalies commonly
present during the newborn period as positional
stridor that worsens progressively over the first few
weeks of life; they may be more prominent during
feeding or crying. Mild laryngomalacia may resolve
spontaneously over time or may require surgical
intervention by an ENT surgeon in certain cases.
Gastroesophageal reflux may also cause stridor in
infants and may present with feeding intolerance
such as regurgitation or vomiting, poor weight
gain, hoarse cry, and chronic cough.
History
Children with croup are typically between the age
of 6 months and 3 years, but croup can be seen until
adulthood. The illness typically starts with upper
respiratory tract symptoms such as rhinorrhea and
low-grade fever. Inspiratory stridor, hoarseness, and
the classic barky “seal-like” cough appear abruptly
within 12 to 48 hours of illness, most often in the
overnight hours, for unknown reasons. Most symptoms tend to improve during the daytime period.
The symptoms typically resolve progressively
within 2 to 5 days.30
The ED evaluation should focus on eliminating
other life-threatening causes of stridor. Confirm the absence of drooling, nontoxic appearance or dysphagia,
no neck pain or limitations of movements, and no history of choking on food or small object. Ask questions
regarding immunization status. Review past medical
history for previous episodes of croup, airway hyperreactivity, previous endotracheal intubation, or subglottic
manipulations, as these can lead to subglottic stenosis
and precipitate upper airway obstruction.
Physical Examination
Vitals signs (heart rate, respiratory rate, temperature, oxygen saturation) should be obtained on all
children with suspected croup; however, symptoms
may worsen if the child is anxious or agitated. Observation is a key tool. The urgency and aggressiveness of interventions are driven by the appearance,
breathing, and circulation status of the child. Moderate tachypnea and tachycardia may be seen as well
as varying degrees of respiratory distress. Stridor
may be audible at rest or on auscultation and may be
inspiratory, expiratory, or biphasic depending on the
severity of symptoms.
Scoring systems have been developed to attempt to grade the severity of viral croup. Although
useful in clinical research, there is no consensus
as to whether they improve clinical practice. The
most widely used score is the Westley Croup score.
Developed in 1978 by Westley et al,31 its validity and
reliability has been well established.32 It consists of
a maximum of 17 points, depending on the presence
or absence of 5 clinical characteristics: (1) level of
consciousness, (2) cyanosis, (3) stridor, (4) air entry,
and (5) retractions. (See Table 2, page 6.)
The Alberta Clinical Practice Guideline Working
Group categorizes croup according to its clinical signs
into 4 categories that are more useful in a clinical setting.6 These categories include: (1) mild, (2) moderate,
(3) severe, and (4) impending respiratory failure. (See
Table 3, page 6.) According to these categories, over
85% of children presenting to EDs have mild croup,
and < 1% fall into the severe croup category.33
Prehospital Care
Patients should be immediately assessed for lifethreatening conditions, especially airway obstruction. Do not agitate the child. Allow the child
to remain in his position of comfort, even if this
means being carried or lying in a parent’s lap.
Avoid unnecessary procedures or examinations
such as examination of the posterior pharynx.
Oxygen may be administered if cyanosis is present.
If nebulized epinephrine is available to specialized
advanced life support teams and the child demonstrates audible stridor and respiratory distress, it
may be administered on the way to the hospital to
alleviate symptoms. Nonetheless, transport to the
hospital must not be delayed for the administration
of inhaled medications.
September 2012 • www.ebmedicine.net
5
Pediatric Emergency Medicine Practice © 2012
Diagnostic Studies
Croup is a clinical diagnosis, and laboratory and
imaging studies are not necessary to make the diagnosis. Imaging studies may be useful in excluding
other causes of stridor (such as foreign body aspiration) in situations where the history and physical
examination are unclear or when the child’s symptoms do not respond to usual treatment.
The most common radiological sign of croup
on anteroposterior chest radiograph is the “steeple
sign.”34 This distinctive narrowing of the trachea
in the shape of an inverted V is produced by the
presence of edema in the trachea, which results in
loss of the normal shoulder-like appearance of the
subglottis. (See Figure 1.) Other causes of steepling
on radiograph include epiglottitis, thermal injury,
angioneurotic edema, and bacterial tracheitis. The
majority of children with croup will have normal
radiographs, and films should not be routinely
obtained. If epiglottitis cannot be ruled out clinically, a lateral neck radiograph may be obtained,
which may show the thickening of the epiglottis and
aryepiglottic folds called the “thumb sign.” In croup,
the radiological findings on lateral neck radiographs
are variable and may be difficult to identify, as they
are tied to the dynamics of the hypopharynx during
inspiration and expiration.35 Patients with suspected
Table 2. Westley Croup Score Criteria31
Characteristic
epiglottitis or croup must always be accompanied
and monitored during procurement of the radiographs,6 as upper airway obstruction may progress
rapidly in children. If a child looks unwell or has
signs of severe airway obstruction, emergent airway
management should occur first and obtention of
radiographs is contraindicated.
Laboratory studies such as complete cell count
or blood culture are not useful when evaluating a
child with croup, and viral cultures or rapid antigen
testing are not routinely recommended. If intubation
is attempted, trachea cultures should be obtained to
rule out the presence of bacterial tracheitis and to
guide antibiotic treatment.
Treatment
Humidified Air
Humidity has been used routinely to treat croup
ever since steam produced by hot baths appeared to
alleviate symptoms of croup during the 19th century.
“Croup kettles” became popular to achieve relief
“...by applying hot fomentations to the throat...
and by steam inhalations.”36 Umbrellas and bed
sheets were tied over a child’s crib in the fashion
of a canopy, and boiling water from a kettle was
administered through an opening in the sheets. Not
unexpectedly, scald burns were a common adverse
effect of this therapy.37 Croup kettles were progressively replaced by cool air mist after the observation
that cool night air seemed to be more effective at
Points
Table 3. Assessment Of Severity Of Croup6
Level of Consciousness
Normal (including sleep)
Disoriented
0
5
Level of Severity
Cyanosis
None
Cyanosis with agitation
Cyanosis at rest
Corresponding
Westley Croup
Score
0
4
5
0-2
Stridor
None
When agitated
At rest
Mild
Occasional barky cough
No audible stridor at rest
No mild suprasternal/intercostal retractions
0
1
2
3-5
Air Entry
Normal
Decreased
Markedly decreased
0
1
2
Moderate
Frequent barky cough
Easily audible stridor at rest
Suprasternal and sternal wall retraction at rest
No or little distress or agitation
6-11
Retractions
None
Mild
Moderate
Severe
0
1
2
3
Severe
Frequent barking cough
Prominent inspiratory and expiratory stridor
Marked sternal wall retractions
Significant distress and agitation
≥ 12
Total
_____
Impending Respiratory Failure
Barky cough (not prominent)
Audible stridor at rest (hard to hear)
Sternal wall retractions (may not be marked)
Lethargy or decreased level of consciousness
Dusky appearance
Mild croup, ≤ 2; Moderate, 3-5; Severe, 6-11; Impending respiratory
failure, ≥ 12.
Pediatric Emergency Medicine Practice © 20126
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reducing the symptoms of upper airway obstruction.38 Croup tents were a common therapeutic
modality in hospitals until the 1990s. They are now
rarely used, as they isolate and separate the child
from the caregiver, increasing the child’s anxiety,
which then potentiates the symptoms of upper airway obstruction. Humidity, if used, is now delivered
in the hospital setting by a “blow-by” flexible tubing
hose, which is usually held by a caregiver and aimed
towards the child’s face. Discharge instructions also
routinely recommend that parents run hot water in
the shower and sit with the child in the steam-filled
bathroom or in front of a freezer or outdoors for a
period of time, if living in a cooler climate.6,39 There
are no studies, however, evaluating the effectiveness
of this practice.
