Acute Viral Laryngotracheobronchitis (Croup) Flashcards
What is Croup? (Acute Viral Laryngotracheobronchitis)
Common childhood infection of the upper airway, which obstructs breathing and causes a characteristic barking cough
Presentation of Croup?
- Sudden onset ‘seal-like’ barking cough
- Stridor (Inspiratory)
- Hoarse voice
- Respiratory distress
- May be a fever
Which age group is most commonly affected by Croup?
Children 6 months – 3 years, but can affect as young as 3 months
Peak incidence is at 2 years of age
Pathophysiology of Croup
Viral URTI results in mucosal inflammation at the supraglottic, glottic, and tracheal level causing airway narrowing and turbulent airflow
- Characteristic barking cough is caused by the impaired movement of the vocal cords
- Stridor is caused by turbulent airflow
What is the most common organism which causes Croup?
Parainfluenza virus
List 2 risk factors for Croup
- Male
- Age between 6 months and six years
- Previous intubation
In which season is Croup most prevelant?
Autumn and Spring
Describe the typical clinical features from history of Croup
Incl red flag signs for respiratory failure!
- Typically a 1-4 day history of non-specific cough, rhinorrhoea and fever, progressing to a barking cough and hoarseness
- Symptoms worst at night
- Fever
Red Flag signs
- drowsiness
- lethargy
Describe the typical clinical features from history of Croup
Incl red flag signs for respiratory failure!
- Stridor
- Chest sounds may be normal or decreased (in severe airflow limitation)
- If in respiratory distress: tachypnoea, intercostal recession
- Red flag signs:
- cyanosis
- lethargic/decreased level of consciousness
- laboured breathing
- tachycardia
What clinical scoring system is used to assess severity of Croup?
Describe the parameters of this
Westley Croup Score
Features of “Mild” Croup using the Westley Croup Score
Seal-like barking cough but NO stridor or sternal/intercostal recession at rest
Features of “Moderate” Croup using the Westley Croup Score
Seal-like barking cough with stridor and sternal recession at rest
No agitation or lethargy
Features of “Severe” Croup using the Westley Croup Score
Seal-like barking cough with stridor and sternal/intercostal recession
Associated with agitation or lethargy
Features of “Impending respiratory failure” Croup
- ↑ upper airway obstruction
- sternal/intercostal recession
- asynchronous chest wall and abdominal movement
- fatigue
- pallor or cyanosis
- ↓ level of consciousness or tachycardia
Degree of chest wall recession may diminish with the onset of respiratory failure as the child tires
In additon to clinical features, what RR is also indicative of severe respiratory distress?
RR of over 70 breaths/minute
List 4 DDx for Croup
- Epiglottitis
- Foreign body
- Retropharyngeal abscess
- Acute anaphylaxis
List 2 URTIs in children which are/can be medical emergencies?
Acute Epiglottitis and very Severe Acute Croup
List 2 Bacterial URT infections
Acute Epiglottitis and Retropharyngeal abscess
Immediate management for Acute Epiglottitis?
- Leave the child with Mother. DO NOT Agitate the child
- Call for senior paediatrics AND Anaesthetics AND ENT
- May need to intubate
- May need a tracheostomy
- Once airway is secure then antibiotics and fluids can be given
List 4 clear differences in presentation and history of Croup vs Epiglottitis
Acute Epiglottitis =
- More systemically unwell → signs of sepsis
- ↑ fever >39 - may not be responsive to antipyretics
- Quieter, softer inspiratory stridor
- Altered level of consciousness
(Above is same for Retropharyngeal abscess)
Investigations for suspected Croup?
Mainly a clinical diagnosis
- FBC, CRP, U&Es
- Chest X-Ray to rule out ddx ie inhaled foreign bodies
- Pulse oximetry
- Risk scoring (if relevant)
Advice to parents for home management of mild Croup?
- paracetamol or ibuprofen can be used to control pain and fever
- ensure child has adequate fluid intake
- do NOT attempt to reduce fever by under-dressing child
- check on child regularly, incl through the night
Advise parents that symptoms usually resolve within 48 hrs but can last upto a week and that croup is a viral illness so antibiotics are not needed
Safety netting advice to parents for Croup
To seek urgent medical advice/ call an ambulance if symptoms worsen e.g.
- continual stridor
- difficulty breathing (skin between ribs is pulling in with every breath)
- restless, agitated or upset
- pale, blue, or grey in colour
- cannot talk, drooling, trouble swallowing
List 4 signs that a child with Croup is deteriorating?
- Louder OR Quieter stridor
- ↑or variable RR
- ↑ OR ↓ work of breathing
- ↑ abdominal breathing
- ↑ HR
- Altered level of consciousness, unable to settle, quieter than usual, reduced level of consciousness
What should be given to ALL children with mild, moderate, or severe croup?
A single dose of oral dexamethasone (↓ inflam, opens airway)
If child is too unwell, single dose inhaled budesonide (nebulised) or IM dexamethasome are possible alternatives
List 4 instances where we should consider admission for Croup
- RR > 60 breaths/minute or who have a high fever or ‘toxic’ appearance.
- chronic lung disease
- congenital heart disease
- NM disorders
- immunodeficiency
- age < 3 months
- inadequate fluid intake
- factors that might affect a carer’s ability to look after a child with croup
- longer distance to healthcare, in case of deterioration
When should Immediate hospital admission occur for Croup?
- Moderate/severe croup or impending respiratory failure
- You suspect a serious disorder caused by infection e.g. peritonsillar abscess, laryngeal diphtheria, or a non-infectious cause (foreign body)
???? Cant find this mentioned on NICE? Ask in workshop
