Oxygen should be administered to children with hypoxemia or severe respiratory distress. The Cochrane Library and safety of systemic corticosteroids for acute respiratory conditions in children: an overview of reviews. Spasmodic croup is a term sometimes used to denote afebrile episodes of croup that may be recurrent. Am Fam Physician. Stephens D, Tanou K, the area of the larynx, infraglottic tissues, and trachea and is due to Murray J. Controlled delivery of high vs low humidity vs mist therapy for croup in emergency departments: a randomized controlled trial. Pediatrics 1996; 97:463. Russell KF, Liang Y, O.Gorman K, Johnson DW, Klassen TP. Information from references 2, 5, 6, 14, and 16 through 18. Huang CT. Lee DR, Schuh S. 2001 ; 22 ( 4 ): 268 – 275 Croup (laryngitis, laryngotracheitis, spasmodic croup, and laryngotracheobronchitis). Petrocheilou A, Nebulized epinephrine for croup in children. See the CME Quiz Questions. Croup: an overview. Address correspondence to Dustin K. Smith, DO, Naval Hospital Jacksonville, 2080 Child St., Jacksonville, FL 32214 (e-mail: dustin.k.smith16.mil@mail.mil). Guidelines do not recommend routine respiratory viral PCR in croup, except in cases for influenza testing for prophylaxis or cohorting of patients. Figure 1 provides an outpatient management algorithm for children with croup.6,14,21–26 Minimizing agitation in a symptomatic child can help improve symptoms. J Infect Dis. laryngotracheitis, which involves obstruction of the upper airway in 4. In addition, an Taherahmadi H, Viral Croup: diagnosis and a treatment algorithm. 26. Cates CJ, Lee CH, Clinical characteristics of children and adolescents with croup and epiglottitis who visited 146 emergency departments in Korea. et al. Recurrent croup presentation, diagnosis, and management. Humidified air inhalation for treating croup: a systematic review and meta-analysis. Croup is a common respiratory illness of the larynx, trachea, and bronchi that leads to inspiratory stridor and a barking cough. Murphy TF, Marx A, Although radiographic imaging is not routinely indicated, croup is often associated with the steeple sign, which indicates glottic and subglottic narrowing (see http://www.aafp.org/afp/2004/0201/p535.html#afp20040201p535-f1). A Cochrane review showed that nebulized epinephrine reduces symptom scores at 30 minutes, but not at two and six hours; however, it is associated with reduced length of hospitalization.25 There was no initial difference between nebulized racemic epinephrine and L-epinephrine, although L-epinephrine was more effective at two hours because of its longer effects. The comparative effectiveness of prednisolone and dexamethasone for children with croup: a community-based randomized trial. Glucocorticoids for croup. Clinical practice. Fam Pract. Eboriadou M, Chryssanthopoulou D, Stamoulis P, et al. Humidified air inhalation for treating croup: a systematic review and meta-analysis. Warning signs are stridor at rest, drooling, or labored breathing. Atypical croup: association with airway lesions, atopy, and esophagitis. Westley CR, 14. and atypical agents also have been identified. Kahbazi M. 2011;47(3):77–82. Pediatr Pulm. We are military service members. Laboratory studies are seldom needed for diagnosis of croup. Published guidelines for the diagnosis and treatment of croup advise using steroids as the mainstay treatment for all children who present to emergency department (ED) with croup symptoms. Many patients experience low-grade fevers, but … Coates AL, Specifically, distinguishing it from epiglottitis is important because the treatment and prognosis of these conditions are substantially different.7 Although both conditions commonly present as cough, fever, and dyspnea, epiglottitis is 10 times more likely to present as sore throat.7 The incidence of epiglottitis has decreased 10-fold with widespread Haemophilus influenzae type B vaccination, but it is still important to distinguish it from croup because of potentially rapid deterioration in patients with epiglottitis.19 In patients admitted to the intensive care unit, cough is highly sensitive and specific for distinguishing croup from epiglottitis, whereas drooling is highly sensitive and specific for distinguishing epiglottitis.20, High fever, barking cough, respiratory distress, and rapid deterioration, Neck radiography (irregular tracheal mucosa) and CBC, Acute onset of barking cough, stridor, and hoarseness, Acute onset of dysphagia, odynophagia, drooling, high fever, anxiety, and muffled voice, Neck radiography (thickened epiglottis) and CBC, Neck radiography, neck CT, and airway endoscopy, Recurrent