3/4 IN PROZENT

DUSTIN K. SMITH, DO; ANDREW J. MCDERMOTT, MD; and JOHN F. SULLIVAN, DO, navy Hospital Jacksonville, Jacksonville, Florida

Am Fam Physician. 2018 May 1;97(9):575-580.

Du schaust: 3/4 in prozent

*
geduldig information: seen related handzettel on croup, written von the authors of this article.

This clinical content conforms kommen sie oered.org criteria weil das continuing medical education and learning (CME). Seen the CME Quiz Questions.


Croup is a common respiratory illness affecting 3% von children six months to three years des age. That accounts weil das 7% des hospitalizations annually weil das fever and/or acute respiratory illness in children younger than 5 years. Croup is a manifestation of upper airway obstruction resulting from swelling des the larynx, trachea, and bronchi, leading zu inspiratory stridor und a barking cough. Many patients endure low-grade fevers, yet fever zu sein not necessary for diagnosis. Less commonly, stridor tun können be damit verbundenen with acute epiglottitis, bacter tracheitis, and foreign body airway obstruction. Laboratory lernen are rarely needed zum diagnosis des croup. Famous cultures and rapid antigen testing have minimal influence on management and are notfall routinely recommended. Radiography und laryngoscopy should be reserved weil das patients in whom different diagnoses are suspected. Randomized regulated trials schutz demonstrated that a einzel dose of oral, intramuscular, or intravenous dexamethasone boosts symptoms und reduces return visits und length des hospitalization an children v croup von any severity. Bei patients with moderate kommen sie severe croup, die addition von nebulized epinephrine boosts symptoms and reduces length von hospitalization.


Croup zu sein a common respiratory illness des the larynx, trachea, and bronchi the leads kommen sie inspiratory stridor and a barking cough. Laryngotracheitis, laryngotracheobronchitis, und laryngotracheobronchopneumonitis room included an the croup spectrum und 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 weil das fever and/or acute respiratory illness an children younger than 5 years.3,4


WHAT is NEW on THIS TOPIC

A community-based randomized trial of children with mild to moderate croup found no difference bei symptom scores bolzen a single dose von dexamethasone und three täglich doses of prednisolone.

In patient with more than two croup episodes über year, clinically significant bronchoscopy findings are verbunden with risk determinants such together prior intubation, period younger than three years, und prematurity. Although gastroesophageal reflux disease and asthma are very prevalent bei patients through recurrent croup, no is verbunden with significant bronchoscopy findings.


SORT: crucial RECOMMENDATIONS zum PRACTICEClinical recommendationEvidence ratingReferences

Diagnosis des croup ist based top top clinical findings von barking cough, stridor, und hoarseness. Diagnostic testing ist typically not necessary.

C

5, 6

Humidified wait inhalation does not improve symptoms an patients v moderate croup.

B

27

Corticosteroids should be administered zu patients with croup von any severity.

A

21, 22

Epinephrine need to be administered kommen sie patients through moderate zu severe croup.

A

25, 26


A = consistent, good-quality patient-oriented evidence; b = inconsistent or limited-quality patient-oriented evidence; samen = consensus, disease-oriented evidence, usual practice, expert opinion, or instance series. Weil das information about the SORT proof rating system, go to http://www.oered.org/afpsort.


SORT: crucial RECOMMENDATIONS zum PRACTICEClinical recommendationEvidence ratingReferences

Diagnosis des croup zu sein based top top clinical findings von barking cough, stridor, und hoarseness. Diagnostic testing is typically not necessary.

C

5, 6

Humidified air inhalation does notfall improve symptoms bei patients through moderate croup.

B

27

Corticosteroids should be administered to patients with croup of any severity.

A

21, 22

Epinephrine must be administered to patients through moderate to severe croup.

A

25, 26


A = consistent, good-quality patient-oriented evidence; b = inconsistent or limited-quality patient-oriented evidence; ns = consensus, disease-oriented evidence, usual practice, expert opinion, or situation series. Weil das information about die SORT evidence rating system, go kommen sie http://www.oered.org/afpsort.


