eMedicine Specialties > Emergency Medicine > Pediatric

Pediatrics, Croup or Laryngotracheobronchitis: Follow-up

Author: Lonnie King, MD, Consulting Staff, Department of Emergency Medicine, Children's Healthcare of Atlanta at Scottish Rite
Contributor Information and Disclosures

Updated: Aug 11, 2009

Follow-up

Further Inpatient Care

  • Perform frequent or continuous monitoring of respiratory status in patients with laryngotracheobronchitis (ie, croup).
  • Obtain a continuous pulse oximetry measurement.
  • Provide a humidified environment, which may include use of the following:
    • Mist therapy
    • A croup tent (still used but generally not recommended unless no alternative therapy is available)
    • A vaporizer at bedside
  • Give intravenous fluids to dehydrated children not tolerating oral fluids.

Further Outpatient Care

  • Parents must provide a humidified environment at night, which may include use of the following:
    • A cool mist vaporizer
    • A steamed bathroom environment, which may relieve mild exacerbation
    • Exposure to cool night air, which may relieve mild exacerbation, especially if a spasmodic component is present
  • Tobacco smoke and other irritants should not be allowed to come in contact with the child.

Inpatient & Outpatient Medications

  • Inhalation of racemic epinephrine is the cornerstone of symptomatic relief during exacerbations of croup.
  • Some authorities recommend a repeat dose of dexamethasone in 6 hours.

Complications

  • Intubation (required in as many as 2% of patients)
  • Subglottic stenosis in intubated patients
  • Bacterial tracheitis
  • Cardiopulmonary arrest
  • Pneumonia

Prognosis

  • Recovery is usually complete.

Patient Education

  • For excellent patient education resources, visit eMedicine's Lung and Airway Center. Also, see eMedicine's patient education article Croup.

Miscellaneous

Medicolegal Pitfalls

  • Rebound stridor after epinephrine therapy has been described in patients with laryngotracheobronchitis (ie, croup), but it appears to be less of a problem if corticosteroid therapy is initiated early in the ED course.
  • Failure to treat patients with steroids can be a pitfall.
  • Always consider other causes of stridor, such as foreign bodies, bacterial tracheitis, and epiglottitis.
  • Failure to observe patients for an adequate period before ED discharge and failure to document satisfactory pulse oximetry.
 


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References
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References

  1. Johnson DW. Croup. Clin Evid (Online). Mar 10 2009;2009:[Medline].

  2. [Guideline] Mazza D, Wilkinson F, Turner T, Harris C. Evidence based guideline for the management of croup. Aust Fam Physician. Jun 2008;37(6 Spec No):14-20. [Medline].

  3. Bjornson CL, Klassen TP, Williamson J, et al. A randomized trial of a single dose of oral dexamethasone for mild croup. N Engl J Med. Sep 23 2004;351(13):1306-13. [Medline].

  4. Connors K, Gavula D, Terndrup T. The use of corticosteroids in croup: a survey. Pediatr Emerg Care. Aug 1994;10(4):197-9. [Medline].

  5. Dawson KP, Steinberg A, Capaldi N. The lateral radiograph of neck in laryngo-tracheo-bronchitis (croup). J Qual Clin Pract. Mar 1994;14(1):39-43. [Medline].

  6. Eitzen EM. Croup, epiglottis, and bacterial tracheitis. In: Rosen, ed. Emergency Medicine: Concepts and Clinical Practice. 4th ed. 1998:1123.

  7. Geelhoed GC, Macdonald WB. Oral and inhaled steroids in croup: a randomized, placebo-controlled trial. Pediatr Pulmonol. Dec 1995;20(6):355-61. [Medline].

  8. Geelhoed GC, Macdonald WB. Oral dexamethasone in the treatment of croup: 0.15 mg/kg versus 0.3 mg/kg versus 0.6 mg/kg. Pediatr Pulmonol. Dec 1995;20(6):362-8. [Medline].

  9. Johnson DW, Schuh S, Koren G, Jaffee DM. Outpatient treatment of croup with nebulized dexamethasone. Arch Pediatr Adolesc Med. Apr 1996;150(4):349-55. [Medline].

  10. Kelley PB, Simon JE. Racemic epinephrine use in croup and disposition. Am J Emerg Med. May 1992;10(3):181-3. [Medline].

  11. Klassen TP, Rowe PC. Outpatient management of croup. Curr Opin Pediatr. Oct 1996;8(5):449-52. [Medline].

  12. Kunkel NC, Baker MD. Use of racemic epinephrine, dexamethasone, and mist in the outpatient management of croup. Pediatr Emerg Care. Jun 1996;12(3):156-9. [Medline].

  13. Leung AK, Kellner JD, Johnson DW. Viral croup: a current perspective. J Pediatr Health Care. Nov-Dec 2004;18(6):297-301. [Medline].

  14. Orenstein DM. Acute inflammatory upper airway obstruction. In: Behman, ed. Nelson Textbook of Pediatrics. 15th ed. 1996:1201.

  15. Rittichier KK, Ledwith CA. Outpatient treatment of moderate croup with dexamethasone: intramuscular versus oral dosing. Pediatrics. Dec 2000;106(6):1344-8. [Medline].

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Further Reading

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Keywords

croup, laryngotracheobronchitis, viral infection of the upper respiratory tract, airway obstruction, parainfluenza type 1, parainfluenza type 2, parainfluenza type 3, upper respiratory infection, URI, paramyxovirus, influenza virus type A, respiratory syncytial virus, RSV, adenovirus, rhinovirus, enterovirus, coxsackievirus, enteric cytopathogenic human orphan virus, ECHO virus, reovirus, measles virus, barking cough, viral infection

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Contributor Information and Disclosures

Author

Lonnie King, MD, Consulting Staff, Department of Emergency Medicine, Children's Healthcare of Atlanta at Scottish Rite
Lonnie King, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, and American College of Emergency Physicians
Disclosure: Nothing to disclose.

Medical Editor

Jerry Balentine, DO, Professor of Emergency Medicine, New York College of Osteopathic Medicine; Executive Vice President, Chief Medical Officer, Attending Physician in Department of Emergency Medicine, St. Barnabas Hospital
Jerry Balentine, DO is a member of the following medical societies: American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, American College of Physician Executives, American Osteopathic Association, and New York Academy of Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Wayne Wolfram, MD, MPH, Clinical Associate Professor, Departments of Pediatrics, Children's Hospital and University of Cincinnati
Wayne Wolfram, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Pediatrics, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Richard G Bachur, MD, Associate Professor of Pediatrics, Harvard Medical School; Associate Chief and Fellowship Director, Attending Physician, Division of Emergency Medicine, Children's Hospital of Boston
Richard G Bachur, MD is a member of the following medical societies: American Academy of Pediatrics, Society for Academic Emergency Medicine, and Society for Pediatric Research
Disclosure: Nothing to disclose.

 
 
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