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Aim: To determine differentiating symptoms and signs of epiglottitis and laryngotracheobronchitis (croup)., Methods: Contemporaneous interview of parents and clinical examination of children with acute upper airway obstruction presenting to the intensive care unit of a paediatric hospital., Results: Two hundred and three children were examined over a 40-month period. One hundred and two had croup, of whom 49 had the diagnosis confirmed at intubation and another six by direct laryngeal inspection without intubation. One hundred and one had epiglottitis of whom 95 were diagnosed by direct inspection of the larynx at intubation, five by a lateral X-ray of the neck and one on direct inspection without intubation. One child with epiglottitis died. Although both illnesses presented with stridor, the additional presence of drooling had a high sensitivity (0.79, 95% CI 0.70-0.86) and specificity (0.94, 95% CI 0.88-0.97) for epiglottitis while coughing had a high sensitivity (1.00, 95% CI 0.96-1.00) and high specificity (0.98, 95% CI 0.93-0.99) for croup. Coughing predicted croup but drooling predicted epiglottitis. Additional reliable signs of epiglottitis were a preference to sit, refusal to swallow and dysphagia. Thirty-seven percent of children with epiglottitis and 16% with croup were treated as having another respiratory illness at least once before definitive diagnosis., Conclusions: Epiglottitis and croup are often confused because they share symptoms and signs including stridor. However, differentiation in early illness is possible by additional observation of coughing and absence of drooling in croup and by the additional observation of drooling with absence of coughing in epiglottitis., (© 2010 The Authors. Journal of Paediatrics and Child Health © 2010 Paediatrics and Child Health Division (Royal Australasian College of Physicians).)

Infections of the upper airways are a frequent cause of morbidity in children. Viral laryngotracheobronchitis (croup) is the most common cause of stridor in children and usually has a self-limited course with occasional relapses in early childhood. Epiglottitis has become rare in developed countries with the advent of universal vaccinations against Haemophilus influenzae. It can be rapidly fatal, however, if not promptly recognized and appropriately managed. This article reviews the pathogenesis, epidemiology, clinical presentation, diagnosis, and management of these pediatric upper airway infections.

Acute dyspnea is one of the most frequent pediatric emergencies in the medical practice. The severity of the condition ranges from mild and self-limiting to severe and life threatening. The primary care physician must recognize the clinical symptoms of impending respiratory distress in a child and, especially, in an infant or very young child who is not yet able to communicate verbally, so that the appropriate therapy can be initiated as quickly as possible and, therefore, to fundamentally influence the development of the condition. The most important clinical causes of dyspnea are croup, epiglottitis, foreign body aspiration, and bronchial obstruction.

Acute infections of the respiratory tract are common in pediatric patients. Respiratory disease is the leading cause of hospitalization in children less than 4 years of age and is responsible for many physicians' office and emergency department visits.(1) The severity of upper respiratory tract infection ranges from mild, self-limited disease to potentially life-threatening airway obstruction. The prepared clinician can often make a diagnosis based solely on the history and physical examination, using radiographs and laboratory examinations to aid in diagnosis when the clinical picture is unclear. At times, airway collapse is imminent, and the clinician must proceed directly to endoscopy for definitive diagnosis and airway protection. This article will discuss the pathogenesis, clinical presentation, and management of epiglottitis, croup, and bacterial tracheitis in the pediatric population.

Although laryngotracheobronchitis is the most common upper respiratory tract disorder in pediatrics, several other diseases are potentially life-threatening. The emergency physician must recognize both the obvious and subtle distinctions among upper airway diseases. The status of the patient's airway remains the primary concern regardless of the suspected disorder, but further definitive care depends on the specific disease entity. The prompt recognition and action of both the prehospital care provider and the ED physician in maintaining a critical airway and supporting ventilation until definitive pediatric critical or surgical care can be delivered is essential in ensuring optimal outcome for children suffering from a life-threatening upper airway illness.

