Croup or Barky Cough (Laryngotracheobronchitis)

This tends to occur in a previously well child aged 3 months to 6 years but can occur in older children. The term croup refers to a clinical syndrome characterised by barking cough, inspiratory stridor and hoarseness of voice. It results from viral infection, most often with parainfluenza virus with inflammation of the upper airway, including larynx, trachea and bronchi; hence the term laryngotracheobronchitis.

The symptoms are typically worse at night and peak on about the second or third night. Differentiating spasmodic croup from viral croup is diffi-cult and often not useful.Consider other causes of acute stridor, such as epiglottitis (much rarer since Hib vaccine), bacterial tracheitis (rare), or laryngeal foreign body (very rare). Refer to upper airways obstruction section.

History

The loudness of the stridor is not a good guide to the severity of obstruction. Children with pre-existing narrowing of the upper airways (e.g. subglottic stenosis, congenital or secondary to prolonged neonatal ventilation) or children with Down syndrome are prone to more severe croup and admission should be considered even with mild symptoms.

General Management

Avoid distressing procedures, e.g. examining throat, because anxiety exacerbates croup. Nurse the child on the parent’s lap. Blood tests, pulse oxymetry, or O2 mask are rarely indicated. A routine nasopharyngeal aspirate (NPA) is not required for children with a ypical clinical picture of croup.

Primary assessment and initial management of croup

1. Mild

Signs: No stridor at rest, Not distressed, No sternal retraction, No signs of hypoxia.

Managements: Can be managed at home. No specific treatment is usually required, although steroids can be considered if the patient is seen early in the course of the illness. Explanation to parent needed

2. Moderate

Signs: Stridor at rest, Distressed, Sternal retraction at rest, Normal breath sounds, No signs of hypoxia

Managements: Administer steroids, Observe and settle child with minimal interventions, Consider use of nebulized epinephrine (adrenaline) (1% eye drop solution 0.05 mg/kg weight or 1:1000 preparation 0.5 ml/kg weight (max 2ml), If settles well after prednisolone consider discharge (see notes on discharge)

3. Severe

Signs: Marked stridor at rest or may be soft, Very distressed, Marked increase work of breathing, Reduced breath sounds, Evidence of hypoxia (restless, lethargy, pallor, cyanosis)

Managements: Continually assess the child and response to therapy, Involve senior staff early on Administer nebulized epinephrine, Administer steroids, Rarely will require intubation, Admission to PICU

Steroids

There is little evidence supporting the use of steroids in mild croup, although the current studies are underpowered. However there is good evidence for the efficacy of corticosteroids for the treatment of moderate to severe croup. There are a number of ways of administering the steroids: use nebulized budesonide, oral prednisolone or dexamethasone or i.m. dexamethasone. Varying doses have been suggested in the literature and all are effective in the treatment of the acute symptoms. Cost and availability may influence the treatment choice. Suggested doses are prednisolone (1 mg/kg weight), nebulized budesonide 2 mg, dexamethasone (0.15 mg/Kg weight).

Epinephrine (adrenaline)

There has been a change in the use of nebulized epinephrine (adrenaline) in the last few years and nebulized epinephrine (adrenaline) no longer needs to be reserved only for children with severe croup. Current evidence would support the use of nebulized epinephrine (adrenaline) in children with moderate and severe croup. In a number of selected children following observation in the Emergency Department for 3 hours after the administering of nebulized epinephrine (adrenaline) and the start of steroid treatment,it may be safe to discharge the child home. Nebulized epinephrine (adrenaline) may cause circumoral pallor.

Admission or discharge

The decision to admit a child is made after initial treatment and observation. As is usual with other children, the time of the day, parent’s anxiety and access to transport, and ability of early review should be taken into account if admission or discharge is being considered. Some centres will suggest that if the child still has stridor at rest after treatment, he or she should be admitted. It has been suggested that if there is no sign of increased work of breathing and no sternal recession but minimal stridor at rest, then they could be discharged with adequate explanation and follow up.