The postulated benefits of mist therapy include
the decreased viscosity of tracheal secretions as
well as mucosal cooling and a subsequent reduction in edema.40 Nonetheless, known adverse effects
include bronchospasm in children who are prone
to airway hyperreactivity, hyponatremia secondary
to excessive moisture, and secondary infection by
pathogens such as Pseudomonas aeruginosa or fungi.38
Randomized controlled trials with small numbers
of patients failed to show improvement after the
administration of humidified air by croup tents and
blow-by technique, respectively.41,42 One hypothesis
to explain the failure to show positive results was
that the water particles were not of the correct size
to reach the larynx. Scolnik et al designed a randomized controlled trial with 140 patients to try to
identify the ideal particle size for laryngeal deposition.43 As explained by the investigators, particles
larger than 10 micrometers in diameter deposit in
the nose and mouth, whereas particles smaller than
5 micrometers reach the lower airway where they
may cause bronchospasm. Therefore, particles that
are 5 to 10 micrometers in diameter have the greatest probability of reaching the larynx, making this
particle size the most appropriate choice for croup
therapy. Despite empirically testing this theory, the
investigators were unable to demonstrate any improvement in Westley Croup Score with humidity as
compared to placebo. A systematic review and metaanalysis by Moore and Little reviewed the aforementioned randomized controlled trials and concluded
that there was insufficient evidence of therapeutic
benefit to support the routine use of humidified air
in the treatment of croup.40 When pooling the results
to perform a meta-analysis, their results were not
methodologically strong enough to rule in or out
any beneficial effect of humidified air.
Figure 1. The Steeple Sign
Nebulized Epinephrine
Nebulized epinephrine has been thoroughly studied for the treatment of croup.31,44,45 Epinephrine
induces vasoconstriction in laryngeal mucosa by
stimulating alpha-adrenergic receptors, thus decreasing the symptoms of upper airway narrowing.
It also promotes bronchial smooth muscle relaxation
and thinning of bronchial secretions by stimulation
of beta-adrenergic receptors. Epinephrine comes under 2 different forms: racemic, which is composed of
equal parts of L- and D-isomers, and L-epinephrine,
which is the drug routinely used in acute situations
in concentrations of 1:1000 and 1:10,000.
In 1971, Adair et al first reported the benefits of
administration of nebulized epinephrine by intermittent positive-pressure breathing (IPPB) by observing a
significant reduction in clinical croup score, although
the beneficial effect lasted for less than 2 hours.46
Subsequent trials showed that similar benefits were
achieved if racemic epinephrine was administered
via IPPB or only nebulized without IPPB.47 Racemic
epinephrine was initially used in the treatment of
croup because it was thought to cause fewer cardiovascular effects than L-epinephrine. In a study of 66
patients, Waisman et al showed no difference in croup
score at 30 minutes when comparing administration
of 2.25% racemic epinephrine 0.5 mL diluted in 2.5
mL of saline versus L-epinephrine 1:1000 diluted in 5
mL of saline.48 In addition, L-epinephrine showed a
statistically significant longer duration of benefit with
Image courtesy of Jasmine Allaire, MD.
September 2012 • www.ebmedicine.net
7
Pediatric Emergency Medicine Practice © 2012
Clinical Pathway For Management Of Croup In The Emergency Department
Diagnosis of croup
Dexamethasone 0.6 mg/kg orally to
max dose of 10 mg (Class I)
Mild (no stridor or chest wall
retractions at rest)
Moderate (stridor and chest wall retractions at rest without agitation)
• Parental education:
Expected course of illness
Signs of respiratory distress
When to seek medical care
• Discharge home without further
observation
• No specific follow-up required
• Minimize intervention
• Keep child on caregiver’s lap in position of comfort
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Consider nebulized epinephrine; if
given, observe for 2 h (Class I)
Severe (stridor and retractions
of the sternum associated with
agitation or lethargy)
• Minimize intervention as for
moderate croup
• Provide blow-by oxygen only if
cyanosis is present
• Nebulized epinephrine (Class I):
Racemic epinephrine 2.25% (0.5
mL in 2.5 mL saline)
or
L-epinephrine 1:1000 (5 mL)
• Observe for improvement for minimum of 2 h, if epinephrine given
• If vomiting, consider budesonide (2.5
mg) nebulized with epinephrine or
dexamethasone 0.6 mg/kg IV or IM
(Class I)
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Improvement?
Patient improves and no longer has
stridor at rest or chest wall retractions:
• Educate parents (as per mild croup)
• Discharge home
No or minimal improvement
• Repeat nebulized epinephrine;
observe for 4 h
Poor response to nebulized epinephrine (signs of respiratory failure)
• Contact pediatric ICU for further
management
• Consider contacting anesthesiology
+/- ENT consult if airway management is required
Note: treatment based on severity at time of initial
assessment
Abbreviations: ENT, ear, nose, and throat; ICU,
intensive care unit; IM, intramuscular; IV, intravenous.
For class of evidence definitions, see page 9.
• Consider hospitalization (general ward) if the patient received steroids > 4 h ago and still
shows signs of continued moderate respiratory distress (without agitation and lethargy)
requiring ongoing nebulized epinephrine
• Contact pediatric ICU if recurrent severe episodes of agitation or lethargy or need for > 2-3
doses of nebulized epinephrine within 60 min (Class Indeterminate)
Pediatric Emergency Medicine Practice © 20128
www.ebmedicine.net • September 2012
a better croup score at 120 minutes as opposed to racemic epinephrine.1,48 Nebulized epinephrine has also
been shown to decrease the rate of admission to the
hospital and the need for intubation or tracheotomy.1
The rarity of adverse effects makes it a safe drug to
give for otherwise healthy children with symptoms
of croup.49,50 Butte et al reported 1 case of ventricular
tachycardia and myocardial infarction in a child with
severe croup who received 3 doses of epinephrine
within 1 hour.51 Up to 2 doses of nebulized epinephrine administered every 15 to 20 minutes within the
same hour is most likely safe in an otherwise healthy
child. Consultation with a pediatric critical care unit
for cardiac monitoring should be made if more doses
are required.6 If a child continues to exhibit symptoms
of stridor and altered level of consciousness after repeated doses of epinephrine, urgent consultation with
the ICU, an ENT specialist, and an anesthesiologist is
mandated to prepare for further airway management,
as this clinical situation may quickly lead to respiratory failure.
