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)
