Supportive Therapy

A second- or third-generation cephalosporin such as cefuroxime, cefotaxime, or ceftriaxone is generally administered to ensure adequate coverage of H. influenzae. With the increasing incidence of S. pneumoniae as a cause for epiglottitis and the marked increase in resistance of this organism to cephalosporins, one can empirically give vancomycin also. Some recommend adding nafcillin instead, based on the increasing incidence of gram-positive cocci, including S. aureus, as etiologic agents. Blood cultures are positive in 80 to 90 percent of patients. Cultures of the epiglottis itself are much less sensitive. Typically oral antibiotics are continued for 7 to 10 days after the patient is extubated.

Viral croup (laryngotracheitis or laryngotracheobronchitis) is responsible for more than 90 percent of cases of stridor outside of the neonatal period. About $20 to $76 million per year is spent in the United States alone on health care related to viral croup. Children 6 months to 3 years of age are most commonly affected, with a peak incidence between 1 and 2 years of age.5 It is uncommon after age 6. This is due to the much greater effect of a small amount of mucosal edema and inflammation in the airway of a small child versus that of an adult. As little as 1 mm of airway edema in an infant may cause a decrease in cross-sectional area of 50 to 60 percent. This leads to increased resistance and work of breathing. In the adult airway, 1 mm of edema is nearly inconsequential. The incidence of true croup is thought to be equal in males and females, but many authors believe that moderate to severe cases are twice as common in males. Most cases occur in the late fall or early winter.

Acute viral croup is thought to be on a continuum with spasmodic croup. It is very difficult or impossible to differentiate them prospectively. Retrospectively, spasmodic croup is seen more commonly in atopic children, has no seasonal variation, usually has almost complete symptom resolution within 6 h, is not characteristically associated with fever, and is often recurrent. Both spasmodic croup and acute viral croup have nocturnal exacerbations.

Practically all cases are viral. Parainfluenza virus types I, II, and III are most common by far, but sometimes indistinguishable syndromes can be caused by influenza A or B, respiratory syncytial virus (RSV), rhinoviruses, adenoviruses, and even measles virus. Cases caused by adenovirus may be associated with hemorrhagic cystitis and conjunctivitis. Measles pneumonitis should be considered in atypical cases and, if suspected, treated aggressively. In unimmunized or immunosuppressed adults, measles pneumonitis is not uncommonly fatal. The incubation period for parainfluenza virus is 2 to 6 days. These viruses are usually shed for about 2 weeks. In cases caused by RSV, the shedding may continue for a much longer period and symptoms may take months to clear completely. In children over the age of 5, Mycoplasma pneumoniae infection has also been associated with a croup-like syndrome.

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