Croup

Question 1

Other name for croup?

Answer 1

Laryngotracheobronchitis

Question 2

Differential diagnoses?

Answer 2

Upper airway

• Inhaled foreign body
• Epiglottitis
• Bacterial tracheitis

Question 3

What to look for when assessing a child with croup?

Answer 3

Children with croup should have minimal examination. Do not examine throat. Do not upset child further.

• barking cough
• inspiratory stridor
• may have associated widespread wheeze
• increased work of breathing
• may have fever, but no signs of toxicity

Question 4

Risk factors for severe croup

Answer 4

• pre-existing narrowing of upper airways
  
  • subglottic stenosis (congenital or secondary to prolonged neonatal ventilation)
  • Down Syndrome
• previous admissions with severe croup
• uncommon <6 months, rare <3 months of age. Consider alternative diagnosis. Acute upper airway obstruction.

Question 5

Signs of mild croup?

Answer 5

Behaviour

Normal

Stridor*

Barking cough

Stridor only when active or upset

Respiratory Rate

Normal

Accessory Muscle Use

None or minimal

Oxygen

No oxygen requirement

Question 6

Signs of moderate croup?

Answer 6

Behaviour

Some/intermittent irritability

Stridor*

Some stridor at rest

Respiratory Rate

Increased Resp rate
Tracheal Tug
Nasal Flaring

Accessory Muscle Use

Moderate chest wall retraction

Oxygen

No oxygen requirement

Question 7

Signs of severe croup?

Answer 7

Behaviour

Increasing irritability and/or lethargy

Stridor*

Stridor present at rest

Respiratory Rate

Marked increase or decrease
Tracheal Tug
Nasal Flaring

Accessory Muscle Use

Marked chest wall retraction

Oxygen

Hypoxemia is a late sign of significant upper airways obstruction

Question 8

Investigations for croup?

Answer 8

not indicated unless child gets worse

Question 9

Management of a child with croup

Answer 9

Acute management

• minimal handling
  
  • includes limiting examination, nursing with parents.
• Supplemental oxygen is not usually required. If needed consider severe airways obstruction.
• Do not forcibly change a child’s posture - they will adopt the posture that minimises airways obstruction.
• No IV access - with further distress the child
• Avoid distressing the child further.

TREATMENT

Children with cough only do not require treatment.

Mild to Moderate Croup

• Prednisolone 1mg/kg, AND prescribe a second dose for the next evening.
• OR
• a single dose of Oral Dexamethasone 0.15mg/kg. (NB. Oral dexamethasone suspension ONLY available in hospitals, NOT available at commercial pharmacies)
• Observe for half an hour post steroid administration. Discharge once stridor-free at rest.

Severe croup

• Nebulised adrenaline: 5 mL of 1:1000 (5mg) adrenaline, undiluted.
• AND
• Give 0.6mg/kg (max 12mg) IM/IV dexamethasone
  
  • If good improvement, observe for 4 hours post adrenaline. Consider discharge once stridor free at rest.
• Improvement then deterioration
• Give further doses of adrenaline. Consider admission/transfer as appropriate.
• No improvement
• Reconsider diagnosis. Acute upper airway obstruction.