Source: Manual of Ambulatory Pediatrics 2010
SOAP Note – Viral Croup
Laryngotracheobronchitis characterized by inspiratory stridor. Inflammation of the respiratory mucosa of all airways is generally present. The classic symptoms are caused by inflammation and edema in the larynx and subglottic area.
I. Etiology: Generally caused by the parainfluenza virus; less commonly caused by the respiratory syncytial virus, influenza virus, and adenoviruses.
II. Incidence
A. Most common age range is 3 months to 3 years.
B. Peak incidence is 1 to 2 years.
C. Occurs predominantly in late fall or early winter
III. Subjective data
A. History of gradual onset
B. Symptoms of upper respiratory infection for several days prior to onset
C. Low-grade or moderate fever
D. Harsh, barking cough
E. Wheezing with lower respiratory tract involvement
F. Hoarseness
G. High-pitched sound on inspiration; often at night
H. Child does not appear toxic.
I. Important questions to ask in history to rule out epiglottitis
1. Acute onset
2. Dysphagia
3. Drooling
4. Apprehension and air hunger
J. If answer is affirmative for any of the above or child appears toxic, do not attempt to examine child: Refer to physician immediately.
IV. Objective data
A. Elevated temperature
B. Slight hyperemia and edema of nasopharynx
C. Inspiratory stridor, usually of abrupt onset
D. Harsh, barking cough
E. Hoarseness
F. Dyspnea
G. Wheezing with lower respiratory tract involvement
H. Prolonged expiratory phase
I. With increased obstruction, breath sounds decrease and anxiety increases.
J. Laboratory test: WBCs normal or low
K. Lateral neck x-ray to rule out epiglottitis
V. Assessment
A. Diagnosis is generally made by history and clinical presentation.
B. Differential diagnoses
1. Epiglottitis of bacterial etiology. Toxic, drooling, dysphagic, high fever, acute onset, anxious; generally 3 to 7 years of age
2. Foreign body: Fever absent; dysphagia, visualization of foreign body, sudden onset of coughing and wheezing; careful history may reveal episode of choking just prior to onset of wheezing
3. Congenital laryngeal stridor: Stridor present from birth
4. Bronchiolitis, pneumonia, bronchitis (see Table 2-2)
VI. Plan
A. Home management if child
1. Is well-hydrated and pink
2. Has little or no retraction
3. Has normal air exchange on auscultation
4. Has respirations and pulse within normal range
5. Has absence of stridor at rest
B. Systemic steroids
1. Use is controversial.
2. Some studies have shown a single dose of steroids significantly improves symptoms within 5 hours and reduces the incidence of hospitalization by 75%.
3. Dexamethasone: 0.15 mg/kg, PO, once
a. Do not use if child has received varicella vaccine within preceding 2 weeks, or if child has been exposed to varicella within the previous 3 weeks.
C. Cool-mist vaporizer: Use continuously.
D. Force fluids, especially clear liquids.
E. Monitor respiratory rate.
F. Refer to physician for hospitalization if moderate to severe respiratory distress.
VII. Education
A. Cool-mist vaporizers are preferred over steam vaporizers. Warm steam may have a partial drying effect and may raise the temperature of a febrile child. Also, steam vaporizers are more dangerous to use around small children.
B. Fluids—especially clear liquids—are important in the acute phase. They help keep secretions thin.
C. Croup is generally self-limited.
D. Antibiotic therapy is not indicated for management of croup.
E. Inspiratory obstruction at a maximum for the first 24 to 48 hours. Respiratory symptoms persist for 1 week.
F. Recurrences are common until 5 to 6 years of age.
G. Do not use antihistamines; they tend to cause inspissation of laryngeal and tracheal secretions.
H. Restlessness and anxiety are indications of hypoxemia.
I. Monitor respiratory rate; teach parent how to count respirations.
J. Symptoms generally worsen at night.
K. For immediate relief of acute symptoms, take child into bathroom and turn on hot water. Symptoms also improve when child is taken outside. If no improvement after 5 minutes, take child to hospital.
L. Avoid situations or stimuli that upset child. Crying causes hyperventilation, resulting in increased respiratory distress. Keep child calm and comforted.
M.Signs and symptoms of airway obstruction are tachypnea, cyanosis, increased retractions, and increased anxiety or restlessness. Should any of these occur, call physician immediately.
VIII. Follow-up
A. Call immediately if child becomes restless or anxious.
B. Call immediately if respiratory rate or retractions increase.
IX. Complications: Principal complication is asphyxia secondary to laryngeal obstruction.
X. Consultation/referral
A. Any child with an acute onset of inspiratory stridor, tachypnea, retractions, or diminished breath sounds
B. Any child with cyanosis, restlessness, anxiety, or flaring of the alae nasi
C. Any child who is toxic, drooling, dysphagic
D. Child younger than 1 year of age