Understanding Croup and Differentiating from Other Conditions

Assessing and managing the pediatric airway can be challenging, especially when dealing with conditions like croup, epiglottitis, and other respiratory pathologies. Here is what you need to know.

Croup - typically seen in children aged 6 months to 3 years, is a viral infection characterized by a "barking" cough, stridor, hoarseness, and respiratory distress. Symptoms often worsen at night and improve with cool, moist air. Croup is usually caused by the parainfluenza virus and primarily affects the upper airway, leading to inflammation and swelling of the larynx and trachea.

Epiglottitis Differentiation - although now rare due to vaccination, remains a critical differential diagnosis. It presents with rapid onset of high fever, severe sore throat, drooling, muffled voice, and significant distress without the barking cough typical of croup. Children with epiglottitis often appear toxic, prefer sitting up and leaning forward (tripod position), and have difficulty swallowing. Epiglottitis is a bacterial infection requiring immediate intervention due to the risk of sudden airway obstruction.

Other Considerations - When assessing a child with stridor and respiratory distress, consider other conditions such as foreign body aspiration, retropharyngeal abscess, or allergic reactions. These conditions may present similarly but require different management strategies.

Anatomical and Physiological Differences between Adults and Peds:

Pediatric airways are not just smaller versions of adult airways. Key differences include:
• Airway Size and Shape: The pediatric airway is smaller, more flexible, and cone-shaped,
with the narrowest part at the cricoid cartilage rather than the vocal cords.
• Tongue Size: Children have proportionally larger tongues, which can more easily obstruct
the airway.
• Epiglottis: The pediatric epiglottis is floppier and more u-shaped, making it more prone to
obstruction.
• Larynx Position: The larynx is higher and more anterior in children, which can complicate
intubation.
• Oxygen Consumption: Children have higher metabolic rates and oxygen consumption,
leading to faster desaturation during periods of apnea or hypoventilation.

Management Tips:

Calm the Child: Keep the child calm and in a position of comfort. Agitation can worsen airway obstruction.

Oxygen Administration: Where applicable, administer humidified oxygen, if available. Avoid unnecessary agitation which may exacerbate the condition.

Nebulized Epinephrine: For moderate to severe croup, consider nebulized epinephrine in accordance with the Croup Medical Directive to reduce airway swelling.

Steroids: Administer corticosteroids, such as dexamethasone, in accordance with the Croup Medical Directive to reduce inflammation.

Airway Control: Prepare for advanced airway management, including bag-valve-mask ventilation combined with supraglottic airways and/or intubation (if authorized). This is particularly crucial in cases of epiglottitis or severe respiratory compromise. Airway interventions should be attempted only when there is imminent airway compromise, as any intervention could exacerbate the situation.

Transport: Rapid transport to an emergency department with pediatric capabilities is crucial; however, life-saving interventions should be prioritized ahead of extrication.

Early recognition and differentiation of croup from other potentially life-threatening conditions like epiglottitis are vital. Understanding the anatomical and physiological differences in pediatric patients will enhance your assessment and management, ensuring the best outcomes for your young patients.

Stay vigilant, stay informed, and keep those airways clear!

References:
Bjornson, C. L., & Johnson, D. W. (2013). Croup in children. Canadian Medical Association Journal (CMAJ), 185(15), 1317-1323. doi:10.1503/cmaj.121645.
American Heart Association. (2020). Pediatric Advanced Life Support (PALS) Provider Manual. Dallas, TX: American Heart Association.