So, What Would You Do? Croup, croup, baby…

Last week, I gave you a scenario involving a child with a nasty sounding cough, in a very remote location.  Your task was to figure out what was going on with the patient, then come up with a treatment plan.  If you haven’t had a chance to watch the video and consider my scenario, you can do both by following this link!

The title of the video perhaps gave the diagnosis away.  This is a classic croup cough.  Basically, croup is swelling in the larynx due to (usually) viral infection.  The swelling causes the larynx to narrow, which produces stridor on inspiration and expiration, as well as the characteristic “barking” cough.  Or, to quote a more “medical” sounding source:

Croup is a generic term that encompasses a heterogeneous group of relatively acute conditions (mostly infectious) that are characterized by a syndrome of distinctive brassy coughs. These conditions may be accompanied by inspiratory stridor, hoarseness, and signs of respiratory distress as a result of laryngeal obstruction.  The word croup derives from an old Scottish term roup, which means “to cry out in a shrill voice.”

The most common form of croup is acute laryngotracheobronchitis or viral croup, an infection of both the upper and lower respiratory tracts. A reactive inflammatory response causes subglottic edema. Narrowing of the airway can be life threatening in infants and young children because of their small airway.

–Source

Just to give you a quick idea of how these patients present; typically, kids with croup start out showing signs of a nagging viral upper respiratory infection, with a fever, nasal and chest congestion, and coughing.  They typically feel miserable, but typically show no serious or worrying symptoms.  The barking cough usually happens in the evening, and usually comes on acutely.  Speaking as a parent of small children, croup can be terrifying for both patients and parents.  One minute, you feel like you have your sick child under control; you’ve comforted them, checked their fever, given them some tylenol, and gotten them off to bed for some needed rest.  Suddenly, they have this horrible sounding cough, and they appear pale, scared, and look like they can’t breathe well.

Luckily for parents (and you, because you’re the one providing care in this scenario), croup is very manageable, and typically responds very well to treatment.  Mild croup may not require any special treatment, and will usually go away on its own after a few days.

Let’s quickly review some pathophysiology, and some croup signs and symptoms.

Croup_steeple_sign
Steeple sign, in an x-ray of a croup patient’s neck

A viral infection in the larynx causes an immune response, which brings fluid and white blood cells.  This migration of fluid causes swelling in the larynx, which narrows the passageway.  When the child coughs, air being forced through a narrow space causes the characteristic “barking” cough.  If you were to have access to an x-ray of the patient’s neck, you may see the narrowed airway.  This characteristic finding called “Steeple Sign” because it looks a bit like a church steeple.

You can listen for inspiratory or expiratory stridor by listening to the patient’s neck with a stethoscope.  Many patients will have audible stridor that you won’t need a stethoscope to hear.  Lung sounds will frequently be clear or be rhonchorous due to congestion.  The patient will usually have a low-grade fever, congestion, nasal drainage, and recent history of 2-3 days of cold or “flu-like” symptoms.  Try to take a temperature.  The most accurate measure of core body temperature is a rectal temperature, which tends to work better with babies and toddlers.  Older kids will tolerate an oral thermometer fairly well if they’re coached.  The newer skin sensors are excellent, but I have an abiding distrust of the old temperature stickers.

Croup is classified as mild, moderate, severe, or impending respiratory failure.  I could type it all out, but instead (because it’s already been done) I’m going to quote a source:

Another clinically useful croup severity assessment rating system has been developed by the Alberta Clinical Practice Guideline Working Group. [15, 16]  By following this classification scheme, 21 different general emergency rooms in Alberta, Canada diagnosed 85% of children to have mild croup, and less than 1% with severe croup. The assessment tool used was as follows:

  • Mild severity – Occasional barking cough, no audible stridor at rest, and either no or mild suprasternal and/or intercostal retractions
  • Moderate severity – Frequent barking cough, easily audible stridor at rest, and suprasternal and sternal wall retractions at rest, with no or minimal agitation
  • Severe severity – Frequent barking cough, prominent inspiratory (and occasionally expiratory) stridor, marked sternal wall retractions, significant agitation and distress
  • Impending respiratory failure – Barking cough (often not prominent), audible stridor at rest, sternal wall retractions may not be marked, lethargy or decreased consciousness, and often dusky appearance without supplemental oxygen support. (Source)

To review, retractions are when accessory muscle use to expand the chest cavity causes “tugging” at the skin.  You may see retractions around the bottom of the rib cage, around the collar bones, or between the ribs.

As you assess the patient, keep a close eye out for another condition that can look similar to croup.  Epiglottitis is an infection of the epiglottis.  The epiglottis is a fold of tissue that covers the entrance to the larynx, and keeps food from getting into the lungs (if you need a review of airway anatomy, I rather helpfully did a post about that too!).  I do not intend to spend a great deal talking about epiglottitis right now; that said, the classic symptoms are drooling, distress (shortness of breath), and dysphagia (difficulty or inability to swallow), with a fever.  Croup patients are small kids, and small kids leak all sorts of fluids.  However, croup patients do not typically drool excessively.  If you see evidence that your patient is having a hard time swallowing, and is drooling, you should be thinking epiglottitis!  In a wilderness context, patients with epiglottitis need evacuation right now!  Airway management becomes a major challenge, and advanced airway techniques are frequently needed.  If you want to learn more, I highly recommend this article.

