Croup - Revision history

Danbot: Add MedicationDose SMW annotations (dexamethasone, epinephrine); dosing verified per AAP/pediatric EM guidelines

2026-03-20T16:26:46Z

Add MedicationDose SMW annotations (dexamethasone, epinephrine); dosing verified per AAP/pediatric EM guidelines

← Revisión anterior		Revisión del 16:26 20 mar 2026
Línea 169:		Línea 169:
	*≥2 treatments with [[epinephrine]]		*≥2 treatments with [[epinephrine]]


			<div style="display:none">
			<!-- SMW MedicationDose annotations for croup medications -->
			{{MedicationDose\|drug=Dexamethasone\|dose=0.15-0.6 mg/kg PO/IV/IM (max 10 mg)\|route=PO/IV/IM\|context=Corticosteroid (1st line, any severity)\|indication=Croup\|population=Pediatric\|max_dose=10 mg\|notes=Standard of care; 0.6 mg/kg is traditional dose but lower doses may be equally effective}}
			{{MedicationDose\|drug=Epinephrine\|dose=0.5 mL/kg of 1:1000 nebulized (max 5 mL); or 0.05 mL/kg racemic epi 2.25% (max 0.5 mL)\|route=Nebulized\|context=Moderate-severe croup with stridor at rest\|indication=Croup\|population=Pediatric\|onset=Up to 30 min\|duration=2 hours\|notes=Observe 2-3 hours after administration; frequent dosing requires ICU admission}}
			</div>
	==See Also==		==See Also==
	*[[Bronchiolitis (RSV)]]		*[[Bronchiolitis (RSV)]]

Rossdonaldson1: /* Video */

2024-04-17T20:09:35Z

Video

← Revisión anterior		Revisión del 20:09 17 abr 2024
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	*Inability to tolerate PO		*Inability to tolerate PO
	*≥2 treatments with [[epinephrine]]		*≥2 treatments with [[epinephrine]]

	~~==Video==~~
	~~{{#widget:YouTube\|id=Z01e1bJ9p-g}}~~

	==See Also==		==See Also==

Rossdonaldson1 at 19:36, 17 January 2024

2024-01-17T19:36:25Z

← Revisión anterior		Revisión del 19:36 17 ene 2024
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	==Background==		==Background==
			[[File:Cross section of a trachea and esophagus.png\|thumb\|Cross section of a trachea and esophagus anatomy.]]
			[[File:Blausen 0865 TracheaAnatomy.png\|thumb\|Tracheal anatomy.]]
	*Also known as laryngotracheobronchitis		*Also known as laryngotracheobronchitis
	*Typically affects ages 6 mo-3 yr (peak in 2nd year)		*Typically affects ages 6 mo-3 yr (peak in 2nd year)

Patricklin at 08:56, 20 December 2023

2023-12-20T08:56:22Z

← Revisión anterior		Revisión del 08:56 20 dic 2023
Línea 4:		Línea 4:
	**May affect older children		**May affect older children
	**Most common in fall & winter		**Most common in fall & winter
			**300k annual ED visits with significant hospitalization rates<ref>Hanna J, Brauer PR, Morse E, Berson E, Mehra S. Epidemiological analysis of croup in the emergency department using two national datasets. Int J Pediatr Otorhinolaryngol. 2019 Nov;126:109641. doi: 10.1016/j.ijporl.2019.109641. Epub 2019 Aug 13. PMID: 31442871.</ref>
			*Pathophysiology: Infection leading to inflammation of any structure inferior to larynx, including larynx, trachea, or bronchi; swelling leads to airway obstruction and characteristic stridor and cough

	===Etiologies===		===Etiologies===
	*[[Parainfluenza]] (50% - 75%)		*Viral
	*[[Influenza]] A and B (usually more severe clinical picture)		**[[Parainfluenza]] (50% - 75%)
	*[[RSV]]		**[[Influenza]] A and B (usually more severe clinical picture)
	**[[Rhinovirus]]		**[[RSV]]
			**[[Rhinovirus]], [[adenovirus]]
			*Bacterial ([[Bacterial tracheitis]])
			**Same organisms as sinopulmonary infections: [[Streptococcus pneumoniae]], [[Haemophilus influenzae]], [[Moraxella catarrhalis]], [[Staphylococcus aureus]] <ref>Sizar O, Carr B. Croup. [Updated 2023 Jul 24]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK431070/</ref>
	**Consider [[Diphtheria]] if not immunized		**Consider [[Diphtheria]] if not immunized
	*Spasmodic croup		*Spasmodic croup
Línea 18:		Línea 23:

