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 of the proximal trachea evident on this anteroposterior film. Courtesy of Dr. Kelly Marshall, CHOA at Scottish Rite. 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.
Johnson DW. Croup. Clin Evid (Online). Mar 10 2009;2009:[Medline].
[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].
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].
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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