Croup zu sein typically self-limited in immuno-competent children, emerging predominantly during the fall and winter. It is more common in boys than bei girls (1.5:1 ratio). Although die incidence des croup zu sein highest betwee six months and three years des age, it kann occur in children hoch to sechs years des age, or previously than six months in atypical cases.5–7 around 85% of cases are identified as mild, and less 보다 1% accomplish criteria weil das severe croup, which can be distinguished von signs von hypoxia.8,9 much less than 5% des all kids with croup are hospitalized, and of those just 1% to 3% require intubation.10

In patients v recurrent croup (more than two episodes per year), clinically far-ranging bronchoscopy findings are associated with risk determinants such as prior intubation, prematurity, und age younger than three years. Back gastroesophageal reflux disease und asthma are highly prevalent in patients through recurrent croup, neither is relevant with far-ranging bronchoscopy findings.11

Outcomes room favorable; croup has a mortality rate des less than 0.5%, even for intubated patients.10


Viruses space detected bei up to 80% of patients who have croup through identifiable pathogens.12 Parainfluenza virus (types 1 zu 3) accounts zum 75% des all cases, and human parainfluenza virus 1 zu sein the most typical type.9,13 other viral etiologies encompass influenza A und B, adenovirus, respiratory syncytial virus, rhinovirus, and enterovirus. Viral infection von the subglottic region and laryngeal mucosa causes inflammation and edema, which significantly decrease wait movement und lead zu respiratory distress and stridor.9,13 bacterial croup ist less common and may be caused von Mycoplasma pneumoniae und Corynebacterium diphtheriae.8,12 the type des infectious certified dealer does not affect outcomes or frühen zeitpunkt management.


Viral croup regularly presents an in similar way to an upper respiratory infection, v 12 zu 72 hours von low-grade fever and coryza. Narrowing of the larynx leads kommen sie stridor, boosted respiratory rate, respiratory tract retractions, und a barking cough. Symptoms might be exacerbated by emotional distress, room worse weist night, und peak betwee 24 und 48 hours. Croup generally resolves spontaneously within 48 hours zu one week; however, the abrupt onset und harsh cough tun können be concerning.5,6


HISTORY und PHYSICAL EXAMINATION

Croup is primarily a clinical diagnosis, with typical findings des abrupt onset of a barking cough, inspiratory stridor, und hoarseness (https://www.youtube.com/watch?v=RXJxtAHtkcs). Plenty of patients will also have dyspnea and fever,5,6 but the absence von fever should not reduce suspicion zum croup.

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Respiratory rate ist often increased an patients through croup. Clinicians need to use age-appropriate rates; zum patients six months kommen sie three years von age, a normal rate is 20 to 30 breaths von minute. Additionally, patients kann present v tachycardia. If pulse oximetry zu sein performed, low oxygen levels may be noted bei patients with much more severe cases.12–15

Visual inspection tun können reveal clues to ns severity des illness. Retractions and nasal flaring might indicate an ext severe cases. Although cyanosis zu sein absent in most patients with croup, that is presence argues severe disease.12,13,16

The most typical auscultatory finding is overt inspiratory stridor bei the neck. If wheezing is present, it zu sein typically mild; substantial wheezing should prompt evaluation zum alternate diagnoses. Rhonchi might be present yet are not typical. Rales room generally not present bei croup, deshalb this detect should sofort further evaluation.12,13,16

DIFFERENTIAL DIAGNOSIS

More than 99% des children with abrupt stridor schutz croup, but ns differential diagnosis is broad6 (Table 12,5,6,14,16–18). Separating croup from various other acute illnesses kann sein be challenging. Specifically, distinguishing it indigenous epiglottitis is important because die treatment and prognosis von these problems are dramatically different.7 return both conditions frequently present as cough, fever, and dyspnea, epiglottitis zu sein 10 mal more likely to present as sore throat.7 the incidence des epiglottitis has diminished 10-fold through widespread Haemophilus influenzae type ns vaccination, yet it is blieb important kommen sie distinguish it from croup because von potentially quick deterioration in patients through epiglottitis.19 in patients admitted to die intensive care unit, cough zu sein highly sensitive and specific weil das distinguishing croup native epiglottitis, whereas drooling is highly sensitive and specific for distinguishing epiglottitis.20


TABLE 1.Differential Diagnosis von Croup and Associated Clinical FeaturesConditionTypical period rangePresentationDiagnostic tests

Bacterial tracheitis

*


*—Large airway lesions include subglottic stenosis, laryngeal cleft, tracheomalacia, and laryngomalacia.


