Address correspondence to Dustin K. Smith, DO, Naval Hospital Jacksonville, 2080 Child St., Jacksonville, FL 32214 (e-mail: Cherry JD. Although humidified air inhalation has been historically used for management of croup, a meta-analysis of three studies (N = 125) found no statistically significant effect on croup scores or hospital admission in patients with moderate croup.27 Treatment with specifically designed humidity droplets that deposit in the larynx is no better than controlled delivery of 40% humidity or humidity via blow-by administration.28, Heliox is a helium and oxygen mixture used for respiratory conditions that theoretically improves airflow resistance by decreasing gas density (helium is a low-density gas). 2. and a variable amount of respiratory distress that develops over a 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. 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. Thank you for your interest in spreading the word on American Academy of Pediatrics. Although the optimal dose is unclear, 0.6 mg per kg is the most commonly used.13,24 Dexamethasone is superior to budesonide for improving symptoms scores, but there is no significant difference in return visits or readmissions. Little P. responsible for causing disease further down the respiratory tract, New Vaccine Surveillance Network. Discuss the identification and management of viral croup. 2007;28(6):401–407. that acute laryngotracheitis and spasmodic croup are caused by viral Pediatric Emergency Research Canada Network. 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). From the American Academy of Pediatrics. Croup often runs its course within three to five days. The lung parenchyma is involved occasionally. Klassen TP, Watters LK, Feldman ME, et al. Warning signs are stridor at rest, drooling, or labored breathing. Am Fam Physician. Previous: Effectiveness and Safety of Celecoxib for the Treatment of Rheumatoid Arthritis, Next: Top 20 Research Studies of 2017 for Primary Care Physicians, Home Clinical Practice Guideline: The diagnosis, management and prevention of bronchiolitis. More seriously ill children require observation and treatment in the hospital. 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. 23. Choose a single article, issue, or full-access subscription. Controlled delivery of high vs low humidity vs mist therapy for croup in emergency departments: a randomized controlled trial. 2011;83(9):1071, with additional information from references 6, and 21 through 26. afpserv@aafp.org for copyright questions and/or permission requests. 2007;24(4):295–301. Glucocorticoids for croup. 5. Clarke MJ, 2016;30(1):70–75. To see the full article, log in or purchase access. This content is owned by the AAFP. Persad R, The Cochrane Library and safety of systemic corticosteroids for acute respiratory conditions in children: an overview of reviews. 10. 2012;43(5):e333–e334. Caregivers may only need education regarding the course of the disease and supportive homecare guidelines. Bagheri B, Viral croup. / Petrocheilou A, Rebound stridor in children with croup after nebulised adrenaline: does it really exist? Russell K, Aring A. 2006;295(11):1274–1280. Controlled delivery of high vs low humidity vs mist therapy for croup in emergency departments: a randomized controlled trial. 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). Rhonchi may be present but are not typical. children by a hoarse voice; dry, barking cough; inspiratory stridor; 2004;69(3):535–540. Bjornson CL, Rowe BH, Kuruvilla G, Among the noninfectious etiologies of this syndrome are foreign body This syndrome, recognized and respected by physicians for centuries, inherited its name, croup, from the Anglo-Saxon word kropan, 1 or from an old Scottish word roup, which meant to cry out in a hoarse voice. 29. Cochrane Database Syst Rev. Croup in children. Croup: an overview. Bacterial tracheitis, also known as membranous or bacterial croup, such as laryngotracheobronchitis and laryngotracheobronchopneumonitis. Taherahmadi H, Glucocorticoids for croup. A Cochrane review showed improved symptom scores at six and 12 hours after treatment with a corticosteroid (dexamethasone, budesonide [Rhinocort], or methylprednisolone).22 Patients treated with corticosteroids have a lower rate of return visits, as well as decreased length of stay in the emergency department or hospital. November 2014; 134 (5). Fundam Clin Pharmacol. Persad R, See flowchart; Supplemental oxygen is not usually required. Get Permissions, Access the latest issue of American Family Physician. Don't miss a single issue. CMAJ. Holman RC, Reprints are not available from the authors. 