Croup

Question 1

Croup - background

Answer 1

1. Definition = respiratory illness characterised by inspiratory stridor, cough and hoarseness
2. Viral inflammation of upper airway, larynx, trachea and bronchi
3. Barking cough = hallmark amongst infants and young children
4. Epi = generally affects children b/n 6mo and 6y; peak incidence during 2nd year of life
5. Most common viruses = parainfluenza virus type 1 or 3, respiratory syncytial virus (10%)

Question 2

Croup - symptoms

Answer 2

Usually begins with:

1. Fever, rhinitis
2. Cough = barking, croupy, usually beginning during the night/early hours of the morning (barking cough = hallmark)

As the disease progresses:

3. Stridor may be heard on exertion initially. If obstruction progresses further, may be heard at rest + expiratory component may be heard. Typical cough continues to be heard
4. If obstruction worsens, child may become distressed and restless. Cough and stridor may be absent (bc amount of air moving is not sufficient to generate cough/noise)
5. Resolution/time course - viral illness lasts 7-10d, but typical cough usually only occurs on first 2-3 nights

Question 3

Croup - signs

Answer 3

1. Minimal examination. Do not examine throat. Do not upset child further
2. Barking cough
3. Inspiratory stridor
4. Associated widespread wheeze. May have increased WOB
5. May have fever

Note: the loudness of the stridor is not a good guide to the severity of the obstruction

Question 4

Croup - ax of severity

Answer 4

1. Mild (5)
   - Normal behaviour
   - Barking cough, stridor only when active or upset
   - RR normal
   - WOB none or minimal, no accessory muscle use
   - No oxygen requirement
2. Moderate (5)
   - Intermittent irritability
   - Some stridor at rest
   - Increased RR
   - Increased WOB with moderate chest wall retraction, tracheal tug and nasal flaring
   - No oxygen requirement
3. Severe (5)
   - Increasing irritability +/- lethargy
   - Stridor present at rest
   - Marked increase or decrease in RR
   - Increased WOB with marked chest wall retraction, tracheal tug and nasal flaring
   - Hypoxaemia - late sign of significant upper airway obstruction

*Note: the loudness of the stridor is not a good guide to the severity of the obstruction

Question 5

Croup - RF for severe croup (3)

Answer 5

Pre-existing narrowing of upper airways
1. Subglotting stenosis (congenital or secondary to prolonged neonatal ventilation)
2. Down syndrome
\_\_
3. Previous admissions with severe croup

Question 6

Croup - ix (2 x 2)

Answer 6

1. Most children with croup do not warrant any ix (may cause child distress and worsening of symptoms)
   i. Viral dx on nasal secretions (NPA) helpful for epi but does not alter mx
   ii. CXR not helpful for typical croup
2. If children

Question 7

Croup - mx

Answer 7

Acute management (5)

1. Minimal handling. Limit examination, nurse with parents. Avoid distressing the child further
2. Supplemental oxygen not usually required. If needed, consider severe airway obstruction
3. Do not forcibly change a child’s posture. They will adopt the posture that minimises airway obstruction
4. Defer IV access
5. Consider transfer when no improvement following nebulised adrenaline, >2 doses of nebulised adrenaline required or if child requires care above the level provided by the local hospital

Main tx
Mild to moderate croup (3)
1. Children with cough only do not require treatment
2. If stridor, give oral prednisolone 1mg/kg + second dose for next evening, or single dose oral dexamethasone 0.15mg/kg
3. Observe for half an hour post steroid admission; discharge once steroid free at rest

Severe croup

1. Nebulised adrenaline (1mL of 1% adrenaline solution + 3mL normal saline, or 4mL adrenaline 1:1000), AND
2. 0.6mg/kg (max 12mg) IM or IV dexamethasone
3. If good improvement, observe for 4hrs post-adrenaline. Consider discharge once stridor-free at rest
4. If improvement then deterioration, give further doses of adrenaline; consider admission/transfer as appropriate
5. If no improvement, reconsider dx. Acute upper airway obstruction

Question 8

Croup vs. epiglottitis

Answer 8

Epiglottitis has:

1. Abrupt onset and rapid progression (within hours) of dysphagia, drooling and distress (3 Ds). Sudden onset of high fever (38.8-40 deg C)
2. Cough typically absent
3. Usually appear ‘toxic’ (but wide spectrum of severity)