On to the scenario.  As I watch this video, what do I see?

  • General impression:  Our patient looks generally healthy and well-cared for.
  • Could it be epiglottitis?  She doesn’t look particularly pale or cyanotic, I don’t see any obvious drooling, I see no evidence of difficulty swallowing.
  • What about the cough?  The cough is obviously a barking cough, but I don’t hear any stridor when she breathes.
  • How bad does this look?  Based on the work of breathing that I can see (and bearing in mind that I can’t visualize her chest to be sure) as well as the occasional nature of her coughing, I’m pretty comfortable classifying her croup as being mild in severity.

Some other information I’d like to gather here:

  • How long has she been feeling unwell?  This is called the “history of the present illness,” sometimes abbreviated HPI.  How did her current illness start?  Has she been to a doctor about it yet, and if so, what did they say?
  • Let’s check a temperature.  Based on her age, I’ll enlist her parent’s assistance to take a rectal temperature if possible.  While I’m at it, I’ll also inquire about her recent diaper outputs; how many wet diapers has she produced?  Is this a usual amount for her, or is it less or more than usual?  Does her urine appear particularly yellow or smelly?  This gives me information about how well hydrated she is, but I’ll also ask how she’s been eating and drinking lately.
  • Auscultate and check chest wall.  I’m going to pull out my handy stethoscope here.  Word of advice; when working with kids, be sure to warm your stethoscope!  This is good advice for adults as well, but particularly when dealing with kids we want to build trust.  They’re already probably scared and feeling bad, and if we surprise them with a cold stethoscope bell we may make them distrust us even more.  Distrust = inability to do a good exam = inability to provide good treatment = not making the patient feel better.  I want to check for retractions.  I also want to listen to lung sounds, and listen to the neck for stridor.
  • What’s the oxygen saturation?  We can go about this several ways.  Optimally, I have a pulse oximeter and can measure the patient’s SPO2 (concentration of oxygen-carrying hemoglobin).  If I don’t have a pulse oximeter, I can also look for signs of poor perfusion.  I’d want to pay attention to cyanosis (a bluish tinge to the skin), pale mucus membranes or conjunctiva, a “dusky” or “mottled” appearance to the skin, or altered mental status.  All of these would clue me in to a low oxygen concentration.
  • Other vitals.  I’m probably not going to get a blood pressure on this young lady.  Not only do I probably not have the right sized BP cuff (I only carry an adult cuff), she probably won’t hold still and quiet enough for me to take an accurate pressure.  With kids this age, I prefer to use the Pediatric Assessment Triangle, which factors the child’s appearance (which usually means the child’s mental status), work of breathing, and skin color/temperature/moisture together to get an idea of the child’s severity of illness or injury.

So, what am I going to do?  Bearing in mind that I’ve determined this is mild croup, here are my thoughts.

  • Reduce swelling in the throat.  The easiest way to do this is by having the patient breathe cool air.  The easiest way to do that is to wrap them up in a blanket, and take them outside.  My kids have all spent at least some time wrapped in a blanket, sitting with me in a deck chair at ungodly hours of the night on the front porch after a croupy coughing spell.  Some other things we could consider would be to have the child breathe in cool air from an open refrigerator, or enjoy a popsicle.  Cold food has the added benefit of soothing the sore throat often brought on by repetitive coughing.
  • Treat the fever.  I’m going to consider giving the child the recommended dose of OTC tylenol (acetaminophen) or ibuprofen to manage the fever and provide some symptomatic relief.
  • Encourage hydration.  I’m going to try to keep the child hydrated with oral fluids.  This will allow her body to keep working to fight off the infection.
  • Sleep and time.  Because this is a viral infection, there really isn’t any medication we can give to knock it out.  It will just have to run its course.  I can encourage my patient’s body to keep fighting hard, though, by giving the patient lots of opportunities to rest.  So, lots of naps and early bedtimes!

What if this wasn’t mild croup?  What if the patient showed dusky, cyanotic skin, with frequent barking coughs and retractions?  What if a pulse oximeter showed a concentration of 88% on room air, and the patient looked agitated and fidgety?  The patient has moved into severe croup, and while our treatment goals remain largely the same, the way we achieve them changes somewhat.  Please note that my recommendations here are largely for you advanced-level wildmed providers (my wilderness medics and wilderness PA/MD/DO types).

