Respiratory: Croup Flashcards
Croup is a term used to describe what?
Viral laryngotracheobronchitis
In rare cases bacterial tracheitis
What are the main features of croup?
Coryza and fever followed by:
Stridor
Barking cough
Hoarseness due to inflammation of vocal cords
Variable degree of difficulty breathing with chest retraction
When are the symptoms often worse?
At night
Between what ages does croup occur?
6 months to 3 years
But can occur in children as young as 3 months and in older children and teens
What causes croup?
Parainfluenza virus - accounts for majority of cases
Adenovirus
Influenza virus
Respiratory syncytial virus
Is the onset sudden or gradual?
Sudden
What age is the peak incidence?
2 years old
What time of year does it most commonly occur?
Autumn and winter
Describe the pathophysiology
Subglottic oedema, inflammation and infiltration of inflammatory cells causing narrowing of the subglottic airway and increased work of breathing
Does it have a prodromal phase?
Yes 1-2 days of:
Rhinitis
Low grade fever
Possible erythematous pharynx
The severity of croup symptoms can be classified into..
Mild
Moderate
Severe
Describe mild croup
Seal like barking cough
No stridor
No sternal/ intercostal recession at rest
Describe moderate croup
Seal like barking cough with stridor and sternal recession at rest
No agitation or lethargy
Describe severe croup
Seal like barking cough with stridor and sternal/ intercostal recession
Associated agitation or lethargy
What indicates impending respiratory failure?
Increasing upper airway obstruction Sternal/ intercostal recession Asynchronous chest wall and abdominal movement Fatigue Pallor or cyanosis Decreased level of consciousness Tachycardia RR over 70/ min also indicative or respiratory distress
Who should be admitted?
Features of moderate or severe illness
Or if mild plus chronic lung disease, neuromuscular disorders, immunodeficiency, under 6 months old, inadequate fluid intake, concerns that carer may not be able to spot deterioration, uncertainty about diagnosis
What should be done for mild illness?
Single dose oral dexamethasone 0.15mg/kg
(Oral prednisolone is alternative if dexamethasone not available)
Advise parents that symptoms usually resolve in 48 hours
Encourage fluids (in most cases oral adequate)
Paracetamol or ibuprofen if child uncomfortable
Check on them regularly
A second dose of dexamethasone considered if residual symptoms of stridor or if patient returns
How should moderate disease be managed?
Oral dexamethasone or nebulise budesonide if cannot take orally
O2 if saturations below 92%
How should severe croup be managed?
Nebulised adrenaline 0.4mg/kg (max 5mg) of 1:1000 solution
Nebulised budesonide
Notify CICU
Urgent senior review
What should you do if respiratory failure?
Alert CICU
Fast bleep senior SpR, ENT and anaesthetics
Nebulised adrenaline
Nebulised budesonide
Do not attempt IV access unless airway secure or senior input
In severe disease will stridor be soft?
Yes
Is croup a common illness?
Yes
The majority of those with croup have mild to moderate symptoms, but severe croup can result in…
Significant airway compromise
Needs expert airway management
Children with croup should be approached in what manner?
Calm as unnecessary upset will increase respiratory distress
Can most cases be managed in primary care?
Yes
Up to 30% require hospitalisation - of these less than 2% require intubation
How long do symptoms typically last?
3-5 days, can last up to 2 weeks
When assessing the child what general principles should you follow?
Assess child where most comfortable e.g on parents lap
Avoid distressing child
Assess degree of airway obstruction, not loudness of stridor
Should you examine the throat?
No!
Do children with croup need an X-ray or IV access?
No
What should the assessment include?
A - biphasic stridor, dysphonia, drooling and dysphagia all concerning. Beware quietening stridor and increased resp distress
B - assess work of breathing and effectiveness of respiration, look for recessions, tiring and falling saturations
C - assess for shock and cardiovascular effects of impending respiratory failure
D - deteriorating or altering consciousness is a sign of severe upper airway obstruction
What differentials of acute airway issues are there?
Tracheitis
Epiglottitis
Foreign body
Angioedema
If a child receives nebulised adrenaline, they will need what?
At least 3-4 hours of normal observations prior to discharge
What is the criteria for discharge?
Absent/ mild intermittent stridor with saturations above 93%
And other diagnosis considered and excluded
And parents confident they can manage the child
Should steroids be routinely given as TTO?
No
Children with what condition are more prone to croup?
Down syndrome
Children with pre existing narrowing of upper airways e.g subglottic stenosis
What discharge advice should be given?
Highlight red flag features: stridor at rest, difficulty breathing, pallor or cyanosis, severe cough spells, drooling of difficulty swallowing, fatigue, prolonged symptoms > 7 days
Above needs prompt review
What sign can be seen on CXR?
Steeple sign - subglottic narrowing
Is croup the most common cause of acute URT obstruction?
Yes
