1.
Croup
Dr. Javate
PRIME 2
December 15, 2022
Submitted by:
PRIME 2 JUNIOR INTERNS

2.
Animas, Archie J. ✓
Aquino, Janjer Bon M. *
Aquino, Trisha Mae V. ✓
Arzaga, John Joel C. ✓
Ascano, John Christian *
Aslam, Areej D. *
Asprer, Calman Jan M. ✓
Atienza, Marielle M. ✓
Bartolome, Nimrod Ramil II C. ✓
Fortes, Hannah Selina V. *
Francisco, Jenica Vianca Loren
G.
*
Francisco, Krizza Mae A. *
Fule, Sofia Gabrielle B. *
Gabriel, Mark Joseph D. ✓
Gaceta, Chelsea Denise T. ✓
Gaite, Summer Marionne ✓
Gamilde, Lourdes Gayle R. ✓
Garcia, Jan Rossana S. ✓
Garcia, Marc Wilhelm M. ✓
Garong, Maria Ana Therese D. ✓
Gille, Genree Ann B. ✓
Gonzales, Jan Chloe C. ✓
*F2F Duty
✓= DONE

3.
JI Animas, Archie J.
Prime 2 (Written Output under Dr. Javate)
Croup
December 15, 2022
Croup is a common acute upper respiratory illness seen in infants and children affecting
about 5% of children in their second year of life. Most commonly, it is seen between the ages of
6 and 36 months, although it can affect children older and younger than this as well. It has a
peak incidence in the fall and early winter and is generally considered a mild, self-limited illness
but can be complicated by respiratory distress an upper airway obstruction.
PATHOPHYSIOLOGY
● It affects the upper airway and is also referred to as laryngotracheitis or an inflammation
of the trachea and larynx.
● It is most commonly due to parainfluenza virus, which affects the nasopharynx before
spreading distally.
● Other viral etiologies include:
● Respiratory syncytial virus
● Adenovirus
● Enterovirus
● Human bocavirus
● Influenza virus
● Inflammation causes narrowing of the larynx just below the vocal chords, called the
subglottic airway.
● The cartilage in this airway forms a complete ring which restricts the airway’s ability to
expand when inflamed.
● Inflammation in this are causes distinctive barky cough and stridor which are hallmarks
of the disease
CLINICAL PRESENTATION
● Often but not always presents with initial upper respiratory infection symptoms. These
initial symptoms are followed by fever, hoarseness, a barky cough and stridor which is a
high-pitch sound heard upon inspiration indicating some levels of upper airway
obstruction.
● Symptomes characteristically can wax and wane often worst at night and can become
more pronounced when a child is anxious and upset.
● If there are signs of respiratory distress, hypoxia cyanosis, or stridor at rest, this should
prompt concern for severe airway obstruction.
DIAGNOSIS
● Differential diagnosis for a child with stridor aside from croup includes:
● Angioedema - as seen in allergic reactions

4.
● Epiglottitis
● Retropharyngeal abscess
● Foreign body aspiration
● Inhalational injury
● Anatomic airway anomalies
● Evaluation of the suspected croup should include:
● Thorough history and physical exam to exclude less common etiologies
● When asking about the history, make sure to ask about the:
● Onset and progression of the illness
● Recent oral intake
● Presence of dyphasia or drooling
● A choking episode
● History of croup
● Underlying airway abnormalities
● Previous intubations
● Respiratory conditions
● A recent history of a viral URTI can be reassuring in the diagnosis of croup
● When performing a PE, the first step should be an overall assessment of the child:
● Are the vital signs normal?
● Does the child appear comfortable?
● Are they working hard to breathe?
● Is the child awake or sleepy?
● Do they appear to be dehydrated?
● A thorough pulmonary examination is also necessary, listening for any abnormal sounds
on inspiration and expiration.in particular, listening for:
● Stridor
● For barky cough
● Many children with mild croup have stridor when they are upset which will improve once
they have calmed down.
● Stridor at rest is concerning for more severe disease.
● Croup is a more clinical disease
● Investigations:
● Chest and neck X-ray and lab works are not routinely recommended.unless the
diagnosis of croup is uncertain.
● If a neck x-ray is obtained, it may show evidence of subglottic narrowing, known
as the “steeple sign”
MANAGEMENT
● Appropriate management depends on the severity of the case.
● It is graded using the Westley’s score which categorizes the patients based on chest wall
retractions, stridor, cyanosis, level of consciousness and air entry
● Treatment of Mild Croup
● Mild cases without respiratory distress or stridor at rest.
● Can be treated with single dose of oral steroids (dexamethasone)
● At home, treated with supportive measures such as antipyretics and oral
hydration.

5.
● Some clinicians recommend humidity such as hot showers but studies have not
demonstrated the efficacy of this.
● Moderate to Severe Cases
● With presence of retractions or stridor at rest (Westley > 3) should be treated with
oral/intramuscular/ intravenous steroids and nebulized racemic epinephrine.
● This will work to decrease airway edema by causing vasoconstriction of
precapillary arteries leading to decrease capillary pressure and fluid resorption
● Inpatient hospitalization should be considered if improvements are not seen with
the therapies or if the child is required to have multiple doses of racemic
epinephrine.
● If there is evidence of impending respiratory failure, an ICU admission with
intubation may be required but this is seen in <1% presenting with croup.
COMPLICATIONS
● Secondary bacterial infection
● Recurrent croup
● However, most cases resolve without any complications within 1-3 days.
SUMMARY
● Croup is an upper respiratory tract infection often caused by parainfluenza virus seen in
young children in fall and early winter.
● Clinical features include:
● Barky cough
● Inspiratory stridor
● Management may include:
● Supportive measures
● Steroids
● Nebulized epinephrine
● Most cases resolving within 3 days

6.
JI Arzaga, John Joel C..
Prime 2 (Written Output under Dr. Javate)
Croup
December 15, 2022
Croup is a common acute upper respiratory illness seen in infants and children,
affecting about 5% of children in their second year of life.
Most commonly, it is seen between the ages 6 and 36 months, although it can affect
children older and younger than this as well. It has a peak incidence in the fall and early
winter, and is generally considered a mild, el-limited illness, but can be complicated by
respiratory distress and upper airway obstruction.
PATHOPHYSIOLOGY
● Croup affects the upper airway and is also referred to as laryngotracheitis, or an
inflammation of the larynx and trachea.
● Most commonly due to Parainfluenza virus which affects the nasal pharynx
before spreading distally. Other viral etiologies include
o Respiratory syncytial virus
o Adenovirus
o Enterovirus
o Human bocavirus
o Influenza
● The inflammation causes narrowing of the larynx just below the vocal cords,
called the subglottic airway.
● The cartilage in this part of the airway forms a complete ring, which restricts the
airway’s ability to expand when inflamed
● Inflammation in this area causes the distinctive barky cough and stridor, which
are hallmarks of the disease.
CLINICAL PRESENTATION
● Initial upper respiratory infection symptoms followed by
o Fever
o Hoarseness
o Barky cough
o Stridor: a high-pitched sound heard upon inspiration indicating some level
of obstruction
● Symptoms wax and wane, often worst at night
● More pronounced when child is anxious or upset
● Signs like the ones below are signs of severe airway obstruction
o Respiratory distress
o Hypoxia
o Cyanosis