A systematic review conducted by Bjornson et al
looking at 8 studies (with a total of 225 participants)
concluded that nebulized epinephrine may be used to
alleviate symptoms of croup in patients with moderate-to-severe presentation and that these symptoms
do not tend to worsen after the effect of epinephrine
dissipates.1 In the early 1990s, standard ED practice
was to hospitalize all patients with a presentation
severe enough to require the use of nebulized epinephrine. Since then, several trials have demonstrated
that patients treated with nebulized epinephrine and
therapeutic doses of corticosteroids may be observed
for 2 to 4 hours, and, if they remain stable, they may
be safely discharged home.49,52,53
the 1950s were unable to show any effect on the severity or length of symptoms of acute viral croup.7,8
Further investigations conducted until the late 1980s
consistently demonstrated significant improvement
in patients treated with corticosteroids compared to
placebo.9-12 The meta-analysis published by Kairys
et al in 1989 included 10 studies with a total of 1286
patients and provided the most reliable estimate of
the impact of steroid therapy on the morbidity associated with croup.13 Their results showed significant clinical improvement 12 hours and 24 hours
posttreatment and a significantly reduced incidence
of endotracheal intubation. Super at al confirmed
these results in a well-designed randomized controlled trial looking at 29 hospitalized patients.54
The Canadian Pediatric Society published a position
statement in 1992 recommending the use of steroid
therapy as a single dose of dexamethasone (Decadron®) 0.6 mg/kg IV or intramuscular (IM) in children admitted to hospital with severe croup.5
The recently updated Cochrane review on glucocorticoids looked at 24 studies involving 2878 patients and found that treatment with glucocorticoids
is effective in improving symptoms in children as
early as 6 hours and up to 12 hours after treatment,
and that it significantly reduces hospital admissions
and return visits to EDs.2 When compared to children with croup who received placebo, children who
received steroid therapy spent significantly less time
in the ED or hospital.
The benefits of glucocorticoid therapy are not
limited to children with moderate croup. A large
multicenter randomized controlled trial involving 720
children demonstrated multiple benefits in treating
children with mild symptoms of croup with 0.6 mg/
kg of oral dexamethasone as compared to placebo.55
The treated children had half the rate of revisits to a
healthcare practitioner and lost less sleep in 48 hours,
and their parents experienced less stress in the 24
hours following treatment.
Corticosteroids
The use of corticosteroids has truly revolutionized
the management of croup in the last 30 years. The
first trials addressing the role of corticosteroids in
Class Of Evidence Definitions
Each action in the clinical pathways section of Pediatric Emergency Medicine Practice receives a score based on the following definitions.
Class I
• Always acceptable, safe
• Definitely useful
• Proven in both efficacy and
effectiveness
Level of Evidence:
• One or more large prospective
studies are present (with rare
exceptions)
• High-quality meta-analyses
• Study results consistently positive and compelling
Class II
• Safe, acceptable
• Probably useful
Level of Evidence:
• Generally higher levels of
evidence
• Non-randomized or retrospective studies: historic, cohort, or
case control studies
• Less robust randomized controlled trials
• Results consistently positive
Class III
• May be acceptable
• Possibly useful
• Considered optional or alternative treatments
Level of Evidence:
• Generally lower or intermediate
levels of evidence
• Case series, animal studies, consensus panels
• Occasionally positive results
Indeterminate
• Continuing area of research
• No recommendations until
further research
Level of Evidence:
• Evidence not available
• Higher studies in progress
• Results inconsistent, contradictory
• Results not compelling
Significantly modified from: The
Emergency Cardiovascular Care
Committees of the American
Heart Association and represen-
tatives from the resuscitation
councils of ILCOR: How to Develop Evidence-Based Guidelines
for Emergency Cardiac Care:
Quality of Evidence and Classes
of Recommendations; also:
Anonymous. Guidelines for cardiopulmonary resuscitation and
emergency cardiac care. Emergency Cardiac Care Committee
and Subcommittees, American
Heart Association. Part IX. Ensuring effectiveness of communitywide emergency cardiac care.
JAMA. 1992;268(16):2289-2295.
This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a patient’s individual
needs. Failure to comply with this pathway does not represent a breach of the standard of care.
Copyright © 2012 EB Medicine. 1-800-249-5770. No part of this publication may be reproduced in any format without written consent of EB Medicine.
September 2012 • www.ebmedicine.net
9
Pediatric Emergency Medicine Practice © 2012
Trials comparing oral, parenteral, and nebulized
corticosteroids have demonstrated similar efficacy
and superiority of the different treatment groups to
placebo.55-60 Oral dexamethasone has become the
preferred choice of treatment because it is less expensive than budesonide (Pulmicort®) and is easier
to administer to children with croup. The parenteralinjectable preparation (which is more palatable and
less diluted than the oral preparation) can be given
in a smaller volume mixed with syrup, is rarely
vomited, and is recommended for use in children.6,57
Nonetheless, budesonide 2.5 mg by nebulization
may be safely substituted for dexamethasone if a
child cannot tolerate the oral administration.56,57
Combining inhaled corticosteroids with oral dexamethasone does not confer any added benefit when
looking at length of hospital stay, croup score, revisit
rate, or admission to the hospital.57,61 To the authors'
knowledge, there is no study, to date, looking at the
benefit of multiple doses of corticosteroids in children with croup.
While most of the larger studies on glucocorticoids in croup have been done using 0.6 mg/kg of
oral dexamethasone, there is ongoing debate about
the optimal dosing regimen, particularly in mild
croup. A randomized controlled trial by Geelhoed
with 120 enrolled patients tried to identify the minimum effective dose of dexamethasone.62 Initially,
60 patients were randomized to receive 0.6 versus
0.3 mg/kg dexamethasone. A second group of 60
patients was randomized to receive 0.3 versus 0.15
mg/kg of dexamethasone. There were no significant
differences in outcome detected between the 3 treatment dosages; however, given the small number of
subjects in the study (only 30 were treated with 0.15
mg/kg of dexamethasone), the study was underpowered to demonstrate the equivalence of the
lower dose of dexamethasone with the more-studied
0.6 mg/kg dose. Another small study of 99 subjects with croup found similar outcomes in patients
randomized to 1 of 3 orally administered treatment
regimens: 0.15 mg/kg of dexamethasone, 0.6 mg/
kg dexamethasone, and 1 mg/kg of prednisolone
(a dose of 1 mg/kg of prednisolone is equivalent to
0.15 mg/kg of dexamethasone).58 A retrospective
descriptive report by Dobrovoljac and Geelhoed
describes the experience at their center in the 11
years since they adopted the 0.15 mg/kg oral dose of
dexamethasone.63 While these studies demonstrate
that the 0.15 mg/kg dose of dexamethasone is beneficial in reducing the symptoms and the admission
rate in children with mild croup, there is not enough
evidence to conclude that this dose is equivalent to
the more rigorously studied dose of 0.6 mg/kg. A
large randomized controlled trial is currently underway to answer the question of the optimal dose of
dexamethasone in the treatment of croup.64,65
Pediatric Emergency Medicine Practice © 201210
Heliox
Heliox, a mixture of helium and oxygen, is a
gas with similar viscosity and a sevenfold lower
density than air. It was successfully pioneered in
the 1930s for the treatment of asthma and upper
airway obstruction in adults and children.66 It is
thought to reduce flow resistance by creating a less
turbulent flow, thus decreasing the work of breathing and improving gas exchange by delivering an
increased tidal volume. Several trials have demonstrated beneficial effect in children with croup, but
they are mostly anecdotal case reports or small case
series.67-69 A systematic review conducted by the
Cochrane Collaboration identified 2 small studies
that both found a greater improvement in croup
score in the helium-oxygen group, but this change
did not reach statistical significance.70,71 Thus,
they concluded that there is a lack of evidence to
determine whether heliox inhalation is beneficial
in the treatment of croup. An ongoing randomized
controlled trial that aims to enroll 142 participants
plans to compare changes in croup score as well as
need for additional therapy, admission to hospital,
intubation rate, length of stay, and use of subsequent health services between patients treated with
heliox and patients breathing room air.72
Analgesics, Antipyretics, Antitussives, And
Antibiotics
While the authors were not able to identify any
controlled trials that specifically addressed the use
of antipyretics or analgesics in children with croup,
there are no known contraindications to their use
for relief of fever and pain. Anecdotally, reducing
pyrexia often has the added benefit of reducing the
respiratory rate, and thus the work of breathing.
There is, however, no rationale to support the use
of antitussives in the treatment of croup. Furthermore, the average age of patients affected with
croup is < 2 years, and both the United States Food
and Drug Administration and Health Canada have
issued strong recommendations stating that use of
antitussive medication should be discouraged in
children < 6 years of age.73-75
As croup is most likely the result of viral infection, antibiotic therapy is generally not indicated.
Antibiotics should be reserved for cases of suspected
bacterial tracheitis or laryngotracheobronchopneumonitis. Since the rate of secondary bacterial infection in croup is estimated to be < 1 case in 1000,
there is no rationale for using antibiotics for prophylaxis in viral croup.6
Special Circumstances
Children with known congenital anomalies of their
upper airway may present with more-severe symptoms of croup. These children should be observed
www.ebmedicine.net • September 2012
in the hospital setting, as they are at risk for rapid
progression of airway obstruction and respiratory
failure. These anomalies may include, but are not
limited to, laryngomalacia, acquired or congenital
subglottic stenosis, vocal fold paralysis, juvenile
laryngeal papillomatosis, and subglottic hemangioma.76 Special attention should also be given to
patients with craniofacial anomalies (eg, Pierre
Robin sequence, Treacher Collins syndrome, Goldenhar syndrome, or Crouzon syndrome) if they
present with severe symptoms that may require
airway management.77-78 Urgent consultation with
an otolaryngologist or anesthesiologist for potential
difficult intubation should be made in these cases.
Recurrent episodes of croup in the same year
(more than 2), especially if not accompanied by the
classic prodrome of upper respiratory tract symptoms, should prompt a referral to an otorhinolaryngologist for assessment of the airway by direct laryngoscopy/bronchoscopy.79 Retrospective studies have
shown that these children are often found to have
various degrees of acquired or congenital subglottic
stenosis. Gastroesophageal reflux is emerging as a
possible cause of these recurrent episodes. Patients
with laryngoscopic findings of gastroesophageal
reflux should be adequately treated with antireflux
medications to reduce the progression of airway
narrowing secondary to inflammatory mucosal
edema.80 There is some suggestion that there may
be a correlation between recurrent croup and family
history of atopy.81,82 Children with recurrent croup
should be monitored for development of symptoms
of airway hyperreactivity. A chest radiograph may
be considered to rule out the possibility of occult
foreign body.
reliable and able to return to the hospital should the
symptoms recur.52
Hospital admission should be considered in
cases of moderate to severe croup where patients
have not improved after 4 hours of observation or
who have a poor response to epinephrine. Consultation with a pediatric ICU or anesthesia is critical if a
child exhibits signs of impending respiratory failure
or recurrent episodes of agitation or lethargy that are
not improving with nebulized epinephrine. Children
with croup do not need specific follow-up. If stridor
persists for over a week without any signs of respiratory distress, parents should see their primary
care provider who can decide to further refer to an
otolaryngologist to rule out other causes of stridor.
Summary
Children with acute viral croup commonly present
to EDs or primary care providers. The vast majority of patients will present with mild croup without
showing any signs of upper airway obstruction.
The diagnosis of croup should be made on clinical
grounds, but potentially fatal (even if rare) diagnoses such as bacterial tracheitis or epiglottitis should
be kept in mind. All children presenting with croup
should be treated with oral dexamethasone to
reduce the severity of symptoms, rate of revisits, or
admissions to the hospital and to lessen patient and
parental anxiety and economic burden. Children
exhibiting symptoms of upper airway obstruction
should be treated with nebulized epinephrine and
observed for at least 2 hours after treatment before
being discharged home. With knowledge of the basic
evidence-based principles of emergency management outlined in this article, the emergency clinician
will be able to successfully identify and manage the
different levels of severity of croup.
Disposition
Patients presenting with mild croup without stridor
or chest wall retractions should be treated with oral
dexamethasone. These children can then be safely
discharged home without further observation if
parents appear reliable and adequate key information is provided to them.6,54 Parents should be
educated on the anticipated course of illness, signs
of respiratory distress and, most importantly, when
to seek medical care. (See Figure 2, page 12.)
Children with moderate croup who are experiencing stridor and signs of respiratory distress (such
as chest wall retractions) but who do not have any
alteration in their level of consciousness should also
be treated with oral dexamethasone and nebulized
epinephrine. These children should be observed for
a minimum of 2 to 4 hours following the treatment
with epinephrine. If the child has improved and no
longer shows signs of upper airway obstruction at
the end of the observation period, he or she may be
safely discharged home, provided the caregivers are
September 2012 • www.ebmedicine.net
Case Conclusion
You determined that your patient had viral croup with
moderate symptoms. The nurse moved him into a quiet
room with the lights dimmed. He remained seated on his
mother's lap, and, with her help, he was given a nebulized
dose of racemic epinephrine 0.5 mL of 2.25% solution
diluted in 2.5 mL of saline, for a total volume of 3 mL. An
oral dose of dexamethasone 0.6 mg/kg was given to him
as soon as possible. He responded quickly to the nebulized
epinephrine, with resolution of his stridor and retractions.
He remained in the ED for 2 hours of observation. At the
2-hour mark, he showed no signs of respiratory distress, although he continued to have an intermittent, barky cough.
His parents received written instructions regarding home
treatment of croup and signs of respiratory distress, and the
family was discharged home.
11
Pediatric Emergency Medicine Practice © 2012
Figure 2. Sample Parent Education Sheet
What is croup?
• Croup is a viral infection that causes swelling of the windpipe near the voice box.
• The symptoms of croup can appear quite frightening, but the illness is rarely serious.
• Croup is more common in the fall and winter.
• Croup is contagious and can be spread through sneezing and coughing, like a cold.
• Croup often occurs in small children between the ages of 6 months and 4 years.
What are the symptoms of croup?
• The swelling of the windpipe may cause a typical cough that sounds like a barking dog. You may also notice a raspy voice or cry and, a “whistling”
sound as your child breathes in that is called “stridor.”
• Your child may have symptoms of a cold illness, like a low-grade fever, runny nose, and a decrease in energy and appetite.
• The symptoms of croup usually appear in the middle of the night and get better during the daytime. These symptoms usually last 2 to 5 days and, in
most children, are mild and disappear quite quickly.
• Children eventually outgrow the tendency to develop croup symptoms. Older family members affected by the same virus usually only get sore throat,
raspy voice, and cold-like symptoms (cough, runny nose).
What can I do at home?
• If you believe your child has symptoms of croup, stay calm and make your child comfortable. Being upset makes the breathing even harder for children with swelling in the windpipe.
• If your child has fever or complains of a sore throat, you may give him or her acetaminophen (Tempra® or Tylenol®) or ibuprofen (Advil® or Motrin®).
• Over-the-counter cough and cold medicines should NOT be given to children under the age of 6 years under any circumstances.
• Cold air sometimes helps with “croupy” sounds. If the weather is cool, make sure your child is dressed appropriately and go outside with him or her for
5 to 10 minutes. In warmer weather, you can also open the freezer door and let him or her breathe in the cold air.
• You should keep an eye on your child or stay within hearing range to assess for your child’s breathing:
If you hear a “whistling” sound, note if you hear it all the time even when your child is calm or only when he/she is upset/crying.