	==Clinical Features==		==Clinical Features==
	*1-3 days of [[URI]] symptoms, followed by barking [[cough]], hoarse voice, and [[~~stridor~~]]		*1-3 days of nonspecific [[URI]] symptoms, followed by 3-4 days of "barking" [[cough]], hoarse voice, [[stridor]], and [[acute dyspnea]]
			**Usually most severe on days 3-4
	*Low-grade [[fever]]		*Low-grade [[fever]]
	*NO drooling or dysphagia		*Rarely drooling or dysphagia; consider alternate etiology if present
	*Duration 4 - 7 days
	**Usually most severe on days 3-4

	===Mild<ref>Rose, E. (2018) Pediatric respiratory emergencies: Upper airway obstruction and infections. Rosen's Emergency Medicine (9th ed.) Philadelphia, PA: Elsevier/Saunders</ref>===		===Mild<ref>Rose, E. (2018) Pediatric respiratory emergencies: Upper airway obstruction and infections. Rosen's Emergency Medicine (9th ed.) Philadelphia, PA: Elsevier/Saunders</ref>===
Línea 39:		Línea 43:
	===Severe<ref>Rose, E. (2018) Pediatric respiratory emergencies: Upper airway obstruction and infections. Rosen's Emergency Medicine (9th ed.) Philadelphia, PA: Elsevier/Saunders</ref>===		===Severe<ref>Rose, E. (2018) Pediatric respiratory emergencies: Upper airway obstruction and infections. Rosen's Emergency Medicine (9th ed.) Philadelphia, PA: Elsevier/Saunders</ref>===
	*[[Hypoxia]]		*[[Hypoxia]]
			*Tachypnea and marked retractions
			*[[Altered mental status]]
	*Less than 1% of cases		*Less than 1% of cases

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	===Work-up===		===Work-up===
	[[File:Croup steeple sign.jpg\|thumb\|The steeple sign as seen on an AP neck X-ray (dedicated neck film not typically indicated).]]		[[File:Croup steeple sign.jpg\|thumb\|The steeple sign as seen on an AP neck X-ray (dedicated neck film not typically indicated).]]
	*Consider CXR if concerned about alternative ~~diagnosis~~		*Typically a clinical diagnosis
			*Consider CXR if concerned about alternative diagnoses causing stridor
	**In typical cases, imaging is not needed and does not change management		**In typical cases, imaging is not needed and does not change management
	**Steeple sign on AP XR (not specific or sensitive)		**Steeple sign (subglottic narrowing) on AP neck XR; note that this is not specific nor sensitive
	*Consider nasal pharyngeal swab		*Consider nasal pharyngeal swab for viral panel
			*IV insertion or other exam steps may lead to agitation and further airway obstruction

