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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 www.ebmedicine.net • September 2012 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 l l l 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) l l 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. l l l l 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. l l l l l 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. 1. Bjornson C, Russell KF, Vandermeer B, et al. Nebulized epinephrine for croup in children. Cochrane Database Syst Rev. 2011,16;(2): CD006619. (Systematic review; 8 studies; 225 patients) 2. Russell KF, Liang Y, O’Gorman K, et al Glucocorticoids for croup. Cochrane Database Syst Rev. 2011,19;(1):CD001955. (Systematic review; 24 studies; 2878 patients) 3. Vorwek C, Coats T. Heliox for croup in children. Cochrane Database Syst Rev. 2010,17;(2):CD006822. (Systematic review; 2 studies; 44 patients) 4. Moore M, Little P. Humidified air inhalation for treating croup. Cochrane Database Syst Rev. 2006,19;(3):CD002870. (Systematic review) 5. Infectious Diseases and Immunization Committee. Canadian Paediatric Society. Steroid therapy for croup in children admitted to hospital. CMAJ. 1992; 147(4):429-432. (Position statement) 6.* Alberta Clinical Practice Guideline Working Group. Guideline for diagnosis and management of croup. 2007 Update. Available at: http://www.albertadoctors.org/bcm/ama/ ama-website.nsf/AllDoc/87256DB000705C3F87256E0500553 4E2/$File/CROUP.PDF. Accessed October 2, 2011. (Clinical guidelines) 7. Eden AN, Larkin VP. Corticosteroid treatment of croup. Pediatrics. 1964;33(5):768-769. (Randomized controlled trial; 41 patients) www.ebmedicine.net • September 2012 8. 9. 10. 11. 12. 13.* 14. 15. 16. 17. 18.* 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. (Prospective study; 203 patients) 30. Leung AKC, Kellner JD, Johnson DW. Viral croup: a current perspective. J Pediatr Health Care. 2004;18(6)297-301. (Review article) 31.* Westley CR, Cotton EK, Brooks JG. Nebulized racemic epinephrine by IPPB for the treatment of croup. Am J Dis Child. 1978;132(5):484-487. (Randomized controlled trial; 20 patients) 32. Klassen TP, Feldman ME, Watters LK, et al. Nebulized budesonide for children with mild-to-moderate croup. N Engl J Med. 1994;331(5):285-289. (Randomized controlled trial; 54 patients) 33. Bjornson CL, Johnson DW. Croup. Lancet. 2008;371(9609):329339. (Review article) 34. Salour M. The steeple sign. Radiology. 2000;216(2):428-429. (Case report) 35. Currarino G, WIlliams B. Lateral inspiration and expiration radiographs of the neck in children with laryngotracheitis. Radiology. 1982;145(2):365-366. (Retrospective chart review; 100 patients) 36. Pope, AE. The Profession of Home Making: A Condensed Homestudy Course on Domestic Science; The Practical Application of the Most Recent Advances in the Arts and Sciences to the Home Industries. Chicago: American School of Home Economics, 1911. (Textbook) 37. Greally P, Cheng K, Tanner MS, et al. Children with croup presenting with scalds. Br Med J. 1990;301(6743):113. (Case reports; 2 patients) 38. Lavine E, Scolnik D. Lack of efficacy of humidification in the treatment of croup: why do physicians persist in using an unproven modality? CJEM. 2001;3(3):209-212. (Review article) 39. Rosenkrans JA. Viral croup: current diagnosis and treatment. Mayo Clin Proc. 1998;73(11):1102-1107. (Review article) 40. Moore M, Little P. Humidified air inhalation for treating croup: a systematic review and meta-analysis. Fam Prac. 2007;24(4):295-301. (Systematic review and meta-analysis of 3 studies; 135 patients) 41. Bourchier D, Dawson KP, Fergusson DM. Humidification in viral croup: a controlled trial. Aust Paedatr J. 1984;20(4):289291. (Randomized controlled trial; 16 children) 42. Neto GM, Kentab O, Klassen TP, et al A randomized controlled trial of mist in the acute treatment of moderate croup. Acad Emerg Med. 2002;9(9):873-879. (Randomized controlled trial; 71 patients) 43. Scolnik D, Coates AL, Stephens D, et al. Controlled delivery of high vs low humidity vs mist therapy for croup in emergency departments. JAMA. 2006;295(11):1274-1280. (Randomized controlled trial; 140 patients) 44. Corkey C, Barker G, Edmonds J, et al. Radiographic tracheal diameter measurements in acute infectious croup: an objective scoring system. Crit Care Med. 1981;9(8):587-590. (Randomized controlled trial; 14 patients) 45. Kristjansson S, Berg-Kelly K, Winso E. Inhalation of racemic adrenaline in the treatment of mild and moderately severe croup. Clinical symptom score and oxygen saturation measurements for evaluation of treatment effects. Acta Paediatrica. 1994;83(11):1156-1160. (Randomized controlled trial; 54 patients) 46. Adair JC, Ring WH, Jordan WS, et al. Ten-year experience with IPPB in the treatment of acute laryngotracheobronchiolitis. Anest Analg. 1971;50(4):649-655. (Retrospective chart review) 47. Fogel JM, Berg IJ, Gerber MA, et al. Racemic epinephrine in the treatment of croup: nebulization alone versus nebulization with intermittent positive pressure breathing. J Pediatr. 1982;101(6):1028-1031. (Randomized controlled trial; 14 patients) 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 treatment of acute laryngotracheitis. Amer J Dis Child. 1952;83(4):440-445. 