Review Question - QID 221254

This patient with a fever, high-pitched cough, inspiratory stridor, respiratory distress, and a chest radiograph demonstrating subglottic narrowing, most likely has croup. Patients with severe croup should be treated with corticosteroids and nebulized epinephrine.

Croup is caused by the parainfluenza virus and results in inflammation of the upper airways. It typically presents with a high-pitched "seal-like” cough and inspiratory stridor that worsens at night. Mild to moderate cases can result in subcostal retractions and nasal flaring with exertion. The diagnosis is primarily clinical. Cool mist and corticosteroids are the preferred treatment. Severe cases are characterized by stridor at rest and should be treated with corticosteroids and nebulized epinephrine to relieve the upper airway obstruction. Epinephrine is preferred over albuterol because this medication has alpha-1 activity that reduces edema via vasoconstriction.

Gates et al. studied the use of glucocorticoids in children with croup. They found that glucocorticoids were associated with reduced symptoms within 2 hours and shortened hospital stays. They recommend that glucocorticoids be used in this patient population.

Figure/Illustration A is a chest radiograph highlighting subglottic narrowing, also known as the “steeple sign” (red circle). This finding is classically seen in patients with croup.

Incorrect Answers:
Answer 1: Bronchoscopy would be performed if foreign body aspiration were suspected which can also present with cough, respiratory distress, and stridor; however, it presents more acutely and would not be accompanied by fever and rhinorrhea as seen in this infant.

Answer 2: Cool mist and corticosteroids would be the treatment of choice for mild to moderate croup. This patient presents with severe croup as he has inspiratory stridor and respiratory distress at rest.

Answer 4: Intubation is the treatment of choice for rapidly deteriorating respiratory distress, such as in a patient with epiglottitis. Although this patient demonstrates respiratory distress at rest, he is not hypoxemic nor has vital sign changes (tachycardia, bradycardia, and hypotension) that would suggest an imminent threat of respiratory compromise.

Answer 5: Nebulized albuterol is a short-acting beta-2 agonist commonly used for the treatment of asthma or bronchospasm. Asthma may also present with respiratory distress and decreased breath sounds. However, low-pitched wheezing is characteristic, not inspiratory stridor. Nebulized albuterol is not a common treatment for croup as it lacks the alpha-1 activity essential for reducing upper airway edema.

Bullet Summary:
Severe croup presents with inspiratory stridor at rest, a barking cough, and respiratory distress and should be treated with corticosteroids and nebulized epinephrine.