Croup

Quick Ref Guide

Document Severity @ discharge:  Remember sometimes well children that it is appropriate to discharge can deteriorate. So ensure the reason for your decision is well documented, and the patient is safety netted.

 

Background

  • Croup is a common cause of upper airway obstruction in young children.
  • It is usually mild and self-limiting, though occasionally it may cause severe respiratory obstruction
  • Croup, also known as laryngotracheobronchitis, is a clinical syndrome of a hoarse voice, barking cough and inspiratory stridor

 

Clinical Presentation

  • Typical History: Child typically aged 6-36 months. Usually 2-3 days coryzal symptoms, often low grade fever, usually happy to eat and drink, often presents at night.
  • Croup symptoms: Hoarse voice, barking cough, inspiratory stridor.
  • Clinical examination: Non-toxic child, well-perfused, possible tracheal and intercostal recessions.
  • Exclusion of other causes of upper airway obstruction (see Table).
  • Only when all 4 criteria are satisfied should the clinical condition of croup be diagnosed

Other causes of upper airway obstruction to exclude

Supraglottic Laryngeal / Subglottic Tracheal
Acute tonsillar enlargement

Epiglottitis

Retropharyngeal abscess

Foreign body (Hx of choking, no fever)

Acute angioedema 

Viral croup

Spasmodic croup

Laryngomalacia

Bacterial tracheitis (Septic)

Foreign body (Hx of choking, no fever)

Diphtheria(Grey Membrane)

Thermal / chemical injury

Trauma (i.e. with intubation)

Laryngospasm

Trauma (haematoma)

Foreign body (Hx of choking, no fever)

Bacterial tracheitis (Septic)

Congenital abnormality

Tumour

 

 

What to do

  • Assess severity: appearance, degrees of respiratory distress, oxygen desaturation
  • Disturb the child as little as possible: keep with parent, minimal monitoring (O2 sats only)
  • Hypoxia (<92%):  move to resus, give oxygen immediately and call for help – this is a LATE SIGN
  • Life threatening features: move to Resus and call for paediatric and anaesthetic support – start severe treatment, make preparations for intubation
  • Severe features: use nebulised adrenaline (5ml 1:1000), oral or nebulised steroids, repeat as necessary and call for senior help
  • Moderate features: oral steroids (dexamethasone 0.15mg/kg), refer to paeds for observation on PAU – if improves and meets discharge criteria – discharge with advice sheet
  • Mild features: oral steroids, if meets discharge criteria – discharge with advice sheet

 

Other treatments

  • Mist therapy: no benefits of mist therapy
  • Oral and nebulised steroids: are as effective as each other and effect seen within 30 mins. Prednisolone as efficacious as Dexamethasone but second dose after 12 hours required
  • Heliox: no benefit over standard treatments

 

Discharge Criteria

  • Presence of mild symptoms during initial evaluation or after a period of observation
  • Clinical diagnosis of croup i.e. no uncertain diagnosis
  • Age > 6 months
  • No known structural airway abnormality e.g. subglottic stenosis
  • Patient taking adequate fluids
  • If symptoms have not recurred within 4 hours of observation following treatment with epinephrine
  • Parents can return child for care if respiratory distress recurs at home
  • Parents have been advised when to seek medical intervention and have received the croup patient information leaflet

 

Reference:

Management of Croup in Children Over 3 Month (CHFT policy)

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