TABLE 1.Differential Diagnosis des Croup und Associated Clinical FeaturesConditionTypical period rangePresentationDiagnostic tests

Bacterial tracheitis

*


*—Large airway lesions incorporate subglottic stenosis, laryngeal cleft, tracheomalacia, und laryngomalacia.


DIAGNOSTIC TESTING

Laboratory lernen are seldom needed to diagnose croup. Famous cultures and rapid antigen experimentation should be reserved for patients in whom frühen zeitpunkt treatment is ineffective.6 A finish blood count may help distinguish croup from bacter etiologies von stridor (e.g., bacter tracheitis, epiglottitis, peritonsillar abscess, retropharyngeal abscess), but it is nonspecific. Lymphocytosis may indicate a famous etiology.5,6 A carboxyhemoglobin level might be helpful in identifying cases von thermal injury/smoke inhalation, but the history alone ist typically sufficient zum this diagnosis.

Although radiographic imaging is not regularly indicated, croup zu sein often damit verbundenen with ns steeple sign, which indicates glottic und subglottic narrowing (see http://www.oered.org/afp/2004/0201/p535.html#afp20040201p535-f1). However, this finding zu sein neither details nor sensitive weil das croup und may be present bei patients v epiglottitis, bacter tracheitis, neoplasm, or thermal injury.18 Computed tomography des the neck can be considered for patients through suspected abscess, tumor, or international body aspiration.5

Laryngoscopy should be reserved for atypical gift or wie alternate diagnoses space suspected.16 If epiglottitis zu sein suspected, laryngoscopy must be performed with caution because of concern zum rapid airway obstruction.6


Management von croup ist based on the severity of illness. Although a scoring system zu sein not necessary, ns most commonly studied und commonly used zu sein the Westley Croup Score (Table 2).15

Figure 1 provides an outpatient monitoring algorithm weil das children with croup.6,14,21–26 Minimizing agitation an a symptomatic child kann sein help boost symptoms. Placing die child in a comfortable position may help improve the evaluation and treatment process.


TABLE 2.Westley Croup ScoreClinical signScore

Level des consciousness

Normal (including sleep)

0

Disoriented

5

Cyanosis

None

0

With agitation

4

At rest

5

Stridor

None

0

When agitated

1

At rest

2

Air entry

Normal

0

Decreased

1

Markedly decreased

2

Retractions

None

0

Mild

1

Moderate

2

Severe

3

Total score

Croup severity

≤ 2

Mild

3 zu 7

Moderate

8 zu 11

Severe

≥ 12

Impending respiratory tract failure


Adapted v permission native Westley CR, cotton EK, Brooks JG. Nebulized racemic epinephrine von IPPB zum the treatment des croup: a double-blind study. Am J Dis Child. 1978;132(5):485.


TABLE 2.Westley Croup ScoreClinical signScore

Level des consciousness

Normal (including sleep)

0

Disoriented

5

Cyanosis

None

0

With agitation

4

At rest

5

Stridor

None

0

When agitated

1

At rest

2

Air entry

Normal

0

Decreased

1

Markedly decreased

2

Retractions

None

0

Mild

1

Moderate

2

Severe

3

Total score

Croup severity

≤ 2

Mild

3 zu 7

Moderate

8 zu 11

Severe

≥ 12

Impending respiratory tract failure


Adapted v permission native Westley CR, cotton EK, Brooks JG. Nebulized racemic epinephrine von IPPB weil das the treatment von croup: a double-blind study. Am J Dis Child. 1978;132(5):485.


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FIGURE 1.

Algorithm for the management von croup.

Adapted v permission indigenous Zoorob R, Sidani M, Murray J. Croup: in overview. Bei der Fam Physician. 2011;83(9):1071, with additional die info from recommendations 6, and 21 with 26.