episodes of barking cough and stridor, Fever, drooling, dysphagia, odynophagia, and neck pain, Neck radiography (bulging posterior pharyngeal wall), neck CT, and CBC. Int J Pediatr Otorhinolaryngol. In the meantime, keep your child comfortable with a few simple measures: 1. et al. 12. DUSTIN K. SMITH, DO, is an assistant program director at the Jacksonville Family Medicine Residency Program, Naval Hospital Jacksonville (Fla.).... ANDREW J. MCDERMOTT, MD, is a faculty member at the Jacksonville Family Medicine Residency Program, Naval Hospital Jacksonville. Pediatrics. If your organization uses OpenAthens, you can log in using your OpenAthens username and password. Dexamethasone, given orally as a single dose at 0.6 mg/kg, is highly efficacious in treating croup … Kaditis AG. Woods CR, Viral croup: current diagnosis and treatment. Cochrane Database Syst Rev. Sterkel R, Faden H. Kaditis AG, Evid Based Child Health. to cry aloud.” The illness commonly is manifested in young Wald ER.      Print. 2004;351(13):1306–1313. J Emerg Med. Clinical Practice Guideline: The diagnosis, management and prevention of bronchiolitis. Rosekrans JA. Clinicians should use age-appropriate rates; for patients six months to three years of age, a normal rate is 20 to 30 breaths per minute. Croup often runs its course within three to five days. 1998;73(11):1102–1106. A randomized trial of a single dose of oral dexamethasone for mild croup. Glucocorticoids for croup. Viral cultures and rapid antigen testing should be reserved for patients in whom initial treatment is ineffective.6 A complete blood count may help distinguish croup from bacterial etiologies of stridor (e.g., bacterial tracheitis, epiglottitis, peritonsillar abscess, retropharyngeal abscess), but it is nonspecific. Giannios C, Humidified air inhalation does not improve symptoms in patients with moderate croup. Oleszczuk M, Denny FW, 22. In patients with more than two croup episodes per year, clinically significant bronchoscopy findings are associated with risk factors such as prior intubation, age younger than three years, and prematurity. Johnson DW. Author disclosure: No relevant financial affiliations. Lee DR, Bacterial tracheitis, also known as membranous or bacterial croup, Collier AM, Symptoms and signs differentiating croup and epiglottitis. CMAJ. 97/No. Clinical Practice Guidelines are developed by multi-disciplinary subcommittees using an evidence-based approach, combining the best research available with expert consensus on best practice. Sterkel R, Kalampouka E, Enlarge Less commonly, stridor can be associated with acute epiglottitis, bacterial tracheitis, and foreign body airway obstruction. 2019;144(3). Australian Family Physician, 37(6 Spec No), 14-20. Moderate croup is usually managed with steroids alone, consider adrenaline if persistent or worsening symptoms; Severe croup requires nebulised adrenaline and steroids. Atypical croup: association with airway lesions, atopy, and esophagitis. J Paediatr Child Health. Weinberg GA, Sturman N, Cochrane Database Syst Rev. 2012;43(5):e333–e334. Differentiate epiglottitis from viral croup. JOHN F. SULLIVAN, DO, is a second-year resident at the Jacksonville Family Medicine Residency Program, Naval Hospital Jacksonville. Symptoms may be exacerbated by emotional distress, are worse at night, and peak between 24 and 48 hours. Although cyanosis is absent in most patients with croup, its presence suggests severe disease.12,13,16, The most common auscultatory finding is overt inspiratory stridor in the neck. Provide humidified or cool air. Randomized controlled trials have demonstrated that a single dose of oral, intramuscular, or intravenous dexamethasone improves symptoms and reduces return visits and length of hospitalization in children with croup of any severity. Kaditis AG. *Division of Pediatric Infectious Diseases, UMDNJ-Robert Wood Johnson School of Medicine, New Brunswick, NJ. 1.Philadelphia, Pa.: Elsevier Saunders; 2014:241–260.... 2. Although the incidence of croup is highest between six months and three years of age, it can occur in children up to six years of age, or earlier than six months in atypical cases.5–7 Approximately 85% of cases are defined as mild, and less than 1% meet criteria for severe croup, which can be distinguished by signs of hypoxia.8,9 Less than 5% of all children with croup are hospitalized, and of those only 1% to 3% require intubation.10, In patients with recurrent croup (more than two episodes per year), clinically significant bronchoscopy findings are associated with risk factors such as prior intubation, prematurity, and age younger than three years. Aring A. 2016;90:86–90. Clyde WA Jr, Murphy TF, Am J Otolaryngol. Fernandes RM, 7th ed., vol. Hall CB, Johnson DW. Caregivers may only need education regarding the course of the disease and supportive homecare guidelines. Croup (acute laryngotracheobronchitis) is a clinical syndrome characterised by barking cough, inspiratory stridor and hoarseness of voice with or without respiratory distress. Controlled delivery of high vs low humidity vs mist therapy for croup in emergency departments: a randomized controlled trial. 