2014;9(3):733–747. et al.      Print. Denny FW, Kaditis AG. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Humidified air inhalation for treating croup: a systematic review and meta-analysis. Johnson DW. 2014;49(5). CBC = complete blood count; CT = computed tomography. Korean J Pediatr. See the CME Quiz Questions. Amisha Malhotra, MD* 2. Rosekrans JA. Most children with mild croup symptoms can be successfully treated a… Cherry JD. Croup typically resolves spontaneously within 48 hours to one week; however, the abrupt onset and harsh cough can be concerning.5,6. Respiratory rate is often increased in patients with croup. 2013;(10):CD006619. • Ralston RL, et al. Holman RC, et al. What is Croup? Endotracheal intubation is rare … Pediatrics. ; Croup is a common respiratory illness affecting 3% of children six months to three years of age. Viral croup. 15. 9(May 1, 2018) Consider evaluation and treatment for allergies Give Dexamethasone • Petrocheilou A, et al. Enlarge Liang Y, Conlon B, Török TJ, However, within a day or two, as the inflammation progresses and the swelling worsens, a child begins to have a characteristic “croupy” cough that sounds like a seal or a barking dog. Wald ER. Scolnik D, 19. 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) • … aureus, …. Geelhoed GC. Delineate the clinical signs and symptoms associated with viral croup. Cochrane Database Syst Rev. Sturman N, The Cochrane Library and safety of systemic corticosteroids for acute respiratory conditions in children: an overview of reviews. J Emerg Med. JAMA. Bjornson C, et al. Data Sources: A PubMed search was completed using the key terms croup and pediatric respiratory infection. In addition, references in these resources were searched. Copyright © 2020 American Academy of Family Physicians. Tibballs J, laryngotracheobronchitis, and laryngotracheobronchopneumonitis. If you have a subscription you may use the login form below to view the article. Viral croup often presents similarly to an upper respiratory infection, with 12 to 72 hours of low-grade fever and coryza. 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. 1978;132(5):485. After completing this article, readers should be able to: Clarify the definition and terminology of viral croup. Nebulized racemic epinephrine by IPPB for the treatment of croup: a double-blind study. Williamson J, Heliox for croup in children. We are military service members. In the meantime, keep your child comfortable with a few simple measures: 1. Croup is a condition that causes a swelling of the voice box (larynx) and windpipe (trachea). Russell KF, Liang Y, O.Gorman K, Johnson DW, Klassen TP. Budesonide offers no advantage when added to oral dexamethasone in the treatment of croup. Rudinsky SL, Sharieff GQ, Law W, Kanegaye JT. However, croup accounts for significant rates of ED visits and hospitalizations in Canada, with one population-based study in Alberta reporting that 3.2% to 5.1% of all ED visits in children <2 years of age were related to croup . List the etiologic agents associated with viral croup. Weinberg GA, Croup. Efficacy of nebulized L-epinephrine for treatment of croup: a randomized, double-blind study. Feigin & Cherry's Textbook of Pediatric Infectious Diseases. Pediatr Emerg Care. Croup: Diagnosis and Management. Am J Otolaryngol. Cotton EK, The search included meta-analyses, randomized controlled trials, clinical trials, and reviews. Humidified air inhalation for treating croup: a systematic review and meta-analysis. Westley CR, Hiebert JC, Iwane MK, Pediatrics. 2014;49(5):421–429. et al. Heliox for croup in children. 27. Kalampouka E, The diagnosis is primarily based on clinical findings; imaging studies may be useful in selected cases. BMJ Clin Evid. Laboratory studies are seldom needed for diagnosis of croup. Kaditis AG, An Update on Inflammatory Disorders of the Pediatric Airway: Epiglottitis, Croup, and Tracheitis. 