Croup (Parainfluenza)

2 y/o pt born at 37 WGA and with no h/o intubation presents with acute onset cough and hoarseness. Parents report 2-3 days of low-grade fever and nasal congestion; symptoms typically worse at night. Parents deny possibility for recent foreign-body aspiration. Low-grade fever, tachypnea, nasal flaring, barking cough, inspiratory stridor, retractions, cyanosis, disorientation on exam. No drooling, wheezing, crackles noted.

• Do not obtain respiratory virus panel at present; may reconsider if pt does not respond to initial treatment

• CXR shows steeple sign

• Treatment

  • Administer single-dose oral dexamethasone 0.6 mg/kg

  • Westley Croup Score 3 or greater: Administer 0.5 mL nebulized racemic epinephrine

  • Administer oxygen to maintain SPO2 >94%

• Monitor for 2 hours; admit to hospital if no improvement after initial treatment

• Parents counseled that symptoms typically peak at 48 hours and resolve after 1 week

Notes

• Pathology: Virally-mediated swelling of larynx, trachea, and bronchi

• Epidemiology

  • Most common between age 6 months and 3 years

  • Croup is responsible for 99% of acute onset stridor cases in children

  • 75% of cases are due to parainfluenza virus

  • Risk factors for severe croup include prematurity, prior intubation, and age < 3 years

• Differential

  • Absence of cough and presence of drooling should raise suspicion for epiglottis

  • Steeple sign is not sensitive or specific for croup

• Nebulized epinephrine reduces length of hospital stay in severe cases