Croup

Question 1

Definition

Answer 1

• laryngotracheobronchitis
• inflamation of the larynx and trachea

The MOST COMMON cause are parainfluenza viruses
Other viruses:
* Rhinovirus
* RSV
* Influenza

Viral infection leads to generalised inflammation and oedema of the airways which causes upper airway obstruction. This can lead to narrowing of the subglottic regions leading the characteristic signs and symptoms of barking cough and harsh inspiratory stridor

Age range affected: 6 months to 6 years
* Peak incidence: 1-2 years
* More common in autumn
* Symptoms peak after 1-2 days

RFs: FHx, LBW/ Prematurity , Autumn/ winter , M > F

DDx
* Layngomalacia
* Acute epiglottis
* Inhaled foreign body

Question 2

Symptoms

Answer 2

1st… coryzal symptoms and low fever

2nd… “Barking cough” like a ‘sea-lion’ (from tracheal oedema and collapse) and stridor (from inflamed/oedematous airways)

Hoarseness- due to inflammation of the vocal cords

Variable degree of breathing difficulty with chest retraction

Symptoms often start, and are WORSE at night

Question 3

Signs

Answer 3

Respiratory distress/ failure:

• Persistent agitation
• Lethargy/ fatigue
• Asynchronous chest wall and abdominal movement - increased work of breathing (use of accessory muscles)
• Pallor/ cyanosis
• Decreased level of consciousness

NOTE: if upper airway obstruction is MILD, then stridor and chest recession will disappear when the child is at rest, so can be managed at home

Children < 12 months old have a low threshold for hospital admission

Question 4

Investigations

Answer 4

• Basic observations - oxygen saturation
• Examination- DO NOT EXAMINE THE THROAT -> risk of airway obstruction

Usually CLINICAL diagnosis
* If CXR is done- ‘steeple sign’ (subglottic narrowing in PA view)

Question 5

Management

Answer 5

Westley score classification:

Mild
* Seal-like barking cough but NO stridor or sternal/ intercostal recession at rest
* Child can usually be managed at home

Moderate
* Seal-like barking cough WITH stridor and sternal recession at rest
* NO agitation and lethargy

Severe - while waiting for hospital admission, give controlled supplementary oxygen and admin oral dex
* Seal-like barking cough WITH stridor and sternal/ intercostal recession
* Associated with agitation or lethargy

Impending respiratory failure:
* Increasing upper airway obstruction
* Sternal/ intercostal recession
* Asynchronous chest wall and abdominal movement
* Fatigue
* Pallor/ cyanosis
* Reduced consciousness
* Respiratory rate > 70 breaths per minute

IMPORTANT: admit ALL children with croup that is > mild (unless have factors warranting admission e.g. < 6 months, chronic lung disease, inadequate fluid intake, neuromusc disorders, Down’s syndrome, immunodeficiency)

Mild: Oral dexamethasone (0.15mg/kg) + discharge

Advise:
* “With oral dexamethasone, the symptoms should resolve within 48 hours”
* Advise to seek medical attention if stridor continues, skin between the ribs is pulling in, if the child is restless or agitated
* Advise to call an ambulance if very pale, blue or grey for more than a few seconds, unusually sleep or unresponsive, having a lot of trouble breathing or generally unwell
* Paracetamol or ibuprofen can be used if the child has a fever and is distressed
* Advise good fluid intake
* Advise parents to check the child regularly during the night
* Sit child up if having a coughing fit

Moderate: ADMIT + dexamethasone PO single dose
* Nebulised adrenaline is given - if nebulised steroids haven’t worked

Severe: ADMIT
* Oral/ IV dexamethasone (0.15mg/kg)
* Nebulised adrenaline with oxygen by face (non-rebreathe) mask- causes rapid but transient improvement
* Give this first if they are severe as they wouldn’t be able to swallow dexamethasone

Impending respiratory failure (RR>70) ADMIT + dexamethasone ± adrenaline

Question 6

Management summary

Answer 6

Question 7

Complications

Answer 7

Complications

• Severe upper airway obstruction can rarely lead to respiratory failure and arrest
• Intubation may be required in those with impending respiratory failure
• Secondary bacterial superinfection
• Pulmonary oedema
• Pneumothorax

Prognosis

• Self-limiting even without treatment
• Symptoms resolve without significant complications

Question 8

PACES

Answer 8

PACES Counselling:

Name of Diagnosis:

Durai has an airway infection called croup

Briefly explain what it is:

It is usually caused by a virus and typically occurs in children in this age group.

It typically causes mild symptoms, including cold like symptoms, barking cough and noise whilst breathing in

How is it managed:

We are going to give your child a single dose of a steroid, which will help to decrease the inflammation in the airway

This should help Durai to improve his breathing and help him feel more comfortable

As this is a moderate case of croup, we would like to admit him for further observation and oxygen therapy if needed.

Usually, children will start to improve with treatment without complications

Risks/Safety net (Mum to ask what additional symptoms will make this a severe case of croup?):

If Durai had presented to us feeling very tired, very agitated and didn’t look well at all, then we would be slightly more concerned and think about escalating treatment quicker

Leaflets/Offer more information:

Does this all make sense? Do you have any questions?

*Croup Key Management Points

Ask candidate to classify severity of croup -> MODERATE CROUP in this case

Give PO Dexamethasone (0.15mg/kg) IMMEDIATELY

Admit to hospital for further care