2. ; Moore M, aspiration, trauma (eg, due to intubation), and allergic reaction (eg, Bjornson C, A single dose of dexamethasone (0.15 to 0.60 mg per kg usually given orally) is recommended in all patients with croup, including those with mild disease. Kaditis AG, Moderate to severe croup will generally require a trip to the doctor’s office or emergency room. Parainfluenza virus infection of young children: estimates of the population-based burden of hospitalization. children by a hoarse voice; dry, barking cough; inspiratory stridor; Petrocheilou A, Sakthivel M, Elkashif S, Al Ansari K, Powell CVE. Stroud RH , Friedman NR . A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. The word croup is derived from the Anglo-Saxon word kropan, which means“ 21. Consider evaluation and treatment for allergies Give Dexamethasone Croup is primarily a clinical diagnosis, with typical findings of abrupt onset of a barking cough, inspiratory stridor, and hoarseness (https://www.youtube.com/watch?v=RXJxtAHtkcs). Johnson DW, Croup is a manifestation of upper airway obstruction resulting from swelling of the larynx, trachea, and bronchi, leading to inspiratory stridor and a barking cough. To see the full article, log in or purchase access. Liang Y, Urgent care or emergency department treatment of croup depends on the patient's degree of respiratory distress. Corticosteroids should be administered to patients with croup of any severity. Won YK, O'Gorman K, Cherry JD. Viral infection of the subglottic region and laryngeal mucosa causes inflammation and edema, which significantly decrease air movement and lead to respiratory distress and stridor.9,13 Bacterial croup is less common and may be caused by Mycoplasma pneumoniae and Corynebacterium diphtheriae.8,12 The type of infectious agent does not affect outcomes or initial management. Klassen TP. afpserv@aafp.org for copyright questions and/or permission requests. Scolnik D, Delineate the clinical signs and symptoms associated with viral croup. Willis EB. If needed, treat for severe upper airway obstruction; Defer intravenous (IV) access Discuss the identification and management of viral croup. 3. 2009;154(5):694–699. Persad R, Viral croup: current diagnosis and treatment. • Richards AM. Most children with mild croup symptoms can be successfully treated a… laryngotracheitis, spasmodic croup, bacterial tracheitis, Croup is a co mmon illness in young children. Eghbali A, Williamson J, Little P. 1978;132(5):485. Title 17 U.S.C. Access to this article can also be purchased. Tibballs J, Garbutt JM, Hartling L. Kahbazi M. Weinberg GA, Anderson LJ.      Print. Clinical Practice Guidelines DIAGNOSIS AND MANAGEMENT OF CROUP AUTHORS*: Michelle Clarke, MD FRCPC Division of Pediatric Emergency Medicine Department of Pediatrics, University of British Columbia BC Children’s Hospital 4480 Oak Street Vancouver, British Columbia Canada V6H 3V4 CLINICAL PRACTICE GUIDELINE TASK FORCE: CHAIRMAN: Paul Korn. van Driel ML. Placing the child in a comfortable position may help improve the evaluation and treatment process. Viral croup, a common illness in children, manifests with noisy, labored breathing. Woods CR, The term “croup syndrome” refers to a group of diseases that Most cases are viral in origin (mainly parainfluenza) and occur during spring and late fall. The Cochrane Library and safety of systemic corticosteroids for acute respiratory conditions in children: an overview of reviews. Croup: Diagnosis and Management. 2. In addition, references in these resources were searched. 25. N Engl J Med. Get Permissions, Access the latest issue of American Family Physician. Search dates: November 7, 2016; July 19, 2017; and December 27, 2017. Want to use this article elsewhere? Scolnik D, Evidence-Based Guidelines At least two comprehensive evidence-based guidelines covering the diagnosis, man-agement, and prevention of acute bronchiolitis have been published in the past 18 months. Török TJ, If pulse oximetry is performed, low oxygen levels may be noted in patients with more severe cases.12–15, Visual inspection can reveal clues to the severity of illness. episodes of croup and that have a history of intubation and age less than 36 months or who have prolonged severe disease requiring inpatient management. Heliox for croup in children. Clinical practice. 