Background
Croup is a viral illness with inflammation of the upper airway. It is also known as acute viral laryngo-tracheo-bronchitis.
Key points
- Hypoxia is a late sign & indicates severe croup
- Minimal handling is key principle of management. Avoid distressing the child
- Investigations are usually not necessary
- If the child requires two or more adrenaline nebulisers, he/she should be admitted for an extended period of observation
- Beware children <6 months with stridor
- Croup is less common in children less than 6 months of age. All children <6 months of age with new onset stridor should have a review by a senior clinician prior to discharge with strong consideration for an emergent ENT review, especially for children <3 months of age
Assessing Severity
Signs of life threatening croup:
- Hypoxia
- Cyanosis
- ↓ alertness
Signs of severe croup:
- Moderate/severe chest wall retractions
- Markedly decreased air entry
History
- Viral prodrome (1-2 days corryzal symptoms)
- Harsh barking cough
- Hoarse voice and stridor
- Fever <38°
- Stridor worse on crying and worse at night
Signs
- Tachypnoea
- Tachycardia
- Sternal recession
- Tracheal tug
- Cyanosis on crying
Stridor
- Continuous harsh sound
- Caused by obstruction in the larynx and trachea
- Predominantly inspiratory
- Expiratory component may be present - ? subglottic lesion
- Higher incidence in children than in adults (anatomical differences)
Differential diagnosis
Epiglottitis
- Drooling and pain on swallow
- Unwell appearance
- Absence of barking cough
- Muffled hot potato voice
- Tripod or sniffing position
- Anxiety out of proportion to degree of resp. distress
Bacterial tracheitis
- Often school age
- Associated pain on swallowing
- Soft stridor 2-7 days after onset of URTI symptoms
- Often unwell looking
- Significant tracheal tenderness on palpation
- Reluctant to cough because of pain
Foreign body
- Often < 3 years of age
- Abrupt onset @ daytime (croup @ night)
- Dysphagia, drooling
- Dysphonia depending on location of foreign body
- Minimal response to adrenaline nebuliser
Others
- Deep space neck infection
- Angioneurotic oedema
- Anaphylaxis
If <6 months of age consider:
- Laryngomalacia
- Subglottic haemangioma
- Vascular ring
- Laryngotracheomalacia
- Vocal cord abnormality
- Other congenital airway anomaly
Croup management
Severe croup
- Manage in Resusc. room & record case in the log please
- Minimal handling, place on parents lap if felt to be appropriate by clinical staff
- Avoid distressing the child. Allow the child to find a position of comfort
- Adrenaline nebuliser 5mg (5mls of 1:1000). Repeat if necessary
- Dexamethasone 0.6mg/kg PO. This may be deferred 10-15 minutes while adrenaline nebuliser is being completed
- Consider IM dexamethasone 0.6mg/kg if PO route is not feasible eg vomiting, patient refusal or obtunded
- An IV line should be deferred
- Supplemental O2 if hypoxic. Consider “blow-by” O2:
- Hypoxia is rare in croup and indicates severe airways obstruction
- Any of hypoxia/altered mental state/paradoxical breathing / poor response to adrenaline nebuliser contact paediatric anaesthesia to arrange emergent gaseous induction for intubation. This is a life threatening situation
Mild/moderate croup
- Minimal handling, place on parents lap if felt to be appropriate by clinical staff
- Avoid distressing the child. Allow the child to find a position of comfort
- PO dexamethasone 0.15mg/kg
- No investigations required unless diagnosis is doubt
Disposition
Admit
Indicators of increasing severity:
- Increasing respiratory rate
- Increasing stridor
- ↓ air entry on auscultation
- Cyanosis at rest with O2 sats. <95% in air
- Δ level of consciousness
Can go home when:
- No stridor at rest
- No oxygen requirement
- No increased work of breathing
- Parents confident about ongoing management at home and know when to return
- Must be observed for >4 hours after adrenaline nebuliser
At risk:
- Children with pre-existing narrowing of the upper airways (eg. subglottic stenosis congenital or 2° to neonatal ventilation) or
- Children with Down Syndrome
At risk are prone to more severe croup and admission should be considered even with mild symptoms.