7.
o Stridor at rest
DIAGNOSIS
Differential diagnosis of a child with stridor
● Croup
● Angioedema: seen in allergic reactions
● Epiglottitis
● Retropharyngeal abscess
● Foreign body aspiration
● Inhalation injury
● Anatomic airway anomalies
Evaluation for suspected croup should include thorough history and physical
examination to exclude these less common etiologies of stridor.
History
● Onset and progression of the illness
● Recent oral intake
● Presence of dysphagia or drooling
● Choking episode
● History of croup
● Underlying airway abnormalities
● Previous intubations
● Respiratory infections
A recent history of viral upper respiratory infection (URI) can be reassuring when trying
to make a diagnosis of croup
Physical Exam
● Overall assessment of the child
o Vital signs
o Comfortable
o Working hard to breathe
o Awake or sleepy
o Dehydrated
● Thorough pulmonary exam
o Abnormal sounds
▪ Stridor: Many children with mild croup will have stridor when they
are upset, which will improve once they have calmed down. Stridor
at rest is concerning for more severe disease
▪ Barky cough
Investigations
● Chest and neck x-rays and labworks are not routinely recommended, unless the
diagnosis of croup in uncertain
● Neck x-ray may show subglottic narrowing, known as a steeple sign

8.
MANAGEMENT
Appropriate management of croup depends on the severity of the case
Croup is graded using the Westley score, which categorizes patients based on chest
wall retraction, stridor, cyanosis, level of consciousness, and air entry.
Mild cases without respiratory distress or stridor at rest, Westley <2
● In clinic: Single dose of oral steroids, usually dexamethasone
● At home: supportive measures
o Antipyretics
o Oral hydration
o Humidity such as hot showers but studies have not demonstrated efficacy
Moderate to severe cases with presence of retractions or stridor at rest, Westley
>3
● Oral steroids, or IM/IV if indicated
● Nebulize racemic epinephrine which works to decrease airway edema by causing
vasoconstriction of precapillary arterioles, leading to decreased capillary
pressure and fluid resorption
● Consider inpatient hospitalization if improvement is not seen with these
therapies or if a child has required multiple doses of racemic epinephrine.
● If there is evidence of impending respiratory failure, ICU admission with
intubation may be required, but this is seen in less than 1% of patients presenting
with croup
COMPLICATIONS
● Secondary bacterial infections
● Recurrent croup
● Most cases resolve without complications within 1-3 days

9.
JI Aquino, Trisha Mae V.
Prime 2 (Written Output under Dr. Javate)
Croup
December 15, 2022
INTRODUCTION
● Croup is a common acute upper respiratory illness seen in infants and children,
affecting about 5% of children in their second year of life.
● It is seen between the ages 6 and 36 months, although it can affect children older
and younger than this as well.
● It has a peak incidence in the fall and early winter, and is generally considered a
mild, el-limited illness, but can be complicated by respiratory distress and upper
airway obstruction.
PATHOPHYSIOLOGY
● Croup affects the upper airway and is also referred to as laryngotracheitis, or an
inflammation of the larynx and trachea.
● Most commonly due to Parainfluenza virus which affects the nasal pharynx
before spreading distally. Other viral etiologies include
o Respiratory syncytial virus
o Adenovirus
o Enterovirus
o Human bocavirus
o Influenza
● The inflammation causes narrowing of the larynx just below the vocal cords,
called the subglottic airway.
● The cartilage in this part of the airway forms a complete ring, which restricts the
airway’s ability to expand when inflamed
● Inflammation in this area causes the distinctive barky cough and stridor, which
are hallmarks of the disease.
CLINICAL PRESENTATION
● Initial upper respiratory infection symptoms followed by
o Fever
o Hoarseness
o Barky cough
o Stridor: a high-pitched sound heard upon inspiration indicating some level
of obstruction
● Symptoms wax and wane, often worst at night
● More pronounced when child is anxious or upset
● Signs like the ones below are signs of severe airway obstruction
o Respiratory distress
o Hypoxia
o Cyanosis

10.
o Stridor at rest
DIAGNOSIS
● thorough history and physical examination
Differential diagnosis of a child with stridor
● Croup
● Angioedema: seen in allergic
reactions
● Epiglottitis
● Retropharyngeal abscess
● Foreign body aspiration
● Inhalation injury
● Anatomic airway anomalies
History
● Onset and progression of the
illness
● Recent oral intake
● Presence of dysphagia or
drooling
● Choking episode
● History of croup
● Underlying airway abnormalities
● Previous intubations
● Respiratory infections
● A recent history of viral upper respiratory infection (URI) can be reassuring when
trying to make a diagnosis of croup
Physical Exam
● Overall assessment of the child
o Vital signs
o Comfortable
o Working hard to breathe
o Awake or sleepy
o Dehydrated
● Thorough pulmonary exam
o Abnormal sounds
▪ Stridor: Many children with mild croup will have stridor when they
are upset, which will improve once they have calmed down. Stridor
at rest is concerning for more severe disease
▪ Barky cough
Investigations
● Chest and neck x-rays and labworks are not routinely recommended, unless the
diagnosis of croup in uncertain
● Neck x-ray: subglottic narrowing, known as a steeple sign
MANAGEMENT
● Depends on the severity of the case
● Graded using the Westley score, which categorizes patients based on chest wall
retraction, stridor, cyanosis, level of consciousness, and air entry.

11.
Mild cases without respiratory distress
or stridor at rest, Westley <2
Moderate to severe cases with
presence of retractions or stridor at
rest, Westley >3
● In clinic: Single dose of oral
steroids, usually dexamethasone
● At home: supportive measures
o Antipyretics
o Oral hydration
o Humidity such as hot
showers but studies have
not demonstrated efficacy
● Oral steroids, or IM/IV if indicated
● Nebulized racemic epinephrine →
decrease airway edema by
causing vasoconstriction of
precapillary arterioles, leading to
decreased capillary pressure and
fluid resorption
● Inpatient hospitalization:
o If improvement is not seen
with these therapies or if a
child has required multiple
doses of racemic
epinephrine.
● ICU admission:
o If there is evidence of
impending respiratory
failure, but this is seen in
less than 1% of patients
presenting with croup
COMPLICATIONS
● Secondary bacterial infections
● Recurrent croup
● Most cases resolve without complications within 1-3 days

12.
JI Asprer, Calman Jan M.
Prime 2 (Written Output under Dr. Javate)
Croup
December 15, 2022
INTRODUCTION
Croup is an acute upper respiratory illness common in infants and children, It affects
5% of children in their second year of life. It can affect both younger and older children
but most commonly, it is seen between 6-36 months. Incidence peaks during fall and
early winter. Although croup usually is a mild and self-limited illness, it can be
complicated by respiratory distress and upper airway obstruction.
PATHOPHYSIOLOGY
○ Croup affects the upper airway and is also referred to as laryngotracheitis, or an
inflammation of the larynx and trachea.
○ Most commonly due to Parainfluenza virus which affects the nasopharynx before
spreading distally.
○ The inflammation causes narrowing of the larynx just below the vocal cords,
called the subglottic airway.
○ The cartilage in this part of the airway forms a complete ring, which restricts the
airway’s ability to expand when inflamed
○ Inflammation in this area causes the distinctive barky cough and stridor, which
are hallmarks of the disease.
CLINICAL PRESENTATION
○ Initial upper respiratory infection symptoms followed by
● Fever
● Hoarseness
● Barky cough
● Stridor: a high-pitched sound heard upon inspiration indicating some level
of obstruction
○ Symptoms wax and wane, often worse at night
○ More pronounced when child is anxious or upset
○ Signs like the ones below are signs of severe airway obstruction and should be
admitted immediately
● Respiratory distress
● Hypoxia
● Cyanosis
● Stridor at rest