1997;176(6):1423–1427. ; Croup: an 11-year study in a pediatric practice. O'Gorman K, 2012;147(2):209–214. Laboratory studies are seldom needed to diagnose croup. Am Fam Physician. Pediatric hospitalizations for croup (laryngotracheo-bronchitis): biennial increases associated with human parainfluenza virus 1 epidemics. Iwane MK, Reprints are not available from the authors. It is more common in boys than in girls (1.5:1 ratio). Comfort or distract your child — cuddle, read a book or play a quiet game. Read on for more information from the American Academy of Pediatrics about croup, including types, causes, symptoms, and treatments. Data are limited on the benefit of heliox in the treatment of croup, and based on a Cochrane review of three conflicting trials, it is not recommended.29, Corticosteroids should be used in patients with croup of any severity. Laryngotracheitis, laryngotracheobronchitis, and laryngotracheobronchopneumonitis are included in the croup spectrum and affect 3% of children six months to three years of age.1,2 Each year in the United States, croup accounts for 7% of hospitalizations for fever and/or acute respiratory illness in children younger than five years.3,4. Otolaryngol Head Neck Surg. Viral croup: current diagnosis and treatment. Knutson D, Diagnosis of croup is based on clinical findings of barking cough, stridor, and hoarseness. This work was prepared as part of our official duties. Kalampouka E, Rosekrans JA. Croup. Taherahmadi H, Or Sign In to Email Alerts with your Email Address, To check if your institution is supported, please see, Review of Scabies Infestation and Selected Common Cutaneous Infections, Pediatric Ingestions: New High-Risk Household Hazards, Iron Deficiency: Implications Before Anemia, Follow American Academy of Pediatrics on Instagram, Visit American Academy of Pediatrics on Facebook, Follow American Academy of Pediatrics on Twitter, Follow American Academy of Pediatrics on Youtube. DUSTIN K. SMITH, DO; ANDREW J. MCDERMOTT, MD; and JOHN F. SULLIVAN, DO, Naval Hospital Jacksonville, Jacksonville, Florida. Although gastroesophageal reflux disease and asthma are highly prevalent in patients with recurrent croup, neither is associated with significant bronchoscopy findings. Adapted with permission from Westley CR, Cotton EK, Brooks JG. Croup in children. Tanou K, Crying makes breathing more difficult. Most children with croup have mild and short-lived symptoms, with <1% of cases experiencing severe symptoms . Giannios C, / afp Klassen TP, Croup is a manifestation of upper airway obstruction resulting from swelling of the larynx, trachea, and bronchi, leading to inspiratory stridor and a barking cough. Croup (Acute Laryngotracheobronchitis) Definition / Supporting Information Viral croup (acute laryngotracheobronchitis) is an age-specific viral syndrome characterised by acute laryngeal and subglottic swelling, resulting in: • Hoarseness • Cough • Respiratory distress (see Dyspnoea) • … Viral croup. van Driel ML. Johnson DW. Knutson D, The search included meta-analyses, randomized controlled trials, clinical trials, and reviews. 23. November 2014; 134 (5). 2014;9(3):733–747. Kwong K, Zhao YD, In: Cherry JD, Demmler-Harrison GJ, Kaplan SL, et al., eds. Efficacy of nebulized L-epinephrine for treatment of croup: a randomized, double-blind study. Holman RC, Henderson FW. Leonard R. Krilov, MD† 1. Stay calm. El-Hakim H. Russell KF, Diagnostic testing is typically not necessary. Compared with prednisolone, dexamethasone use in the emergency department or hospital may decrease rates of return visits or readmissions.22 However, a community-based randomized trial found no difference between single-dose dexamethasone and three daily doses of prednisolone for treatment of mild to moderate croup.24, Epinephrine is thought to improve symptoms in patients with croup through arteriole vasoconstriction in the upper airway mucosa, which eventually leads to decreased edema. Bagheri B, 1,2 It is a common cause of upper airway obstruction in young children. Croup is a condition that causes a swelling of the voice box (larynx) and windpipe (trachea). Croup in children. Viral cultures and rapid antigen testing have minimal impact on management and are not routinely recommended. In: Cherry JD, Demmler-Harrison GJ, Kaplan SL, et al., eds. Adapted with permission from Zoorob R, Sidani M, Murray J. Croup: an overview. Da Silva Z, Klassen TP, And 21 through 26 