Look at your child’s chest wall when he/she is sleeping to see if you can see his/her ribs appearing when breathing (retractions) or if the notch
above their breastplate is sucking in.
See if you can get your child to calm down or if he/she remains fussy and restless even when you try to soothe them.
Try to notice the color of your child’s lip and face in a good light, checking for a bluish-gray color.
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When should I go to the hospital?
• You should seek medical care if:
Your child makes a constant “whistling” sound OR the chest wall is “caving in” or “sucking in” as he/she breathes, especially when calm.
You are unable to calm your child down and feel that he/she is unusually fussy or restless.
• You should call 9-1-1 if:
Your child’s face is bluish-gray for more than 5-10 seconds OR
Your child becomes unusually sleepy and you have difficulty seeing their chest wall moving when he/she breathes OR
Your child is struggling to breathe in and you are unable to calm them within a few minutes.
• If your child has severe symptoms, ambulance paramedics may start some treatment right away, and it is safer to call 9-1-1 than to drive yourself to
the hospital, especially if you are nervous and panicked.
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How is croup diagnosed and treated in the hospital?
• Croup is a viral infection; therefore, antibiotics that are used to treat bacterial infections will not help. Blood tests or x-rays do not help in making the
diagnosis of croup and doctors are usually able to recognize it by the symptoms you describe.
• The most effective treatment for croup is dexamethasone, an oral corticosteroid that is given with syrup. This medication helps to reduce the swelling
in your child’s windpipe. It is safe, starts to work within 2 or 3 hours, and lasts for a few days.
• Your child may need a breathing mask if he or she has “stridor” or chest wall retractions. The medication given by mask is adrenaline (sometimes
called epinephrine) and very quickly reduces the swelling in the windpipe. Its effects last only 1 to 2 hours. If your child receives adrenaline by mask,
he/she will need to be observed in the Emergency Department for at least 2 hours.
• Very few children with croup need to stay in the hospital for more than a few hours of observation. Even children with the most severe symptoms who
require hospital admission usually get completely better after a couple of days without any residual problems.
Used courtesy of Jasmine Allaire, MD.
Pediatric Emergency Medicine Practice © 201212
www.ebmedicine.net • September 2012
Risk Management Pitfalls For Croup In Children
1. “But I needed to document his blood pressure.”
Avoid causing further agitation in a child with
stridor. Observation of the child on the parent’s
lap and an oxygen saturation monitor is all you
need to do.
6. “This is the third time this kid has had croup
this winter.”
It is important to consider other causes of
stridor in children with recurrent symptoms
or who present with stridor in the absence of
a viral prodrome or who do not improve with
treatment with epinephrine.
2. “He’ll be fine. His saturations came right up
with oxygen.”
If a child requires oxygen to maintain
adequate oxygen saturation, consider serious
upper airway obstruction with impending
respiratory failure or lower respiratory
tract parenchymal involvement, such as
laryngotracheobronchopneumonitis, or
pneumonia.
7. “She looked so good after that dose of epinephrine that I let her go…”
Physicians should observe children who have
been treated with epinephrine for at least 2
hours before discharging them home. The effects
of epinephrine typically wear off after about 2
hours, and the child may develop recurrence of
symptoms similar to the ones exhibited prior to
treatment with epinephrine.
3. “This kid just had a barky cough yesterday.
Why did his parents bring him back today?” Evidence shows that treating even mild croup
with oral dexamethasone prevents repeat ED
and other healthcare visits and improves sleep.
8. “He still had symptoms 4 days later, so I gave
him more dexamethasone.”
There is no evidence to support the use of
multiple doses of dexamethasone in the
treatment of croup. Croup generally lasts 2
to 5 days. If a child is still having moderate
symptoms days after receiving a dose of
dexamethasone, other diagnoses must be
considered, such as bacterial tracheitis or
anatomic abnormalities of the airway.
4. ”The child vomited the dexamethasone. What
do I do now?”
Pay attention to the form of oral dexamethasone
that is administered or dispensed in your
practice setting. Many of the commercially
available oral solutions of dexamethasone
are quite dilute. This means that a child will
have to take a large volume of medication. For
example, a 10-kg child who is prescribed 0.6
mg/kg of the 0.5 mg/5 mL oral dexamethasone
solution would have to ingest 60 mL of the
solution to get his dose. Most of the studies
on oral dexamethasone in croup have used
the much more concentrated parenteralinjectable form of the drug given orally. The
small volume is absorbed rapidly and is
well tolerated, with vomiting in fewer than
5% of patients.57 In children with persistent
vomiting, dexamethasone can be given IM or IV.
Nebulized budesonide is another option when a
child cannot tolerate oral medications.
9. “They’re calling a code blue in radiology!”
Children with signs of worsening upper
airway obstruction should not leave the ED for
diagnostic imaging. They may decompensate
rapidly if they become upset or are laid down
for radiographs.
10. “What size endotracheal tube should I use?”
If a child with signs of severe croup does not
improve with nebulized epinephrine and/or
if they show signs of increasing agitation or
lethargy, they should be referred to a pediatric
critical care unit. If intubation is necessary, it
should be done under controlled circumstances
by someone with expertise in managing difficult
pediatric airways. It is advisable to start with a
cuffed endotracheal tube a half-size smaller than
would be predicted for the child’s age. It may be
necessary to size down even more, depending
on the degree of subglottic edema.
5. “Antibiotics can’t hurt…”
Antibiotics should be reserved for suspected
cases of bacterial tracheitis (high fever, toxic
appearance, acute onset of stridor, poor response
to epinephrine) or pneumonia (focal findings
on auscultation such as crackles, wheezing, or
infiltrate on chest radiograph). There is no role
for antibiotic prophylaxis in croup.
September 2012 • www.ebmedicine.net
13
Pediatric Emergency Medicine Practice © 2012
Key Points
• Croup is a common viral childhood illness
occurring most often in the late autumn and
winter in children between the age of 6 months
and 3 years.
• Croup symptoms usually worsen during the
night, making it a frequent chief complaint in
the ED.
• Most cases presenting to EDs are assessed as
mild, and mortality due to croup is very low.
• Symptoms of croup are a low-grade fever with
or without an upper respiratory infection-like
prodrome, a characteristic “seal-like” barking
cough, and inspiratory stridor, accompanied by
varying degrees of respiratory distress.
• A toxic-looking child presenting with drooling,
tripod stance, and stridor with the absence of
a barky cough should prompt quick assessment for epiglottitis, with airway management
handled by highly skilled specialist physicians
(ENT and/or anesthesiologist).
• Diagnosis of croup should be made clinically. If
imaging studies are obtained to rule out another
diagnosis, patients should be closely monitored
because of the risk of rapidly progressive upper
airway obstruction.
• Treatment of croup consists of oxygen by
blow-by technique, oral corticosteroids (dexamethasone 0.15-0.6 mg/kg/dose) even for mild
cases, and nebulized epinephrine for children
Time- And Cost-Effective
Strategies
1. Do not order routine laboratory or imaging
studies in children with suspected croup.
2. The diagnosis of croup should be made clinically, and further investigations should be reserved
for patients in which the diagnosis is unclear.
3. Early treatment of mild disease with corticosteroids may prevent unnecessary or late presentations to the ED and reduce visits to primary care
providers.
4. The use of oral dexamethasone is recommended because it is less expensive than inhaled
budesonide with no significant difference in
clinical outcomes.