	~~===Diagnosis===~~
	*Clinical
	**Steeple sign unreliable

	====Westley Croup Score<ref>Westley CR, et al. Nebulized racemic epinephrine by IPPB for the treatment of croup: a double-blind study. Am J Dis Child. 1978; 132(5):484-487.</ref><ref>Klassen TP, et al. Croup. A current perspective. Pediatr Clin North Am. 1999; 46(6):1167–1178.</ref>====		====Westley Croup Score<ref>Westley CR, et al. Nebulized racemic epinephrine by IPPB for the treatment of croup: a double-blind study. Am J Dis Child. 1978; 132(5):484-487.</ref><ref>Klassen TP, et al. Croup. A current perspective. Pediatr Clin North Am. 1999; 46(6):1167–1178.</ref>====
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	==Management==		==Management==
	[[File:VEP Croup Care Pathway 2019.png\|thumb\|VEP Croup Care Pathway]]		[[File:VEP Croup Care Pathway 2019.png\|thumb\|VEP Croup Care Pathway]]
	#~~Cool mist~~		#Supplemental oxygen
			#*Consider utilizing blow-by oxygen to decrease agitation
	#*Humidified air may provide symptomatic treatment for patients with ongoing stridor<ref>Scolnik D, Coates AL, Stephens D, Da Silva Z, Lavine E, Schuh S. Controlled delivery of high vs low humidity vs mist therapy for croup in emergency departments. JAMA. 2006;295(11):1274–1280</ref>		#*Humidified air may provide symptomatic treatment for patients with ongoing stridor<ref>Scolnik D, Coates AL, Stephens D, Da Silva Z, Lavine E, Schuh S. Controlled delivery of high vs low humidity vs mist therapy for croup in emergency departments. JAMA. 2006;295(11):1274–1280</ref>
	#Steroids ~~(first~~ line treatment)		#Steroids
	#*[[Dexamethasone]] 0.15-0.6mg/kg PO/IM (max 10mg)<ref>Geelhoed GC, Macdonald WB. Oral dexamethasone in the treatment of croup: 0.15mg/kg versus 0.3mg/kg versus 0.6mg/kg. Pediatr Pulmonol. 1995;20(6):362–368.</ref><ref>Bjornson, C.L., Klassen, T.P., Williamson, J., Brant, R., Mitton, C., Plint, A., Bulloch, B., Evered, L. and Johnson, D.W. (2004) ‘A Randomized trial of a single dose of oral dexamethasone for mild Croup’, New England Journal of Medicine, 351(13), pp. 1306–1313.</ref>		#*First-line treatment and standard of care for any severity of croup
			#*[[Dexamethasone]] 0.15-0.6mg/kg PO/IV/IM (max 10mg)<ref>Geelhoed GC, Macdonald WB. Oral dexamethasone in the treatment of croup: 0.15mg/kg versus 0.3mg/kg versus 0.6mg/kg. Pediatr Pulmonol. 1995;20(6):362–368.</ref><ref>Bjornson, C.L., Klassen, T.P., Williamson, J., Brant, R., Mitton, C., Plint, A., Bulloch, B., Evered, L. and Johnson, D.W. (2004) ‘A Randomized trial of a single dose of oral dexamethasone for mild Croup’, New England Journal of Medicine, 351(13), pp. 1306–1313.</ref>
			#*Typically one dose is sufficient
	#*No differences between intramuscular and oral dexamethasone <ref>Donaldson D, Intramuscular versus oral dexamethasone for the treatment of moderate-to-severe croup: a randomized, double-blind trial. Acad Emerg Med. 2003 Jan;10(1):16-21.</ref>		#*No differences between intramuscular and oral dexamethasone <ref>Donaldson D, Intramuscular versus oral dexamethasone for the treatment of moderate-to-severe croup: a randomized, double-blind trial. Acad Emerg Med. 2003 Jan;10(1):16-21.</ref>
	#*Onset 6 hrs, duration 72 hrs		#*Onset 6 hrs, duration 72 hrs
	#*Recent study showing non-inferiority of low dose (0.15mg/kg) dexamethasone and prednisolone at 1mg/kg<ref>Prednisolone versus dexamethasone for croup: a randomized controlled trial Parker CM, Cooper MN. Pediatrics. 2019;144(3):e20183772.</ref>.		#*Recent study showing non-inferiority of low dose (0.15mg/kg) dexamethasone and prednisolone at 1mg/kg<ref>Prednisolone versus dexamethasone for croup: a randomized controlled trial Parker CM, Cooper MN. Pediatrics. 2019;144(3):e20183772.</ref>.
	#[[Epinephrine]] ~~(nebulized)~~		#Nebulized [[Epinephrine]]
	#*Use in moderate to severe cases based on the croup scores. Use either Racemic or Standard Epinephrine<ref>Adair JC, Ring WH, Jordan WS, Elwyn RA. Ten-year experience with IPPB in the treatment of acute laryngotracheobronchitis. Anesth Analg. 1971;50(4):649–55</ref>		#*Use in moderate to severe cases based on the croup scores. Use either Racemic or Standard L-Epinephrine<ref>Adair JC, Ring WH, Jordan WS, Elwyn RA. Ten-year experience with IPPB in the treatment of acute laryngotracheobronchitis. Anesth Analg. 1971;50(4):649–55</ref>
	#*Symptomatic relief via local vasoconstriction		#*Symptomatic relief via local vasoconstriction
	#*'''Racemic Epi (2.25%)''': 0.05 mL per kg (maximal dose: 0.5 mL) of racemic epinephrine 2.25% <ref>Westley CR, Cotton EK, Brooks JG. Nebulized racemic epinephrine by IPPB for the treatment of croup: a double-blind study. Am J Dis Child. 1978;132(5):484–487</ref>		#*'''Racemic Epi (2.25%)''': 0.05 mL per kg (maximal dose: 0.5 mL) of racemic epinephrine 2.25% <ref>Westley CR, Cotton EK, Brooks JG. Nebulized racemic epinephrine by IPPB for the treatment of croup: a double-blind study. Am J Dis Child. 1978;132(5):484–487</ref>
Línea 135:		Línea 143:
	#*Onset up to 30 min, duration 2 hrs		#*Onset up to 30 min, duration 2 hrs
	#*Watch child 2-3 hrs after administration to ensure no return of stridor at rest		#*Watch child 2-3 hrs after administration to ensure no return of stridor at rest
			#*Treatment may be repeated, but frequent dosing requires admission to ICU for cardiac monitoring
	#[[Intubation]]		#[[Intubation]]
	#*Rarely needed but if so, use tube that is one half size smaller than normal for age/size of patient		#*Rarely needed but if so, use tube that is one-half size smaller than normal for age/size of patient, considering the presumed upper airway edema

	===Contraindicated===		===Contraindicated===
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	===Admit===		===Admit===
	*Persistent respiratory symptoms/signs		*Persistent respiratory symptoms/signs
			*Inability to tolerate PO
	*≥2 treatments with [[epinephrine]]		*≥2 treatments with [[epinephrine]]

