Differentiating and Managing Croup versus Bacterial Tracheitis

Clinical Presentation and Differentiation

The American Academy of Pediatrics recommends that the initial approach to differentiate croup from bacterial tracheitis should focus on clinical presentation, with croup typically presenting with sudden onset of barky cough, stridor, and respiratory distress, while bacterial tracheitis should be suspected when a patient fails to respond to standard croup treatment 1
Croup presents with sudden onset of distinctive barking cough, usually accompanied by stridor, hoarse voice, and respiratory distress, and typically without fever or other respiratory symptoms such as antecedent cough or congestion 1

Assess for signs of respiratory distress: stridor, accessory muscle use, tracheal tug, sternal/subcostal/intercostal recession, as recommended by the American Society of Anesthesiologists 2
An agitated, restless, or obviously distressed child may indicate airway obstruction, according to the American Academy of Pediatrics 2
Radiographic studies are generally unnecessary for typical croup and should be avoided unless there is concern for an alternative diagnosis, as suggested by the American College of Radiology 1

For suspected croup, administer oral corticosteroids for all cases of croup regardless of severity (prednisolone 1.0 mg/kg), as recommended by the American Academy of Pediatrics 1
For moderate to severe cases of croup, add nebulized epinephrine (0.5 ml/kg of 1:1000 solution) and provide high-flow oxygen to maintain saturation ≥94%, according to the American Thoracic Society 1
Consider hospital admission when three or more doses of racemic epinephrine are required, as suggested by the American Academy of Pediatrics 3, 1

Nebulized epinephrine should not be used in children who are shortly to be discharged or on an outpatient basis due to risk of rebound symptoms, as warned by the American Academy of Pediatrics 1
Waveform capnography should be immediately available in pediatric critical care areas for airway management, as recommended by the American Society of Anesthesiologists 2
When managing a child with respiratory distress, ensure emergency equipment is readily available, including appropriate facemasks, airway adjuncts, and equipment for front-of-neck access if needed, according to the American Heart Association 2

The American Academy of Pediatrics explicitly recommends further workup when a patient fails to respond to racemic epinephrine, specifically to avoid missing croup-mimicking conditions such as bacterial tracheitis or foreign body aspiration 4
The American Academy of Pediatrics recommends that lateral neck radiographs should not be relied upon for diagnosis, as clinical assessment is more important, and radiographic studies are generally unnecessary and should be avoided unless there is concern for an alternative diagnosis is not supported by the provided citations, however, chest inspiration/expiration films in the evaluation of treatment-refractory croup are not recommended 4, 5, 6

Direct visualization by laryngoscopy is the most important investigation to rule out croup-mimicking conditions such as bacterial tracheitis, foreign body aspiration, or other airway pathology 4
When standard treatment fails, proceed to direct laryngoscopy and bronchoscopy to visualize the airway and identify the true pathology 4

Bronchoscopy should be undertaken in all patients in whom inhalation of a foreign body is suspected, and it may be useful in patients in whom other more targeted investigations are normal, as recommended by the British Thoracic Society 7, 8
High-resolution CT scanning may be of use in patients with persistent atypical cough in whom other more targeted investigations are normal, but this applies to chronic cough evaluation, not acute croup failure, according to the British Thoracic Society 7, 8

Laryngoscopy should not be delayed in patients who have received 3 or more doses of racemic epinephrine without improvement, as this indicates potential alternative pathology, as suggested by the American Academy of Pediatrics 9