PANCE Blueprint Pulmonary (12%)

Croup (ReelDx)

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croup (2)

Patient will present as → a 2-year-old boy who is brought to you by his father who is concerned about a "barking cough," mild fever, and a hoarse voice. He reports that he had a runny nose last week that has since resolved. Physical exam reveals an inspiratory stridor. AP neck film is shown here.

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Croup is caused by parainfluenza virus

  • Commonly in children 6 months - 3 years of age.
  • Fall and early winter months (same time of year as bronchiolitis)
  • Patient presents with → Barking cough and stridor

"Steeple sign" on PA neck X-Ray (narrowing of the trachea in the subglottic region)

STEEPLE SIGN

Steeple sign on frontal radiograph of tracheal narrowing

Treatment is antipyretics, hydration, nebulized racemic epinephrine (only if signs of distress), and corticosteroids.

  • Prognosis is excellent.
IM_NUR_Croup_V1.1_ Croup is a general term that describes a group of conditions characterized by edema and inflammation of the upper airway. The focus of this Picmonic is on the most common croup disorder - laryngotracheobronchitis, often abbreviated as LTB, which often leads to hospitalization. The other group disorders are acute epiglottitis, acute spasmodic laryngitis, and acute tracheitis.

Croup (Laryngotracheobronchitis) Picmonic

parainfluenza-virus_5725_1482261879 Parainfluenza virus is a single-stranded RNA paramyxovirus that causes croup in children. Croup is an upper respiratory infection that presents with respiratory difficulty and a characteristic barking cough. In adults, it causes mild upper respiratory infections. However, parainfluenza infections can cause inflammation and swelling in the upper airway to the point of obstruction in children. Severe cases present with inspiratory stridor, and airway swelling can be seen on a frontal neck X-Ray indicated by a steeple sign. These cases require immediate medical intervention.

View Parainfluenza Virus Picmonic

Question 1
Which of the following is a common symptom associated with laryngotracheobronchitis (viral croup)?
A
drooling
Hint:
Drooling and a "hot potato" voice are seen with epiglottitis, not viral croup.
B
high fever
Hint:
Fever is usually absent or low grade in patients with viral croup.
C
"hot potato" voice
Hint:
See A for explanation.
D
barking cough
Question 1 Explanation: 
Viral croup is characterized by history of an upper respiratory tract symptoms followed by onset of a barking cough and stridor.
Question 2
A 2 year-old presents to the emergency department in acute respiratory distress. The parents relate a history of a recent upper respiratory illness that was followed by a sudden onset of barking cough during the night, but this morning they noted increased difficulty breathing. The child is noted to have stridor at rest, but has no evidence of cyanosis. Which of the following is the most appropriate initial intervention?
A
Intravenous antibiotics
Hint:
Laryngotracheobronchitis is caused by viruses, not bacteria, and therefore antibiotic therapy is not indicated.
B
Endotracheal intubation
Hint:
If patients fail to respond to initial treatment and progress to impending respiratory failure, endotracheal intubation is then indicated.
C
Inhaled mucolytic agent
Hint:
Inhaled mucolytic agents are not indicated in the treatment of laryngotracheobronchitis.
D
Nebulized racemic epinephrine
Question 2 Explanation: 
This patient most likely has laryngotracheobronchitis (viral croup). Treatment with nebulized racemic epinephrine and glucocorticosteroids is indicated for patients with stridor at rest.
Question 3
A 22 month-old male infant presents with one day of barking cough preceded by three days of cold symptoms. On physical examination, his axillary temperature is 100.4°F and he has no stridor at rest. Inspiratory stridor is evident when he becomes agitated during the examination. There are no signs of respiratory distress or cyanosis. Which of the following is the most appropriate treatment for this patient?
A
Nebulized albuterol
Hint:
Viral croup is an upper airway disease and there is no role for bronchodilator therapy.
B
Nebulized epinephrine
Hint:
Nebulized racemic epinephrine is only indicated in the treatment of croup in cases of moderate to severe rest stridor, respiratory distress, or hypoxia.
C
Oral amoxicillin
Hint:
Croup is almost always a viral illness and antibiotics have no role in the treatment of this condition.
D
Oral dexamethasone
Question 3 Explanation: 
Corticosteroids are beneficial in the treatment of croup. Intramuscular administration has shown no benefit over oral administration.
Question 4
An 18 month-old male presents with his parents who report symptoms of a barking cough and intermittent stridor that has worsened over the past 12 hours. They note improvement in symptoms when he was taken outdoors to the cool night air. Which of the following is the most likely organism causing this patient's symptoms
A
Rubeola virus
Hint:
See D for explanation.
B
Adenovirus
Hint:
See D for explanation.
C
Influenza virus
Hint:
See D for explanation.
D
Parainfluenza virus
Question 4 Explanation: 
Croup is most often caused by parainfluenza virus.
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