5. Treating moderate cases of croup with oral
corticosteroids and nebulized epinephrine may
prevent hospital admissions. Children should
be observed at least 2 hours after the last administration of nebulized epinephrine, and, if
symptoms of croup do not reappear, they may
be safely discharged home.
Pediatric Emergency Medicine Practice © 201214
with signs of upper airway obstruction (audible stridor or marked chest wall retractions).
L-epinephrine 1:1000 has been shown to be as
effective as racemic epinephrine 2.25%, and institutional preference may guide management.48
• Signs of impending respiratory failure include
a change in mental status, less respiratory effort, disappearance of stridor accompanied by a
pale, dusky appearance, and decreasing oxygen
saturation.
• Children with significant respiratory symptoms
4 hours after the administration of corticosteroids or repeated doses of epinephrine should be
admitted to the hospital.
• Children with recurrent episodes of croup
should be referred to an otorhinolaryngologist
for assessment of their upper airway to rule out
anatomical anomalies such as subglottic stenosis
or gastroesophageal reflux.
References
Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are
equally robust. The findings of a large, prospective,
randomized, and blinded trial should carry more
weight than a case report.
To help the reader judge the strength of each
reference, pertinent information about the study,
such as the type of study and the number of patients
in the study will be included in bold type following
the references, where available. The most informative references cited in this paper, as determined by
the author, will be noted by an asterisk (*) next to the
number of the reference.
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2. Russell KF, Liang Y, O’Gorman K, et al Glucocorticoids for
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3. Vorwek C, Coats T. Heliox for croup in children. Cochrane
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4. Moore M, Little P. Humidified air inhalation for treating
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6.* Alberta Clinical Practice Guideline Working Group. Guideline for diagnosis and management of croup. 2007 Update.
Available at: http://www.albertadoctors.org/bcm/ama/
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32. Klassen TP, Feldman ME, Watters LK, et al. Nebulized
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39. Rosenkrans JA. Viral croup: current diagnosis and treatment.
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45. Kristjansson S, Berg-Kelly K, Winso E. Inhalation of racemic
adrenaline in the treatment of mild and moderately severe
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46. Adair JC, Ring WH, Jordan WS, et al. Ten-year experience
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47. Fogel JM, Berg IJ, Gerber MA, et al. Racemic epinephrine in
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48. Waisman Y, Klein BL, Boenning DA, et al. Prospective randomized double-blind study comparing L-epinephrine and
Turner JA, Morgan EA. Corticotropin (ACTH) in the
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Martensson B, Nilson B. The effect of corticosteroids in the
treatment of pseudo-croup. Acta Otolaryngol. 1960;158(suppl):52. (Randomized controlled trial; 288 patients)
Novik A. Corticosteroid treatment of non-diphtheric croup.
Act Otolaryngol. 1960;158(suppl):20. (Randomized controlled
trial; 160 patients)
James J. Dexamethasone in croup. Am J Dis Child.
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Koren G, Frand M, Barzilay Z, et al Corticosteroid treatment
of laryngotracheitis v spasmodic croup in children. Am J Dis
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patients)
Kairys SW, Olmstead EM, O’Connor GT. Steroid treatment of
laryngotracheitis: a meta-analysis of the evidence from randomized trials. Pediatrics.1989; 83(5):683-693. (Meta-analysis,
10 studies; 1286 patients)
Zach M, Erben A, Olinsky A. Croup, recurrent croup, allergy,
and airways hyper-reactivity. Arch Dis Child. 1981;56(5):336341. (Cohort study; 110 patients)
Cohen B, Dunt D. Recurrent and non-recurrent croup: an
epidemiological study. Aust Paediatr J. 1988;24(6):339-342
(Case-control study; 137 patients)
Edwards KM, Dundon MC, Altemeier WA. Bacterial tracheitis as a complication of viral croup. Pediatr Infect Dis.
1983;2(5):390-391. (Case reports; 2 patients)
Rosychuk, RJ, Klassen TP, Metes D, et al Croup presentations to emergency departments in Alberta, Canada: a large
population-based study. Pediatr Pulmonol. 2010;45(1):83-91.
(Retrospective study; 27,355 ED visits)
Rosychuk RJ, Klassen TP, Voaklander DC, et al. Seasonality
patterns in croup presentations to emergency departments
in Alberta, Canada: a time series analysis. Pediatr Emerg Care.
2011;27(4):256-260. (Retrospective study; 27,355 ED visits)
McEniery J, Gillis J, Kilham H, et al. Review of intubation in
severe laryngotracheobronchitis. Pediatrics. 1991;87(6):847853. (Retrospective chart review; 208 patients)
Knott AM, Long CE, Hall CB. Parainfluenza viral infections
in pediatric outpatients: seasonal patterns and clinical characteristics. Pediatr Infect Dis J. 1994;13(4):269-273. (Prospective surveillance study; 5998 patients)
Wall SR, Wat D, Gelder CM, et al. The viral aetiology of
croup and recurrent croup. Arch Dis Child. 2009;94(5):359360. (Prospective study; 60 patients)
Chapman RS, Henderson FW, Clyde WA, et al The epidemiology of tracheobronchitis in pediatric practice. Am J
Epidemiol. 1981;114(6):786-797. (Epidemiological study; 1824
patients)
Hussey GD, Clements CJ. Clinical problems in measles case
management. Ann Trop Paediatr. 1996;16(4):307-317. (Review
article)
Burton DM, Seid AB, Kearns DB, et al. Candida laryngotracheitis: a complication of combined steroids and antibiotic
usage in croup. Int J Pediatr Otorhinolaryngol. 1992;23(2):171175. (Case report)
Sobol SE, Zapata S. Epiglottitis and croup. Otolaryngol Clin
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Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of
Pediatrics. Philadelphia, Pa: WB Saunders; 1996. (Textbook)
Fleisher GR, Ludwig S. Textbook of Pediatric Emergency Medicine. Philadelphia, Pa: Wolters Kluwer/Lippincott Williams
& Wilkins Health; 2010. (Textbook)
Faden H. The dramatic change in the epidemiology of pediatric epiglottitis. Pediatr Emerg. 2006;22(6):443-444. (Retrospective chart review; 2 cases)
Tibballs J, Watson T. Symptoms and signs differentiating
croup and epiglottits. J Paediatr Child Health. 2011;47(3):77-82.
September 2012 • www.ebmedicine.net
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nebulized racemic epinephrine in conjunction with oral
dexamethasone and mist in the outpatient treatment of
croup. Ann Emerg Med. 1995;25(3):331-337. (Prospective
interventional study; 55 patients)
Zhang L, Sanguebsche L. The safety of nebulization with 3 to
5 ml of adrenaline (1:1000) in children: an evidence based review. J Pediatr (Rio J). 2005;81(3):193-197. (Systematic review;
7 trials; 238 patients)
Butte MJ, Nguyen BX, Hutchison TJ, et al. Pediatric myocardial infarction after racemic epinephrine administration.
Pediatrics. 1999;104(1):e9. (Case report; 1 patient)
Kelly PB, Simon JE. Racemic epinephrine use in croup and
disposition. Am J Emerg. 1992;10(3):181-183. (Retrospective
chart review; 50 patients)
Thomas LP, Friedland LR. The cost-effective use of nebulized
racemic epinephrine in the treatment of croup. Am J Emerg
Med. 1992;10(3):181-183. (Cross-sectional study; 23 hospitals)
Super DM, Cartelli NA, Brooks LJ, et al. A prospective
randomized double-blind study to evaluate the effect
of dexamethasone in acute laryngotracheitis. J Pediatr.
