Croup

Question 1

Definition

Answer 1

Inflammation of supraglottic tissues +/- tracheobrochial tree
Swelling of mucosa, thick/viscous/mucopurulent exudate->compresses upper airway

Question 2

Etiolgy

Answer 2

Viral

Parainfluenza most commonly

Question 3

Differential

Answer 3

Inhaled foreign body
Epiglottitis
Bacterial tracheitis

Question 4

Age commonly affected

Answer 4

6mo-3 years

Question 5

Clinical features

Answer 5

• barking cough
• inspiratory stridor
• may have associated widespread wheeze
• increased work of breathing
• may have fever, but no signs of toxicity
• may or may not have wheeze, hoarse voice

Question 6

Signs (3 S’s)

Answer 6

Stridor
Supraglottic swelling
Seal bark cough

Question 7

Assessment core

Answer 7

Minimal examination
Do not examine throat
Do not upset child

Question 8

Recurrent croup- risk

Answer 8

Supraglottic stenosis
Down syndrome
Previous admission for severe

Question 9

Features used to identify severity

Answer 9

Behaviour
Stridor
Respiratory rate
Accessory muscle use
Oxygen

Question 10

Severity assessment- mild

Answer 10

Normal behaviour
Barking cough, stridor only when active/upset
Normal RR
No accessory
No oxygen required

Question 11

Severity assessment- moderate

Answer 11

Some/intermittent irritability
Some stridor at rest
\+RR, tracheal tug, nasal flaring
Mod chest wall retraction
No oxygen

Question 12

Severity assessment- severe

Answer 12

\+Irritability, lethargy
Stridor at rest
\++/-ve RR
Tracheal tug
Nasal flaring
\++chest wall retraction
Hypoxemia is late and significant sign of upper airways obstruction

Question 13

Investiagtions

Answer 13

Investigations may not be done/necessary
Nasopharyngeal aspirate
CXR
Blood tests not usually indicated

Question 14

Acute management

Answer 14

ABCD- get help
Minimal handling
Assess severity
If O2 needed, consider severe airway obstruction
Do not forcibly change childs position
Defer IV access
Avoid distressing further

Question 15

Benefit of steroids

Answer 15

Decrease hospital stay

Decrease need for nebulised adrenline and other interventions

Question 16

Management of mild-moderate

Answer 16

Prednisolone 1mg/kg, AND prescribe a second dose for the next evening.
OR
a single dose of Oral Dexamethasone 0.15mg/kg.

Observe for half an hour post administration. D/c once stridor free at rest

Question 17

Management of severe, when improvement, then deterioration, no improvement

Answer 17

Nebulised adrenaline (1 mL of 1% adrenaline solution* plus 3ml Normal Saline, or 4ml of adrenaline 1:1000.)

(*some hospitals stock bottles of 1% adrenaline solution, often for ophthalmic use. If not available use 1:1000 vials)

AND

Give 0.6mg/kg (max 12mg) IM/IV dexamethasone, ?consider if can give orally

Improvement

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.

Question 18

When to consider consultation with local pediatric team

Answer 18

Severe airway obstruction
No improvement with adrenalin
Child has risk factors

Question 19

When to consider transfer

Answer 19

No improvement with adrenalin
>2 doses neb adrenalin
Child requiring care above that which can be comfortably given at that hospital

Question 20

Risk factors for severe croup

Answer 20

Downs
Neurological
Sub glottic stenosis
Previous admission with severe
uncommon->need to consider alternate diagnoses

Admit even if mild disease

Question 21

How long after giving nebulised adrenalin do you need to observe patients

Answer 21

4 hours

Adrenalin can wear off, prior to effect of steroids and can then deteriorate

Question 22

Patient advice overview

Answer 22

Signs and symptoms of croup
When to advise on return to hospital
When to advise calling an ambulance

Question 23

Patient advice on signs and symptoms of croup

Answer 23

Hoarse voice
Barking cough
Stridor
Fever

Question 24

Patient advise on when to return to hospital

Answer 24

Continuous stridor
Intercostal recession
Irritability

Question 25

Patient advise on when to call the ambulance

Answer 25

Parents should be instructed to call an ambulance if:

The child’s face is very pale, blue, or grey (includes blue lips) for more than a few seconds

The child is unusually sleepy or is not responding

The child is having a lot of trouble breathing (e.g., the belly is sinking in while breathing, or the skin between the ribs or over the windpipe is pulling in with each breath; the nostrils may also be flaring in and out)

The child is upset (agitated or restless) while struggling to breathe and cannot be calmed down quickly

The child wants to sit instead of lie down

The child cannot talk, is drooling, or having trouble swallowing.