13.
DIAGNOSIS
Differential diagnosis of a child with stridor
○ Croup
○ Angioedema: seen in allergic reactions
○ Epiglottitis
○ Retropharyngeal abscess
○ Foreign body aspiration
○ Inhalation injury
Evaluation for suspected croup should include thorough history and physical
examination to exclude these less common etiologies of stridor.
History
A recent history of viral upper respiratory infection (URI) can be reassuring when trying
to make a diagnosis of croup
○ Onset and progression of the illness
○ Recent oral intake
○ Presence of dysphagia or drooling
○ Choking episode
○ History of croup
○ Underlying airway abnormalities
○ Previous intubations
○ Respiratory infections
Physical Exam
○ Overall assessment of the child
● Vital signs
● Comfortable
● Working hard to breathe
● Awake or sleepy
● Dehydrated
○ Thorough pulmonary exam
● Abnormal sounds
■ Stridor: Many children with mild croup will have stridor when they
are upset, which will improve once they have calmed down. Stridor
at rest is concerning for more severe disease
■ Barky cough

14.
MANAGEMENT
Appropriate management of croup depends on the severity of the case
Croup is graded using the Westley score, which categorizes patients based on chest
wall retraction, stridor, cyanosis, level of consciousness, and air entry.

15.
JI Atienza, Marielle M.
Prime 2 (Written Output under Dr. Javate)
Croup
December 15, 2022
CROUP
INTRODUCTION
➔ Croup
○ Viruses typically cause croup, the most common form of acute upper
respiratory obstruction.
○ The term laryngotracheobronchitis refers to viral infection of the glottic
and subglottic regions.
■ Some clinicians use the term laryngotracheitis for the most
common and most typical form of croup and reserve the term
laryngotracheobronchitis for the more severe form that is
considered an extension of laryngotracheitis associated with
bacterial superinfection that occurs 5-7 days into the clinical
course.
○ A common acute upper respiratory illness seen in infants and children,
affecting about 5% of children in their second year of life.
○ Most commonly, it is seen between the ages 6 and 36 months, although it
can affect children older and younger than this as well.
○ It has a peak incidence in the fall and early winter, and is generally
considered a mild, el-limited illness, but can be complicated by respiratory
distress and upper airway obstruction.
PATHOPHYSIOLOGY
➢ Croup affects the upper airway and is also referred to as laryngotracheitis, or an
inflammation of the larynx and trachea.
➢ Most commonly due to Parainfluenza virus which affects the nasopharynx before
spreading distally.
➢ Other viral etiologies include:
○ Respiratory syncytial virus
○ Adenovirus
○ Enterovirus
○ Human bocavirus
○ Influenza

16.
➢ Subglottic airway: the inflammation causes narrowing of the larynx just below the
vocal cords
➢ The cartilage in this part of the airway forms a complete ring, which restricts the
airway’s ability to expand when inflamed
➢ Inflammation in this area causes the distinctive barky cough and stridor, which
are hallmarks of the disease.
CLINICAL PRESENTATION
➔ Initial upper respiratory infection symptoms followed by:
◆ Fever
◆ Hoarseness
◆ Barky cough
◆ Coryza
◆ Inflamed pharynx
◆ Stridor: a high-pitched sound heard upon inspiration indicating some level
of obstruction
◆ Slightly increased respiratory rate
➔ Symptoms wax and wane, often worse at night
➔ More pronounced when child is anxious or upset
➔ Signs like the ones below are signs of severe airway obstruction
◆ Respiratory distress
◆ Hypoxia
◆ Cyanosis
◆ Stridor at rest
➔ Patients vary substantially in their degrees of respiratory distress.
➔ Rarely, the upper airway obstruction progresses and is accompanied by an
increasing respiratory rate; nasal flaring; suprasternal, infrasternal, and
intercostal retractions; and continuous stridor.
➔ Croup is a disease of the upper airway, and alveolar gas exchange is usually
normal. Hypoxia and low oxygen saturation are seen only when complete airway
obstruction is imminent. The child who is hypoxic, cyanotic, pale, or obtunded
needs immediate airway management.
➔ Occasionally, the pattern of severe laryngotracheobronchitis is difficult to
differentiate from epiglottitis, despite the usually more acute onset and rapid
course of the latter.
DIAGNOSIS
❖ Differential diagnosis of a child with stridor:

17.
➢ Croup
➢ Angioedema: seen in allergic reactions
➢ Epiglottitis
➢ Retropharyngeal abscess
➢ Foreign body aspiration
➢ Inhalation injury
➢ Anatomic airway anomalies
EVALUATION FOR SUSPECTED CROUP SHOULD INCLUDE THOROUGH
HISTORY AND PHYSICAL EXAMINATION TO EXCLUDE THESE LESS COMMON
ETIOLOGIES OF STRIDOR
I. History
○ Onset and progression of the illness
○ Recent oral intake
○ Presence of dysphagia or drooling
○ Choking episode
○ History of croup
○ Underlying airway abnormalities
○ Previous intubations
○ Respiratory infections
A recent history of viral upper respiratory infection (URI) can be reassuring when trying
to make a diagnosis of croup
II. Physical Exam
○ Overall assessment of the child
■ Vital signs
■ Comfortable
■ Working hard to breathe
■ Awake or sleepy
■ Dehydrated
○ Thorough pulmonary exam
■ Abnormal sounds
■ Stridor: Many children with mild croup will have stridor when they
are upset, which will improve once they have calmed down. Stridor
at rest is concerning for more severe disease
■ Barky cough

18.
III. Investigations
○ Croup is a clinical diagnosis and does not require a radiograph of the
neck.
○ Radiographs of the neck can show the typical subglottic narrowing, or
steeple sign, of croup on the posteroanterior view.
○ However, the steeple sign may be absent in patients with croup, may be
present in patients without croup as a normal variant, and may rarely be
present in patients with epiglottitis.
○ The radiographs do not correlate well with disease severity. Radiographs
should be considered only after airway stabilization in children who have
an atypical presentation or clinical course.
○ Radiographs may be helpful in distinguishing between severe
laryngotracheobronchitis and epiglottitis, but airway management should
always take priority.
○ Chest and neck x-rays and labworks are not routinely recommended,
unless the diagnosis of croup in uncertain
○ Neck x-ray may show subglottic narrowing, known as a steeple sign
MANAGEMENT
● Appropriate management of croup depends on the severity of the case
● Croup is graded using the Westley score, which categorizes patients based on
chest wall retraction, stridor, cyanosis, level of consciousness, and air entry.
I. Mild cases without respiratory distress or stridor at rest, Westley <2
○ In clinic: Single dose of oral steroids, usually dexamethasone
○ At home: supportive measures such as:
■ Antipyretics
■ Oral hydration
■ Humidity such as hot showers but studies have not demonstrated
efficacy
II. Moderate to severe cases with presence of retractions or stridor at rest,
Westley >3
○ Oral steroids, or IM/IV if indicated
○ Nebulize with racemic epinephrine which works to decrease airway edema
by causing vasoconstriction of precapillary arterioles, leading to decreased
capillary pressure and fluid resorption

