EpistemisBarking cough with metallic ringing due to acute laryngitis
Specialty: Pediatrics.
Why it occurs
- Viral laryngotracheitis or croup (acute self-limited infection of the upper airway, mainly caused by the parainfluenza virus types 1, 2 and 3)
- Spasmodic laryngitis or "stridulous croup" (recurrent episodes of laryngeal obstruction on a hyperreactive or allergic basis, often triggered by cold air or reflux)
- Bacterial tracheitis (severe invasive bacterial infection, secondary mainly to Staphylococcus aureus or Streptococcus pneumoniae, with thick purulent exudate)
- Acute epiglottitis (severe bacterial infection of the epiglottis due to Haemophilus influenzae type b, now rare thanks to vaccination)
- Laryngotracheal foreign body aspiration (acute mechanical obstruction due to small objects or food)
Initial workup
The diagnosis of croup is fundamentally clinical and is graded using the Westley Scale. Invasive examinations and radiology are not recommended in typical cases, as they can trigger fatal laryngeal spasm. In case of doubt or suspicion of a foreign body/epiglottis in a stable patient: Lateral and AP x-ray of the neck ("pencil" or "bell tower" sign due to subglottic narrowing, or "fingerprint" sign in epiglottitis). Flexible fibrolaryngoscopy performed exclusively in the operating room or intensive care room with personnel prepared for difficult intubation.
red flags
Presence of audible inspiratory stridor at complete rest; progressive increase in respiratory distress manifested by subcostal, intercostal and suprasternal drawing ("flapping" of the sternal fork); perioral cyanosis or extreme paleness during coughing spells; lethargy, uncontrollable psychomotor agitation or confusion (signs of impending hypoxia or hypercapnia); constant drooling with total inability to swallow saliva and tripod position (trunk leaning forward and neck in hyperextension, highly suggestive of epiglottitis); absence of active barking cough but with auscultatory silence despite vigorous respiratory effort.
Standard management
- Dexamethasone — systemic corticosteroid of choice, reduces laryngeal edema; single dose of 0.15 to 0.6 mg/kg orally, intramuscularly or intravenously, with an effect that begins within 1-2 hours and lasts up to 72 hours
- Nebulized adrenaline — L-adrenaline at 1:1000 at a dose of 0.5 ml/kg, maximum 5 ml, or racemic adrenaline at 2.25% at a dose of 0.05 ml/kg by inhalation mixed with physiological saline; indicated in moderate to severe croup with stridor at rest; requires hospital observation of at least 2-3 hours due to risk of rebound effect when the drug is cleared
- Nebulized budesonide (alternative if the oral route is not feasible and a parenteral route is not available; single dose of 2 mg nebulized).
Educational guidance for study. It is NOT a prescription recommendation. The actual choice depends on the cause, the patient, and current guidelines.
- Area
- Pediatrics
- Listed causes
- 5
- Treatment options
- 3