barking cough.4. Hoarseness.5. Inspiratory stridor.6. Increasing obstruction.a. Tachycardia, tachypnea–usually not > 50 breaths/min.b. Suprasternal, supraclavicular, substernal, and intercostal retractions.c. Paradoxical abdominal and chest wall movement.d. Progressive restlessness and anxiety correlates with hypoxemia.D. Physical findings.1. Normal or mildly elevated temperature.2. Mild erythema and edema of nasal mucosa.3. Inspiratory stridor.4. Hoarseness.5. Harsh, barky cough.6. Nontoxic appearing.7. On auscultation, normal breath sounds except transmission of stridor.8. With increased obstruction: wheezing, prolonged expiration, decreased breath sounds.E. Diagnostic tests.1. Diagnosis made on basis of history and clinical presentation.2. Imaging is not usually necessary in the ambulatory setting; posteroanterior neck X-ray.a. Classic “steeple sign”: narrowed air column consistent with narrowing of subglottic space.b. Lateral view is useful in ruling out epiglottitis, retropharyngeal abscess, or radiopaque foreign body.3. If indicated, WBC normal or low with polymorphonucleotides (PMNs).4. Clinical croup score can classify severity of illness and aid in decision making regarding hospitalization.F. Differential diagnosis.Diphtheria, 032.9 Peritonsillar abscess, 475Epiglottitis, 464.3 Retropharyngeal abscess, 478.24Foreign obstruction, 933.1 1. Epiglottitis: toxic appearing, drooling, high fever, acute onset, age range typically 3-7 years.2. Laryngeal foreign body: history, age, abrupt onset, lack of preceding respiratory symptoms.3. Diphtheria: characteristic thin, gray membrane extends from tonsil to associated soft/hard palate.4. Retropharyngeal or peritonsillar abscess: severe throat pain, refusal to swallow or speak, fever to 105°F (40.6°C).5. Bacterial tracheitis: affects children of any age, acute onset with respiratory stridor, high fever, and copious and purulent secretions.G. Treatment.1. Most children have mild airway obstruction that resolves without specific treatment.2. Supportive care at home includes making the child comfortable, avoiding fatigue and anxiety; encourage fluids and antipyretics for fever.3. Cool mist vaporizer may be used.4. Nebulized epinephrine has been beneficial for children with more severe croup in the emergency department or hospital setting.5. Corticosteroids.a. Systemic or nebulized corticosteroids are mainstay of both outpatient and inpatient treatment.b. Decrease edema of laryngeal mucosa.c. Single dose 0.6 mg dexamethasone given orally or IM or 2 mg dose of nebulized budesonide.d. Clinical improvement in 6-12 hours.e. Efficacy did not vary according to route of administrationf. Facilitates clinical improvement, decreases hospitalizations and fewer follow-up visits.6. Criteria for hospitalization:a. Signs of moderate to severe airway obstruction.b. Increased work of breathing and respiratory distress.c. Hypoxemia.d. Restlessness, anxiety, or fatigue.e. Change in level of consciousness.f. Dehydration.H. Follow up.1. Call healthcare provider immediately if signs of respiratory distress increase.2. Increased respiratory rate.3. Stridor at rest.4. Increased retractions.5. Change in level of consciousness, restlessness, or anxiety.6. Cyanosis.I. Complications.1. Acute deterioration in respiratory status requires hospitalization/ intubation.J. Education.1. Croup usually lasts 3-7 days; typically worse at night.2. Give guidelines about oral intake (fluids) and urine output.3. Use of bathroom mist, cool night air, cool-mist vaporizer to relieve symptoms.4. Signs of increasing respiratory distress and hypoxemia.5. Good handwashing, containment of coughs/sneezes prevents spread of illness.6. Maintain calm, reassuring manner.