19.
○ Consider inpatient hospitalization if improvement is not seen with these
therapies or if a child has required multiple doses of racemic epinephrine.
○ If there is evidence of impending respiratory failure, ICU admission with
intubation may be required, but this is seen in less than 1% of patients
presenting with croup
COMPLICATIONS
➢ Secondary bacterial infections
➢ Recurrent croup
➢ Most cases resolve without complications within 1-3 days

20.
JI Bartolome, Nimrod Ramil II C
Prime 2 (Written Output Dr.Javate)
Croup
December 14, 2022
Croup
A common acute upper respiratory illness that affects 5% of children in their second
year of life. Seen mostly between the ages of 6 months to 3 years of life. But it
can also affect children younger or older than this as well. It has a peak incidence in fall
and early winter and is considered a mild and self-limited illness. It can be complicated
by respiratory distress or upper airway obstruction.
Etiology:
Most common agent: parainfluenza virus, which affects the nasal pharynx before spreading
distally.
Other viral etiologies:
● respiratory syncytial virus
● adenovirus
● enterovirus
● human bocavirus
● nfluenza.
Pathophysiology:
The inflammation causes narrowing of the larynx just below the vocal cords, called the
subglottic airway. The cartilage in this part of the airway forms a complete ring, which
restricts the airway's ability to expand when inflamed. Inflammation in this area causes
the distinctive barky cough and stridor, which are hallmarks of the disease.
Clinical Presentation
● Initial Presentation: Fever, Hoarseness, Barky cough, Stridor
● Wax and Wane: worsen at night
● Severe airway obstruction: respiratory distress, hypoxia, cyanosis, stridor at rest
Diagnosis
The differential diagnosis for a child with stridor includes:
● Angioedema due to allergic reactions
● Retropharyngeal abscess
● Foreign body aspiration
● Epiglottitis

21.
Evaluation for suspected croup should include a thorough history and physical exam to
exclude the less common etiologies of stridor
MANAGEMENT
● Management depends on the severity of the case
● Graded using Westley score:
○ chest wall retraction
○ Stridor
○ Cyanosis
○ Level of consciousness
○ Air entry
● Mild cases (without respiratory distress or stridor at rest): Single dose of oral steroids
(Dexamathasone), Supportive measures (antipyeretics & oral hydration)
● Moderate to severe cases (with presence of retractions or stridor at rest): Oral,
intramuscular, or intravenous steroids, and nebulized racemic epinephrine.
● Inpatient hospitalization should be considered if improvement is not seen with these
therapies, or if a child has required multiple doses of racemic epinephrine.
● Evidence of impending respiratory failure: ICU admission with intubation may be
required.
Complications
● Secondary bacterial infections
● Recurrent croup
● Most cases resolve without complications within 1-3 days

22.
JI Gaceta, Chelsea Denise T.
Prime 2 (Written Output under Dr. Javate)
Croup
December 12, 2022
Croup - the term croup refers to a heterogeneous group of mainly acute and infectious
processes that are characterized by a bark-like or brassy cough and may be associated with
hoarseness, inspiratory stridor, and respiratory distress. The cough and other signs and
symptoms of croup are the result of swelling around the voice box (larynx), windpipe (trachea)
and bronchial tubes (bronchi). When a cough forces air through this narrowed passageway, the
swollen vocal cords produce a noise similar to a seal barking. Likewise, taking a breath often
produces a high-pitched whistling sound (stridor).

23.
Etiology - The most common pathogens are Parainfluenza viruses, especially type 1. Less
common causes are respiratory syncytial virus (RSV) and adenovirus followed by influenza
viruses A and B, enterovirus, rhinovirus, measles virus, and Mycoplasma pneumoniae. Croup
caused by influenza may be particularly severe and may occur in a broader age range of
children. Seasonal outbreaks are common. Cases caused by parainfluenza viruses tend to
occur in the fall; those caused by RSV and influenza viruses tend to occur in the winter and
spring. Spread is usually through the air or by contact with infected secretions.
Pathophysiology - The infection causes inflammation of the larynx, trachea, bronchi,
bronchioles, and lung parenchyma. Obstruction caused by swelling and inflammatory exudates
develops and becomes pronounced in the subglottic region. Obstruction increases the work of
breathing; rarely, tiring results in hypercapnia. Atelectasis may occur concurrently if the
bronchioles become obstructed.
Signs and symptoms - Croup is usually preceded by upper respiratory infection symptoms.
● A barking, often spasmodic, cough and hoarseness then occur, commonly at night;
inspiratory stridor may be present as well
● The child may awaken at night with respiratory distress, tachypnea, and retractions
● In severe cases, cyanosis with increasingly shallow respirations may develop as the
child tires
● The obvious respiratory distress and harsh inspiratory stridor are the most dramatic
physical findings
● Auscultation reveals prolonged inspiration and stridor
● Crackles also may be present, indicating lower airway involvement
● Breath sounds may be diminished with atelectasis
● Fever is present in about half of children
● The child’s condition may seem to improve in the morning but worsen again at night
● Recurrent episodes are often called spasmodic croup
○ Allergy or airway reactivity may play a role in spasmodic croup, but the clinical
manifestations cannot be differentiated from those of viral croup. Also, spasmodic
croup usually is initiated by a viral infection; however, fever is typically absent.
Diagnosis
● Clinical presentation (eg, barking cough, inspiratory stridor)
● Anteroposterior (AP) and lateral neck x-rays as needed
● Diagnosis of croup is usually obvious by the barking nature of the cough. Similar
inspiratory stridor can result from epiglottitis, bacterial tracheitis, airway foreign body,
diphtheria, and retropharyngeal abscess. Epiglottitis, retropharyngeal abscess, and
bacterial tracheitis have a more rapid onset and cause a more toxic appearance,
odynophagia, and fewer upper respiratory tract symptoms. A foreign body may cause
respiratory distress and a typical croupy cough, but fever and a preceding upper

24.
respiratory infection are absent. Diphtheria is excluded by a history of adequate
immunization and is confirmed by identification of the organism in viral cultures of
scrapings from a typical grayish diphtheritic membrane.
● If the diagnosis is unclear, patients should have AP and lateral x-rays of the neck and
chest; subepiglottic narrowing (steeple sign) seen on AP neck x-ray supports the
diagnosis. Seriously ill patients, in whom epiglottitis is a concern, should be examined in
the operating room by appropriate specialists able to establish an airway. Patients
should have pulse oximetry, and those with respiratory distress should have arterial
blood gas measurement.
Treatment
● For outpatients, cool humidified air and possibly a single dose of a long-acting
corticosteroid
● For inpatients, humidified oxygen, racemic epinephrine, and corticosteroids
● The illness usually lasts 3 to 4 days and resolves spontaneously. A mildly ill child may be
cared for at home with hydration and antipyretics. Keeping the child comfortable is
important because fatigue and crying can aggravate the condition. Humidification
devices (eg, cold-steam vaporizers or humidifiers) may ameliorate upper airway drying
and are frequently used at home by families but have not been shown to alter the course
of the illness. The vast majority of children with croup recover completely.
● Hospitalization is typically indicated for
○ Increasing or persistent respiratory distress
○ Tachycardia
○ Fatigue
○ Cyanosis or hypoxemia
○ Dehydration
● Pulse oximetry is helpful for assessing and monitoring severe cases. If oxygen saturation
falls below 92%, humidified oxygen should be given and arterial blood gases should be
measured to assess CO2 retention. A 30 to 40% inspired oxygen concentration is
usually adequate. CO2 retention (PaCO2 > 45 mm Hg) generally indicates fatigue and
the need for endotracheal intubation, as does inability to maintain oxygenation.
● Nebulized racemic epinephrine 5 to 10 mg in 3 mL of saline every 2 hours offers
symptomatic relief and relieves fatigue. However, the effects are transient; the course of
the illness, the underlying viral infection, and the PaO2 are not altered by its use.
Tachycardia and other adverse effects may occur. This drug is recommended mainly for
patients with moderate to severe croup.
● High-dose dexamethasone 0.6 mg/kg IM or orally once (maximum dose 10 mg) may
benefit children early in the first 24 hours of the disease. It can help prevent
hospitalization or help the child who is hospitalized with moderate to severe croup;
hospitalized children who do not respond quickly may require several doses. The viruses
that most commonly cause croup do not usually predispose to secondary bacterial
infection, and antibiotics are rarely indicated.

