Croup

Question 1

What is croup and what are the groups it affects?

Answer 1

• also known as laryngotracheobronchitis
• a common viral infection of the upper airways in children, causing oedema in the larynx
• typically affects children aged 6 months - 2 years, but can be older
• more common in males

Question 2

What is the most common cause of croup?

Answer 2

• parainfluenza virus
• influenza A and B
• measles
• adenovirus
• RSV
• some common bacterial causes = S.aureus, S.pneumoniae, H.influenza, Moraxella catarrhalis

Question 3

How is croup spread and when is it most common?

Answer 3

Croup is spread via droplets. Outbreaks can occur in childcare settings or schools, and it is most common in autumn.

Question 4

What is the pathophysiology of croup?

Answer 4

• following a coryzal prodrome → WBC infiltrate the larynx, trachea and large bronchi ⇒ inflammation
• this inflammation causes oedema → partial airway obstruction
• when significant → this airway obstruction dramatically increases the work of breathing and causes the characteristic turbulent airflow = stridor

Question 5

How will a child with croup present?

Answer 5

• increased work of breathing
• low fever - <38 degrees
• hoarseness
• barking cough - worse at night
• stridor - insidious and progressive

Question 6

What features of respiratory distress may develop in croup?

Answer 6

• tachypnoea
• cyanosis
• head bobbing
• nasal flaring
• subcostal and intercostal recession
• suprasternal and sternal recession
• diaphragmatic breathing
• use of accessory muscles
• tracheal tugging

Question 7

What are some differentials of croup?

Answer 7

• viral URTI
• bronchiolitis - but no barking quality to cough
• epiglottitis - tripod or sniffing position, incomplete vaccination history more likely to be present
• foreign body aspiration
• bacterial tracheitis - significant tracheal tenderness on palpation, reluctant to cough because of pain

Question 8

What investigation should not be done on a child with croup and why?

Answer 8

A throat examination should not be done on a child with croup due to the risk of airway obstruction. This also applies to epiglottitis.

Question 9

How do you manage croup and severe croup?

Answer 9

• supportive care - fluids, rest
• during attacks - sit up child and comfort them
• oral dexamethasone - usually a single dose of 150mcg/kg → can be repeated if needed after 12 hours (A single dose of oral dexamethasone (0.15 mg/kg) is to be taken immediately regardless of severity)
• prednisolone is sometimes used as an alternative when dexa isn’t available
• in severe croup; oral dexamethasone, oxygen, nebs budesonide (corticosteroid), nebs adrenalin (faster results that nebuliser steroids( , intubation and ventilation (give oxygen + neb adrenaline)
• make sure to regularly check on child, including throughout the night

Question 10

What are the stepwise options in severe croup to control symptoms?

Answer 10

• oral dexamethasone
• oxygen
• nebulised budesonide
• nebulised adrenaline
• intubation and ventilation

Question 11

When should a child with croup be taken to the doctor or admitted?

Answer 11

A child with croup should be taken to the doctor or admitted if stridor is continually heard at rest, or if the skin between the ribs is pulling in with every breath, and/or the child is restless or agitated.