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
  • croup
    • <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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