25.
JI Gaite, Summer Marionne F.
Prime 2 (Written Output under Dr. Javate)
Croup
December 15, 2022
Croup
Croup
● Common acute upper respiratory illness seen in infants and children
● Affects about 5% of children in their 2nd year of life
● Seen between the ages of 6 and 36 months, but can also affect older and younger
children
● Peak incidence in the fall and early winter and considered a mild, self-limited illness
complicated by respiratory distress and upper airway obstruction
● Most commonly due to parainfluenza virus, which affects the nasal pharynx before
spreading distally
◆ Other viral etiologies: respiratory syncytial virus, adenovirus, enterovirus, human
bocavirus, influenza
● Hallmarks of the disease:
○ Barky cough
○ Stridor
○ The inflammation causes narrowing of the larynx just below the vocal (subglottic
airway). The cartilage in this part of the airway forms a complete ring. It then
restricts the airway's ability to expand when inflamed.
CLINICAL PRESENTATION
◆ Presents with initial upper respiratory infection symptoms:
● Fever
● Hoarseness
● Barky cough
● Stridor: high-pitched sound heard upon inspiration; indicates upper airway
obstruction
◆ Symptoms characteristically can wax and wane
● Worst at night
● Can become more pronounced when child is anxious or upset
◆ Signs of severe airway obstruction:
● Respiratory distress
● Hypoxia
● Cyanosis
● Stridor at rest
DIFFERENTIAL DIAGNOSES

26.
◆ Angioedema
◆ Epiglottitis
◆ Retropharyngeal abscess
◆ Foreign body aspiration
◆ Inhalation injury
◆ Anatomic anomalies of the airway
EVALUATION & DIAGNOSTICS
◆ Clinical presentation (eg, barking cough, inspiratory stridor)
● Important in the diagnosis
◆ Anteroposterior (AP) and lateral neck x-rays as needed
● Request for AP and lateral x-rays if diagnosis is unclear
◆ Pulse oximeter
MANAGEMENT
◆ For outpatients, cool humidified air and possibly a single dose of a long-acting
corticosteroid
◆ For inpatients, humidified oxygen, racemic epinephrine, and corticosteroids
(+) Evidence of impending respiratory failure: seen in less than 1% of patients
presenting with croup
● ICU admission with intubation may be required
COMPLICATIONS
◆ Most cases resolve without complications within one to three days. Some of the
complications include secondary bacterial infections and recurrent croup.
JI Gamilde, Lourdes Gayle
Prime 2 (Written Output under)
Topic CROUP
Date DEC 12 2022
INTRODUCTION
Croup is a common acute upper respiratory illness seen in infants and children, affecting about
5% of children in their second year of life. Most commonly, it is seen between the ages 6 and 36
months, although it can affect children older and younger than this as well. It has a peak
incidence in the fall and early winter, and is generally considered a mild, el-limited illness, but
can be complicated by respiratory distress and upper airway obstruction.
PATHOPHYSIOLOGY
● Croup affects the upper airway and is also referred to as laryngotracheitis, or an
inflammation of the larynx and trachea.
● Most commonly due to Parainfluenza virus which affects the nasopharynx before
spreading distally. Other viral etiologies include
o Respiratory syncytial virus
o Adenovirus

27.
o Enterovirus
o Human bocavirus
o Influenza
● The inflammation causes narrowing of the larynx just below the vocal cords, called the
subglottic airway.
● The cartilage in this part of the airway forms a complete ring, which restricts the airway’s
ability to expand when inflamed
● Inflammation in this area causes the distinctive barky cough and stridor, which are
hallmarks of the disease.
CLINICAL PRESENTATION
● Initial upper respiratory infection symptoms followed by
o Fever
o Hoarseness
o Barky cough
o Stridor: a high-pitched sound heard upon inspiration indicating some level of
obstruction
● Symptoms wax and wane, often worst at night
● More pronounced when child is anxious or upset
● Signs like the ones below are signs of severe airway obstruction
o Respiratory distress
o Hypoxia
o Cyanosis
o Stridor at rest
DIAGNOSIS
Differential diagnosis of a child with stridor
● Croup
● Angioedema: seen in allergic reactions
● Epiglottitis
● Retropharyngeal abscess
● Foreign body aspiration
● Inhalation injury
● Anatomic airway anomalies
Evaluation for suspected croup should include thorough history and physical examination to
exclude these less common etiologies of stridor.
History
● Onset and progression of the illness
● Recent oral intake
● Presence of dysphagia or drooling
● Choking episode
● History of croup
● Underlying airway abnormalities
● Previous intubations
● Respiratory infections

28.
A recent history of viral upper respiratory infection (URI) can be reassuring when trying to make
a diagnosis of croup
Physical Exam
● Overall assessment of the child
o Vital signs
o Comfortable
o Working hard to breathe
o Awake or sleepy
o Dehydrated
● Thorough pulmonary exam
o Abnormal sounds
▪ Stridor: Many children with mild croup will have stridor when they are
upset, which will improve once they have calmed down. Stridor at rest is
concerning for more severe disease
▪ Barky cough
Investigations
● Chest and neck x-rays and labworks are not routinely recommended, unless the
diagnosis of croup in uncertain
● Neck x-ray may show subglottic narrowing, known as a steeple sign
MANAGEMENT
Appropriate management of croup depends on the severity of the case
Croup is graded using the Westley score, which categorizes patients based on chest wall
retraction, stridor, cyanosis, level of consciousness, and air entry.
Mild cases without respiratory distress or stridor at rest, Westley <2
● In clinic: Single dose of oral steroids, usually dexamethasone
● At home: supportive measures
o Antipyretics
o Oral hydration
o Humidity such as hot showers but studies have not demonstrated efficacy
Moderate to severe cases with presence of retractions or stridor at rest, Westley >3
● Oral steroids, or IM/IV if indicated
● Nebulize racemic epinephrine which works to decrease airway edema by causing
vasoconstriction of precapillary arterioles, leading to decreased capillary pressure and
fluid resorption
● Consider inpatient hospitalization if improvement is not seen with these therapies or if a
child has required multiple doses of racemic epinephrine.
● If there is evidence of impending respiratory failure, ICU admission with intubation may
be required, but this is seen in less than 1% of patients presenting with croup
COMPLICATIONS
● Secondary bacterial infections
● Recurrent croup
● Most cases resolve without complications within 1-3 days

