Compare conditions

Put any two — or three — conditions side by side, adult or pediatric, to spot the look-alike differences fast, row by row.

Croup and Bronchiolitis

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In one line

·Croup and bronchiolitis are both viral infections in young children — croup swells the upper airway just below the voice box and causes a barking cough and a high-pitched noise on breathing in (stridor), while bronchiolitis inflames the tiny lower airways and causes wheezing and fast breathing.

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Normal physiology

·A child's airway is a smooth, open tube that carries air from the nose and mouth down past the voice box, through the windpipe, and into the lungs. In young children, this tube is very narrow — even a small amount of swelling can block the flow of air and make breathing hard.

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What goes wrong

·In croup, a virus (usually parainfluenza) infects the airway just below the voice box, causing it to swell and fill with mucus — this narrows the tube and makes a barking cough and a high-pitched noise on breathing in (stridor) (a high-pitched noise when breathing in). In bronchiolitis, a virus (usually RSV) infects the tiny lower airways (bronchioles) deep in the lungs, causing them to swell and fill with thick mucus — this blocks airflow and causes wheezing and fast, hard breathing.

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Hallmark signs

·Croup: Barking cough that sounds like a seal
·Croup: A high-pitched noise on breathing in (Stridor) (high-pitched squeaky sound when breathing in)
·Croup: Hoarse voice
·Croup: Worse at night
·Bronchiolitis: Fast, shallow breathing
·Bronchiolitis: Wheezing (high-pitched whistle when breathing out)
·Bronchiolitis: Chest retractions (skin sucking in between ribs or above collarbone)
·Bronchiolitis: Nasal flaring (nostrils spread wide with each breath)

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Red flags · escalate now

·A high-pitched noise on breathing in (Stridor) when the child is calm and resting (means the airway is very narrow)
·Severe chest retractions or the child is leaning forward and drooling (struggling to breathe)
·Blue or gray lips, tongue, or skin (not enough oxygen in the blood)
·Baby is too tired to cry, feed, or wake up (exhaustion from breathing effort)
·Breathing faster than 60 breaths per minute in an infant, or grunting with each breath

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Workup

·Pulse oximetry (oxygen saturation)
·Respiratory rate and heart rate
·Nasal swab for respiratory syncytial virus (RSV) antigen or PCR
·Chest x-ray
·Blood gas (arterial or capillary) if the child is very sick

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Treatment

·Dexamethasone (steroid) by mouth or through an IV, single dose of 0.6 mg per kilogram (maximum 10 mg)
·Nebulized epinephrine (racemic epinephrine 0.5 mL in 3 mL saline, or L-epinephrine 0.5 mg/kg up to 5 mg) for moderate to severe croup
·Supplemental oxygen (by nasal cannula or blow-by) and keep the child calm
·Nasal suctioning (gentle bulb or suction catheter) and hydration (oral fluids or IV if the child cannot drink)
·Hospital admission with continuous pulse oximetry for a high-pitched noise on breathing in (stridor) at rest, severe retractions, drooling, bluish skin (cyanosis) (blue color), or oxygen saturation below 90%
·Do NOT use cough medicine, albuterol (bronchodilator), or antibiotics in routine croup or bronchiolitis

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NCLEX trap

·Croup is swelling in a fixed tube (the area just below the voice box). Albuterol relaxes muscles around airways, but it does not shrink swelling. Instead, give dexamethasone (a steroid that calms inflammation) and nebulized epinephrine (shrinks the swelling fast) for moderate to severe croup.
·Both croup and bronchiolitis are caused by viruses. Antibiotics only kill bacteria, not viruses. Using antibiotics when you do not need them creates stronger, harder-to-kill germs (antibiotic resistance) and does not help the child get better.
·Croup is in the upper airway, right below the voice box. You hear a high-pitched noise on breathing in (stridor) (a high-pitched squeaky sound when breathing in), a barking cough like a seal, and treat it with dexamethasone and epinephrine. Bronchiolitis is in the lower airways (tiny tubes deep in the lungs). You hear wheezing, see a wet cough, and treat it with oxygen, suctioning mucus, and sometimes high-flow oxygen through the nose. Where the swelling is changes everything about treatment.
·Nebulized epinephrine works fast but only lasts 2 to 4 hours. The swelling can come back (called rebound) when the medicine wears off. The child also needs dexamethasone, which takes a few hours to work but lasts much longer. Watch the child for at least 2 to 4 hours after the epinephrine before deciding if it is safe to go home.
·Bronchiolitis swelling happens in tiny tubes deep in the lungs (bronchioles). Steroids do not shrink this kind of swelling well, and research shows they do not help most children with bronchiolitis (AAP, Cochrane). Focus on oxygen, suctioning mucus from the nose, keeping the child hydrated, and sometimes high-flow nasal oxygen. Do not give steroids routinely.
·The barking cough (sounds like a seal or a dog) is the key clue for croup. Croup causes a high-pitched noise on breathing in (stridor), not wheezing. Always ask the parent, 'What does the cough sound like?' That one detail often tells you the diagnosis right away.

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