Croup_Flashcards
What is croup and what commonly causes it?
Croup is an upper respiratory tract infection in infants and toddlers characterized by stridor due to laryngeal edema and secretions, with parainfluenza viruses being the most common cause.
What is the peak incidence age and seasonal occurrence of croup?
The peak incidence of croup is between 6 months and 3 years of age, and it is more common in autumn.
What are the clinical features of croup?
Clinical features include a barking, seal-like cough that worsens at night, stridor, fever, coryzal symptoms, and increased work of breathing, such as retractions.
How is the severity of croup graded according to Clinical Knowledge Summaries (CKS)?
Severity is graded as mild (occasional cough, no stridor at rest), moderate (frequent cough, audible stridor, some retractions), and severe (constant cough, prominent stridor, marked retractions, distress or lethargy).
When should a child with croup be admitted to the hospital?
Admission is recommended for children with moderate or severe croup, those under 3 months old, those with known upper airway abnormalities, or where there is uncertainty about the diagnosis.
What does a chest X-ray show in a child with croup?
A posterior-anterior view shows subglottic narrowing, known as the ‘steeple sign’. A lateral view in cases of acute epiglottitis shows epiglottis swelling, the ‘thumb sign’.
What is the recommended management for croup?
Management includes a single dose of oral dexamethasone (0.15mg/kg) for all severity levels. Prednisolone is an alternative if dexamethasone is unavailable.
What are emergency treatments for croup?
Emergency treatments include high-flow oxygen and nebulised adrenaline.
summarise
Croup
Croup is a form of upper respiratory tract infection seen in infants and toddlers. It is characterised by stridor which is caused by a combination of laryngeal oedema and secretions. Parainfluenza viruses account for the majority of cases.
Epidemiology
peak incidence at 6 months - 3 years
more common in autumn
Features
cough
barking, seal-like
worse at night
stridor
remember, the throat should be not examined due to the risk of precipitating airway obstruction
fever
coryzal symptoms
increased work of breathing e.g. retraction
Clinical Knowledge Summaries (CKS) suggest using the following criteria to grade the severity:
Mild
Occasional barking cough
No audible stridor at rest
No or mild suprasternal and/or intercostal recession
The child is happy and is prepared to eat, drink, and play
Moderate
Frequent barking cough
Easily audible stridor at rest
Suprasternal and sternal wall retraction at rest
No or little distress or agitation
The child can be placated and is interested in its surroundings
Severe
Frequent barking cough
Prominent inspiratory (and occasionally, expiratory) stridor at rest
Marked sternal wall retractions
Significant distress and agitation, or lethargy or restlessness (a sign of hypoxaemia)
Tachycardia occurs with more severe obstructive symptoms and hypoxaemia
CKS suggest admitting any child with:
moderate or severe croup
< 3 months of age
known upper airway abnormalities (e.g. Laryngomalacia, Down’s syndrome)
uncertainty about diagnosis (important differentials include acute epiglottitis, bacterial tracheitis, peritonsillar abscess and foreign body inhalation)
Investigations
the vast majority of children are diagnosed clinically
however, if a chest x-ray is done:
a posterior-anterior view will show subglottic narrowing, commonly called the ‘steeple sign’
in contrast, a lateral view in acute epiglottis will show swelling of the epiglottis - the ‘thumb sign’
Management
CKS recommend giving a single dose of oral dexamethasone (0.15mg/kg) to all children regardless of severity
prednisolone is an alternative if dexamethasone is not available
Emergency treatment
high-flow oxygen
nebulised adrenaline
A 9-month-old baby is brought to the emergency department by his father. He has had a barking cough for the past 3 days and his father says he has been feeding poorly for the past 4 days. On examination the child does not appear agitated and is easily distracted by his toys. The barking cough is audible at rest and there is mild sternal retraction. Observations are otherwise stable. A diagnosis of croup is made and treatment is commenced. What is the most suitable first-line treatment for this child?
Nebulised salbutamol
Oral dexamethasone
Humidified oxygen
IV hydrocortisone
Broad spectrum antibiotics
Oral dexamethasone
Croup - A single dose of oral dexamethasone (0.15 mg/kg) is to be taken immediately regardless of severity
Important for meLess important
This scenario focuses on the immediate management of croup in a 9-month-old baby. Guidelines suggest categorising this condition into mild, moderate and severe, depending on symptoms. This baby would be mild to moderate.