29.
JI Garcia, Jan Rossana S.
Prime 2 (Written Output under)
Topic: Croup
Date: Dec 12, 2022
★ WHAT IS CROUP?
Croup is a common acute upper respiratory illness seen in infants and children, affecting
about 5% of children in their second year of life. Most commonly, it is seen between the ages 6
and 36 months, although it can affect children older and younger than this as well. It has a peak
incidence in the fall and early winter, and is generally considered a mild, el-limited illness, but
can be complicated by respiratory distress and upper airway obstruction.
PATHOPHYSIOLOGY
➔ Croup affects the upper airway and is also referred to as laryngotracheitis, or an
inflammation of the larynx and trachea.
➔ Most commonly due to Parainfluenza virus which affects the nasal pharynx before
spreading distally. Other viral etiologies include
◆ Respiratory syncytial virus
◆ Adenovirus
◆ Enterovirus
◆ Human bocavirus
◆ Influenza
➔ The inflammation causes narrowing of the larynx just below the vocal cords, called the
subglottic airway.
➔ The cartilage in this part of the airway forms a complete ring, which restricts the airway’s
ability to expand when inflamed
➔ Inflammation in this area causes the distinctive barky cough and stridor, which are
hallmarks of the disease.
CLINICAL PRESENTATION
★ Initial upper respiratory infection symptoms followed by
○ Fever
○ Hoarseness
○ Barky cough
○ Stridor: a high-pitched sound heard upon inspiration indicating some level of
obstruction
★ Symptoms wax and wane, often worst at night
★ More pronounced when child is anxious or upset
★ Signs like the ones below are signs of severe airway obstruction
○ Respiratory distress
○ Hypoxia
○ Cyanosis
○ Stridor at rest

30.
DIAGNOSIS
Differential diagnosis of a child with stridor
➔ Croup
➔ Angioedema: seen in allergic reactions
➔ Epiglottitis
➔ Retropharyngeal abscess
➔ Foreign body aspiration
➔ Inhalation injury
➔ Anatomic airway anomalies
Evaluation for suspected croup should include thorough history and physical examination to
exclude these less common etiologies of stridor.
★ History
○ Onset and progression of the illness
○ Recent oral intake
○ Presence of dysphagia or drooling
○ Choking episode
○ History of croup
○ Underlying airway abnormalities
○ Previous intubations
○ Respiratory infections
○ A recent history of viral upper respiratory infection (URI) can be reassuring when
trying to make a diagnosis of croup
★ Physical Exam
○ Overall assessment of the child
■ Vital signs
■ Comfortable
■ Working hard to breathe
■ Awake or sleepy
■ Dehydrated
○ Thorough pulmonary exam
■ Abnormal sounds
● Stridor: Many children with mild croup will have stridor when they
are upset, which will improve once they have calmed down.
Stridor at rest is concerning for more severe disease
● Barky cough
★ Diagnosis
○ Chest and neck x-rays and labworks are not routinely recommended, unless the
diagnosis of croup in uncertain
○ Neck x-ray may show subglottic narrowing, known as a steeple sign
HOW DO WE MANAGE PATIENTS WITH CROUP?

31.
Appropriate management of croup depends on the severity of the case. Croup is graded using
the Westley score, which categorizes patients based on chest wall retraction, stridor, cyanosis,
level of consciousness, and air entry.
Mild cases without respiratory distress or stridor at rest, Westley <2
● In clinic: Single dose of oral steroids, usually dexamethasone
● At home: supportive measures
o Antipyretics
o Oral hydration
o Humidity such as hot showers but studies have not demonstrated efficacy
Moderate to severe cases with presence of retractions or stridor at rest, Westley >3
● Oral steroids, or IM/IV if indicated
● Nebulize racemic epinephrine which works to decrease airway edema by causing
vasoconstriction of precapillary arterioles, leading to decreased capillary pressure and
fluid resorption
● Consider inpatient hospitalization if improvement is not seen with these therapies or if a
child has required multiple doses of racemic epinephrine.
● If there is evidence of impending respiratory failure, ICU admission with intubation may
be required, but this is seen in less than 1% of patients presenting with croup
COMPLICATIONS
● Secondary bacterial infections
● Recurrent croup
● Most cases resolve without complications within 1-3 days

32.
JI Garcia, Marc Wilhelm M
Prime 2 (Written Output under Dr. Javate)
Topic: Croup
December 15, 2022
Croup is a common acute upper respiratory illness seen in infants and children affecting about
5% of children in their second year of life. Most commonly, it is seen between the ages of 6 and
36 months, although it can affect children older and younger than this as well. It has a peak
incidence in the fall and early winter and is generally considered a mild, self-limited illness but
can be complicated by respiratory distress an upper airway obstruction.
Etiology
● most commonly viral, with some cases caused by bacteria.
- Parainfluenza virus most commonly causes viral croup or acute laryngotracheitis,
primarily types 1 and 2.
- Other causes include influenza A and B, measles, adenovirus, and respiratory
syncytial virus (RSV).
● The common bacterial causes are Staphylococcus aureus, Streptococcus pneumoniae,
Hemophilus influenzae, and Moraxella catarrhalis.
Pathopysiology
● It affects the upper airway and is also referred to as laryngotracheitis or an inflammation
of the trachea and larynx.
● It is most commonly due to parainfluenza virus, which affects the nasopharynx before
spreading distally.
● Other viral etiologies include:
● Respiratory syncytial virus
● Adenovirus
● Enterovirus
● Human bocavirus
● Influenza virus
● Inflammation causes narrowing of the larynx just below the vocal chords, called the
subglottic airway.
● The cartilage in this airway forms a complete ring which restricts the airway’s ability to
expand when inflamed.
● Inflammation in this are causes distinctive barky cough and stridor which are hallmarks
of the disease
Clinical Presentation
● Hallmarks of the disease:
○ Barky cough
○ Stridor

33.
○ The inflammation causes narrowing of the larynx just below the vocal (subglottic
airway). The cartilage in this part of the airway forms a complete ring. It then
restricts the airway's ability to expand when inflamed.
● Often but not always presents with initial upper respiratory infection symptoms. These
initial symptoms are followed by fever, hoarseness, a barky cough and stridor which is a
high-pitch sound heard upon inspiration indicating some levels of upper airway
obstruction.
● Symptomes characteristically can wax and wane often worst at night and can become
more pronounced when a child is anxious and upset.
● If there are signs of respiratory distress, hypoxia cyanosis, or stridor at rest, this should
prompt concern for severe airway obstruction.
Diagnosis
● Differential diagnosis for a child with stridor aside from croup includes:
● Angioedema - as seen in allergic reactions
● Epiglottitis
● Retropharyngeal abscess
● Foreign body aspiration
● Inhalational injury
● Anatomic airway anomalies
● Evaluation of the suspected croup should include:
● Thorough history and physical exam to exclude less common etiologies
● When asking about the history, make sure to ask about the:
● Onset and progression of the illness
● Recent oral intake
● Presence of dyphasia or drooling
● A choking episode
● History of croup
● Underlying airway abnormalities
● Previous intubations
● Respiratory conditions
● A recent history of a viral URTI can be reassuring in the diagnosis of croup
● When performing a PE, the first step should be an overall assessment of the child:
● Are the vital signs normal?
● Does the child appear comfortable?
● Are they working hard to breathe?
● Is the child awake or sleepy?
● Do they appear to be dehydrated?
● A thorough pulmonary examination is also necessary, listening for any abnormal sounds
on inspiration and expiration.in particular, listening for:
● Stridor
● For barky cough
● Many children with mild croup have stridor when they are upset which will improve once
they have calmed down.
● Stridor at rest is concerning for more severe disease.
● Croup is a more clinical disease
● Investigations:

