croup

Dr. Fawzi Abu Nijmeh

Ahmad waleed
Case presentation
A previously healthy 2-year-old girl is brought to the emergency department by
her mother because of a dry, barking cough for 2 days that worsens at night. She
has also had mild rhinorrhea and fever. Her older brother has asthma and had a
cold last week. Immunizations are up-to-date. She appears to be in mild distress.
Her temperature is 38.1°C (100.5°F), pulse is 140/min, respirations are 35/min,
and blood pressure is 99/56 mm Hg. Pulse oximetry on room air shows an oxygen
saturation of 98%. Examination shows clear rhinorrhea and a dry, hoarse cough.
There is mild inspiratory stridor upon agitation that resolves with rest. The skin
and oral mucosa appear normal. The remainder of the examination shows no
abnormalities. Which of the following is the most appropriate initial step in
treatment?

a-Inhaled racemic epinephrine therapy

b-Ceftriaxone therapy
c-Intubation and mechanical ventilation
d-Albuterol nebulizer therapy
e-Chest x-ray
f-Oral dexamethasone therapy
g-Noninvasive positive pressure ventilation
 Definition & Etiology
Laryngotracheobronchitis, as the name implies, refers to inflammation
of the larynx, trachea, and bronchi. Cases of laryngotracheobronchitis
can be more severe than laryngotracheitis as the former extends into
the lower airway. Both may be difficult to distinguish clinically. The
term "croup" colloquially describes both laryngotracheobronchitis and
laryngotracheitis Briefly describing the patient's condition and
relevant clinical findings.

Occurs in children 6 months of age to 4 years of age, with a peak

incidence in children 12 months to 2 years of age.

Croup is most often a viral infection that affects the subglottic airway,
commonly caused by the parainfluenza virus(75%). Other viruses that
are known to cause croup include the respiratory syncytial virus
 Clinical feature
● Prodromal phase: 1–2 days of upper respiratory tract infection
symptoms (rhinitis, low-grade fever, sore throat) .
● Symptoms of croup last 2–7 days and typically manifest in the late
evening/night.
● Characteristic features include seal-like barking cough, hoarseness,
and inspiratoryMild
stridor due to subglottic narrowing.
croup
Stridor may be absent or only manifest
in agitated individuals.

• Stridor and dyspnea may be present at

rest.
Moderate croup • Thoracic retractions are typically visible.
• Affected individuals may
be tachycardic or tachypneic.

Severe stridor and dyspnea are present at

rest.
Air entry is decreased.

Severe croup Hypoxemia, an altered mental state, and/or

other signs of impending respiratory
failure may be present.
Agitation can worsen symptoms and
precipitate complete airway obstruction.
 95%
Use percentages in your case report to quantify and
communicate the frequency or proportion of important
findings or outcomes
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a thousand words
Using an image in your case report
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provides a concise and impactful way
to present key findings or illustrate
important aspects of the case
Table of contents

01 02 03

Abstract Introduction Case presentation

04 05 06

Discussion Conclusion Roadmap

Diagnostics
General principles :
● Croup is most commonly diagnosed based on the presence of
characteristic clinical features of croup.
● Diagnostic studies are not routinely required; do not delay treatment
in unstable patients to obtain studies.
● Indications for diagnostic studies include:
● Atypical presentation or diagnostic uncertainty, to rule out
differential diagnoses of pediatric stridor
● Severe disease
● Recurrent episodes of croup
 Diagnostics
other:
● X-ray chest and neck (anteroposterior
and lateral) May identify subglottic narrowing on
anteroposterior view (steeple sign)
● CT chest and neck: usually performed for differential
diagnoses or suspected underlying congenital
abnormalities) E.g., subglottic
hemangioma, vascular ring(
● Laryngoscopy/bronchoscopy: may be performed for
suspected foreign bodies or atypical croup
● Blood gas
○ Indicated for severe respiratory symptoms,
e.g., signs of impending respiratory failure
○ May show hypoxemia and/or CO2 retention
 Westley croup score
Clinical features score

