Croup vs Epiglottitis: How to Tell Them Apart in the Field

Croup and epiglottitis both swell the upper airway and both can make a child breathe with stridor, the harsh noise of air forced through a narrowed airway. They are very different illnesses. Croup is common, usually viral and usually mild. Epiglottitis is rare and bacterial, and it can close the airway completely. Telling them apart at the door changes how you approach the child, and the most important rule applies to both: do not make a child with a swollen airway upset.

Croup

Croup (laryngotracheobronchitis) is a viral infection that swells the airway at and just below the vocal cords. It usually affects young children, most often between about 6 months and 3 years, and typically follows a day or two of cold symptoms. The signature is a barking, seal-like cough, a hoarse voice and stridor on breathing in, often worse at night and worse when the child cries. Most children with croup have a low-grade fever and still look well between coughing spells.

Stridor at rest, while the child is calm, marks moderate to severe croup. Stridor only when the child cries or is active is a milder finding. Retractions, agitation and a child who is becoming tired or quiet are signs that it is getting worse.

Epiglottitis

Epiglottitis is a bacterial infection of the epiglottis, the flap above the vocal cords, and the tissue around it. The swelling sits right at the entrance to the airway, and it can close it. It classically affected children of about 2 to 7 years. Since the vaccine against Haemophilus influenzae type b (Hib) came into routine use, epiglottitis in children has become rare in the US, and it is now seen relatively more often in adults and in children who are not vaccinated.

The child with epiglottitis gets sick fast, over hours rather than days. They have a high fever and look toxic, anxious and very still. Swallowing hurts so much that they drool rather than swallow. The voice is muffled, sometimes described as a hot-potato voice, and there is usually little or no cough. They sit upright and lean forward, often sitting forward braced on the arms (the tripod position) with the chin pushed forward (the sniffing position), and refuse to lie down. Some texts teach the four Ds: drooling, dysphagia (difficulty swallowing), dysphonia (a changed voice) and distress.

In adults, epiglottitis usually shows as a severe sore throat and pain on swallowing that seem out of proportion to what can be seen in the mouth, sometimes with a muffled voice and drooling. It can still obstruct the airway.

Croup vs epiglottitis compared

Other causes of stridor in a child

• Bacterial tracheitis: a bacterial infection of the windpipe, often following a viral illness. The child looks like they have croup but is toxic, with a high fever and thick secretions, and does not improve with the usual croup treatment. It can obstruct the airway.
• Foreign body: a sudden onset, often after a witnessed choking episode while eating or playing, with no fever, most often in a toddler. If the child is moving air and coughing, let them cough and keep them calm. If the obstruction becomes complete, use the foreign-body airway obstruction maneuvers for the child's age. Never do a blind finger sweep.
• Retropharyngeal abscess: an infection behind the throat, with fever, neck pain or stiffness, drooling and difficulty swallowing.
• Anaphylaxis: stridor with hives, swelling of the lips or tongue, wheezing, vomiting or low blood pressure. Our Perfusion and Shock guide covers it.

Field principles

The approach to a child with stridor is mostly about what you do not do. Every procedure is weighed against what it costs in crying, because crying increases the turbulent flow through a swollen airway and can turn a partial obstruction into a complete one.

• Look before you touch. The pediatric assessment triangle answers most of the first questions from across the room: appearance, work of breathing and skin color.
• Keep the child with the caregiver, in the position the child has chosen, often upright on a lap. A child with a swollen airway has already found the position that keeps it open. Do not lay them down.
• Do not look in the throat, with a tongue depressor or otherwise. In epiglottitis this can trigger the spasm that closes the airway completely, and in croup it gains nothing that changes the care, while upsetting the child, and you cannot always be sure at the door which illness it is.
• Put nothing in the mouth.
• Offer oxygen by blow-by, held by the caregiver, if the child tolerates it. Do not force a mask onto a frightened child.
• Defer what will upset the child. The blood pressure cuff and an IV can usually wait unless the child deteriorates. Use pulse oximetry if the child tolerates the probe.
• Do not lay a child with stridor flat to measure them with a length-based tape; an age-based estimate or the caregiver's report of a recent weight is the less upsetting choice.
• Prepare for the worst out of the child's sight: bag-valve-mask, suction and airway equipment sized for the child, ready but not displayed.
• If a swollen airway (croup, epiglottitis) obstructs completely, two-person bag-mask ventilation with high-concentration oxygen can often push air past the swelling. A complete obstruction from a foreign body gets the obstruction maneuvers for the child's age first. Any advanced airway is a decision for your protocol and your scope.
• For croup, nebulized treatment is given per protocol, with the caregiver holding the mask or giving it blow-by rather than the crew fighting the child for it.
• Transport gently and calmly with the caregiver, and tell the receiving facility early so that the people who manage difficult pediatric airways are ready.

Estimate a weight from age when nothing better is available

Organize an early report to the receiving facility

The short version

• Croup: viral, young children, gradual onset after a cold, barking cough, hoarse voice, low fever, usually not toxic.
• Epiglottitis: bacterial, rapid onset, high fever, toxic, drooling, muffled voice, little cough, sitting forward and refusing to lie down. Now rare in vaccinated children.
• Also think of bacterial tracheitis, a foreign body, a retropharyngeal abscess and anaphylaxis.
• Do not agitate the child, do not look in the throat and put nothing in the mouth.
• Keep the child with the caregiver in the position they chose, give blow-by oxygen if tolerated, and prepare airway equipment out of sight.
• Treatments for croup are per protocol. Tell the receiving facility early.