In many ways the management of sicker patients with suspected croup is more straightforward. Give them steroids early, let the patient protect their own airway and use inhaled racemic epinephrine. But what about the larger majority of kids that you might see in the ED (usually between 10PM and 4AM) who now have a barky cough and that’s it. Sure, maybe they had stridor at home, but not in the ED with you, where they are as happy as a clam watching Jake and the Neverland Pirates.

Let’s take a step back and talk about croup

Croup is an acute respiratory illness with barky cough, inspiratory stridor and hoarseness caused by inflammation in the larynx and subglottic upper airway. The usual causes are viral (parainfluenza 1 is at the top of the list). It is more common in the fall or winter, and the peak age is 6-36 months. Cases are more rare past kindergarten, and in infants less than 3 months of age and should prompt additional evaluation as warranted. The illness starts with symptoms typical for URI, but within 12 to 48 hours the symptoms progress and upper airway symptoms take over.

Emergency Department Treatment and Disposition

Goal #1 is to identify kids with complete or partial upper airway obstruction. If a child in distress with stridor is moving air, and is at least somewhat comfortable LEAVE THEM BE (Preferably in the arms of a caregiver). A scared child will get tachypneic, which causes increased negative intrathoracic pressure which  leads to further narrowing of the subglottic airway upon inspiration.

Mild croup is most often characterized by barky cough and hoarseness alone. Stridor at rest occurs in moderate to severe cases. If you think that it is croup, you’re probably right, especially in a child in the right season with a URI-like prodrome. Therefore, if your pretest probability is high, don’t get an X-Ray. Conversely, do get an X-Ray in children with suspected foreign body inhalation, when expected therapy is ineffective and in children where the diagnosis is uncertain. The characteristic finding is the “steeple sign” showing subglottic narrowing of the airway.

subglottic narrowing caused by croup, not by being shot by a tiny archer

Children that are hypoxic, have significant stridor with increased work of breathing and lethargy are at risk for respiratory failure. Consider pulling out a smaller endotracheal tube (0.5 to 1mm) just in case. Oral steroids given in the ED reduce the risk of a return ED visit. Even kids with mild croup should be given a single dose of oral dexamethasone (0.6mg/kg). Studies have indicated that the number of children that need to receive a single dose of dexamethasone (number needed to treat) in order to prevent a return visit to the ED is approximately 8. Check out this article for more info. Children with stridor at rest and moderate to severe croup can benefit from racemic epinephrine – which leads to vasoconstriction of the airway and temporary resolution of symptoms. Be careful however, as the effects may only last for less than 2 to 3 hours. This could buy the child enough time for the steroids to start working (usually takes 4 to 6 hours) and if they are asymptomatic at this point you can discharge them home. Children needing subsequent treatments with racemic epinephrine are generally good candidates for inpatient admission. Though most children with croup present at night (as seen above) the risk of admission is greater if children present during the daylight hours.

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The smaller the airway – the more severe the symptoms in croup
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What to tell parents at the time of discharge

The kid alluded to earlier in this post got dexamethasone, and ate a popsicle. He is done with the ED. His mom, however is still a bit nervous – but you surmise that good education and anticipatory guidance will help. You are good at surmising. So, aside from clarifying the diagnosis and reiterating the rationale for treatment it would be a good idea to tell the mom the following:

  • The stridor may re-occur
  • If it does keep him calm
  • Try exposing him to cold air – either outside or via the freezer
  • If the stridor persists for greater than 15 minutes, or if he looks blue or is not responding to you normally, then he needs to return to the ED