Normal 0
Levels of consciousness
Disoriented 5
None 0

Cyanosis With agitation 4

At rest 5

None 0

Stridor With agitation 1

At rest 2

Normal 0

Air entry Decreased 1

Markedly decreased 2

None 0

Mild 1
Retraction
Moderate 2

Severe 3

≥ 12 points: impending respiratory failure/ 8–11 points: severe croup/ 3–7 points: moderate croup/ ≤ 2 points: mild croup
Management
● Keep the patient calm and minimize distress.
○ Allow the patient to maintain a comfortable position (usually semi-
upright).
○ Examine the child in the parent's lap.
○ Avoid examining the throat as this may precipitate airway obstruction.
● Hypoxemia/signs of impending respiratory failure: Initiate immediate
stabilization (e.g., supplemental oxygenation, intubation).
● Perform a croup severity assessment to guide treatment; consider using a
scoring system (e.g., Westley croup score).
○ All patients: dexamethasone and supportive care as needed
(e.g., antipyretics, IV fluids)
○ Patients with moderate/severe croup: Add nebulized racemic epinephrine.
● Regularly reassess patients.
● Admit patients with admission criteria for croup
○ Severe croup
○ Need for oxygen or IV fluids
○ > 1 treatment with nebulized epinephrine
○ Age < 6 months
○ Persistent tachypnea or tachycardia
Complication
● Respiratory failure (rare)
● Pulmonary edema
● Pneumothorax
● Pneumomediastinum
● Secondary bacterial infection (e.g., bacterial
tracheitis)
● Cardiac arrest and death
Spasmodic Croup
● Spasmodic croup is very similar to infectious croup. It can be triggered
by infection, but it isn't caused by infection. It tends to run in families,
and may be triggered by an allergic reaction.
● Spasmodic croup tends to come on suddenly, without fever.
Sometimes it can be hard to tell spasmodic croup from infectious
croup.
● Spasmodic croup usually affects children who are between three
months and three years old. Before the age of three months, a child's
risk of either type of croup is fairly low.
● A child with spasmodic croup often looks fairly healthy before
coughing starts. Episodes of cough and loud, raspy breathing generally
start without warning. They typically occur in the middle of the night.
● These symptoms often will pass if the child is carried into cool night air
or taken into a steamy bathroom.
● Symptoms from spasmodic croup usually improve within a few hours.
However, it is common for the symptoms to reappear several nights in
a row.
01
Case presentation
A previously healthy 2-year-old girl is brought to the emergency department by
her mother because of a dry, barking cough for 2 days that worsens at night. She
has also had mild rhinorrhea and fever. Her older brother has asthma and had a
cold last week. Immunizations are up-to-date. She appears to be in mild distress.
Her temperature is 38.1°C (100.5°F), pulse is 140/min, respirations are 35/min,
and blood pressure is 99/56 mm Hg. Pulse oximetry on room air shows an oxygen
saturation of 98%. Examination shows clear rhinorrhea and a dry, hoarse cough.
There is mild inspiratory stridor upon agitation that resolves with rest. The skin
and oral mucosa appear normal. The remainder of the examination shows no
abnormalities. Which of the following is the most appropriate initial step in
treatment?

a-Inhaled racemic epinephrine therapy

b-Ceftriaxone therapy
c-Intubation and mechanical ventilation
d-Albuterol nebulizer therapy
e-Chest x-ray
f-Oral dexamethasone therapy
g-Noninvasive positive pressure ventilation
Answer

The correct answer is f-Oral dexamethasone therapy

This patient is alert and has stridor that resolves with rest,
an oxygen saturation of 98% on room air, and no subcostal
retractions, all of which indicate mild croup. Because croup is
commonly caused by viruses (e.g., parainfluenza
virus, respiratory syncytial virus), symptomatic relief is sufficient
for mild cases. This includes keeping the patient calm and
minimizing distress. In addition, all patients with croup should be
treated with (oral or parenteral) dexamethasone,
which reduces airway swelling within hours.
Thanks