34.
● Chest and neck X-ray and lab works are not routinely recommended.unless the
diagnosis of croup is uncertain.
● If a neck x-ray is obtained, it may show evidence of subglottic narrowing, known
as the “steeple sign”
Management
● Appropriate management depends on the severity of the case.
● It is graded using the Westley’s score which categorizes the patients based on chest wall
retractions, stridor, cyanosis, level of consciousness and air entry
● Treatment of Mild Croup
● Mild cases without respiratory distress or stridor at rest.
● Can be treated with single dose of oral steroids (dexamethasone)
● At home, treated with supportive measures such as antipyretics and oral
hydration.
● Some clinicians recommend humidity such as hot showers but studies have not
demonstrated the efficacy of this.
● Moderate to Severe Cases
● With presence of retractions or stridor at rest (Westley > 3) should be treated with
oral/intramuscular/ intravenous steroids and nebulized racemic epinephrine.
● This will work to decrease airway edema by causing vasoconstriction of
precapillary arteries leading to decrease capillary pressure and fluid resorption
● Inpatient hospitalization should be considered if improvements are not seen with
the therapies or if the child is required to have multiple doses of racemic
epinephrine.
● If there is evidence of impending respiratory failure, an ICU admission with
intubation may be required but this is seen in <1% presenting with croup.
Complication
● Secondary bacterial infection
● Recurrent croup
● However, most cases resolve without any complications within 1-3 days.
Summary
● Croup is an upper respiratory tract infection often caused by parainfluenza virus seen in
young children in fall and early winter.
● Clinical features include:
● Barky cough
● Inspiratory stridor
● Management may include:
● Supportive measures
● Steroids
● Nebulized epinephrine
● Most cases resolving within 3 days

35.
JI Garong, Maria Ana Therese D.R.
Prime 2 (Written Output under Dr. Javate)
Croup
December 15, 2022
Croup is a common respiratory illness of the trachea, larynx, and bronchi that can lead
to inspiratory stridor and barking cough. It is a self-limited disease that is seen in
children under the age of 5.
Etiology
- most commonly viral, with some cases caused by bacteria. Parainfluenza virus
most commonly causes viral croup or acute laryngotracheitis, primarily types 1
and 2. Other causes include influenza A and B, measles, adenovirus, and
respiratory syncytial virus (RSV). The common bacterial causes are
Staphylococcus aureus, Streptococcus pneumoniae, Hemophilus influenzae, and
Moraxella catarrhalis.
Pathophysiology
- Croup causes swelling of the larynx, trachea, and large bronchi due to infiltration
of white blood cells. Swelling results in partial airway obstruction which, when
significant, results in dramatically increased work of breathing, and the
characteristic turbulent, noisy airflow known as stridor.
Typical Presentation
- Croup is characterized by a "seal-like barking" cough, stridor, hoarseness, and
difficulty breathing, which typically becomes worse at night. Agitation worsens the
stridor, and it can be heard at rest.
- Other symptoms include fever and dyspnea, but the absence of fever should not
reduce suspicion for croup.
- Respiratory rate and heart rate may also be increased with a normal respiratory
rate being between 20 to 30 breaths per minute. Visual inspection of nasal
flaring, retraction, and rarely cyanosis increases suspicion for croup
- One to 2 days of upper respiratory infection (URI) followed by barking cough and
stridor
- Low-grade fever
- No drooling or dysphagia
- Duration is 3 to 7 days with the most severe symptoms on days 3 or 4
Diagnosis

36.
- Croup is typically a clinical diagnosis based on signs and symptoms.
- A frontal x-ray of the neck may be considered but is not routinely performed. It
may show a characteristic narrowing of the trachea in 50% of cases, known as
the steeple sign, because of the subglottic stenosis, which resembles a steeple.
- Rule out other obstructive conditions, such as epiglottitis, an airway foreign body,
subglottic stenosis, angioedema, retropharyngeal abscess, and bacterial
tracheitis.
Management
- Corticosteroids, such as dexamethasone, results in faster resolution of
symptoms, decreased return to medical care, and decreased length of stay.
- For moderate to severe cases, nebulized racemic epinephrine has been found to
improve symptom scores at 30 minutes, but the benefits may wear off after 2
hours.
- Deliver oxygen by "blow-by" administration as it causes less agitation than the
use of a mask or nasal cannula.
- Immunization against influenza and diphtheria may reduce the incidence of
croup.
- Admit the patient if: there are persistent respiratory signs and symptoms after two
or more treatments with epinephrine, worsening symptoms, also consider
admission or longer observation periods and for repeat visits.

37.
JI Gille, Genree Ann B.
Prime 2 (Written Output under Dr. Javate)
Croup
December 15, 2022
Croup
● the term croup refers to a heterogeneous group of mainly acute and infectious
processes that are characterized by a bark-like or brassy cough and may be
associated with hoarseness, inspiratory stridor, and respiratory distress.
● The cough and other signs and symptoms of croup are the result of swelling
around the voice box (larynx), windpipe (trachea) and bronchial tubes (bronchi).
When a cough forces air through this narrowed passageway, the swollen vocal
cords produce a noise similar to a seal barking. Likewise, taking a breath often
produces a high-pitched whistling sound (stridor).
Etiology
● The most common pathogens are Parainfluenza viruses, especially type 1. Less
common causes are respiratory syncytial virus (RSV) and adenovirus followed by
influenza viruses A and B, enterovirus, rhinovirus, measles virus, and
Mycoplasma pneumoniae. Croup caused by influenza may be particularly severe
and may occur in a broader age range of children. Seasonal outbreaks are
common. Cases caused by parainfluenza viruses tend to occur in the fall; those
caused by RSV and influenza viruses tend to occur in the winter and spring.
Spread is usually through the air or by contact with infected secretions.
Pathophysiology
● The infection causes inflammation of the larynx, trachea, bronchi, bronchioles,
and lung parenchyma. Obstruction caused by swelling and inflammatory
exudates develops and becomes pronounced in the subglottic region.
Obstruction increases the work of breathing; rarely, tiring results in hypercapnia.
Atelectasis may occur concurrently if the bronchioles become obstructed.
Signs and symptoms - Croup is usually preceded by upper respiratory infection
symptoms.
● A barking, often spasmodic, cough and hoarseness then occur, commonly at
night; inspiratory stridor may be present as well
● The child may awaken at night with respiratory distress, tachypnea, and
retractions

