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Croup

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Croup

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Croup also know as laryngotracheobronchitis or laryngotracheitis has been reviewed on A4Medicine. Latest guidance has been reviewed and an easy to use visual on croup can guide the GPs in management. The dose of dexamethasone or prednisolone can often be confusing – it has been shown as per CKS guidance here.

Acute illness → mucosal swelling and inflammation of the larynx , subglottic area and upper trachea 
( Laryngotracheitis , Laryngotracheobrinchitis ) Usually viral 
○ Parainfluenza types 1 and 3 ( most common )
○ Enterovirus
○ Respiratory synctial virus
○ Influenza A and B
○ Adenovirus

Viral infection of laryngeal mucosa leads to inflammation , hyperemia , edema , epithelial necrosis and shedding → narrowing of the subglottic region
 Spread is usually through the air or by contact with infected secretions More common in boys than girls Usually affects children 6 months to 3 yrs of age 
( some mention 6 months to 6 yrs ) Peak incidence 2nd year or life More common in late fall and early winter

Clinical features- Sudden onset of a seal- like barking cough Inspiratory stridor Hoarse voice Variable respiratory distress ( Airway obstruction ) No to moderately high fever Symptoms worse at night Absence of drooling Non toxic appearance Often preceding 1-4 day h/o non-specific cough , rhinorrhoe or fever Symptoms typically resolve within 3-7 days but can last as long as 2 weeks

Differential diagnosis- Acute epiglottitis Bacterial tracheitis Peritonsillar / Retropharyngeal abscess Inhaled foreign body Angiodema Anaphylaxis

rule out-Epiglottitis→ caused by H influenza B infection
○ intense swelling of the epiglottis and surrounding tissue leading to airway obstruction
○ acute onset with a few hrs of high fever , lethargy , soft inspiratory stridor and rapidly worsening resp distress
○ difficulty swallowing and a sore throat
○ minimal to no cough
○ child sits up , leans forward and drools
○ rare now ( HiB vaccine )


Bacterial Tracheitis →infection of tracheal mucosa
○ staph aureus or streptococci
○ child looks unwell ( septic or toxic )
○ high fever , croupy cough
○ copious secretions and mucosal necrosis
○ no drooling
○ can be difficult to distinguish from croup- consider in a child who has high fever and has not responded to treatment of croup


Both are potentially fatal if missed and are airway emergencies . Management is to secure airway and administer appropriate antibiotics

Assessment-Initial assessment should follow the Primary Survey ABCDE approach. Mild croup-Ocassional barking and no audible stridor at rest No or minimal suprasternal and or intercostal recession Child is happy , prepared to eat drink and play

All children with mild , moderate or severe croup → administer single dose of oral dexamethasone ( 0.15 mg per kg body weight ) If exact weight not possible- as a rough guide
○ 1.5 to 2mg for a child average size aged 12-15 months
○ 2-3 mg for a child average size aged 3-4 yrs
○ improvement should begin from 2 hrs post administration
○ anti inflammatory effect of dexamethasone lasts 2-4 days
 Oral prednisolone ( 1-2 mg per kg body weight ) is an alternative
○ Consider giving a second dose if residual symptoms of stridor are still present the following day

Moderate croup-Frequent barking cough Easily audible stridor at rest Suprasternal and sternal wall retraction at rest No or little distress or agitation

Severe croup-Frequent barking cough Prominent inspiratory and occasionally expiratory stridor Marked sternal wall retractions Significant distress and agitation Tachycardia occurs with more severe obstructive symptoms and hypoxaemia

Impending respiratory failure-Barky cough ( often not prominent ) Audible stridor at rest ( occasionally hard to hear ) Sternal wall retractions ( may not be marked as respiratory failure progresses ) Lethargy or decreased level of consciousness Often dusky appearance without supplemental oxygen A child who appears to be deteriorating but whose stridor appears to be improving has worsening airways obstruction and is at high risk of complete airway obstruction

Management-Significant respiratory symptoms persisting at least 4 hrs after steroid administration
○ audible stridor at rest
○ sig respiratory effort
○ oxygen requirement
 If you suspect a serious disorder -
○ caused by infection – epiglottitis , bacterial tracheitis , peritonsillar abscess or laryngeal diptheria
○ not caused by infection – foreign body , angioneurotic oedema , hypocalcaemic tetany or ingestion of corrosives
 Immediate admission for a child who has moderate or severe croup or impending respiratory failure
 Mid croup can be managed at home. However consider admission if any of following present -
○ h/o severe obstruction
○ previous severe croup
○ structural upper airways abnormality eg larnygomalacia , tracheomalacia , vascular ring , Down’s syndrome ( ↑ ed risk of severe croup )
 Less than 6 months of age
 Immunocompromised Inadequate fluid intake or is refusing fluids Poor response to oral treatment Uncertain diagnosis Sig parental anxiety Late evening or night – time presentation Child’s home long way from the hospital No transport

Prognosis-Advice that croup 
is self limiting and usually resolves within 48 hrs
 ( occasionally may last 
up to a week )

Do not advice humidified
 air eg steam inhalation Explain that cough medicines , decongestants and 
SABA are not effective

safety-netting advice –Advice parents to seek urgent medical advice if
 Progression from mild to moderate airway obstruction such as intermittent stridor at rest or ↑ ed effort of breathing
 (chest and suprasternal in-drawing ) If child becomes toxic ( pale , very high fever , tachycardia ) → ? alternative diagnosis Cyanosed Unusually sleepy Struggling to breathe

References ; Further reading Croup an Overview AAFP via http://www.aafp.org/afp/2011/0501/p1067.html South Australian Paediatric Guidelines Acute Croup in Children via https://www.sahealth.sa.gov.au/wps/wcm/connect/
0dc0488040d03df596cabe40b897efc8/Acute+Croup+in+Children
_Aug2013.pdf?MOD=AJPERES&CACHEID=0dc0488040d03df596cabe40b897efc8 Croup-E Medicine via http://emedicine.medscape.com/article/962972-overview Croup NHS Greater Glasgow and Clyde via http://www.clinicalguidelines.scot.nhs.uk/Emergency%20Medicine/YOR-AE-008%20Croup.pdf Clinical Guideline for the Management of Viral croup – Royal Cornwall Hospitals via http://www.rcht.nhs.uk/DocumentsLibrary/RoyalCornwallHospitalsTrust/
Clinical/Paediatrics/ViralLaryngoTracheobronchitisCroupManagementOf.pdf Croup by John T McBride MD via http://www.merckmanuals.com/professional/pediatrics/respiratory-
disorders-in-young-children/croup Diagnosis and Management of Croup Clinical Practice Guideline January 2008 via http://www.topalbertadoctors.org/download/252/croup_guideline.pdf CKS NHS via http://cks.nice.org.uk/croup#!scenario Croup : Diagnosis and Treatment M Canciani et al Breathe June 2006 Volume 2 No 4

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