From the Guidelines
When you see a steeple sign, manage it as a potential indicator of central airway obstruction, and consider therapeutic bronchoscopy as an adjunct to systemic medical therapy and/or local radiation, as suggested by the American College of Chest Physicians clinical practice guideline 1. The steeple sign is a radiographic finding that can indicate subglottic narrowing, which may be caused by various conditions, including malignant or nonmalignant central airway obstruction.
- The management of central airway obstruction involves a comprehensive history and physical examination, a CT scan of the chest, and appropriate laboratory investigations pertinent to nonmalignant central airway obstruction and preoperative assessment, as recommended by the American College of Chest Physicians 1.
- Therapeutic bronchoscopy, either rigid or flexible, can be used to relieve airway obstruction, and the choice of bronchoscopy type and sedation level should be individualized based on the patient's condition and the operator's expertise, with a suggestion to use rigid bronchoscopy over flexible bronchoscopy for therapeutic interventions 1.
- For patients with symptomatic malignant or nonmalignant central airway obstruction, the use of general anesthesia/deep sedation over moderate sedation for therapeutic bronchoscopy is suggested, as well as the use of either jet ventilation or controlled/spontaneous assisted ventilation during rigid therapeutic bronchoscopy with general anesthesia 1.
- Airway dilation, tumor or tissue excision, and/or ablation can be performed to help achieve airway patency, and stent placement can be considered if other therapeutic bronchoscopic and systemic treatments have failed and when feasible for the underlying disorder 1.
From the Research
Management of Croup
When a steeple sign is seen, it is indicative of croup, a common viral respiratory tract illness in the pediatric population 2. The management of croup involves:
- Decreasing symptoms and reducing inflammation
- Glucocorticoids are effective by oral, parenteral, or nebulized routes, and continue to provide the mainstay of therapy 3
- Nebulized epinephrine provides effective additional therapy for more severe cases 3
- Heliox is also effective in the short-term management of refractory croup 3
Treatment Options
The following treatment options are available for croup:
- Corticosteroids (dexamethasone, intramuscular and oral) 4
- Nebulised budesonide 4
- Oral prednisolone 4
- Heliox 4
- Humidification 4
- Nebulised adrenaline (racemate and L-adrenaline [ephinephrine]) 4
Effectiveness of Glucocorticoids
Glucocorticoids have been shown to be effective in relieving the symptoms of croup, with:
- Improved Westley score at 6 and 12 hours 5
- Fewer return visits and/or (re)admissions 5
- Decreased length of time spent in accident and emergency or hospital 5
- Decreased use of epinephrine 5
Diagnosis and Management
Croup is a manifestation of upper airway obstruction resulting from swelling of the larynx, trachea, and bronchi, leading to inspiratory stridor and a barking cough 6. The diagnosis and management of croup involve: