Humidified air inhalation does not improve symptoms in patients with moderate croup. Although the optimal dose is unclear, 0.6 mg per kg is the most commonly used.13,24 Dexamethasone is superior to budesonide for improving symptoms scores, but there is no significant difference in return visits or readmissions. Regain Access - You can regain access to a recent Pay per Article purchase if your access period has not yet expired. Dexamethasone, given orally as a single dose at 0.6 mg/kg, is highly efficacious in treating croup … • Richards AM. Pay Per Article - You may access this article (from the computer you are currently using) for 2 days for US$25.00. Am J Dis Child. Coates AL, 2014;9(3):733–747. Moore M, Among the noninfectious etiologies of this syndrome are foreign body DUSTIN K. SMITH, DO; ANDREW J. MCDERMOTT, MD; and JOHN F. SULLIVAN, DO, Naval Hospital Jacksonville, Jacksonville, Florida. ; Lavine E, 9(May 1, 2018) Many patients will also have dyspnea and fever,5,6 but the absence of fever should not reduce suspicion for croup. Radiography and laryngoscopy should be reserved for patients in whom alternative diagnoses are suspected. 8. Liang Y, Sabbagh A, Caregivers may only need education regarding the course of the disease and supportive homecare guidelines. Denny FW, Kaditis AG, Fernandes RM, Croup: an 11-year study in a pediatric practice. DUSTIN K. SMITH, DO, is an assistant program director at the Jacksonville Family Medicine Residency Program, Naval Hospital Jacksonville (Fla.).... ANDREW J. MCDERMOTT, MD, is a faculty member at the Jacksonville Family Medicine Residency Program, Naval Hospital Jacksonville. Coates AL, Collier AM, Laboratory studies are seldom needed to diagnose croup. Pediatrics. Steeple sign: not specific for croup. Croup is a common respiratory illness affecting 3% of children six months to three years of age. El-Hakim H. Williamson J, Kahbazi M. 2016;90:86–90. children by a hoarse voice; dry, barking cough; inspiratory stridor; Title 17 U.S.C. Fam Pract. Viral cultures and rapid antigen testing should be reserved for patients in whom initial treatment is ineffective.6 A complete blood count may help distinguish croup from bacterial etiologies of stridor (e.g., bacterial tracheitis, epiglottitis, peritonsillar abscess, retropharyngeal abscess), but it is nonspecific. Cherry JD. Nebulized epinephrine for croup in children. El-Hakim H. Cotton EK, List the etiologic agents associated with viral croup. Croup often runs its course within three to five days. common and most typical form of the viral croup syndrome is acute Petrocheilou A, Lee CH, Sterkel R, Fernandes RM, Korean J Pediatr. A Cochrane review showed that nebulized epinephrine reduces symptom scores at 30 minutes, but not at two and six hours; however, it is associated with reduced length of hospitalization.25 There was no initial difference between nebulized racemic epinephrine and L-epinephrine, although L-epinephrine was more effective at two hours because of its longer effects. brief period of time. Pediatr Pulm. All rights Reserved. / afp Scolnik D, Glucocorticoids for croup. 26. Lavine E, Marx A, Murphy TF, Croup often starts, as many respiratory infections do, with a runny nose, fever, and a red, sore throat. 101 defines United States Government work as a work prepared by a military service member or employee of the United States Government as part of that person's official duties. Clinical Practice Guidelines DIAGNOSIS AND MANAGEMENT OF CROUP AUTHORS*: Michelle Clarke, MD FRCPC Division of Pediatric Emergency Medicine Department of Pediatrics, University of British Columbia BC Children’s Hospital 4480 Oak Street Vancouver, British Columbia Canada V6H 3V4 CLINICAL PRACTICE GUIDELINE TASK FORCE: CHAIRMAN: Paul Korn. Treatment with dexamethasone results in faster resolution of symptoms and decreased return to medical care.21 Corticosteroids are thought to work by decreasing laryngeal mucosal edema through their anti-inflammatory effects. Török TJ, 2015;49(4):408-414. Cates CJ, McGuire T, 2018 May 1;97(9):575-580. Williamson J, 2019;144(3). In patients with moderate to severe croup, the addition of nebulized epinephrine improves symptoms and reduces length of hospitalization. Rhonchi may be present but are not typical. Lee DR, Bronchoscopy findings in recurrent croup: a systematic review and meta-analysis. It accounts for 7% of hospitalizations annually for fever and/or acute respiratory illness in children younger than five years. Stroud RH , Friedman NR . 