Viral Laryngotracheitis (Croup)

Acute laryngotracheitis (viral croup) is the most common infectious cause of acute upper airway obstruction in
pediatrics, causing 90% of cases. The disease is usually benign and self-limited. Children in the 1-2-year-old age group
are most commonly affected, and the male-to-female ratio is 2:1. Viral croup affects 3-5% of all children each year.
Although croup is most common from the late fall to early spring, cases have been reported throughout the year.
I.

Clinical Evaluation of Upper Airway Obstruction and Stridor

A.

Stridor is the most common presenting feature of all causes of acute upper airway obstruction. It is a harsh
sound that results from air movement through a partially obstructed upper airway.
1.

Supraglottic disorders, such as epiglottitis, cause quiet, wet stridor, a muffled voice, dysphagia and a
preference for sitting upright.

2.
B.

Subglottic lesions, such as croup, cause loud stridor accompanied by a hoarse voice and barky cough.

Patient Age
1. Upper airway obstruction in school age and older children tends to be caused by severe tonsillitis or
peritonsillar abscesses.
2. From infancy to 2 years of age, viral croup and retropharyngeal abscess are the most common causes.
3. Between three to six years of age, epiglottitis peaks.

C. Mode of Onset
1.
2.
3.
4.

Gradual onset of symptoms, usually preceded by upper respiratory infection symptoms, suggests viral
croup, severe tonsillitis or retropharyngeal abscess.
Very acute onset of symptoms suggests epiglottitis.
A history of a choking episode or intermittent respiratory distress may represent a foreign body inhalation.
Facial edema and urticaria suggests angioedema.

D. Emergency Management of Upper Airway Obstruction

1.
2.
3.

4.

Maintaining an adequate airway takes precedence over other diagnostic or therapeutic interventions.
If a supraglottic disorder is suspected, a person skilled at intubation must accompany the child at all
times.
Patients with suspected supraglottic pathology, severe respiratory distress from an obstruction, or
suspected foreign body inhalation should be taken to the operating room for direct visualization and
possible intubation.
Those patients who are not suspected of having epiglottitis, but who have only mild or moderate
respiratory distress can be managed in the emergency room.

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Causes of Upper Airway Obstruction in Children

Supraglottic Infectious Disorders
Epiglottitis
Peritonsillar abscess
Retropharyngeal abscess
Severe tonsillitis
Subglottic Infectious Disorders
Croup (viral laryngotracheitis)
Spasmodic croup
Bacterial tracheitis
Non-Infectious Causes
Angioedema
Foreign body aspiration
Congenital obstruction
Neoplasms
External trauma to neck

Causes of Upper Airway Obstruction in Children

Epiglottitis

Laryngotracheo-

Bacterial Tracheitis

Foreign Body Aspiration

bronchitis (Croup)
History
Incidence in children

8%

88%

2%

2%

presenting with
stridor
Onset

Rapid, 4-12 hours

Prodrome, 1-7 days

Prodrome, 3 days, then

Acute or chronic

10 hours
Age

1-6 years

3 mo-3 years

3 mo-2 years

Any

Season

None

October-May

None

None

Etiology

Haemophilus

Parainfluenza viruses

Staphylococcus

Many

Inflammatory edema

Edema and inflammation of

Tracheal bronchial

Localized tracheitis

of epiglottis and

trachea and bronchial tree

edema, necrotic debris

influenza
Pathology

supraglottis
Signs and Symptoms
Dysphagia

Yes

No

No

Rare

Difficulty swallowing

Yes

No

Rare

No

Drooling

Yes

No

Rare

No

Stridor

Inspiratory

Inspiratory and expiratory

Inspiratory

Variable

Voice

Muffled

Hoarse

Normal

Variable

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Cough

No

Barking

Variable

Yes

Temperature

Markedly elevated

Minimally elevated

Moderate

Normal

Heart rate

Increased early

Increased late

Proportional to fever

Normal

Position

Erect, anxious, "air

No effect on airway

No effect

No effect

hungry, supine

obstruction

Normal

Increased if bronchial

position exacerbates
Respiratory rate

Increased early

Increased late

obstruction present

Differentiation of Epiglottitis from Viral Laryngotracheitis

Clinical Feature

Epiglottitis

Viral Croup

Retractions

present

present

Wheezing

absent

occasionally present

Cyanosis

present

present in severe cases

"Toxicity"

present

absent

Preference for sitting

yes

no

II.

Epidemiology and Etiology of Viral Laryngotracheitis (Croup)

A.

Parainfluenza virus type 1 causes 40% of all cases of laryngotracheitis. Parainfluenza type 3, respiratory

B.

syncytial virus (RSV), parainfluenza type 2, and rhinovirus may also cause croup.
RSV commonly affects infants younger than 12 months of age, causing wheezing and stridor. Influenza viruses
A and B and mycoplasma have been implicated in patients older than 5 years.

III. Clinical Manifestations

A.