  • Reduce swelling in the throat.  With severe croup, airway management becomes a priority, and we can’t rely on cool air and popsicles anymore.  We’re going to move towards drug therapies now.  When confronted with croup, many of my paramedic students hear “narrowed airway” and want treat the patient like an asthma patient, with inhaled bronchodilators such as albuterol.  This is incorrect.  Asthma is caused by narrowed bronchioles in the lungs themselves, and albuterol opens them by relaxing smooth muscle in the bronchiole walls.  Croup is caused by swelling in the tissue of the larynx, and won’t be affected by albuterol.  Our patient needs steroids.  The preferred steroid is dexamethasone, or Decadron, due to its long half life.  The preferred dose is 0.6 mg/kg, and can be provided as an IM injection, as an IV push, or even as an oral drug (PO).
  • Consider nebulizer treatments.    In severe croup, the patient needs aerosolized epinephrine treatments.  Epinephrine works very quickly, and causes vasoconstriction, which rapidly reduces swelling in the patient’s larynx.  Ideally, epinephrine and dexamethasone should be used as a “1-2 punch” to provide rapid-onset, short-term relief (epinephrine) followed by slow-onset, long-acting relief (dexamethasone).  The American Academy of Family Physicians recommends 0.05 mL/kg racemic epinephrine up to 0.5 mL via nebulizer.  As a backcountry medical provider, you are unlikely to have racemic epinephrine (which is slightly different in shape from regular epinephrine) in your backpack; as such, AAFP recommends 0.5 mL/kg 1:1000 epinephrine, up to a maximum dose of 5 mL, by nebulizer w/oxygen at 6-8 Liters/minute.  Note that epinephrine is (typically) 1:1 packaging, where 1 mL of fluid (usually) contains 1 mg of drug, and that 1:1000 epinephrine is the same epinephrine that is carried by auto injectors such as the Epipen.  There are some fantastic videos on Youtube showing how to disassemble auto injectors to get at that sweet, sweet epinephrine.  I’ll leave it to you to check those out.
  • Venous access and cardiac monitoring.  Epinephrine is a wonderful drug, but has the potential to cause some pretty serious side effects to your patient.  They’re going to feel jumpy/anxious, they’re going to have a rapid heart rate, and they may show some rapid respirations; par for the course, considering we just induced a fight or flight reaction.  My philosophy is, if I’m administering medication to a patient, I want to have an IV in place and I want to have them on a monitor.  If you’re able to get access on this child, by all means do it.  I may consider giving her a fluid bolus of 10-20 mL/kg while I’m at it, if I have the capability.  I recognize that in this scenario I placed us way up in the backcountry in a ski cabin, and that we’re unlikely to have a cardiac monitor; I get that, but I’m just talking in best practices right now.
  • Comfort care.  If the patient has mild or moderate croup, and you have the equipment, a nebulizer setup may be used to deliver oxygen humidified with aerosolized sterile water.  This works like a humidifier, and can treat hypoxia as well as sooth the patient’s sore throat.  Please note, this is only a comfort measure; this is not a fix!  Research has shown that humidification nebulizer treatments do not make any difference in outcome!
  • Then, continue with basic treatments.  Most of the previous treatments apply here as well.  Manage the fever.  Keep the patient hydrated.  Allow the patient to rest.  Continuously monitor and re-examine.
  • Prepare for the worst.  With severe croup, the patient is getting dangerously close to respiratory failure and severe airway compromise.  I want to prepare for the worst.  I’m going to have my BVM handy, and be ready to ventilate the patient if her respiratory drive and quality start to diminish.  I also want to be ready to defend her airway, so I’ll have my intubation kit ready to go.  I’ll probably want a smaller tube than what I’d normally reach for; remember, we’re dealing with a narrowed airway.  If her airway swells enough, I likely won’t be able to intubate and will have to opt for a surgical airway.  In airway managements, all roads end at the surgical cricothyrotomy.
  • Evacuate.  If my patient is at the point where she requires drugs and I’m preparing to emergently manage her airway, she needs to be evacuated to definitive care.  Now, do we need to venture out in the snowstorm at night?  Probably not, but maybe.  That’s going to be determined by your group, your resources, and your situation.

So, ending on a personal note.  I can attest to how well these drug therapies work.  When my oldest was nine-months-old he came down with a mild respiratory infection for several days.  One night, around 10PM, he began coughing with a coarse, barking cough.  It was the first time I had ever heard a croup cough.  I pulled out my pocket pulse oximeter, which showed his oxygen saturation at 92%.  He was pale, breathing heavily, and had retractions, all indications of moderate to “sort-of” severe croup.  I ended up taking him to the local emergency department, where they gave him dexamethasone and a nebulized epinephrine treatment (which he did not enjoy at all).  This picture is him right after treatment; he was so exhausted from the sickness and the coughing that he passed out and slept for about an hour after he was given the meds.

IMG_1903

This next picture is after he woke up.  His color improved, his work of breathing improved, the retractions went away, his pulse oximeter readings came up to 100%, and the barking cough went away.  His affect improved as well; we knew he was feeling better because he went from being listless and tired, to being happy and trying to escape from the exam room into the rest of the ED to make friends!  The picture is slightly out of focus because he was moving around so much (epinephrine is a hell of a drug).

IMG_1905

I hope you found this article helpful.  Croup is generally pretty benign, but can be dramatic!

Just for your planning purposes, I’ll be taking a short break for the next two weeks.  I’m headed to Wyoming for until Thanksgiving, and blogging should pick up soon after I get home.  As always, I’m reachable by email and by twitter!

 

 

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Author: Ethan Zook

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