38.
● In severe cases, cyanosis with increasingly shallow respirations may develop as
the child tires
● The obvious respiratory distress and harsh inspiratory stridor are the most
dramatic physical findings
● Auscultation reveals prolonged inspiration and stridor
● Crackles also may be present, indicating lower airway involvement
● Breath sounds may be diminished with atelectasis
● Fever is present in about half of children
● The child’s condition may seem to improve in the morning but worsen again at
night
● Recurrent episodes are often called spasmodic croup
○ Allergy or airway reactivity may play a role in spasmodic croup, but the
clinical manifestations cannot be differentiated from those of viral croup.
Also, spasmodic croup usually is initiated by a viral infection; however,
fever is typically absent.
Diagnosis
● Clinical presentation (eg, barking cough, inspiratory stridor)
● Anteroposterior (AP) and lateral neck x-rays as needed
● Diagnosis of croup is usually obvious by the barking nature of the cough. Similar
inspiratory stridor can result from epiglottitis, bacterial tracheitis, airway foreign
body, diphtheria, and retropharyngeal abscess. Epiglottitis, retropharyngeal
abscess, and bacterial tracheitis have a more rapid onset and cause a more toxic
appearance, odynophagia, and fewer upper respiratory tract symptoms. A foreign
body may cause respiratory distress and a typical croupy cough, but fever and a
preceding upper respiratory infection are absent. Diphtheria is excluded by a
history of adequate immunization and is confirmed by identification of the
organism in viral cultures of scrapings from a typical grayish diphtheritic
membrane.
● If the diagnosis is unclear, patients should have AP and lateral x-rays of the neck
and chest; subepiglottic narrowing (steeple sign) seen on AP neck x-ray supports
the diagnosis. Seriously ill patients, in whom epiglottitis is a concern, should be
examined in the operating room by appropriate specialists able to establish an
airway. Patients should have pulse oximetry, and those with respiratory distress
should have arterial blood gas measurement.
Treatment
● For outpatients, cool humidified air and possibly a single dose of a long-acting

39.
corticosteroid
● For inpatients, humidified oxygen, racemic epinephrine, and corticosteroids
● The illness usually lasts 3 to 4 days and resolves spontaneously. A mildly ill child
may be cared for at home with hydration and antipyretics. Keeping the child
comfortable is important because fatigue and crying can aggravate the condition.
Humidification devices (eg, cold-steam vaporizers or humidifiers) may ameliorate
upper airway drying and are frequently used at home by families but have not
been shown to alter the course of the illness. The vast majority of children with
croup recover completely.
● Hospitalization is typically indicated for
○ Increasing or persistent respiratory distress
○ Tachycardia
○ Fatigue
○ Cyanosis or hypoxemia
○ Dehydration
● Pulse oximetry is helpful for assessing and monitoring severe cases. If oxygen
saturation falls below 92%, humidified oxygen should be given and arterial blood
gases should be measured to assess CO2 retention. A 30 to 40% inspired
oxygen concentration is usually adequate. CO2 retention (PaCO2 > 45 mm Hg)
generally indicates fatigue and the need for endotracheal intubation, as does
inability to maintain oxygenation.
● Nebulized racemic epinephrine 5 to 10 mg in 3 mL of saline every 2 hours offers
symptomatic relief and relieves fatigue. However, the effects are transient; the
course of the illness, the underlying viral infection, and the PaO2 are not altered
by its use. Tachycardia and other adverse effects may occur. This drug is
recommended mainly for patients with moderate to severe croup.
● High-dose dexamethasone 0.6 mg/kg IM or orally once (maximum dose 10 mg)
may benefit children early in the first 24 hours of the disease. It can help prevent
hospitalization or help the child who is hospitalized with moderate to severe
croup; hospitalized children who do not respond quickly may require several
doses. The viruses that most commonly cause croup do not usually predispose
to secondary bacterial infection, and antibiotics are rarely indicated.

40.
JI Gonzales, Jan Chloe C.
Prime 2 (Written Output under Dr. Javate)
Croup
December 15, 2022
Croup
Croup is a disease that causes swelling in the airways and problems breathing. Children with
croup often have a high-pitched “creaking” or whistling sound when breathing in. This is called
stridor.
Etiology
Croup is most commonly caused by a virus. It is sometimes, but rarely, caused by bacteria,
allergies, or reflux from the stomach. Viruses that are known to cause croup are:
● Parainfluenza virus
● Respiratory syncytial virus (RSV)
● Influenza virus
● Adenovirus
● Enteroviruses
Croup is spread through direct contact with a person, or fluids from another person who has the
disease. The infection starts in the nose and throat and moves into the lungs. Swelling affects
the area around the voice box (larynx) and into the windpipe (trachea).
Pathophysiology
Croup causes swelling of the larynx, trachea, and large bronchi due to infiltration of white blood
cells. Swelling results in partial airway obstruction which, when significant, results in dramatically
increased work of breathing, and the characteristic turbulent, noisy airflow known as stridor.
Clinical Presentation
Symptoms of croup are not always the same. As the disease moves from the nose to the lungs,
the symptoms can change. Common symptoms of croup are:
● A runny nose, a stuffy nose, and slight cough
● A cough that turns into a "seal's bark"
● Laryngitis (losing his or her voice)
● Fever
● Stridor
Symptoms are often worse at night and wake the child from sleep. Symptoms also seem to
improve in the morning but worsen as the day goes on. Most children improve in three to seven
days. The symptoms of croup can be mistaken for other conditions and medical problems.
Always see your child's provider for a diagnosis.
Diagnosis
Your child’s provider will do a complete medical history and physical examination. Other tests
may be needed, including:
● Neck and chest X-rays
● Blood tests
● Pulse oximetry
●

41.
Management
In severe cases of croup, or if your child is not breathing well, your child may need to go to the
hospital. This is sometimes hard to tell because the disease changes. Your child may seem
better at one moment, and then get worse the next. Your child's provider may also order the
following medications to help with the symptoms of croup:
● Inhaled medications
● Injected medications
● Oral medications (taken by mouth)
Home treatments may include:
● Using a cool mist humidifier
● Taking the child outside into cool, moist, night air
● Drinking lots of fluids
● Treating a fever with acetaminophen or ibuprofen, as instructed by your child's provider
(Do NOT give a child aspirin as it can cause a condition called Reye syndrome)
● Keeping your child as quiet and calm as possible to make it easier to breathe

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JI Gabriel, Mark Joseph D.
Prime 2 (Written Output under Dr. Javate)
Croup
December 15,2022
● Croup is a common acute upper respiratory illness seen in infants and children,
affecting about 5% of children in their second year of life.
● Croup affects the upper airway and is also referred to as laryngotracheitis, or an
inflammation of the larynx and trachea.
● Most commonly due to Parainfluenza virus which affects the nasopharynx before
spreading distally.
● Inflammation in this area causes the distinctive barky cough and stridor, which
are hallmarks of the disease.
● Symptoms wax and wane, often worst at night
● More pronounced when child is anxious or upset
● Signs like the ones below are signs of severe airway obstruction
o Respiratory distress
o Hypoxia
o Cyanosis
o Stridor at rest
● Differentials: angioedema, epiglottitis, retropharyngeal abscess, foreign body
aspiration, inhalational injury, anatomic abnormalities
Evaluation for suspected croup should include thorough history and physical
examination to exclude these less common etiologies of stridor.
History
● Onset and progression of the illness
● Recent oral intake
● Presence of dysphagia or drooling
● Choking episode
● History of croup
● Underlying airway abnormalities
● Previous intubations
● Respiratory infections
A recent history of viral upper respiratory infection (URI) can be reassuring when trying
to make a diagnosis of croup
Physical Exam
● Overall assessment of the child

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● Thorough pulmonary exam
a. Abnormal sounds: Stridor and Barky cough
Investigations
● Chest and neck x-rays and labworks are not routinely recommended, unless the
diagnosis of croup in uncertain
● Neck x-ray may show subglottic narrowing, known as a steeple sign
MANAGEMENT
● Appropriate management of croup depends on the severity of the case
Croup is graded using the Westley score, which categorizes patients based on
chest wall retraction, stridor, cyanosis, level of consciousness, and air entry.
● Mild: supportive
● Moderate to severe: oral steroids, nebulized racemic epinephrine and ICU
admission
Complications: secondary bacterial infections, recurrent croup, most cases resolve
without complications within 1-3 days