Croup

Question 1

What is it?

Answer 1

• = Laryngotracheobronchitis

- = Viral, respiratory infection of upper airway, larynx, trachea and bronchi

Question 2

Age group of croup

Answer 2

• Uncommon <6 months, rare <3 months of age. Consider alternative diagnosis e.g. acute upper airway obstruction.

Question 3

Most common causative organism of croup

Answer 3

• Viral: mostly parainfluenza virus, rarely RSV

Question 4

Features of croup

Answer 4

• Typically begins with coryza and URTI Sx (e.g. fever, rhinitis +/- cough)
• Barking croupy cough
• Breathing difficulty + tachypnoea
• Inspiratory stridor
• Widespread wheeze
• Hoarse voice

Question 5

Risk factors for croup

Answer 5

• Pre-existing narrowing of upper airways (e.g. Down syndrome, subglottic stenosis)
• Previous admissions with severe croup

Question 6

Normal course of croup

Answer 6

• Peak of cough 2-3 days, normal course of whole croup is 7-10 days

Question 7

What time of day is croup worse, and why?

Answer 7

• Cough worse at night, when air is cooler

Question 8

What should you remember about examination in croup?

Answer 8

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

Question 9

Roughly, what determines mild vs mod vs severe croup?

Answer 9

Mild:

• Normal behaviour, RR, WOB, O2 sat
• Barking cough, stridor only when upset

Mod:

• Irritable
• Inc RR, mod WOB (chest wall retraction, nasal flaring, tracheal tug), O2 sat ok
• Some stridor at rest

Severe:

• Irritable/lethargic
• Stridor always present at rest
• Inc/DEC RR, severe WOB (marked chest wall retraction etc)
• Hypoxaemia - late sign

Question 10

DDx for croup

Answer 10

• Inhaled foreign body
• Epiglottitis
• Bacterial tracheitis

Question 11

When Ix for croup

Answer 11

• Most not needed, may worsen symptoms

- <6mo warrants Ix

Question 12

Mx of mild, mod and severe croup

Answer 12

• Minimal handling
• IV access deferred
• No abx (viral), no antitussive (?sedation - can’t assess)
• Mild croup at home: calm, paracetamol to settle
• Mild to moderate croup
  ○ Prednisolone/dexa
  ○ D/C once stridor-free at rest
• Severe croup
  ○ Nebulised adrenaline + dexa IM/IV

Question 13

D/C requirements for croup

Answer 13

1. 4h post-nebulised adrenaline and/or half an hour post oral steroid
2. Stridor free at rest