Croup is a common upper airway infection characterized by a barking cough, stridor, and hoarseness. It is usually caused by viral infection. A small number of croup caused by coronavirus disease 2019 (COVID-19) has been reported in children before the omicron variant surge. Previously reported cases indicated that croup caused by COVID-19 can be treated in the same manner as those with other viral causes. We describe two cases (9-month-old girl and 11-month-old boy) of previously healthy infants who presented with a barking cough and chest retraction and required endotracheal intubation and cardiopulmonary resuscitation. Despite receiving dexamethasone and nebulized racemic epinephrine (NRE) treatment for croup in the emergency department, these patients still developed acute respiratory failure. Reverse transcription polymerase chain reaction (RT-PCR) of nasopharyngeal samples revealed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) omicron BA.2 variant (Stealth omicron) and no other common respiratory viral pathogens. Both patients were treated with mechanical ventilation, dexamethasone, and NRE in the pediatric intensive care unit. The duration of intubation was 112 hours and 80 hours, respectively. Both patients were discharged without complications. To the best of our knowledge, this is the first report of life-threatening croup produced by the omicron BA.2 variant and confirmed by RT-PCR. We suggest that this SARS-CoV-2 variant may cause severe croup that may not improve with conventional treatment, even in children without underlying diseases.

An 88-year-old woman presented to our emergency room with complaints of fever, coryza, barking cough and generalised fatigue for 2 days. Physical examination showed stridor, tachypnoea with use of accessory muscles of respiration on admission. Laboratory tests were unremarkable except for monocytosis with a normal total white cell count. Rapid influenza diagnostic test was positive for influenza A. Chest X-ray showed subglottic narrowing of the trachea suggestive of steeple sign. A diagnosis of influenza A-induced croup was made. She was given humidified oxygen, nebulised racemic epinephrine, intravenous dexamethasone and oseltamivir. Stridor resolved within minutes of giving nebulised epinephrine. Work of breathing improved within 4-6 hours. She was discharged 2 days later on a tapering dose of steroids.

Croup, or laryngotracheobronchitis, is a common viral respiratory tract illness seen in the pediatric population (). This article describes the case of a child who presents with croup and the characteristic "steeple sign" seen on the radiograph. The patient received a diagnosis of croup secondary to the parainfluenza virus infection. It is imperative for advanced practice nurses to recognize the signs and symptoms of croup when these patient present to emergency care settings. Advanced practice nurses must also consider possible differential diagnoses, accurately interpret the radiographs, and intervene according with supportive care and appropriate management.

Viral croup is a frequent disease in early childhood. Although it is usually self-limited, it may occasionally become life-threatening. Mild croup is characterized by the presence of stridor without intercostal retractions, whereas moderate-to-severe croup is accompanied by increased work of breathing. A single dose of orally administered dexamethasone (0.15-0.6 mg/kg) is the mainstay of treatment with addition of nebulized epinephrine only in cases of moderate-to-severe croup. Nebulized budesonide (2 mg) can be given alternatively to children who do not tolerate oral dexamethasone. Exposure to cold air or administration of cool mist are treatment interventions for viral croup that are not supported by published evidence, but breathing heliox can potentially reduce the work of breathing related to upper airway obstruction. In summary, corticosteroids may decrease the intensity of viral croup symptoms irrespective to their severity on presentation to the emergency department.

A term infant treated for post-extubation stridor with nebulized racemic epinephrine developed localized facial blanching due to cutaneous absorption of the aerosolized vasoconstrictor. Local application of heat restored circulation to the afflicted area. This complication of a commonly used medication is not previously reported in the medical literature and has the potential for severe sequelae.

The Food and Drug Administration (FDA) is amending the final monograph (FM) for over-the-counter (OTC) bronchodilator drug products to add additional warnings (e.g., an "Asthma alert'') and to revise the indications, warnings, and directions in the labeling of products containing the ingredients ephedrine, ephedrine hydrochloride, ephedrine sulfate, epinephrine, epinephrine bitartrate, racephedrine hydrochloride, and racepinephrine hydrochloride. FDA is issuing this final rule after considering data and information submitted in response to the Agency's proposed labeling revisions for these products. This final rule is part of FDA's ongoing review of OTC drug products.