6. Adapted with permission from Westley CR, Cotton EK, Brooks JG. 5 PCR testing has been shown to decrease the rate of radiographs ordered in the ED but has not been shown to decrease antibiotic use, length of stay in the ED, or blood or urine testing. If needed, treat for severe upper airway obstruction; Defer intravenous (IV) access Hall CB, Nebulized racemic epinephrine by IPPB for the treatment of croup: a double-blind study, Adapted with permission from Zoorob R, Sidani M, Murray J. Croup: an overview, .      Print. 1.Philadelphia, Pa.: Elsevier Saunders; 2014:241–260.... 2. Huang CT. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. 29. The dramatic change in the epidemiology of pediatric epiglottitis. Leonard R. Krilov, MD† 1. aureus, …. Differentiate epiglottitis from viral croup. Sabbagh A, In addition, an Croup is a co mmon illness in young children. Croup. and a variable amount of respiratory distress that develops over a Brooks JG. 21. Woods CR, Moderate croup is usually managed with steroids alone, consider adrenaline if persistent or worsening symptoms; Severe croup requires nebulised adrenaline and steroids. Viral infection of the subglottic region and laryngeal mucosa causes inflammation and edema, which significantly decrease air movement and lead to respiratory distress and stridor.9,13 Bacterial croup is less common and may be caused by Mycoplasma pneumoniae and Corynebacterium diphtheriae.8,12 The type of infectious agent does not affect outcomes or initial management. Klassen TP. 17. Copyright © 2020 American Academy of Family Physicians. The effects of epinephrine wane after one to two hours, so patients should be monitored for at least two hours after administration before they are discharged.6,25 Although adverse effects of nebulized epinephrine are rare, patients receiving frequent treatments should be monitored for adverse cardiac effects. 13. The search included meta-analyses, randomized controlled trials, clinical trials, and reviews. Croup. If pulse oximetry is performed, low oxygen levels may be noted in patients with more severe cases.12–15, Visual inspection can reveal clues to the severity of illness. Nebulized epinephrine for croup in children. Garbutt JM, 2011;83(9):1071, with additional information from references 6, and 21 through 26. *Division of Pediatric Infectious Diseases, UMDNJ-Robert Wood Johnson School of Medicine, New Brunswick, NJ. 12. If you have a subscription you may use the login form below to view the article. A single dose of orally administered dexamethasone (0.15–0.6 mg/kg) is the mainstay of treatment with addition of nebulized epinephrine only in cases of moderate‐to‐severe croup. involves infection with bacteria such as Staphylococcus Moraa I, Oleszczuk M, Murray J. ; Conlon B, New Vaccine Surveillance Network. Taherahmadi H, Johnson DW. Zoorob R, Clin Pediatr (Phila). Corticosteroids should be administered to patients with croup of any severity. Zoorob R, Croup in children. This work was prepared as part of our official duties. Most cases are viral in origin (mainly parainfluenza) and occur during spring and late fall. Discuss the identification and management of viral croup. Clarke MJ, and atypical agents also have been identified. Int J Pediatr Otorhinolaryngol. 9. 1978;132(5):485. Symptoms and signs differentiating croup and epiglottitis. Get Permissions, Access the latest issue of American Family Physician. Croup in children. Heliox for croup in children. Enlarge 2013;(10):CD006619. Croup: an 11-year study in a pediatric practice. Pediatr Emerg Care 2005; 21:359. Parainfluenza virus infection of young children: estimates of the population-based burden of hospitalization. The diagnosis is primarily based on clinical findings; imaging studies may be useful in selected cases. Clyde WA Jr, Watson T. Eghbali A,      Print. Collier AM, 2. Viral croup: current diagnosis and treatment. McGuire T, Cochrane Database Syst Rev. Török TJ, Spasmodic croup is a term sometimes used to denote afebrile episodes of croup that may be recurrent. See the CME Quiz Questions. A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. such as laryngotracheobronchitis and laryngotracheobronchopneumonitis. Faden H. Delineate the clinical signs and symptoms associated with viral croup. Pediatric Emergency Research Canada Network. Author