FIGURE 1.

Algorithm weil das the management des croup.

Adapted with permission native Zoorob R, Sidani M, Murray J. Croup: in overview. In Fam Physician. 2011;83(9):1071, through additional information from recommendations 6, und 21 with 26.


Oxygen must be administered zu children v hypoxemia or serious respiratory distress. Although humidified air inhalation has been historically used for management von croup, a meta-analysis of three studies (N = 125) discovered no statistically far-ranging effect on croup scores or hospital admission in patients v moderate croup.27 therapy with particularly designed humidity droplets the deposit bei the larynx ist no far better than managed delivery of 40% humidity or humidity via blow-by administration.28

Heliox zu sein a helium and oxygen mixture used weil das respiratory conditions that theoretically boosts airflow resistance über decreasing gas density (helium zu sein a low-density gas). Säule are limited on the benefit von heliox bei the treatment des croup, and based ~ above a Cochrane review des three conflicting trials, it ist not recommended.29

CORTICOSTEROIDS

Corticosteroids have to be used bei patients v croup of any severity. Treatment with dexamethasone results an faster resolution von symptoms and decreased return to medical care.21 Corticosteroids room thought zu work von decreasing laryngeal mucosal edema through their anti-inflammatory effects. A Cochrane testimonial showed boosted symptom noten at six and 12 hours after treatment v a corticosteroid (dexamethasone, budesonide , or methylprednisolone).22 patient treated through corticosteroids oase a lower rate des return visits, as well as decreased length of stay in the emergency department or hospital. There ist no statistically far-reaching difference bolzen corticosteroids and epinephrine, although patient treated with corticosteroids require much less epinephrine.22 another review proved that corticosteroids space safe zu use in children v acute respiratory tract conditions.23

Dexamethasone is the desired corticosteroid since it ist given together a single dose und can be provided orally, intramuscularly, or intravenously. Although ns optimal dose ist unclear, 0.6 mg von kg zu sein the most typically used.13,24 Dexamethasone zu sein superior kommen sie budesonide zum improving symptoms scores, yet there ist no significant difference bei return visits or readmissions. Contrasted with prednisolone, dexamethasone use in the notfall department or hospital may decrease rates of return visits or readmissions.22 However, a community-based randomized trial uncovered no difference bolzen single-dose dexamethasone and three daily doses von prednisolone weil das treatment des mild kommen sie moderate croup.24

EPINEPHRINE

Epinephrine zu sein thought zu improve symptoms bei patients v croup with arteriole vasoconstriction in the top airway mucosa, which at some point leads to decreased edema. Epinephrine is typically used bei conjunction v corticosteroids since it has actually a fast onset des action but a short half-life, whereas corticosteroids schutz a slower onset von action however a longer half-life. Epinephrine reduce symptom scores in children v moderate or significant croup and should be offered at die 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 sheep = 5 mL).25,26

A Cochrane review proved that nebulized epinephrine reduces symptom scores at 30 minutes, but notfall at two und six hours; however, that is verbunden with diminished length von hospitalization.25 There was no anfangsverdacht difference between nebulized racemic epinephrine und L-epinephrine, return L-epinephrine was more effective hinweisen two hrs because von its much longer effects. The effects of epinephrine wane ~ one zu two hours, dafür patients need to be monitored zum at the very least two hrs after administration before they space discharged.6,25 Although disadvantage effects des nebulized epinephrine space rare, patient receiving frequent treatments should be monitored for adverse cardiac effects.


This article updates previous short articles on this topic von Zoorob, et al.,14 und by Knutson and Aring.17


Data Sources: A PubMed search was completed using the key terms croup und pediatric respiratory tract infection. Ns search had meta-analyses, randomized regulated trials, clinical trials, and reviews. We deshalb searched ns Cochrane database, crucial Evidence Plus, and the national Guideline Clearinghouse. In addition, references in these resources were searched. Search dates: november 7, 2016; July 19, 2017; and December 27, 2017.


The see expressed an this post are those des the authors und do notfall necessarily reflect the official plan or position of the Department of the Navy, Department of Defense, or the U.S. Government.

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