Viral croup and epiglottitis are two major inflammatory causes of airway obstruction in children. Two conditions, spasmodic croup and membranous laryngotracheobronchitis, are also frequent causes of obstruction on an inflammatory basis. Rapid diagnosis and effective management are required to ensure an uncomplicated outcome. The pharmacologic treatment, role and timing of endoscopy, and airway management principles are discussed.

Although viral croup is usually a self-limiting disease, its signs and symptoms are distressing enough to make parents seek immediate medical advice. This is fortunate because a much more serious disorder may be present. Indeed, morbidity requiring hospitalization may occur, as may a true emergency. Drs Thomsen and Edmonds discuss the epidemiology and current management of croup and related conditions.

Acute respiratory distress in children is a terrifying experience for both the child and the parents. It also poses a tremendous challenge to nurses and physicians who must diagnose and treat the child's illness. Although the cause of acute respiratory distress in children can vary, the initial symptoms can all look the same to even the most experienced practitioner. Epiglottitis, a potentially life-threatening bacterial infection, often masquerades as the more common and less severe viral illness croup.

The exact diagnosis of pharyngitis remains a problem despite the advent of rapid streptococcal screening. An apparent resurgence of rheumatic fever outbreaks makes it more important to attempt to accurately diagnose pharyngitis. Positive identification of streptococci should be followed by treatment with penicillin, or erythromycin in the patient with penicillin allergy. The patient without positive identification of streptococci will need either observation or further evaluation depending on the degree of illness. Classic croup or laryngotracheobronchitis is a clinical entity that can be diagnosed with reasonable confidence. The few patients that require hospitalization can be treated with humidity, racemic epinephrine, corticosteroids, parental and child support, or any combination of these with good results. Continued observation of all patients with croup is necessary to recognize the uncommon complication of bacterial tracheitis when it occurs. Epiglottitis has a varied clinical appearance and management according to age groups. Infants show a mixed clinical picture similar to croup, but with more obstruction. The classic epiglottitis with acute airway obstruction is seen in the 3-8-year-old age group. Adults have a less fulminant form of supraglottitis. Infants and children will need artificial airway management in most cases, whereas many adults can be treated simply with observation.

Croup and epiglottitis continue to be potentially life-threatening diseases in children. Early distinction is imperative as definitive treatment differs significantly. To determine the correlation of various clinical features, x-rays, and laboratory tests with diagnosis and management planning, a retrospective chart analysis of 194 children with croup (N = 169) and epiglottitis (N = 25) was performed. The clinical history and physical findings were most important in differential diagnosis. Patient age, lateral neck x-ray, and white blood count (WBC) strongly correlated with diagnosis. Counter immunoelectrophoresis (CIE) results did not alter therapy. No blood cultures were positive unless the patient had: WBC over 15,000 with more than 10 stabs, WBC over 20,000, or WBC with more than 20 stabs. Ampicillin resistant H. influenzae occurred in 21% of positive blood cultures. Capillary blood gases did not correlate with clinical need for intubation. It is suggested that a selective evaluation of patients with epiglottitis and croup can be performed in a more cost-effective manner without sacrifice in patient care.

Spasmodic croup has a sudden onset, almost always at night, and usually responds well to humidification. Laryngotracheobronchitis is the most common form of the croup syndrome; children with this disease generally do well, although some require hospitalization and intubation. Bacterial tracheitis may mimic severe laryngotracheobronchitis; diagnosis is usually established during visualization of the airway. Epiglottitis is rare but is often life-threatening.

Croup syndromes are common in children, most frequently being infectious in origin. Children present with a slow progression of inspiratory and expiratory stridor and a croupy, "barking seal" cough. Children are variably febrile and with progression of disease, exhaustion, agitation, cyanosis and air hunger may develop. The evaluation of the patient must focus on the degree of respiratory distress and associated findings. Epiglottitis and foreign body aspiration must be excluded. Management is primarily dependent upon administration of humidified air. Children with moderate to severe croup benefit from racemic epinephrine and steroids. Admission is indicated in children with stridor at rest, evidence of exhaustion, toxicity or respiratory distress. Active airway intervention is rarely required but may be life saving if obstruction develops.