Croup - GM

Question 1

another name for croup

Answer 1

laryngotracheobronchitis

Question 2

what is croup

Answer 2

upper respiratory tract infection commonly caused by viral infection

Question 3

what age does croup occur

Answer 3

aged 6months - 3 years old

Question 4

croup presents primarily with

Answer 4

characteristic barking cough, inspiratory stridor, respiratory distress

Question 5

which type of stridor does croup present with

Answer 5

inspiratory

Question 6

pathophysiology of croup

Answer 6

upper respiratory tract infection inflames the mucosa in the larynx
this inflammation causes airway obstruction leading to turbulent airflow resulting in audible stridor

Question 7

poiseuille’s law

Answer 7

resistance to laminar airway increase in inverse proportion to the fourth power of the radius of the lumen

therefore, a small reduction in airway radius (due to inflammation and secretions) dramatically increases resistance to airflow and therefore work of breathing

Question 8

croup is most commonly caused by

Answer 8

parainfluenza viruses and respiratory syncytial virus (RSV) but can be caused by other viruses

Question 9

risk factors

Answer 9

age: croup most commonly occurs in children aged 6-36 months
family history
male (the male:female ratio is 1.4:1)
congenital airway narrowing
hyperactive airways
acquired airway narrowing

Question 10

features of croup on history

Answer 10

upper respiratory tract symptoms including coryza and nasal congestion/discharge
fever
hoarse voice
coryza
barking cough (often described as seal-like)
inspiratory stridor
symptoms worse at night
no history of inhaled foreign body

Question 11

approach of clinical examination

Answer 11

clinical examination should not agitate the child as this will worsen respiratory distress
guidelines recommend minimal handing of the child
throat exmination is rarely required but may be considered if the diagnosis is unclear, but not if epiglottitis is suspected
ABCDE assessment
further exmination can be performed once the situation is stabilised, which may include ENT examination, examination of cervical lymph nodes, lung auscultation and assessment of rashes

Question 12

typical clinical findings of croup

Answer 12

increased work of breathing: intercostal and sternal recession
agitation: in severe croup
lethargy: in severe croup

Question 13

clinical severity of croup

Answer 13

loudness of stridor is not an indication of severity of croup

Question 14

differential diagnosis

Answer 14

epiglottitis
upper airway abscess
foreign body inhalation
allergic reaction / anaphylaxis
injury to the airway
congenital airway anomalies (eg. laryngomalacia, tracheomalacia)
bronchogenic cyst
bacterial tracheitis
early Guillian barre syndrome

Question 15

how to tell epiglottitis apart from croup

Answer 15

presents without the barking cough seen in croup, child will appear anxious, pale and toxic.
difficulty swallowing is associated with increased rolling, fever and typically patients sit in an upright position
these children should have minimal handling, do not examine the mouth

Question 16

how to tell upper airway abscess apart from croup

Answer 16

such as peritonsillar, paraapharyngeal and retropharyngeal. may present with fevers, stiff neck, torticollis, drooling or hot potato voice
absence of barking cough

Question 17

how to tell foreign body inhalation apart from croup

Answer 17

sudden onset stridor and respiratory distress with Hx of choking
may also present with a barking cough and stridor depending on the location of the obstruction
importantly, there will be no fever

Question 18

diagnosis of croup

Answer 18

clinical diagnosis, does not require investigation
routine viral testing is not required as it does not change management
chest x-ray not indicated (except for those considered for paediatric critical care admission)

Question 19

chest x-ray in croup

Answer 19

not required, but will demonstrate the steeple sign due to subglottic narrowing

Question 20

general rules for management

Answer 20

all children whopresent to emergency department with croup should receive corticosteroids
additional treatment depend on severity and may include nebulised adrenaline
croup is self-limiting, management aims to reduce severity and avoid need for intubation

Question 21

if the croup seems life threatening

Answer 21

Question 22

assessing severity of symptoms

Answer 22

Question 23

severe croup looks like

Answer 23

stridor at rest
marked recession
tracheal tug
drooling
pale or mottled

Question 24

moderate croup looks like

Answer 24

stridor at rest
mild recession
+/- tracheal tug
child interested in surroundings

Question 25

mild croup looks like

Answer 25

barking cough
hoarse cry
stridor soft or absent
no recession or tracheal tug

Question 26

management of severe croup

Answer 26

nebulised adrenaline - can be repeated after 15 minutes
oxygen to correct hypoxia if present
dexamethasone
observe for minimum of 3 hours following dose of adrenaline, due to risk of rebound symptoms when adrenaline wears off

Question 27

management of moderate croup

Answer 27

dexamethasone oral
observe closely over next hour

Question 28

management of mild croup

Answer 28

oral dexmethasone
discharge home with written advice sheet

Question 29

why do you have to monitor after nebulised adrenaline

Answer 29

due to risk of rebound symptoms after the adrenaline wears off

Question 30

when to admit to hospital

Answer 30

severe croup
moderate to severe croup but with deterioration or repeated doses of adrenaline
toxic appearing child
oxygen requirement
inability to tolerate oral fluid intake

Question 31

complications of croup

Answer 31

most children should resolve within 3 days
complications are uncommon but may include:
- secondary bacterial infections (including bacterial tracheitis, bronchopneumonia and pnuemonia)
- post obstructive pulmonary oedema
- pneumothorax
- pneumomediastinum

Question 32

resuscitation

Answer 32

transfer to resus room and activate resus team
give nebulised adrenaline immidiatley
administer high flow oxygen (via non-rebreather mask)
call PCC, anaesthetics, and ENT assistance
prepare for intubation (ideally done in operating theatre by anaesthetic and ENT teams)

Question 33

all severe and life threatening croup should be discussed with

Answer 33

discussed with a senoir doctor +/- the paediatric critical care unit
child should be admittd under general paediatric team

Question 34

how to use corticosteroids for croup

Answer 34

steroids start working by 30 minutes and reduce time in hospital, instances of intubation and reduce likelihood of relapse after discharge
steroid therapy treats stridor, but does not resolve underlying viral symptoms
a single dose is usually all that is required for mild to moderate croup

Question 35

which corticosteroid should ideally be used for all croup presentations

Answer 35

dexamethasone PO

Question 36

which corticosteroid can you use if dexamethasone is not available

Answer 36

prednisolone PO

Question 37

which carticosteroid can you use if oral steroids are not tolerated

Answer 37

Dexamethasone IM

Question 38

which corticostroid should you use for severe cases of croup (ie. PCC candidates)

Answer 38

dexamethasone IV

Question 39

discharge criteria for the child with croup

Answer 39

clinically improved
steroids recieved
no stridor at rest
no other clinical or social concerns