Viral croup begins gradually with a 1-2 day prodrome resembling an upper respiratory infection. Subglottic
edema and inflammation of the larynx, trachea, and bronchi eventually develop. Involvement of these
structures narrows the airway and produces stridor, barky cough, and hoarseness.
B. Low-grade fever, and nocturnal exacerbation of cough are common findings. As airway obstruction increases
retractions develop. Diminished air exchange leads to restlessness, anxiety, tachycardia, and tachypnea.
C. Cyanosis is a late sign; it may not occur until the PO2 drops to less than 40 mm Hg.
D. Severe obstruction leads to respiratory muscle exhaustion, hypoxemia, carbon dioxide accumulation, and
respiratory acidosis. Stridor becomes less apparent as muscle fatigue worsens.
E. Ten percent of croup patients have severe respiratory compromise requiring hospital admission, and 3% of
those children need airway support.
IV. Laboratory Evaluation
A.

The diagnosis of viral croup is based primarily on the history and clinical findings. Laboratory evaluation
provides minimal diagnostic information.

B.

When the diagnosis is uncertain or the patient requires hospitalization, x-rays can be helpful. The
posteroanterior neck radiograph of a patient with viral croup shows symmetrical narrowing of the subglottic
space (the classic steeple sign). Radiographs are unreliable in assessing the severity of illness.

C. The differential diagnosis of viral croup (89% of cases of stridor) requires definitive exclusion of epiglottitis (8%
of cases) as a possible cause of obstruction. Other diagnostic considerations include spasmodic croup,
bacterial tracheitis, foreign body aspiration, and angioedema.

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V.

Inpatient Treatment of Laryngotracheitis

A. The majority of patients who have croup do not require hospitalization, but careful assessment is required to
detect the 10% who do, and especially those who need intubation.
B.

Indications for Hospitalization

1. Dusky, or cyanotic skin color;

2. Decreased air entry on auscultation;
3. Severe stridor;
4. Significant retractions;
5. Agitation, restlessness, or obtundation.
C. Signs that indicate the need for an artificial airway include decreased respiratory effort and stridor, decreased
level of consciousness, and failure to respond to therapy. Pulse oximetry may aid in assessing the severity
of respiratory compromise.
D. All patients suspected of having viral croup should be given humidified-air through the use of vaporizers or
masks. Hypoxic or cyanotic patients require oxygen via mask and may require intubation.
E. Oral hydration is essential to help loosen inspissated secretions; however, intravenous hydration may become
necessary in the very ill child.
F.

Racemic epinephrine has alpha-adrenergic properties which cause local vasoconstriction, decreasing
subglottic inflammation and edema. The severity of airway obstruction often improves acutely.
1. Racemic epinephrine is administered as 0.5 mL of a 2.25% solution, diluted with 3.5 mL of saline (1:8)
by nebulization. It is given every 20-30 minutes for the patient with severe croup, and it is every 4-6 hours
for the patient with moderate croup.
2. Indications for racemic epinephrine include severe croup, moderate croup, or stridor at rest.
3. The patient who receives racemic epinephrine should be admitted to the hospital because epinephrines
effects are short-lived and a rebound obstruction may occur.
4. Children with Tetralogy of Fallot or other forms of ventricular muscle outflow obstruction should not
receive racemic epinephrine because it can cause a sudden decrease in cardiac output.

G. Corticosteroids reduce subglottic edema and inflammation, capillary permeability, and lymphoid swelling.
1.
2.

Dexamethasone (0.6 mg/kg IM) given one time early in the course of croup results in a shorter hospital
stay and reduces cough and dyspnea.
The need for intubation is reduced from 1.2% to 0.1%. Patients who do not require hospitalization should
not receive steroids.

H. Acetaminophen decreases fever and oxygen consumption in the febrile patient with croup.

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VI. Management of Airway Obstruction

Management of Imminent Airway Obstruction

1.
2.
3.
4.
5.

6.

7.
8.
9.
10.
11.
12.
13.
A.

B.

Take no laboratory tests, including blood gases; no radiography; no intravenous

lines.
Administer oxygen facially, 2-4 L/min. Keep child with parents.
Attempt trial of racemic epinephrine
If response is dramatic, severe croup is likely
Assemble bedside supplies:
- Cardiopulmonary resuscitation equipment
- Resuscitation bag; appropriate size mask
- 14-gauge angiocatheter
- Intubation equipment
Notify:
- Otolaryngology (come to bedside)
- Anesthesia (prepare operating room; come to bedside)
- Intensive care unit for bed availability.
Escort patient to operating room with parents holding child
Administer anesthesia to patient while in parents' arms; begin intravenous
administration of fluids
Inspect throat by direct laryngoscopy
Conduct bronchoscopy if indicated
Intubate; change to nasotracheal tube
Obtain cultures of blood, epiglottis
Employ restraints and sedation

If obstruction occurs abruptly and personnel skilled in intubation are not yet available, bag and mask
ventilation is vastly superior to unskilled attempts at intubation. Cricothyrotomy or tracheotomy should be
reserved for the most dire circumstance to prevent cardiopulmonary arrest and death.
An endotracheal tube 1-2 mm smaller than that normally recommended for the patient's age should be
used. Intubation should be undertaken in the operating room after induction with inhalation agents when
possible.

VII. Outpatient Treatment of Laryngotracheitis

A. Patients with mild viral croup usually are not admitted to the hospital and can be treated safely at home.
B. Vaporizers, oral fluids, and antipyretics are the mainstays of home therapy.
C. Parents should be instructed to watch the child closely and return to the ER if there is increasing stridor,
retractions, anxiety, or decreased oral intake.
D. The prognosis for croup is good; however, a subset of children who have croup will later be identified as
having bronchial reactivity following infection.

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