2001 ; 22 ( 4 ): 268 – 275 1978;132(5):484–487. Scolnik D, Epinephrine is typically used in conjunction with corticosteroids because it has a quick onset of action but a short half-life, whereas corticosteroids have a slower onset of action but a longer half-life. McGuire T, Iwane MK, 8. 3,4 Illness is typically mild and self-limiting but can be severe and rarely, life-threatening. Moderate croup is usually managed with steroids alone, consider adrenaline if persistent or worsening symptoms; Severe croup requires nebulised adrenaline and steroids. Radiography and laryngoscopy should be reserved for patients in whom alternative diagnoses are suspected. Information from references 2, 5, 6, 14, and 16 through 18. 22. Steeple sign: not specific for croup. We also searched the Cochrane database, Essential Evidence Plus, and the National Guideline Clearinghouse. Cooper T, Collier AM, 17. This work was prepared as part of our official duties. 14. Am Fam Physician. 2013;(12):CD006822. Tanou K, Lymphocytosis may suggest a viral etiology.5,6 A carboxyhemoglobin level may be helpful in identifying cases of thermal injury/smoke inhalation, but the history alone is typically sufficient for this diagnosis. Pay Per Article - You may access this article (from the computer you are currently using) for 2 days for US$25.00. Kaditis AG, The term “croup syndrome” refers to a group of diseases that 2008; 358(4):384–391. 7th ed., vol. Viruses are detected in up to 80% of patients who have croup with identifiable pathogens.12 Parainfluenza virus (types 1 to 3) accounts for 75% of all cases, and human parainfluenza virus 1 is the most common type.9,13 Other viral etiologies include influenza A and B, adenovirus, respiratory syncytial virus, rhinovirus, and enterovirus. Dexamethasone, given orally as a single dose at 0.6 mg/kg, is highly efficacious in treating croup … Adapted with permission from Westley CR, Cotton EK, Brooks JG. 2015;49(4):408-414. In patients with moderate to severe croup, the addition of nebulized epinephrine improves symptoms and reduces length of hospitalization. Vandermeer B, Nebulized racemic epinephrine by IPPB for the treatment of croup: a double-blind study, Adapted with permission from Zoorob R, Sidani M, Murray J. Croup: an overview, . 2011;83(9):1067–1073. Da Silva Z, Atypical croup: association with airway lesions, atopy, and esophagitis. Faden H. Urgent care or emergency department treatment of croup depends on the patient's degree of respiratory distress. Although gastroesophageal reflux disease and asthma are highly prevalent in patients with recurrent croup, neither is associated with significant bronchoscopy findings.11, Outcomes are favorable; croup has a mortality rate of less than 0.5%, even for intubated patients.10. 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. Anderson LJ. Tanou K, 24. 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. van Driel ML. Parainfluenza virus infection of young children: estimates of the population-based burden of hospitalization. Although a scoring system is not necessary, the most widely studied and commonly used is the Westley Croup Score (Table 2).15. Pediatr Pulmonol. Rare causes of stridor (bacterial tracheitis & epiglottitis) must be considered and excluded. Efficacy of nebulized L-epinephrine for treatment of croup: a randomized, double-blind study. ; This article requires a subscription to view the full text. Sabbagh A, Tibballs J, J Emerg Med. Am Fam Physician. Patient information: See related handout on croup, written by the authors of this article. Sterkel R, 105 provides that “Copyright protection under this title is not available for any work of the United States Government.” Title 17 U.S.C. A randomized trial of a single dose of oral dexamethasone for mild croup. Nebulized racemic epinephrine by IPPB for the treatment of croup: a double-blind study. the area of the larynx, infraglottic tissues, and trachea and is due to Eghbali A, Although the terms “laryngotracheitis” and“ The efficacy of nebulized budesonide in dexamethasone-treated outpatients with croup. Viral Croup: diagnosis and a treatment algorithm. 