1989;115(2):323-329. (Randomized controlled trial; 29 patients)
Bjornson CL, Klassen TP, Williamson J, et al. A randomized
controlled trial of a single of oral dexamethasone for mild
croup. N Engl J Med. 2004;351(13):1306-1313. (Randomized
controlled trial; 720 patients)
Geelhoed CC, Macdonald WBS. Oral and inhaled steroids
in croup: a randomized, placebo-controlled trial. Pediatr
Pulmonol. 1995;20(6):355-361. (Randomized controlled trial;
80 patients)
Klassen TP, Craig WR, Moher D, et al. Nebulized budesonide
and oral dexamethasone for treatment of croup: a randomized controlled trial. JAMA, 1998;21(6):359-362. (Randomized controlled trial; 198 patients)
Fifoot A, Ting JYS. Comparison between single-dose oral
prednisolone and oral dexamethasone in the treatment of
croup: a randomized double-blinded clinical trial. Emerg Med
Australas. 2007;19(1):51-58. (Randomized controlled trial; 99
patients)
Luria JW, Gonzalez-del-Rey JA, DiGiulio GA, et al. Effectiveness of oral or nebulized dexamethasone for children with
mild croup. Pediatr Adolesc Med. 2001;155(12):1340-1345.
(Randomized controlled trial; 264 patients)
Johnson DW, Jacobson S, Edney PC, et al. A comparison
of nebulized budesonide, intramuscular dexamethasone,
and placebo for moderately severe croup. N Engl J Med.
1998;339(8):498-503. (Randomized controlled trial; 144
patients)
Geelhoed, GC. Budesonide offers no advantage when added
to oral dexamethasone in the treatment of croup. Ped Emerg
Care. 2005;21(6):359-362. (Randomized controlled trial; 72
patients)
Geelhoed, GC. Oral dexamethasone in the treatment of
croup: 0.15 mg/kg versus 0.3 mg/kg versus 0.6 mg/kg. Ped
Pulmonol. 1995;20(6):362-368. (Randomized controlled trial;
120 patients)
Dobrovoljac M, Geelhoed GC. 27 years of croup: an update
highlighting the effectiveness of 0.15 mg/kg of dexamethasone. Emerg Med Austral. 2009;21(4):309-314. (Retrospective
descriptive report)
Parker C. “ToPDog” is in progress. Emerg Med J.
2010;27(12):961. (Letter)
A comparison of oral prednisolone and oral dexamethasone
in children with croup: a prospective, randomised, double
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Beckmann KR, Brueggemann WM. Heliox treatment of
severe croup. Am J Emerg Med. 2000;18(6):735-736. (Case
report)
DiCecco RJ, Rega PP. The application of heliox in the management of croup by an air ambulance service. Air Med J.
2000;23(2):33-35. (Case report)
Smith SW Biros M. Relief of imminent respiratory failure
from upper airway obstruction by use of helium-oxygen: a
case series and brief report. Acad Emerg Med. 1999; 6(9):953956. (Case series; 5 patients)
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on croup: a pilot study. Acad Emerg Med. 1998;5(11):11301133. (Randomized trial; 15 patients)
Weber JE, Chudnofsky CR, Younger JG, et al. A randomized
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Walker, RWM. Management of the difficult airway in children. J R Soc Med. 2001;94(7):341-344. (Review article)
Bew S. Managing the difficult airway in children. Anesth Int
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Hoa M, Kingsley EL, Coticchia JM. Correlating the clinical course of recurrent croup with endoscopic findings: a
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2007;28(6):401-407. (Retrospective chart review; 17 patients)
Arslan Z, Cipe FE, Ozmen S, et al. Evaluation of allergic
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www.ebmedicine.net • September 2012
5. Which of the following is a radiographic sign
of croup?
a. Widening of the prevertebral space on lateral neck radiograph
b. Thumb sign on the lateral neck radiograph
c. Tracheal deviation on the chest radiograph
d. Steeple sign on the chest radiograph
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6. Which of the following tests are necessary in
evaluating a child you suspect has croup?
a. A chest x-ray
b. A nasopharyngeal swab or washing for viral molecular testing
c. A complete blood count
d. No diagnostic tests are required
7. All of the following have been shown to be effective therapies for croup EXCEPT:
a. Nebulized budesonide
b. Humidified air
c. Nebulized racemic epinephrine
d. IM dexamethasone
1. The most common cause of croup is:
a. Gastroesophageal reflux
b. Group A streptococci
c. Influenza viruses
d. Parainfluenza viruses
8. Which of the following statements is true
regarding treatment of mild croup with dexamethasone?
a. Dexamethasone is only useful in children with a family history of atopy.
b. Dexamethasone must be given within the first 24 hours of the onset of symptoms to be effective.
c. Treatment of mild croup with dexamethasone reduces healthcare costs.
d. Treatment of mild croup with dexamethasone reduces the infectiousness of the child.
2. Which of the following statements is true?
a. Croup is a self-limited infection generally lasting 2 to 5 days.
b. Croup symptoms often come on gradually over the course of a week.
c. Croup is predominantly an illness of school-
aged children.
d. Many children with croup progress to develop asthma.
9. A child with moderate to severe symptoms of
croup treated with oral dexamethasone has
improved with nebulized epinephrine. His
symptoms recur 1 hour later. What is the most
appropriate next step in management?
a. Administer nebulized budesonide
b. Prepare for intubation
c. Repeat nebulized epinephrine dose
d. Administer inhaled heliox
3. A previously healthy 2-year-old boy presents
with a frequent, barky cough and stridor audible from the door of the examination room.
He has mild subcostal retractions and is sitting happily playing with his mother’s phone.
How would you classify the severity of his
symptoms?
a.Mild
b.Moderate
c.Severe
d. Impending respiratory failure
10. A child with moderate-to-severe symptoms of
croup responds well to a dose of nebulized epinephrine. Provided she remains asymptomatic,
when can she be safely discharged home?
a. After 1 hour of observation
b. After 2 to 4 hours of observation
c. After 5 to 6 hours of observation
d. All children requiring treatment with nebulized epinephrine should be hospitalized for at least 24 hours.
4. A 6-year-old boy comes with a sudden history
of fever and difficulty breathing. On examination, he is toxic-looking and is sitting in a
tripod position and drooling. He is stridorous.
What is the most likely diagnosis?
a. Severe croup
b. Bacterial tracheitis
c.Epiglottitis
d.Anaphylaxis
September 2012 • www.ebmedicine.net
17
Pediatric Emergency Medicine Practice © 2012
Coming Soon In
Pediatric Emergency Medicine Practice
An Evidence-Based Approach
To Pediatric Pain Management In
The Emergency Department
Evidence-Based Emergency
Management Of The
Pediatric Airway
AUTHORS:
AUTHORS:
NEIL G. USPAL, MD
Attending Physician, Division of Emergency
Medicine, Seattle Children’s Hospital; Assistant
Professor of Pediatrics, University of Washington,
Seattle, WA
STEPHEN CICO, MD, FAAEM, FAAP
Assistant Professor of Pediatrics, Associate
Fellowship Director of Pediatric Emergency
Medicine, University of Washington; Attending
Physician, Division of Emergency Medicine,
Seattle Children’s Hospital, Seattle, WA
Analgesia is a critical part of the management of
pediatric patients in the emergency department
(ED). Pain is multifactorial and is influenced by its
etiology, patient age, temperament, beliefs, and
past experiences. Suboptimal treatment of pain can
have deleterious effects in the short term, but it
can also affect a patient’s reaction to future painful
experiences and development. Tools exist to reliably
quantify a patient’s pain level, regardless of age
or developmental stage. Both pharmacologic and
nonpharmacologic methods can be effective in the
management of pediatric pain. Multiple modalities
exist for the management of procedural pain,
ranging from topical analgesia for IV placement
to procedural sedation for more significant
procedures. ED physicians must remain vigilant in
the recognition and treatment of pediatric pain, as
patients’ developmental level may limit their ability to
adequately express their pain experience.
