Respiratory: Croup

Question 1

Croup is a term used to describe what?

Answer 1

Viral laryngotracheobronchitis

In rare cases bacterial tracheitis

Question 2

What are the main features of croup?

Answer 2

Coryza and fever followed by:
Stridor
Barking cough
Hoarseness due to inflammation of vocal cords
Variable degree of difficulty breathing with chest retraction

Question 3

When are the symptoms often worse?

Answer 3

At night

Question 4

Between what ages does croup occur?

Answer 4

6 months to 3 years

But can occur in children as young as 3 months and in older children and teens

Question 5

What causes croup?

Answer 5

Parainfluenza virus - accounts for majority of cases
Adenovirus
Influenza virus
Respiratory syncytial virus

Question 6

Is the onset sudden or gradual?

Answer 6

Sudden

Question 7

What age is the peak incidence?

Answer 7

2 years old

Question 8

What time of year does it most commonly occur?

Answer 8

Autumn and winter

Question 9

Describe the pathophysiology

Answer 9

Subglottic oedema, inflammation and infiltration of inflammatory cells causing narrowing of the subglottic airway and increased work of breathing

Question 10

Does it have a prodromal phase?

Answer 10

Yes 1-2 days of:
Rhinitis
Low grade fever
Possible erythematous pharynx

Question 11

The severity of croup symptoms can be classified into..

Answer 11

Mild
Moderate
Severe

Question 12

Describe mild croup

Answer 12

Seal like barking cough
No stridor
No sternal/ intercostal recession at rest

Question 13

Describe moderate croup

Answer 13

Seal like barking cough with stridor and sternal recession at rest
No agitation or lethargy

Question 14

Describe severe croup

Answer 14

Seal like barking cough with stridor and sternal/ intercostal recession
Associated agitation or lethargy

Question 15

What indicates impending respiratory failure?

Answer 15

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

Question 16

Who should be admitted?

Answer 16

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

Question 17

What should be done for mild illness?

Answer 17

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

Question 18

How should moderate disease be managed?

Answer 18

Oral dexamethasone or nebulise budesonide if cannot take orally
O2 if saturations below 92%

Question 19

How should severe croup be managed?

Answer 19

Nebulised adrenaline 0.4mg/kg (max 5mg) of 1:1000 solution
Nebulised budesonide

Notify CICU
Urgent senior review

Question 20

What should you do if respiratory failure?

Answer 20

Alert CICU
Fast bleep senior SpR, ENT and anaesthetics
Nebulised adrenaline
Nebulised budesonide

Do not attempt IV access unless airway secure or senior input

Question 21

In severe disease will stridor be soft?

Answer 21

Yes

Question 22

Is croup a common illness?

Answer 22

Yes

Question 23

The majority of those with croup have mild to moderate symptoms, but severe croup can result in…

Answer 23

Significant airway compromise

Needs expert airway management

Question 24

Children with croup should be approached in what manner?

Answer 24

Calm as unnecessary upset will increase respiratory distress

Question 25

Can most cases be managed in primary care?

Answer 25

Yes | Up to 30% require hospitalisation - of these less than 2% require intubation

Question 26

How long do symptoms typically last?

Answer 26

3-5 days, can last up to 2 weeks

Question 27

When assessing the child what general principles should you follow?

Answer 27

Assess child where most comfortable e.g on parents lap Avoid distressing child Assess degree of airway obstruction, not loudness of stridor

Question 28

Should you examine the throat?

Answer 28

No!

Question 29

Do children with croup need an X-ray or IV access?

Answer 29

No

Question 30

What should the assessment include?

Answer 30

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

Question 31

What differentials of acute airway issues are there?

Answer 31

Tracheitis Epiglottitis Foreign body Angioedema

Question 32

If a child receives nebulised adrenaline, they will need what?

Answer 32

At least 3-4 hours of normal observations prior to discharge

Question 33

What is the criteria for discharge?

Answer 33

Absent/ mild intermittent stridor with saturations above 93% And other diagnosis considered and excluded And parents confident they can manage the child

Question 34

Should steroids be routinely given as TTO?

Answer 34

No

Question 35

Children with what condition are more prone to croup?

Answer 35

Down syndrome | Children with pre existing narrowing of upper airways e.g subglottic stenosis

Question 36

What discharge advice should be given?

Answer 36

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

Question 37

What sign can be seen on CXR?

Answer 37

Steeple sign - subglottic narrowing

Question 38

Is croup the most common cause of acute URT obstruction?

Answer 38

Yes