The NICE guidelines suggest a single dose of oral steroids at 0.15mg/kg, regardless of severity. For this reason, the correct answer is oral dexamethasone.
Although salbutamol can be used as an airways vasodilator, it is not normally used in the treatment of croup.
Oxygen is only necessary if the oxygen saturations are <92%. This baby is stable.
IV hydrocortisone may be necessary if access to oral routes are limited but would not be the first choice.
Most croup cases are caused by a viral infection, therefore antibiotics are not a drug of choice.
A 4-year-old child presents to the general practitioner accompanied by their mother with a one-week history of cough and low-grade fever. The mother reports that the cough has a barking quality. The child is up-to-date with all vaccinations.
On examination, the child exhibits suprasternal wall retraction at rest but appears alert and responsive. There are no similar symptoms reported in other household members.
What is the most likely causative organism of this presentation?
Bordetella pertussis
Haemophilus influenzae B
Moraxella catarrhalis
Parainfluenza virus
Respiratory syncytial virus
Parainfluenza virus accounts for the majority of cases of croup
Important for meLess important
The correct answer is parainfluenza virus. The patient exhibits a classic presentation of croup, which is characteristically associated with stridor, a barking cough, mild pyrexia, and coryzal symptoms. In moderate cases such as this one, suprasternal wall retraction at rest may also be observed. The parainfluenza virus is the most common etiological agent responsible for croup. Currently, there are no vaccines available to protect against this virus. Management includes administering a single dose of oral dexamethasone (0.15mg/kg) to all children presenting with croup, irrespective of the severity of their symptoms. Admission to the Emergency Department should be considered if any red flags identified by NICE guidelines are present upon history taking and examination.
Bordetella pertussis is the pathogen responsible for whooping cough, an infectious disease marked by paroxysmal coughing spells, an inspiratory ‘whoop,’ and post-tussive vomiting. However, given that the child’s cough has been described as ‘barking’ rather than ‘whooping,’ this option can be discounted.
Haemophilus influenza B causes acute epiglottitis, a rare yet severe infection leading to inflammation of the epiglottis. Signs typically include drooling and stridor but coughing is usually minimal or absent; thus, this diagnosis is unlikely in our patient who does have a cough. Furthermore, there is an effective vaccine against Haemophilus influenzae type B included in the routine immunisation schedule which this patient has received up-to-date.
Moraxella catarrhalis often leads to acute otitis media characterised by ear pain, fever and coryzal symptoms rather than a cough as presented in this case; therefore, it is not the causative organism we are considering here.
Respiratory syncytial virus (RSV), while being the principal cause of bronchiolitis—an inflammatory condition affecting the bronchioles predominantly in infants under one year—presents with wheezing and a dry cough rather than a barking one. Given that our patient is four years old and displays different symptoms, RSV is an unlikely cause for their presentation.
A 5-year-old child presents to the emergency department accompanied by the mother with a week history of cough and low-grade fever. The mother describes the cough as barking. She has completed all the vaccinations to date.
On examination, you can observe suprasternal wall retraction at rest, but the child looks alert and reactive. The child produces strident breath sounds at rest.
What is the most appropriate management plan?
Admit to the paediatric ward
Discharge with dexamethasone
Discharge with oral antibiotics
Discharge with safety-netting
Non-urgent referral to ENT
Admit to the paediatric ward
Croup: audible stridor at rest is an indication for admission
The correct option is to admit to the paediatric ward. This patient is presenting with a clear picture of croup. This condition usually presents with stridor, a barking cough, mild pyrexia and coryzal symptoms. Additionally, in moderate cases, suprasternal wall retraction at rest is noticeable, as in this case. Children which certain red-flag presentations, such as stridor at rest should be admitted for further observation.
Discharge with dexamethasone is inappropriate as even if dexamethasone should be prescribed, this patient should be admitted as stridor at rest is an indication for admission for children with croup.
Discharge with oral antibiotics is incorrect. This child has a diagnosis of croup. A single dose of oral dexamethasone should be administered to all the children with croup, rather than antibiotics. Antibiotics would be appropriate if there was evidence suggesting a bacterial cause of symptoms.