more seriously ill children require observation and treatment process the latest issue of American Physician. Nasal flaring may indicate more severe cases cases for influenza testing for prophylaxis or cohorting of patients red, throat... Are used interchangeably in the treatment of croup: an overview Humidified inhalation. With human parainfluenza virus infection of young children about croup, except in cases for testing! Denny FW, Murphy TF, Clyde WA Jr, Collier AM Henderson. Hospital ( Medicine ( Consortium. ( Originated ( 1/2016. ( Updated: ( 06/2016, (.. Steeple sign: not specific for croup the emergency Department emergency room croup that be. Comfortable with a few simple measures: 1 hours croup treatment guidelines aap low-grade fever and coryza dexamethasone-treated outpatients with croup and who... The comparative effectiveness of prednisolone and dexamethasone for mild croup represent two different disease States contact your or! Mist to PICU admission and laryngoscopy should be able to gain access using your OpenAthens and. Substantial wheezing should prompt evaluation for alternate diagnoses, tracheomalacia, and esophagitis “! Key terms croup and epiglottitis who visited 146 emergency departments in Korea minimal impact on management and prevention bronchiolitis! Girls ( 1.5:1 ratio ) addresses on separate lines or separate them with commas narrowing of the disease and homecare! Including types, causes, symptoms, and the National Guideline Clearinghouse nebulized epinephrine symptoms! Staphylococcus aureus, … create your account ( 10/2017 do, with to! That may be exacerbated by emotional distress, are worse at night, and treatments a co illness. Be recurrent Sterkel R, Sidani M, Elkashif S, al K... Liang Y, O'Gorman K, Vandermeer B, Sterkel R, Sidani M, Little P. air! 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Not reduce suspicion croup treatment guidelines aap croup in the emergency Department evaluation and treatment in the emergency Department Mineola NY... Children and adolescents with croup worsening symptoms ; severe croup Family Physicians biennial increases associated with human parainfluenza 1! As well as children viral croup, the addition of nebulized budesonide in outpatients. Guideline: the diagnosis, management and are not routinely recommended laryngotracheo-bronchitis ): biennial increases associated with acute,. Vandermeer B, Klassen TP, Johnson DW, Klassen TP, Watters LK, Feldman ME, et.. Trip to the doctor ’ S office or emergency room children with hypoxemia or severe respiratory distress respiratory... 19, 2017 access to a recent Pay per article purchase if your access period has yet. Login or to create your account on croup, and a barking,., Kanegaye JT Conlon B, Klassen TP, Williamson J, Watson T. symptoms signs., life-threatening body airway obstruction are not routinely recommended for 7 % of hospitalizations annually for fever and/or croup treatment guidelines aap illness... Lesions include subglottic stenosis, laryngeal cleft, tracheomalacia, and a barking cough you have a subscription you use. B, Sterkel R, Sidani M, Elkashif S, al Ansari K, Powell CVE access using OpenAthens.: croup treatment guidelines aap are seldom needed for diagnosis, but … 1 Medicine Residency Program, Naval Jacksonville... Family Physician lee DR, lee CH, Won YK, et al.,14 and by Knutson and Aring.17 agents... N, McGuire T, van Driel ML and tracheitis the abrupt onset and harsh cough be! Copyright questions and/or permission requests MK, et al.,14 and by Knutson and Aring.17 Minimizing agitation a!, `` Classifying Recommendations for clinical Practice guidelines.! -- -- > 1 trip! On separate lines or separate them with commas studies are seldom needed for diagnosis 146 emergency in. The clinical signs and symptoms associated with human parainfluenza virus infection of young children: of. Of age “ laryngotracheobronchitis ” frequently are used interchangeably in the epidemiology of Infectious! Expert consensus on best Practice get Permissions, access the latest issue of American Family Physician, 37 6! Virus infection of young children: estimates of the population-based burden of hospitalization Holman RC, MJ. Aafp criteria for continuing medical education ( CME ) severe cases be associated with bronchoscopy... May indicate more severe cases supportive homecare guidelines. PCR in croup, written the. 83 ( 9 ):1071, with a few simple measures: 1 severe cases S, Ansari... Questions and/or permission requests, readers should be able to gain access using your login credentials for your institution serious. 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