What is the initial approach to differentiate and manage croup versus tracheitis?

Differentiating and Managing Croup versus Bacterial Tracheitis

The initial approach to differentiate croup from bacterial tracheitis should focus on clinical presentation, with croup typically presenting with sudden onset of barky cough, stridor, and respiratory distress, while bacterial tracheitis should be suspected when a patient fails to respond to standard croup treatment. 1, 2

Clinical Presentation and Differentiation

Croup

• Presents with sudden onset of distinctive barking cough, usually accompanied by stridor, hoarse voice, and respiratory distress 1, 3
• Typically without fever or other respiratory symptoms such as antecedent cough or congestion 1
• Most commonly caused by parainfluenza viruses 4
• Usually responds well to corticosteroids and, if needed, nebulized epinephrine 1, 2

Bacterial Tracheitis

• Features common to both croup and epiglottitis 5
• Often presents initially like croup but fails to respond to standard croup therapy 1, 5
• May have more severe respiratory distress and higher fever 5
• Requires more aggressive management including antibiotics and possibly airway intervention 5

Initial Assessment

• Assess for signs of respiratory distress: stridor, accessory muscle use, tracheal tug, sternal/subcostal/intercostal recession 6
• An agitated, restless, or obviously distressed child may indicate airway obstruction 6
• Note that signs may become absent as obstruction worsens - a concerning sign 6
• Radiographic studies are generally unnecessary for typical croup and should be avoided unless there is concern for an alternative diagnosis 1
• Further workup is recommended if a patient fails to respond to racemic epinephrine, which may indicate bacterial tracheitis or foreign body aspiration 6, 1

Management Algorithm

For Suspected Croup:

1. Initial Treatment:

   • Administer oral corticosteroids for all cases of croup regardless of severity (prednisolone 1.0 mg/kg) 1, 3
   • For mild cases, review in 1 hour after steroid administration 3

2. For Moderate to Severe Cases (stridor at rest or respiratory distress):

   • Add nebulized epinephrine (0.5 ml/kg of 1:1000 solution) 1
   • Note that the effect of nebulized epinephrine is short-lived (1-2 hours) 1
   • Provide high-flow oxygen to maintain saturation ≥94% 1
   • Observe for 2 hours after each racemic epinephrine dose 6

3. Hospitalization Decision:

   • Consider hospital admission when three or more doses of racemic epinephrine are required 6, 1
   • This approach has been shown to reduce hospitalization rates by 37% without increasing revisits or readmissions 1

For Suspected Bacterial Tracheitis:

1. Recognition:

   • Suspect when a patient presents with croup-like symptoms but fails to respond to standard treatment 1, 5
   • Higher fever and more severe respiratory distress may be present 5

2. Management:

   • More aggressive approach required 5
   • May need direct laryngoscopy and bronchoscopy for diagnosis and management 5
   • Requires antibiotics for bacterial infection 5
   • Some cases require endotracheal intubation for airway protection 5

Important Considerations and Pitfalls

• Nebulized epinephrine should not be used in children who are shortly to be discharged or on an outpatient basis due to risk of rebound symptoms 1
• Avoid blind finger sweeps in cases of suspected foreign body aspiration, as this may push objects further into the pharynx 1
• Waveform capnography should be immediately available in pediatric critical care areas for airway management 6
• When managing a child with respiratory distress, ensure emergency equipment is readily available, including appropriate facemasks, airway adjuncts, and equipment for front-of-neck access if needed 6
• If only one oxygen supply is available, apply it to the airway from which spontaneous breathing can be detected 6
• Have a system in place to rapidly deliver appropriate medications to the bedside in case of emergency 6

By following this structured approach, clinicians can effectively differentiate between croup and bacterial tracheitis and provide appropriate management for each condition, improving outcomes and reducing unnecessary hospitalizations.