Emergent Management of Croup (Laryngotracheobronchitis) 

 
Updated: Sep 2, 2011
 

Overview

Laryngotracheobronchitis (ie, croup) is a viral infection of the upper respiratory tract that causes varying degrees of airway obstruction but that,[1] with aggressive emergent management, only infrequently requires hospital admission. However, although the disease is most often self-limited, it occasionally is severe and can in rare cases be fatal. A barking cough, stridor, and fever are characteristic; laryngotracheobronchitis is the most common cause of stridor in children. (See the image below.)

Child with croup. Note the steeple or pencil sign Child with croup. Note the steeple or pencil sign of the proximal trachea evident on this anteroposterior film. Courtesy of Dr. Kelly Marshall, CHOA at Scottish Rite.
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Emergency Care

Prehospital care

Try to avoid actions that may agitate the child with laryngotracheobronchitis in distress and increase the work of breathing. Transport the child in a parent's lap and give oxygen as tolerated, usually via a blow-by technique.

Emergency department care

Goals of emergency department (ED) care are to reduce respiratory distress, monitor for worsening condition, and consider or evaluate for other etiologies of stridor. Evidence-based guidelines have been established for the management of laryngotracheobronchitis.[2]

Make the child as comfortable as possible, and avoid agitating the patient with unnecessary procedures and examinations. Humidified air or mist therapy may be used, but both have unproven efficacy. Provide oxygen (humidified) to all hypoxic patients.

L -epinephrine (1:1000) is as effective as racemic epinephrine. Nebulized epinephrine has proven to significantly reduce symptoms of laryngotracheobronchitis 30 minutes after treatment. (Epinephrine therapy does not indicate the need for admission.)[3]

Rebound stridor after epinephrine therapy has been described in patients with laryngotracheobronchitis, but it appears to be less of a problem if corticosteroid therapy is initiated early in the ED course.

Dexamethasone has been shown to reduce symptoms in patients with moderate to severe laryngotracheobronchitis (0.6 mg/kg IM, not to exceed 10 mg). Some authorities recommend a repeat dose of dexamethasone in 6 hours.[4]

Nebulized budesonide (2 mg) has been shown in several studies to be equivalent to oral dexamethasone. Inhaled dexamethasone is also used, when budesonide is unavailable.

Always consider other causes of stridor, such as foreign bodies, bacterial tracheitis, and epiglottitis. Be sure to observe patients for an adequate period before ED discharge and to document satisfactory pulse oximetry.

Consultation with an otorhinolaryngologist and anesthesia prior to rapid sequence induction (RSI) may be necessary if the patient is exhibiting rapid deterioration that might suggest an alternative diagnosis.

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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.

Specialty Editor Board

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.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Wayne Wolfram, MD, MPH  Associate Professor, Department of Emergency Medicine, Mercy St Vincent Medical Center

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.

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 C, Russell KF, Vandermeer B, Durec T, Klassen TP, Johnson DW. Nebulized epinephrine for croup in children. Cochrane Database Syst Rev. Feb 16 2011;2:CD006619. [Medline].

  4. 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].

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Child with croup. Note the steeple or pencil sign of the proximal trachea evident on this anteroposterior film. Courtesy of Dr. Kelly Marshall, CHOA at Scottish Rite.
 
 
 
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