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Pediatrics, Croup or Laryngotracheobronchitis: Treatment & Medication
Updated: Aug 11, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Prehospital Care
- Try to avoid actions that may agitate the child with laryngotracheobronchitis (ie, croup) 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 ED care are to reduce any 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 croup.2
- Make the child as comfortable as possible.
- Avoid agitating the child 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. Epinephrine therapy does not indicate the need for admission.
- Dexamethasone has been shown to reduce symptoms in patients with moderate-to-severe croup. (0.6 mg/kg IM, not to exceed 10 mg)
- Nebulized budesonide (2 mg) has been shown in several studies to be equivalent to oral dexamethasone. Inhaled Decadron is also used when budesonide is unavailable.
Consultations
- Consultation with an otorhinolaryngologist and anesthesia prior to rapid sequence induction (RSI) may be necessary if patient is exhibiting rapid deterioration that might suggest an alternative diagnosis.
Medication
The goal of pharmacotherapy is to reduce morbidity and prevent complications.
Adrenergic agonist
Alpha-agonist effects include increased peripheral vascular resistance, reversed peripheral vasodilatation, systemic hypotension, and vascular permeability. Beta-agonist effects include bronchodilatation, chronotropic cardiac activity, and positive inotropic effects.
Epinephrine, racemic (microNefrin)
Inhalation of racemic epinephrine is the cornerstone of symptomatic relief during exacerbations of croup. Alpha-receptor stimulation causes mucosal vasoconstriction, leading to decreased edema of the subglottic region of the larynx. Beta2-receptor stimulation may provide additional benefit by causing bronchial smooth muscle relaxation.
Adult
Pediatric
Racemic epinephrine: 0.25-0.5 mL of 2.25% solution via nebulizer (diluted in 3 mL of isotonic sodium chloride solution or sterile water); may be repeated 3 times
Increases toxicity of beta- and alpha-blocking agents and that of halogenated inhalational anesthetics
Documented hypersensitivity; cardiac arrhythmias, obstructed ventricular outflow, or angle-closure glaucoma; local anesthesia in areas such as fingers or toes because vasoconstriction may produce sloughing of tissue; do not use during labor (may delay second stage of labor)
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution or discontinue if heart rate >200; short duration of action and relapse may occur; caution in elderly persons, prostatic hypertrophy, hypertension, cardiovascular disease, patients with diabetes mellitus, hyperthyroidism, and cerebrovascular insufficiency; rapid IV infusions may cause death from cerebrovascular hemorrhage or cardiac arrhythmias
Corticosteroids
Steroids are used to decrease subglottic edema by suppressing local inflammatory process. The effectiveness of steroids in croup has been much debated, and, although no clear-cut information proves that steroids are beneficial, meta-analysis has shown that they decrease symptoms within 24 hours and may reduce the need for endotracheal intubations.
Dexamethasone (Decadron)
Drug of choice. Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reducing capillary permeability.
Adult
Pediatric
0.6 mg/kg PO/IM once; some repeat the dose in 6 h
Effects decrease with coadministration of barbiturates, phenytoin, and rifampin; decreases effect of salicylates and vaccines used for immunization
Documented hypersensitivity; active bacterial or fungal infection
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Increases risk of multiple complications, including severe infections; monitor adrenal insufficiency when tapering drug; abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections are possible complications of glucocorticoid use
Prednisone (Deltasone)
May decrease inflammation by reversing increased capillary permeability and suppressing PMN activity.
Adult
Pediatric
1-2 mg/kg/d PO qd or divided bid for 5 d
Coadministration with estrogens may decrease clearance; concurrent use with digoxin, may cause digitalis toxicity secondary to hypokalemia; phenobarbital, phenytoin, and rifampin may increase metabolism of glucocorticoids (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics
Documented hypersensitivity; viral infection, peptic ulcer disease, hepatic dysfunction, connective tissue infections, and fungal or tubercular skin infections; GI disease
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections may occur with glucocorticoid use
Budesonide (Pulmicort Respules inhalation suspension)
Has been shown in several studies to be equivalent to PO dexamethasone.
Adult
Pediatric
2 mg (2 mL of suspension) via nebulizer
None reported
Documented hypersensitivity; active bacterial or fungal infection
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Prolonged use may increase systemic absorption of corticosteroids and may cause Cushing syndrome, reversible HPA axis suppression, hyperglycemia, and glycosuria
More on Pediatrics, Croup or Laryngotracheobronchitis |
| Overview: Pediatrics, Croup or Laryngotracheobronchitis |
| Differential Diagnoses & Workup: Pediatrics, Croup or Laryngotracheobronchitis |
 Treatment & Medication: Pediatrics, Croup or Laryngotracheobronchitis |
| Follow-up: Pediatrics, Croup or Laryngotracheobronchitis |
| Multimedia: Pediatrics, Croup or Laryngotracheobronchitis |
| References |
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References
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 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].
Connors K, Gavula D, Terndrup T. The use of corticosteroids in croup: a survey. Pediatr Emerg Care. Aug 1994;10(4):197-9. [Medline].
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].
Eitzen EM. Croup, epiglottis, and bacterial tracheitis. In: Rosen, ed. Emergency Medicine: Concepts and Clinical Practice. 4th ed. 1998:1123.
Geelhoed GC, Macdonald WB. Oral and inhaled steroids in croup: a randomized, placebo-controlled trial. Pediatr Pulmonol. Dec 1995;20(6):355-61. [Medline].
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].
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].
Kelley PB, Simon JE. Racemic epinephrine use in croup and disposition. Am J Emerg Med. May 1992;10(3):181-3. [Medline].
Klassen TP, Rowe PC. Outpatient management of croup. Curr Opin Pediatr. Oct 1996;8(5):449-52. [Medline].
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].
Leung AK, Kellner JD, Johnson DW. Viral croup: a current perspective. J Pediatr Health Care. Nov-Dec 2004;18(6):297-301. [Medline].
Orenstein DM. Acute inflammatory upper airway obstruction. In: Behman, ed. Nelson Textbook of Pediatrics. 15th ed. 1996:1201.
Rittichier KK, Ledwith CA. Outpatient treatment of moderate croup with dexamethasone: intramuscular versus oral dosing. Pediatrics. Dec 2000;106(6):1344-8. [Medline].
Further Reading
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
