What is the management approach for croup in elderly adults?

Croup in Elderly Adults: A Clinical Rarity Requiring High Index of Suspicion

Croup in elderly adults is an extremely rare but distinct clinical entity that requires close observation and a low threshold for airway intervention, as it can rapidly progress to life-threatening airway obstruction. 1

Clinical Recognition and Diagnosis

Adult croup presents as a heterogeneous syndrome characterized by:

• Upper airway infection with barking cough, hoarseness, and stridor 2, 1
• Rapid progression to airway obstruction in some cases 1
• Often more subtle presentation compared to pediatric cases, particularly in elderly patients who may have reduced symptom expression 3

The diagnosis is clinical and does not require radiographic confirmation unless alternative diagnoses need exclusion (such as bacterial tracheitis or foreign body aspiration). 4, 5

Critical Management Approach

Immediate Assessment

• Evaluate for signs of respiratory distress: stridor, accessory muscle use, tracheal tug, sternal/subcostal/intercostal recession 5
• Assess vital signs including oxygen saturation, with a target of ≥94% 4
• Agitation or restlessness may indicate hypoxemia and impending airway compromise 4, 5

Treatment Algorithm

First-line therapy:

• Administer systemic corticosteroids immediately (dexamethasone 0.6 mg/kg, maximum 10-12 mg orally or intramuscularly if unable to tolerate oral) 6, 7
• Corticosteroids reduce inflammation, decrease need for intubation, and shorten illness duration 6, 7

For moderate-to-severe cases with stridor at rest or respiratory distress:

• Add nebulized epinephrine (0.5 ml/kg of 1:1000 solution, maximum 5 ml) 4, 8
• The effect lasts only 1-2 hours, requiring continuous monitoring for rebound symptoms 4, 8
• Observe for at least 2 hours after the last epinephrine dose before considering discharge 4, 8

Oxygen therapy:

• Maintain oxygen saturation ≥94% using nasal cannula, face mask, or non-rebreathing mask as needed 4

Hospitalization Criteria for Elderly Patients

Admit elderly patients with croup if:

• Three or more doses of nebulized epinephrine are required 4, 8
• Oxygen saturation <92-94% despite supplemental oxygen 4
• Persistent stridor at rest after treatment 8
• Inability to maintain adequate oral intake 8
• Presence of comorbidities or frailty that increase vulnerability 3

The elderly are at particularly high risk due to:

• Age-associated cardiovascular and autonomic changes 3
• Multiple concurrent morbidities and polypharmacy 3
• Increased frailty and vulnerability to decompensation 3
• Higher risk of physical injury from falls or trauma if syncope occurs 3

Critical Pitfalls to Avoid

1. Do not discharge patients within 2 hours of nebulized epinephrine administration due to risk of rebound airway obstruction 4, 8

2. Do not use nebulized epinephrine in outpatient settings or shortly before planned discharge 4, 8

3. Maintain a low threshold for airway intervention in elderly patients, as progression can be rapid and complete resolution is expected with appropriate management 1

4. Consider alternative diagnoses if patient fails to respond to standard croup treatment, particularly bacterial tracheitis which requires antibiotics and may need surgical airway management 4, 5

5. Avoid humidified air or mist therapy as current evidence shows no benefit for symptom improvement 4, 7

Multidisciplinary Approach for Elderly Patients

Given the rarity of adult croup and the complexity of managing elderly patients, collaboration with geriatric care specialists and otolaryngology is beneficial to address:

• Multiple comorbidities and medication interactions 3
• Frailty assessment 3
• Cognitive impairment that may affect symptom reporting 3
• Goals of care discussions regarding potential intubation 3

Prompt decisions regarding airway intervention are critical, as delay can result in complete airway obstruction requiring emergency surgical airway access. 1