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. 1969;117(5):511-516. (Randomized controlled trial; 88 patients) Koren G, Frand M, Barzilay Z, et al Corticosteroid treatment of laryngotracheitis v spasmodic croup in children. Am J Dis Child. 1983;137(10):941-944. (Randomized controlled trial; 72 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 North Am. 2008;41(3):551-566. (Review article) 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 15 Pediatric Emergency Medicine Practice © 2012 49. 50. 51. 52. 53. 54. 55. 56. 57. 58. 59. 60. 61. 62. 63. 64. 65. racemic epinephrine aerosols in the treatment of laryngotracheitis (croup). Pediatrics. 1992;89(2):302-306. (Randomized controlled trial; 28 patients) Ledwith CA, Shea LM, Mauro RD. Safety and efficacy of 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 blinded multicentre trial, Australian New Zealand Clini- Pediatric Emergency Medicine Practice © 201216 66. 67. 68. 69. 70. 71. 72. 73. 74. 75. 76. 77. 78. 79. 80. 81. 82. cal Trials Registry, ACTRN12609000290291. (Randomized controlled trial, unpublished data) Barach AL. The therapeutic use of helium. JAMA. 1936;107:1273-1280. (Observational study) 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) Terregino C, Nairn S, Chansky M, et al. The effect of heliox 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 comparison of helium-oxygen mixture (heliox) and racemic epinephrine for the treatment of moderate to severe croup. Pediatrics. 2001;107(6):E96. (Randomized controlled trial; 33 patients) ISRCTN82240782. Children receiving heliox inhalation in croup: a randomized controlled trial (CHIC). Current Controlled Trials. (Unpublished data) US Food and Drug Administration. News & Events. FDA releases recommendations regarding use of over-the-counter cough and cold products. Products should not be used in children under 2 years of age; evaluation continues in older populations. Available at: www.fda.gov/NewsEvents/ Newsroom/PressAnnouncements/2008/ucm116839.htm. Accessed October 26, 2011. Health Canada. Advisories and Warnings. Health Canada’s decision on cough and cold medicines. 2008. Available at: http://www.hc-sc.gc.ca/ahc-asc/media/advisoriesavis/_2008/2008_184info1-eng.php. Accessed October 26, 2011. Rimsza ME, Newberry S. Unexpected infant deaths associated with use of cough and cold medications. Pediatrics. 2008;122(2):318-322. (Retrospective chart review; 10 patients) Boudewyns A, Claes J, Van de Heyning P. An approach to stridor in infants and children. Eur J Pediatr. 2010;169(2):135141. (Review article) 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 C Med. 2006;7(5):172-174. (Review article) Hoa M, Kingsley EL, Coticchia JM. Correlating the clinical course of recurrent croup with endoscopic findings: a retrospective observational study. Ann Otol Rhinol Layryngol. 2008;117(6)464-469. (Observational study; 47 patients) Kwong K, Hoa M, Coticchia JM. Recurrent croup presentation, diagnosis, and management. Am J Otolaryng. 2007;28(6):401-407. (Retrospective chart review; 17 patients) Arslan Z, Cipe FE, Ozmen S, et al. Evaluation of allergic sensitization and gastroesophageal reflux disease in children with recurrent croup. Pediatr Int. 2009;51(6):661-665. (Prevalence study; 57 patients) Ramsey, CD, Gold DR, Litonjua AA, et al. Respiratory illnesses in early life and asthma and atopy in childhood. J Allergy Clin Immunology. 2007;119(1):150-156. (Prospective cohort study; 440 patients) 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 CME Questions Take This Test Online! Current subscribers receive CME credit absolutely free by completing the following test. Each issue includes 4 AMA PRA Category 1 CreditsTM, 4 ACEP Category I credits, 4 AAP Prescribed credits, and 4 AOA category Take This Test Online! 2A or 2B credits. Monthly online testing is now available for current and archived issues. To receive your free CME credits for this issue, scan the QR code below or visit www.ebmedicine.net/P912. 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 Want 3 FREE issues added to your subscription? Receiving a FREE 3-issue extension on your Pediatric Emergency Medicine Practice subscription is easy! Simply recommend Pediatric Emergency Medicine Practice to a colleague and ask them to mention your name when they call to subscribe. We’ll automatically add 3 FREE issues to your subscription for every new subscriber you refer. And there’s no limit on the number of people you can refer! Your colleagues can subscribe by calling 1-800-249-5770 and mentioning your name or by visiting: www.ebmedicine.net/subscribe (Ask them to enter Promotion Code: REFERRALP and enter your name in the Comments box.) With this exclusive promotion code, they’ll save $100 off the regular subscription price! They can also use the order form below and mail a check for $199 (a $100 savings) to: EB Medicine / 5550 Triangle Pkwy Ste 150 / Norcross, GA 30092. Start referring today! Subscribe now to Pediatric Emergency Medicine Practice Subscribe now for just $199 — a $100 savings — for a full year (12 issues) of Pediatric Emergency Medicine Practice and we’ll give the colleague who referred you 3 free issues! 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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. 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