Discharge with safety-netting is inappropriate as a single dose of oral dexamethasone should be administered to all children with croup regardless of severity. Additionally, this child has audible stridor at rest, which is an indication for admission.
A non-urgent referral to ENT would be inappropriate as stridor at rest is a red flag for immediate admission to the paediatric ward.
buzz words
emergency department
barking cough for the past 3 days
feeding poorly
mild sternal retraction - suprasternal wall retraction
parainfluenza virus
low-grade fever
up-to-date with all vaccinations.
appears alert and responsive
admit if strident breath sounds at rest.
A mother brings her 18-month-old daughter to the paediatric assessment unit. The child has a two-day history of a barking cough that worsens at night, on a background of a week-long history of coryzal symptoms and fever. She is up to date with all her vaccinations.
At rest, the child uses their accessory muscles to breathe, and a tracheal tug is observed. There is also an audible inspiratory stridor.
What is the most likely causative organism?
Haemophilus influenzae type b
Parainfluenza virus
Respiratory syncytial virus
Rhinovirus
Streptococcus pneumoniae
Parainfluenza virus
Parainfluenza virus accounts for the majority of cases of croup
Parainfluenza virus is correct. Croup, or laryngotracheobronchitis, is the likely diagnosis for this child’s presenting symptoms. The hallmark of croup is a barking cough that typically worsens at night and often follows an upper respiratory tract infection with coryzal symptoms. Viral aetiologies account for approximately 95% of croup cases. While multiple viruses can cause croup, the parainfluenza virus is the most common cause. Other viral causes include influenza types A and B, respiratory syncytial virus (RSV), rhinovirus, and adenovirus.
Haemophilus influenzae type b is incorrect. This is not a recognised cause of croup. However, it is the most common cause of epiglottitis— an important differential diagnosis in such clinical presentations. A key risk factor for developing epiglottitis includes non-immunisation against Haemophilus influenzae type b. This patient’s vaccination history indicates she has received immunisation against Haemophilus influenzae type b at the recommended intervals (three doses at 8, 12, and 16 weeks old with a booster at one year), reducing her risk for epiglottitis. Radiographic differentiation between croup and epiglottitis can be achieved; the ‘thumb sign’ on the X-ray suggests epiglottitis, whereas the ‘steeple sign’ indicates croup.
Respiratory syncytial virus is incorrect. Although capable of causing croup, it is less commonly responsible when compared to parainfluenza virus infections. RSV is the most common cause of bronchiolitis, which may present with coughing and increased respiratory effort but typically manifests with wheezing rather than inspiratory stridor — another distinguishing feature from croup. However, it is not the most common cause of croup, making the parainfluenza virus a more suitable answer.
Rhinovirus is incorrect. Rhinovirus is the most common cause of the ‘common cold’ and is not a recognised cause of croup. Therefore, it is unlikely that this was the cause of this patient’s presentation.
Streptococcus pneumoniae is incorrect. Streptococcus pneumoniae, while not commonly implicated in croup, is frequently associated with pneumonia and bacterial tracheitis and remains one of the leading causes of bacterial meningitis. This patient is experiencing symptoms of croup, which is most commonly associated with the parainfluenza virus, meaning that Streptococcus pneumoniae is not the most appropriate answer.
An 18 month old child attends the paediatric assessment unit with his mother. He has been brought in as he has had a fever, barking cough and difficulty breathing at night. He has been diagnosed with croup and you have been asked to see him to review. After history and assessment you are confident there is no stridor or respiratory distress. What would your next step in management be?
Give antibiotics
Give oxygen
Full ENT exam
Give nebulised adrenaline
Give oral dexamethasone
Give oral dexamethasone
Croup - A single dose of oral dexamethasone (0.15 mg/kg) is to be taken immediately regardless of severity
Important for meLess important
This child has mild croup, the severity of croup is based upon; respiratory rate, respiratory distress, heart rate, O2 saturations and exhaustion. Treatment of mild croup is oral dexamethasone 0.15mg/kg single dose and review. Systemic dexamethasone and nebulised adrenaline 5ml of 1:1000 are used in severe croup, alongside oxygen administration. Antibiotics should not be given unless an underlying bacterial infection is suspected. You should not perform an ENT exam due to the possibility of an epiglottis diagnosis.
