Croup

Common disease of childhood (viral laryngotracheitis) characterised by the sudden onset of a barking cough accompanied usually be stridor, hoarseness and respiratory distress.

Background

• Commonly affects children aged 6 months – 3 years (peak at 2 years).
  • Occurs in around 60/1000 in this age group
• Most commonly caused by the Parainfluenza viruses (type I-IV; type I though to account for the majority of severe cases)
  • Other causes include RSV, Adenovirus, Rhinovirus, etc.  Influenza A is associated with particularly severe disease

Presentation

• Initial symptoms of rhinorrhea, cough, sore throat, fever and possibly problems feeding may precede the barking cough by several days
  • Barking cough, hoarse cry and stridor can develop later due to inflammation and oedema of the subglottic larynx and trachea near the cricoid which narrows the child’s airway.
    • Symptoms are usually worse at night
• Presentation can be assessed as
  • Mild
    • Occasional barking cough and no audible stridor at rest; no/minimal intercostal/suprasternal recession; child is otherwise happy, feeding normally and playing/interactive
  • Moderate
    • Frequent barking cough and stridor at rest; sternal wall/suprasternal retraction at rest; no distress/agitation- the child is alert/interested
  • Severe
    • Frequent barking cough with prominent inspiratory +/- expiratory stridor at rest; marked intercostal recession; significant distress/agitation or lethargy or restlessness***; tachycardia may also be seen
  • Impending respiratory failure
    • Change in mental state/level of consciousness; pallor; dusky appearance; tachycardia
    • NB Barking cough may not be heard in acutely severe disease.  In fact, the absence of bark/stridor in a deteriorating patient is a very serious sign
• NB Another way of assessing severity is using the Westley Score for croup severity
• 
  • <4 mild; 4-6 moderate; >6 severe
• Moderate-severe croup should be considered for referral to hospital.  Other reasons include-
  • Any suspicion of bacterial infection (either a tracheitis or other e.g. epiglottitis, tonsillitis, retropharyngeal abscess etc) should also be referred.
  • A history of severe obstruction/severe croup or upper airway abnormalities
  • <6 months
  • Inadequate feeding/drinking
  • Immunocomprimised

Investigations

• The diagnosis is often clinical and does not require investigation.  However, throat swabs will often be sent to confirm the aetiology.
• In severe disease, CXR may be done if there is failure of treatment.

Management

• Guidelines suggest oral dexamethasone be given to all children with croup (0.15mg/kg) presenting to A&E (those with mild disease presenting to the GP or with very mild/questionable croup do not require steroids)
  • Severe/unresponsive disease can also be given nebulised adrenaline (5ml of 1:1000)- will probably require care in HDU also
  • Prednisolone is not recommended first line, but may be given second line if required
• Oxygen should be given as required to keep sats >93%

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