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Updated: Aug 30 2018


  • Snapshot
    • A 4-year-old boy presents to the emergency room for a cough. His mom reports that he has had this cough for about a day along with fevers, runny nose, and a hoarse voice. He started having some difficulty breathing this afternoon, so his mother brought him to the emergency room. On physical exam, he has a deep barking cough, use of accessory muscles, and inspiratory stridor. He is sent for a chest radiograph, which showed a positive steeple sign. He is immediately given nebulized epinephrine and a dose of steroids. The physician reassures the patient’s mother that this will likely resolve without any complications.
  • Introduction
    • Clinical definition
      • upper respiratory infection characterized by barking cough
    • Epidemiology
      • incidence
        • common
      • demographics
        • children < 6 years of age
        • boys > girls
    • Etiology
      • parainfluenza virus (most common)
        • paramyxovirus
          • RNA virus
      • influenza virus
        • orthomyxovirus
          • RNA virus
    • Pathogenesis
      • the virus causes inflammation of the upper airway
        • edema, epithelial necrosis, and infiltration of inflammatory cells
        • this causes narrowing of subglottic airway, resulting in stridor and increased work of breath
    • Associated conditions
      • bronchiolitis
    • Prognosis
      • most cases resolve without complications
  • Presentation
    • Symptoms
      • “seal-like” deep barking cough
      • difficulty breathing
      • sore throat
      • hoarseness
      • congestion
      • symptoms are worse at night
    • Physical exam
      • fever
      • inspiratory stridor
      • tachypnea
      • accessory muscle use
      • pulsus paradoxus with severe croup and upper airway obstruction
  • Imaging
    • Chest radiography
      • indication
        • all patients
      • findings
        • may show a steeple sign indicating subglottic narrowing
  • Studies
    • Making the diagnosis
      • based on clinical presentation
  • Differential
    • Acute epiglottitis
      • distinguishing factors
        • patients typically have muffled voice, drooling, high fever, and have dysphagia
        • a medical emergency
        • absence of barking cough
  • Treatment
    • Conservative
      • supportive care
        • indication
          • all patients
        • modalities
          • supplemental oxygen
          • hydration
    • Medical
      • single dose of steroids
        • indication
          • all patients
      • nebulized epinephrine
        • indications
          • all patients
  • Complications
    • Respiratory failure
    • Pneumonia
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