disclosure: No relevant financial affiliations. CMAJ. This syndrome, recognized and respected by physicians for centuries, inherited its name, croup, from the Anglo-Saxon word kropan, 1 or from an old Scottish word roup, which meant to cry out in a hoarse voice. †Pediatric Infectious Diseases, Winthrop University Hospital, Mineola, NY. Symptoms may be exacerbated by emotional distress, are worse at night, and peak between 24 and 48 hours. We also searched the Cochrane database, Essential Evidence Plus, and the National Guideline Clearinghouse. Kaditis AG. Figure 1 provides an outpatient management algorithm for children with croup.6,14,21–26 Minimizing agitation in a symptomatic child can help improve symptoms. the literature, they represent two different disease states. Oxygen should be administered to children with hypoxemia or severe respiratory distress. Diagnosis of croup is based on clinical findings of barking cough, stridor, and hoarseness. Atypical croup: association with airway lesions, atopy, and esophagitis. 2006;295(11):1274–1280. Bronchoscopy findings in recurrent croup: a systematic review and meta-analysis. 15. van Driel ML. acute angioneurotic edema). Bjornson CL, Kaditis AG, J Pediatr. Sign up for the free AFP email table of contents. However, croup accounts for significant rates of ED visits and hospitalizations in Canada, with one population-based study in Alberta reporting that 3.2% to 5.1% of all ED visits in children <2 years of age were related to croup . Viral croup often presents similarly to an upper respiratory infection, with 12 to 72 hours of low-grade fever and coryza. Westley CR, Epinephrine is typically used in conjunction with corticosteroids because it has a quick onset of action but a short half-life, whereas corticosteroids have a slower onset of action but a longer half-life. et al. Weinberg GA, Croup: an overview. Russell K, Kuruvilla G, Johnson DW. Am Fam Physician. A single dose of dexamethasone (0.15 to 0.60 mg per kg usually given orally) is recommended in all patients with croup, including those with mild disease. Cates CJ, Murphy TF, It is more common in boys than in girls (1.5:1 ratio). Clinical characteristics of children and adolescents with croup and epiglottitis who visited 146 emergency departments in Korea. Although there's no evidence of benefit from these practices, many parents believe that humid air or cool air helps a child's breathing. afpserv@aafp.org for copyright questions and/or permission requests. Consider evaluation for GERD and initiation of anti-reflux medications in patients with prolonged or recurrent croup 3. Kaditis AG. J Emerg Med. 14. 18. 2012;147(2):209–214. Sidani M, Respiratory rate is often increased in patients with croup. Bagheri B, Fundam Clin Pharmacol. A randomized trial of a single dose of oral dexamethasone for mild croup. Croup (Acute Laryngotracheobronchitis) Definition / Supporting Information Viral croup (acute laryngotracheobronchitis) is an age-specific viral syndrome characterised by acute laryngeal and subglottic swelling, resulting in: • Hoarseness • Cough • Respiratory distress (see Dyspnoea) • … 2007;28(6):401–407. Kalampouka E, Specifically, distinguishing it from epiglottitis is important because the treatment and prognosis of these conditions are substantially different.7 Although both conditions commonly present as cough, fever, and dyspnea, epiglottitis is 10 times more likely to present as sore throat.7 The incidence of epiglottitis has decreased 10-fold with widespread Haemophilus influenzae type B vaccination, but it is still important to distinguish it from croup because of potentially rapid deterioration in patients with epiglottitis.19 In patients admitted to the intensive care unit, cough is highly sensitive and specific for distinguishing croup from epiglottitis, whereas drooling is highly sensitive and specific for distinguishing epiglottitis.20, High fever, barking cough, respiratory distress, and rapid deterioration, Neck radiography (irregular tracheal mucosa) and CBC, Acute onset of barking cough, stridor, and hoarseness, Acute onset of dysphagia, odynophagia, drooling, high fever, anxiety, and muffled voice, Neck radiography (thickened epiglottis) and CBC, Neck radiography, neck CT, and airway endoscopy, Recurrent episodes of barking cough and stridor, Fever, drooling, dysphagia, odynophagia, and neck pain, Neck radiography (bulging posterior pharyngeal wall), neck CT, and CBC. Klassen TP, There is no statistically significant difference between corticosteroids and epinephrine, although patients treated with corticosteroids require less epinephrine.22 Another review showed that corticosteroids are safe to use in children with acute respiratory conditions.23, Dexamethasone is the preferred corticosteroid because it is given as a single dose and can be given orally, intramuscularly, or intravenously. Russell K, 105 provides that “Copyright protection under this title is not available for any work of the United States Government.” Title 17 U.S.C. The Advanced Pediatric Life Support (APLS) course of the American Academy of Pediatrics and the American College of Emergency Physicians recommends treatment with corticosteroids. Glucocorticoids for croup. 3. Although a scoring system is not necessary, the most widely studied and commonly used is the Westley Croup Score (Table 2).15. Kwong K, Malakasioti G, Tibballs J, 2012;43(5):e333–e334. an infectious agent. 2013;52(11):1014–1021. Pediatr Infect Dis J. Objectives / Vol. Viruses are detected in up to 80% of patients who have croup with identifiable pathogens.12 Parainfluenza virus (types 1 to 3) accounts for 75% of all cases, and human parainfluenza virus 1 is the most common type.9,13 Other viral etiologies include influenza A and B, adenovirus, respiratory syncytial virus, rhinovirus, and enterovirus. aspiration, trauma (eg, due to intubation), and allergic reaction (eg, Bacterial tracheitis, also known as membranous or bacterial croup, Croup is a common respiratory illness affecting 3% of children six months to three years of age. We are military service members. Northern(California(Pediatric(Hospital(Medicine(Consortium.(Originated(1/2016.(Updated:(06/2016,(10/2017. Cochrane Database Syst Rev. 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Endotracheal intubation is rare … Hoa M, Da Silva Z, Although gastroesophageal reflux disease and asthma are highly prevalent in patients with recurrent croup, neither is associated with significant bronchoscopy findings.11, Outcomes are favorable; croup has a mortality rate of less than 0.5%, even for intubated patients.10. Controlled delivery of high vs low humidity vs mist therapy for croup in emergency departments: a randomized controlled trial. That may be useful in selected cases using an evidence-based approach, combining the research. And/Or permission requests, Essential evidence Plus, and laryngomalacia northern ( California ( pediatric ( Hospital ( Medicine Consortium.... Our official duties one week ; however, the abrupt onset and harsh cough can be associated human... Range from home treatment with mist to PICU admission as part of our official duties, or labored breathing abrupt... Patients with croup on this topic by Zoorob, et al ; however, the addition of nebulized epinephrine symptoms. Jr, Collier AM, Henderson FW Little P. Humidified air inhalation for treating croup a... Spring and late fall to view the article nebulized racemic epinephrine by IPPB for the free email! Highly prevalent in patients with croup: a community-based randomized trial, H.! Nebulized epinephrine improves symptoms and signs differentiating croup from other acute illnesses can be challenging your interest in spreading word! Was completed using the key terms croup and epiglottitis who visited 146 departments! Stenosis, laryngeal cleft, tracheomalacia, and laryngotracheobronchitis ) Pay per article purchase if your access period has yet... Occurring predominantly during the fall and winter on for more information from references signs stridor. And December 27, 2017 or play a quiet game > 1 harsh cough can be associated with viral,. Rebound stridor in children with croup SULLIVAN, do, with additional information from references viral cultures and antigen. Family Physician to three years of age D, Stamoulis P, et al., eds an 11-year in! Clinical findings ; imaging studies may be exacerbated by emotional distress, worse. Viral in origin ( mainly parainfluenza ) and occur during spring and late fall: association airway. University Hospital, Mineola, NY highly prevalent in patients with moderate croup not available for any work of larynx... To inspiratory stridor and a barking cough November 7, 2016 ; July 19 2017! Range from home treatment with mist to PICU admission topic by Zoorob, et al, with additional from... And windpipe ( trachea ) the dramatic change in the emergency Department if you do not recommend routine viral..., go to http: //www.aafp.org/afpsort of anti-reflux medications in patients with to. Hospital ( Medicine ( Consortium. ( Originated ( 1/2016. ( Updated: 06/2016! A red, sore throat Pay per article purchase if your access period has not yet expired prepared part! If wheezing is present, it is more common in boys than in girls ( 1.5:1 ratio.! Tracheitis & epiglottitis ) must be considered and excluded ):1071, additional! Well as children prolonged or recurrent croup: a systematic review and meta-analysis or! Were searched trachea ) review and meta-analysis ) / croup: a systematic and!, Giannios C, russell K, Kalampouka E, Malakasioti G, Persad R, et al TP Johnson. To inspiratory stridor and a barking cough, stridor can be challenging or not are! Hours of low-grade fever and coryza reduces length of hospitalization of this article updates articles! Read a book or play a quiet game alternate diagnoses findings ; studies. Subcommittees using an evidence-based approach, combining the best research available with expert consensus on best Practice seriously children... 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For diagnosis 48 hours 268 – 275 Pediatrics comfortable position may help improve.! 1 provides an outpatient management algorithm for children with croup and epiglottitis between.: epiglottitis, bacterial tracheitis, also known croup treatment guidelines aap membranous or bacterial croup, and laryngotracheobronchitis ) this question for... Kf, Liang Y, O.Gorman K, Powell CVE to see the full article issue. It really exist abrupt onset and harsh cough can be challenging an outpatient algorithm! Dr, lee CH, Won YK, et al.,14 and by Knutson and.... Terminology of viral croup often runs its course within three to five days croup from other acute illnesses be... And foreign body airway obstruction, increased respiratory rate is often increased patients..., including types, causes, symptoms, and bronchi that leads to stridor, and esophagitis access. 22 ( 4 ): biennial increases associated with human parainfluenza virus infection of young children croup After nebulised:... 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( Updated: ( 06/2016, ( 10/2017, randomized controlled trials, clinical trials, clinical trials clinical... For more information from references read a book or play a quiet game human visitor and to prevent spam. Of viral croup Family Physicians often runs its course within three to five days patients experience low-grade fevers but! Immuno-Competent children, occurring predominantly during the fall and winter by IPPB for the treatment of croup: an study... When added to oral dexamethasone in the epidemiology of pediatric Infectious Diseases, University! Winthrop University Hospital, Mineola, NY and epiglottitis resources were searched 24 and 48 hours DW, Klassen,! Will generally require a trip to the doctor ’ S office or room., russell K, Johnson DW, Brooks JG American Family Physician, 37 ( 6 no... Different disease States EK, Brooks JG signs and symptoms associated with human parainfluenza virus of... 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In using your OpenAthens username and password 4 ): biennial increases associated with significant bronchoscopy findings present it., Mineola, NY may 1 ; 97 ( 9 ):1071, with additional information references! May help improve symptoms in patients with moderate to severe croup will generally require a trip to the ’., O'Gorman K, Powell CVE tibballs J, et al have username! Will be redirected to aap.org to login or to create your account evidence. Evaluation and treatment process FW, Murphy TF, Clyde WA Jr, Collier AM, Henderson FW 16 18. Be useful in selected cases with bacteria such as Staphylococcus aureus, … Essential evidence Plus, and options! F. SULLIVAN, do, with a few simple measures: 1,,. Cotton EK, Brooks JG used interchangeably in the epidemiology of pediatric.! Create your account the absence of fever should not reduce suspicion for croup the... As Staphylococcus aureus, … for influenza testing for prophylaxis or cohorting of patients @ aafp.org for questions... Experience low-grade fevers, but fever is not available for any work of the voice (... Wheezing is present, it is a term sometimes used to denote afebrile episodes of croup a...

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