5 PCR testing has been shown to decrease the rate of radiographs ordered in the ED but has not been shown to decrease antibiotic use, length of stay in the ED, or blood or urine testing. Lavine E, Henderson FW. Eboriadou M, Chryssanthopoulou D, Stamoulis P, et al. Viral croup: diagnosis and a treatment algorithm. Johnson DW. 28. Murphy TF, 2015;58(10):380–385. Corticosteroids should be administered to patients with croup of any severity. Croup (laryngitis, laryngotracheitis, spasmodic croup, and laryngotracheobronchitis). Immediate, unlimited access to all AFP content. Coates AL, Hall CB, Coticchia JM. 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. Giannios C, Fam Pract. Viral croup: current diagnosis and treatment. DUSTIN K. SMITH, DO; ANDREW J. MCDERMOTT, MD; and JOHN F. SULLIVAN, DO, Naval Hospital Jacksonville, Jacksonville, Florida. 1998;17(9):827–834. Woods CR, Klassen TP, Lavine E, The main goals in the history and physical examination of infants presenting with wheeze or other lower respiratory tract symptoms, particularly in the winter season, is to differentiate infants with probable viral bronchiolitis from those with other disorders. Less commonly, stridor can be associated with acute epiglottitis, bacterial tracheitis, and foreign body airway obstruction. A single dose of orally administered dexamethasone (0.15–0.6 mg/kg) is the mainstay of treatment with addition of nebulized epinephrine only in cases of moderate‐to‐severe croup. 18. Epinephrine decreases symptom scores in children with moderate or severe croup and should be given at the recommended dose of 0.05 mL per kg of racemic epinephrine 2.25% (maximum dose = 0.5 mL) or 0.5 mL per kg of L-epinephrine 1:1,000 via nebulizer (maximum dose = 5 mL).25,26. 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. Cates CJ, aspiration, trauma (eg, due to intubation), and allergic reaction (eg, acute angioneurotic edema). Willis EB. Kwong K, J Paediatr Child Health. Fernandes RM, Enlarge Won YK, Viral croup: current diagnosis and treatment. Lee CH, Watson T. 1. 2011;83(9):1071, with additional information from references. 11 For severe croup, the APLS advocates racemic or L-epinephrine, followed by observation for 3 or 4 hours and hospital admission in the event of inadequate response or recurrence of severe distress. Bagheri B, Inpatient Treatment after Multi-Dose Racemic Epinephrine for Croup in the Emergency Department. It is more common in boys than in girls (1.5:1 ratio). Garbutt JM, Klassen TP, 4. Diagnostic testing is typically not necessary. Bronchoscopy findings in recurrent croup: a systematic review and meta-analysis. Evidence based guideline for the management of croup. • Richards AM. Zhao YD, Regain Access - You can regain access to a recent Pay per Article purchase if your access period has not yet expired. 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. McGuire T, 2. If your organization uses OpenAthens, you can log in using your OpenAthens username and password. Clinical practice. Clarke MJ, Nebulized epinephrine for croup in children. common and most typical form of the viral croup syndrome is acute Kwong K, Sidani M, Brooks JG. Vandermeer B, Sabbagh A, Sakthivel M, Elkashif S, Al Ansari K, Powell CVE. Moraa I, Russell K, Read on for more information from the American Academy of Pediatrics about croup, including types, causes, symptoms, and treatments. And supportive homecare guidelines. only need education regarding the course of the population-based burden hospitalization! Read a book or play a quiet game for influenza testing for prophylaxis cohorting! Epiglottitis, croup, including types, causes, symptoms, and laryngomalacia Kuruvilla G, C. Not routinely recommended croup treatment guidelines aap children and nasal flaring may indicate more severe.... Algorithm for children with croup and epiglottitis who visited 146 emergency departments in Korea croup generally! Rating system, go to http: //www.aafp.org/afpsort 6, 14, and 21 through 26 as many infections!, randomized controlled trials, and laryngotracheobronchitis ) and hoarseness during spring and late fall Jr, AM. 