Croup

Last Updated on by FRCEM Intermediate

Overview

  • acute laryngotracheobronchitis
  • Viral prodrome (1-2 days often mild corryzal symptoms)/parainfluenza (common),Respiratory syncytial virus,Adenovirus
  • autumn & early spring
  • 6 months -> 3 years
  • Harsh barking cough
  • Hoarse voice and stridor
  • Fever less than 38 degrees
  • Stridor worse on crying and worse at night
  • Usually ,a benign, self-limited disease-No specific treatment is required for most children

Signs

  • Tachypnoea
  • Tachycardia
  • Sternal recession
  • Tracheal tug
  • Cyanosis on crying

Severity assessment

Westley croup score ( score include Stridor, Intercostal recession, Air entry, SaO2 < 92%, Consciousness)

Mild (croup score 0-2)/Moderate (croup score 3-5)/severe (croup score 6-11)/Impending respiratory failure (croup score 12-17)

Investigations

  • Clinical
  • X-ray finding: Steeple sign on AP view – Not indicated

Management

Mild Croup

  • General supportive measures, gentle handling and reassurance
  • Oral Dexamethasone (0.150 mg /kg)

Or

  • Nebulised Budesonide( 2mg)
  • Oral prednisolone (1 – 2 mg/kg) alternative if dexamethasone is not available
  • Hydration should be assured by allowing the parents to feed the child
  • Investigation should be kept to a minimum

Moderate to severe croup

  1. In the presence of increasing airway obstruction, it is imperative that the child is transferred to a paediatric facility
  2. Oxygen via either a nasal cannula or a face mask- -avoid distressing child – hold mask away, keep on parents lap if appropriate
  3. Nebulised Adrenaline[Epinephrine] (400ug/kg) 0.4–0.5 mL/kg of 1:1,000 concentration to a maximum dose of 5 mL under close supervision with cardiac monitor (Stop if pulse > 200 bpm) or nebulised budesonide
  4. Contact anesthetic, pediatric departments for advice, ENT if Available
  5. If nebulized Adrenaline has been given, intravenous access should be obtained -IV with EMLA (if this will distress the child too much then delay until under anesthesia),

Discharge

  • moderate croup needs to be observed for a minimum of four hours following a single dose of dexamethasone.
  • advice must be given to returning to the hospital if the child develops any of the following:
    • Stridor at rest
    • Increasing respiratory distress
    • Excessive dribbling
    • Difficulty swallowing
    • Reduced feeding
    • Restlessness, confusion, or drowsiness

indication for Admission

  • Oxygen needed to maintain oxygen saturation >93%
  • Poor response to initial therapy
  • Age < 6 months
  • Inadequate fluid intake
  • Late night, Parental anxiety, Lack of transport
  • And Those with severe croup must be admitted.

Indications for Intubation in a child with croup

  • Failure of medical treatment (O2, nebulised adrenaline, dexamethasone) and progression to:
  • exhaustion from increased work of breathing
  • hypercapnic respiratory failure
  • hypoxic respiratory failure (child would usually be obtunded)
  • decreased LOC (and not protecting own airway, responding to pain only)
  • imminent airway obstruction

The differential diagnosis for Causes of stridor

  • Croup
  • Foreign body inhalation
  • Angioedema
  • Bacterial tracheitis
  • Diphtheria
  • Whooping cough
  • epiglottitis
  • Retropharyngeal abscess
  • Trauma

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