Zbuchwald: /* Consider Discharge if */

2023-03-06T20:32:57Z

Consider Discharge if

← Revisión anterior		Revisión del 20:32 6 mar 2023
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	==Disposition==		==Disposition==
	===Consider Discharge if===		===Consider Discharge if===
	*3hr since last [[epinephrine]]		*2-3hr since last [[epinephrine]] and no return of stridor at rest, remains well appearing
	*Able to tolerate PO		*Able to tolerate PO
	*Nontoxic appearance		*Nontoxic appearance

Rossdonaldson1: /* Etiologies */

2022-08-10T19:06:51Z

Etiologies

← Revisión anterior		Revisión del 19:06 10 ago 2022
Línea 6:		Línea 6:

	===Etiologies===		===Etiologies===
	*Parainfluenza (50% - 75%)		*[[Parainfluenza]] (50% - 75%)
	*[[Influenza]] A and B (usually more severe clinical picture)		*[[Influenza]] A and B (usually more severe clinical picture)
	*[[RSV]]		*[[RSV]]

Rossdonaldson1: /* Differential Diagnosis */

2020-07-01T16:22:59Z

Differential Diagnosis

@@ Línea 42: / Línea 42: @@
 ==Differential Diagnosis==
 {{Pediatric stridor DDX}}
 {{Pediatric SOB DDX}}

Rossdonaldson1: /* Differential Diagnosis */

2020-07-01T16:21:52Z

Differential Diagnosis

← Revisión anterior		Revisión del 16:21 1 jul 2020
Línea 65:		Línea 65:

	{{Pediatric stridor DDX}}		{{Pediatric stridor DDX}}
			{{Pediatric SOB DDX}}

	==Evaluation==		==Evaluation==

Gpowellhb: /* Management */

2020-02-20T19:22:36Z

Management

← Revisión anterior		Revisión del 19:22 20 feb 2020
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	#*No differences between intramuscular and oral dexamethasone <ref>Donaldson D, Intramuscular versus oral dexamethasone for the treatment of moderate-to-severe croup: a randomized, double-blind trial. Acad Emerg Med. 2003 Jan;10(1):16-21.</ref>		#*No differences between intramuscular and oral dexamethasone <ref>Donaldson D, Intramuscular versus oral dexamethasone for the treatment of moderate-to-severe croup: a randomized, double-blind trial. Acad Emerg Med. 2003 Jan;10(1):16-21.</ref>
	#*Onset 6 hrs, duration 72 hrs		#*Onset 6 hrs, duration 72 hrs
			#*Recent study showing non-inferiority of low dose (0.15mg/kg) dexamethasone and prednisolone at 1mg/kg<ref>Prednisolone versus dexamethasone for croup: a randomized controlled trial Parker CM, Cooper MN. Pediatrics. 2019;144(3):e20183772.</ref>.
	#[[Epinephrine]] (nebulized)		#[[Epinephrine]] (nebulized)
	#*Use in moderate to severe cases based on the croup scores. Use either Racemic or Standard Epinephrine<ref>Adair JC, Ring WH, Jordan WS, Elwyn RA. Ten-year experience with IPPB in the treatment of acute laryngotracheobronchitis. Anesth Analg. 1971;50(4):649–55</ref>		#*Use in moderate to severe cases based on the croup scores. Use either Racemic or Standard Epinephrine<ref>Adair JC, Ring WH, Jordan WS, Elwyn RA. Ten-year experience with IPPB in the treatment of acute laryngotracheobronchitis. Anesth Analg. 1971;50(4):649–55</ref>

ClaireLewis at 21:28, 5 October 2019

2019-10-05T21:28:17Z

← Revisión anterior		Revisión del 21:28 5 oct 2019
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	*[[Epiglottitis]]		*[[Epiglottitis]]
	*[[Foreign body]]		*[[Foreign body]]
	*Inhalation injury		*[[Inhalation injury]]
	*Laryngeal ~~Fractures~~		*Laryngeal fractures
	*Laryngomalacia		*Laryngomalacia
	*[[Mononucleosis]] and Epstein-Barr ~~Virus Infection~~		*[[Mononucleosis]] and [[Epstein-Barr virus]] infection
	*[[Peritonsillar abscess]]		*[[Peritonsillar abscess]]
	*[[Pertusis]]		*[[Pertusis]]
Línea 61:		Línea 61:
	*[[Retropharyngeal abscess]]		*[[Retropharyngeal abscess]]
	*Subglottic stenosis		*Subglottic stenosis
	*Tracheomalacia		*[[Tracheomalacia]]
	*Vascular ring		*[[Vascular ring]]

	{{Pediatric stridor DDX}}		{{Pediatric stridor DDX}}