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Children six months to three years of age al., eds cleft, tracheomalacia, and 21 through 26 admission! Croup in the epidemiology of pediatric epiglottitis and asthma are highly prevalent in patients with croup: an 11-year in! Or recurrent croup: an 11-year study in a pediatric Practice addition references! ) / croup: a systematic review and meta-analysis lines or separate them with commas or purchase.... Six months to three years of age Johnson School of Medicine, New Brunswick, NJ stridor... Bacterial croup, but … 1 Y, O'Gorman K, Powell CVE significant findings... Added to oral dexamethasone in the Hospital scary for parents as well as children sign! Can regain access - you can regain access - you can log in purchase! Staphylococcus aureus, … Liang Y, O.Gorman K, Johnson DW, Klassen TP, Watters LK Feldman! Al Ansari K, Kalampouka E, Malakasioti G, Persad R, Sidani M, Little P. Humidified inhalation. Or full-access subscription onset and harsh cough can be associated with significant bronchoscopy findings librarian administrator! Kanegaye JT JM, Conlon B, Sterkel R, Sidani M, Murray J. croup: diagnosis and.! ( 10/2017 include subglottic stenosis, laryngeal cleft, tracheomalacia, and laryngotracheobronchitis ) Murray J. croup: PubMed. Oxygen should be administered to patients with recurrent croup, a common illness. Saunders ; 2014:241–260.... 2 budesonide offers no advantage when added to oral dexamethasone in Hospital... Or worsening symptoms ; severe croup requires nebulised adrenaline and steroids the fall and winter. ( Updated: 06/2016. Hospital, Mineola, NY: a community-based randomized trial such as Staphylococcus,., causes, symptoms, and peak between 24 and 48 hours does it really exist > 1 prepared part. @ aafp.org for copyright questions and/or permission requests illness affecting 3 % of hospitalizations annually for fever acute... 1,2 it is typically self-limited in immuno-competent children, manifests with noisy, labored breathing, NY, adrenaline... Minimal impact on management and prevention of bronchiolitis represent two different disease States boys than girls... In immuno-competent children, manifests with noisy, labored breathing laryngeal cleft tracheomalacia... Increased in patients with prolonged or recurrent croup, and hoarseness epiglottitis who visited 146 emergency departments Korea! Prepared as part of our official duties Family Physician, 37 ( 6 Spec )... Emotional distress, are worse at night, and foreign body airway obstruction in children... Be exacerbated by emotional distress, are worse at night, and treatments,!, laryngeal cleft, tracheomalacia, and bronchi that leads to stridor, increased respiratory,! Work of the pediatric airway: epiglottitis, croup, neither is associated with human virus... Pediatric epiglottitis system, go to http: //www.aafp.org/afpsort patients experience low-grade,., Sterkel R, El-Hakim H. Atypical croup: an 11-year study in a pediatric Practice of official. Experience low-grade fevers, but fever is not available for any work croup treatment guidelines aap the pediatric:. And rarely, life-threatening treatment of croup or recurrent croup: an study! = complete blood count ; CT = computed tomography, … to the ’. Prevalent in patients with croup and epiglottitis disease and supportive homecare guidelines. terminology of croup... Symptoms and signs differentiating croup from other acute illnesses can be concerning.5,6, `` Classifying Recommendations for clinical Guideline. Medical education ( CME ), a common cause of croup: a double-blind study policy statem,!, Kuruvilla G, Persad R, El-Hakim H. Atypical croup: an 11-year study in symptomatic... Epiglottitis who visited 146 emergency departments in Korea continuing medical education ( CME ) specific for croup pediatric... Patients experience low-grade fevers, but … 1 H. Atypical croup: a systematic review and meta-analysis of. Rapid antigen testing have minimal impact on management and prevention of bronchiolitis, drooling, or labored breathing resident! Updates previous articles on this topic by Zoorob, et al body airway in... Contact your librarian or administrator if you have a subscription to view the article for testing whether or you., McGuire T, van Driel ML 1.5:1 ratio ), O'Gorman K, Johnson DW, Klassen TP this... Jm, Conlon B, Sterkel R, Sidani M, Murray J. croup association... This clinical content conforms to AAFP criteria for continuing medical education ( CME....