Pediatric Emergency Medicine Practice © 201218
AMANDEEP SINGH, MD
Emergency Department, Alameda County Medical
Center, Highland Hospital, Oakland, CA; Assistant
Professor of Emergency Medicine, University of
California at San Francisco, San Francisco, CA
OREN FRENKEL, MD
Emergency Department, Alameda County Medical
Center, Highland Hospital, Oakland, CA
Pediatric airway emergencies are a relatively
uncommon, yet anxiety-provoking, scenario seen in
both pediatric and general emergency departments.
Several new concepts regarding preoxygenation
during rapid sequence intubation (RSI), anticipation
and prevention of intubation-related complications,
the utility of premedication agents, and the selection
of induction and paralytic agents have gained
popularity among emergency clinicians physicians
for adult RSI. In this issue, we will outline the
data behind these concepts, highlight any current
pediatric literature related to these issues, and
present conclusions based on the best available
evidence. We present a review of the anatomic
and physiologic differences during RSI commonly
encountered in the pediatric patient, a systematic
approach to the assessment of the pediatric
patient in respiratory distress (ie, the pediatric
assessment triangle), and a simple approach to
pediatric RSI, starting with preparation and ending
with postintubation management. We additionally
highlight several alternative airway techniques and
briefly review RSI in the obese pediatric patient and
in the difficult airway patient.
www.ebmedicine.net • September 2012
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September 2012 • www.ebmedicine.net
19
Pediatric Emergency Medicine Practice © 2012
Physician CME Information
Date of Original Release: September 1, 2012. Date of most recent review:
August 15, 2012. Termination date: September 1, 2015.
Accreditation: EB Medicine is accredited by the ACCME to provide continuing
medical education for physicians.
Credit Designation: EB Medicine designates this enduring material for a
maximum of 4 AMA PRA Category 1 CreditsTM. Physicians should claim only
credit commensurate with the extent of their participation in the activity.
ACEP Accreditation: Pediatric Emergency Medicine Practice is also approved
by the American College of Emergency Physicians for 48 hours of ACEP
Category I credit per annual subscription.
AAP Accreditation: This continuing medical education activity has been
reviewed by the American Academy of Pediatrics and is acceptable for a
maximum of 48 AAP credits per year. These credits can be applied toward
the AAP CME/CPD Award available to Fellows and Candidate Fellows of the
American Academy of Pediatrics.
AOA Accreditation: Pediatric Emergency Medicine Practice is eligible for up to
48 American Osteopathic Association Category 2A or 2B credit hours per year.
Needs Assessment: The need for this educational activity was determined by a
survey of medical staff, including the editorial board of this publication; review
of morbidity and mortality data from the CDC, AHA, NCHS, and ACEP; and
evaluation of prior activities for emergency physicians.
Target Audience: This enduring material is designed for emergency medicine
physicians, physician assistants, nurse practitioners, and residents.
Goals: Upon reading Pediatric Emergency Medicine Practice, you should be
able to: (1) demonstrate medical decision-making based on the strongest
clinical evidence; (2) cost-effectively diagnose and treat the most critical ED
presentations; and (3) describe the most common medicolegal pitfalls for each
topic covered.
Discussion of Investigational Information: As part of the newsletter, faculty
may be presenting investigational information about pharmaceutical products
that is outside Food and Drug Administration approved labeling. Information
presented as part of this activity is intended solely as continuing medical
education and is not intended to promote off-label use of any pharmaceutical
product.
Faculty Disclosure: It is the policy of EB Medicine to ensure objectivity, balance,
independence, transparency, and scientific rigor in all CME-sponsored
educational activities. All faculty participating in the planning or implementation
of a sponsored activity are expected to disclose to the audience any relevant
financial relationships and to assist in resolving any conflict of interest that
may arise from the relationship. Presenters must also make a meaningful
disclosure to the audience of their discussions of unlabeled or unapproved
drugs or devices. In compliance with all ACCME Essentials, Standards, and
Guidelines, all faculty for this CME activity were asked to complete a full
disclosure statement. The information received is as follows: Dr. Clarke, Dr.
Allaire, Dr. Bradin, Dr. Silverberg, Dr. Vella, and their related parties report no
significant financial interest or other relationship with the manufacturer(s) of
any commercial product(s) discussed in this educational presentation.
Pediatric Emergency
Medicine Practice
Has Gone Mobile!
You can now view all Pediatric Emergency
Medicine Practice content on your iPhone
or Android smartphone. Simply visit
www.ebmedicine.net from your mobile
device, and you’ll automatically be
directed to our mobile site.
On our mobile site, you can:
•
View all issues of Pediatric Emergency Medicine
Practice since inception
•
Take CME tests for all Pediatric Emergency
Medicine Practice issues published within the
last 3 years – that’s over 100 AMA Category 1
CreditsTM!
•
View your CME records, including scores, dates
of completion, and certificates
•
And more!
Method of Participation:
Print Subscription Semester Program: Paid subscribers who read all CME
articles during each Pediatric Emergency Medicine Practice six-month testing
period, complete the post-test and the CME Evaluation Form distributed
with the June and December issues, and return it according to the published
instructions are eligible for up to 4 hours of CME credit for each issue. You
must complete both the post-test and CME Evaluation Form to receive credit.
Results will be kept confidential.
Online Single-Issue Program: Current, paid subscribers who read this Pediatric
Emergency Medicine Practice CME article and complete the online post-test
and CME Evaluation Form at ebmedicine.net/CME are eligible for up to 4 hours
of Category 1 credit toward the AMA Physician’s Recognition Award (PRA). You
must complete both the post-test and CME Evaluation Form to receive credit.
Results will be kept confidential.
Hardware/Software Requirements: You will need a Macintosh or PC with
internet capabilities to access the website. Adobe Reader is required to
download archived articles.
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interest, source of funding, statement of informed consent, and statement of
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Subscription Information:
1 year (12 issues) including evidence-based print issues;
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Pediatric Emergency Medicine Practice (ISSN Print: 1549-9650, ISSN Online: 1549-9669, ACID-FREE) is published monthly (12 times per year) by EB Medicine. 5550 Triangle Parkway, Suite 150, Norcross,
GA 30092. Opinions expressed are not necessarily those of this publication. Mention of products or services does not constitute endorsement. This publication is intended as a general guide and is intended
to supplement, rather than substitute, professional judgment. It covers a highly technical and complex subject and should not be used for making specific medical decisions. The materials contained herein
are not intended to establish policy, procedure, or standard of care. Pediatric Emergency Medicine Practice is a trademark of EB Medicine. Copyright © 2012 EB Medicine All rights reserved. No part of this
publication may be reproduced in any format without written consent of EB Medicine. This publication is intended for the use of the individual subscriber only, and may not be copied in whole or in part or
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Pediatric Emergency Medicine Practice © 201220
www.ebmedicine.net • September 2012