LARYNGEAL AND TRACHEAL INFLAMMATION

Question 1

What are the three main causes of laryngeal and tracheal inflammation and airway obstruction? Why is one of these causes now much more rare?

Answer 1

• Laryngotracheobronchitis (croup)
• Spasmodic or recurrent croup: barking cough
• Epiglottis: rare due to Haemophilus influenza type B (HiB) immunisation

Question 2

Croup is most often caused by which virus?

Answer 2

Parainfluenza

Question 3

A child presenting with barking cough, stridor and respiratory distress should be differentiated for which 2 main common conditions? How can you differentiate in terms of prodrome, time course, character of stridor and feeding?

Answer 3

Croup and epiglottits

• ​Prodrome: preceding cold in croup, not epiglottis
• Time course: days in croup, hours in epiglottis
• Character of stridor: hoarse in croup, weak or silent in epiglottis
• Feeding: can drink in croup, not epiglottis

Question 4

How do you assess the severity of croup? What specific parameters should you record?

Answer 4

• *C** – Cyanosis
• *R** – Recession of chest
• *O** – Oxygen saturations (keep >92%)
• *UP** – Upper airway obstruction e.g. stridor
• RR
• HR
• Consciousness
• Do not examine throat may cause acute obstruction
• Any clinical concerns call consultant paediatrician immediately

Question 5

How do you grade croup severity?

Answer 5

Question 6

What are the investigations in suspected croup?

Answer 6

**No investigations necessary, do not attempt to take blood or put in cannula

→ If diagnosis unclear, or severely unwell, call consultant as emergency measure**

Question 7

What is the management of mild to moderate croup?

Answer 7

• PO dexamethasone 150 microgram/kg
• Admit/observe for 4 hr
• PRN nebulised adrenaline 0.5 mL/kg of 1:1000
• Paracetamol or ibuprofen for discomfort
• Adequate fluid intake
• If parents do not clearly understand what to do, do not discharge

Question 8

What is the management of severe croup?

Answer 8

Keep child calm on nurse or parent’s lap and in position they find comfortable

• High flow oxygen 15 L/min (non-rebreather)
• Dexamethasone
• Nebulised adrenaline
  → if severe enough to need adrenaline likely to need admitting
  → Escalate to consultant urgently to assess whether to involve anaesthetist and ENT

Question 9

Croup: If no sustained improvement with adrenaline and dexamethasone what is the next step?

Answer 9

Continuous nebulised adrenaline

Secure airway in theatre by anaesthetist and transfer to PICU

Question 10

How do you treat a child with acute epiglottitis?

Answer 10

Endotracheal intubation → ITU

Blood cultures, IV antibiotics (HiB is gram negative bacteria) → 2nd or 3rd gen cephalosporin IV for 7 to 10 days. Rifampicin prophylaxis to close contacts