Croup

Question 1

Define croup.

Answer 1

Croup is a form of URTI seen in infants and toddlers. It is characterised by stridor which is caused by a combination of laryngeal oedema and secretions.

Question 2

What age group is most affected by croup? When is it most common?

Answer 2

6months to 6 years

Peak incidence in second year of life

Most common in autumn

Question 3

How does croup present?

Answer 3

• Coryza and mild fever
• Hoarse voice
• Barking cough (due to tracheal oedema and collapse)
• DIB with chest retractions
• Symptoms worse at night

Question 4

How is croup managed?

Answer 4

Usually at home (but if age <12 months then have low threshold for admission due to narrow airway calibre)

FIRST LINE: CKS recommend 1 dose of oral dexamethasone (or oral prednisolone if not available) to ALL children at 0.15mg/kg regardless of severity

Other (no evidence): inhalation of warm moist air

Question 5

What is the aetiology of croup?

Answer 5

• Parainfluenza virus (most common)
• Rhinovirus
• RSV
• Influenze

(95% viral)

Question 6

Describe the differences between mild, moderate and severe croup.

Answer 6

Question 7

When should you admit a child with croup?

Answer 7

• moderate or severe category
• < 6 months of age
• known upper airway abnormalities (e.g. laryngomalacia, Down’s syndrome)
• uncertainty about diagnosis

Question 8

List some important differentials for croup.

Answer 8

• acute epiglottitis,
• bacterial tracheitis,
• peritonsillar abscess
• and foreign body inhalation

Question 9

What is seen on XR in croup?

Answer 9

• a PA view will show subglottic narrowing, commonly called the ‘steeple sign’
• in contrast, a lateral view in acute epiglottis will show swelling of the epiglottis - the ‘thumb sign

NB: diagnosis usually clinical

Question 10

What is the emergency management of croup?

Answer 10

Nebulised adrenaline 1 in 1000 (same as in anaphylaxis IM) with high flow oxygen in airway obstruction

Call ENT and anaesthetist if worsening respiratory distress

Question 11

Which scoring system is used to assess severity of croup in hospital?

Answer 11

Westley - assesses risk of impending respiratory failure

Question 12

Should you examine a child with croup?

Answer 12

You should not upset a child with stridor as this can precipitate laryngeal spasm

This is usually a clinical diagnosis

Question 13

In simple terms how do you distinguish croup, epiglottitis and bacterial tracheitis?

Answer 13

Croup - otherwise well, mild fever

Epiglottitis - child looks toxic, tripod position, high fever

Bacterial tracheitis - very high fever

Question 14

In foreign object aspiration should you do a CXR? What would you see?

Answer 14

It might be radiopaque (coin) or radiolucent (plastic, crayon)

But might see different signs, like lobar collapse and hyperinflation. Will probably need AP and lateral signs.

Most likely to go down the right as the right main bronchus is straighter.