From the Research
The steeple sign is a radiographic finding on frontal neck X-rays that indicates subglottic airway narrowing, most commonly seen in children with croup (acute laryngotracheobronchitis), and treatment typically includes cool mist, oral dexamethasone, and nebulized epinephrine for moderate to severe cases. This sign appears as a gradual tapering of the subglottic airway, resembling a church steeple or pencil point, and occurs due to inflammation and edema of the subglottic tissues, particularly at the level of the cricoid cartilage, which is the narrowest part of a child's airway 1. The steeple sign should be distinguished from the "thumbprint sign" seen in epiglottitis, which is a more serious condition requiring immediate airway management.
Key Points to Consider
- The steeple sign is a critical radiographic finding that indicates subglottic airway narrowing in children with croup.
- Treatment for croup typically includes a single dose of oral dexamethasone (0.6 mg/kg, maximum 10 mg) and nebulized epinephrine (racemic epinephrine 2.25% solution, 0.5 mL in 3 mL saline) for moderate to severe cases, as supported by studies such as those published in the American Family Physician 1 and The Cochrane Database of Systematic Reviews 2, 3.
- The use of glucocorticoids, such as dexamethasone, has been shown to improve symptoms and reduce the need for additional treatments, including epinephrine, in children with croup 2, 3.
- It is essential to recognize the steeple sign and initiate appropriate treatment promptly to prevent progression to respiratory distress or failure, especially in children, whose airways are naturally smaller than those of adults.
Management and Treatment
- Oral dexamethasone (0.6 mg/kg, maximum 10 mg) as a single dose is recommended for the treatment of croup, regardless of severity, as it has been shown to improve symptoms and reduce the need for additional treatments 1, 2, 3.
- Nebulized epinephrine (racemic epinephrine 2.25% solution, 0.5 mL in 3 mL saline) is recommended for moderate to severe cases of croup, as it can help to reduce airway obstruction and improve symptoms 1.
- Cool mist and other supportive care measures may also be beneficial in the management of croup, although the evidence for these interventions is less clear 1, 4.
Recent Evidence and Recommendations
- A recent study published in Hospital Pediatrics found that the cumulative dose of dexamethasone before PICU discharge did not predict the odds or timing of rebound in critically ill children with croup, suggesting that other factors may be more important in determining the risk of rebound 5.
- The American Family Physician recommends the use of dexamethasone and nebulized epinephrine in the treatment of croup, based on the results of randomized controlled trials and other studies 1.