Croup Guidelines – Nsambya Hospital
Croup (larynotracheal bronchitis) is an acute inflammatory condition that causes
narrowing of the subglottic region of the larynx. It is usually caused by a viral
infection, including (but not exclusively) parainfluenza, influenza, RSV.
Signs:
-Stridor
-Barking cough
-Hoarseness
-Respiratory distress
-+/- fever
- +/- flu like illness
Where appropriate (if severity allows) a HANDS OFF APPROACH is best for
initial assessment as patients can become very distressed with examination and
symptoms worsen as a result.
Differential diagnosis:
Other causes of upper airway obstruction.
Main causes:
-acute foreign body aspiration
-acute anaphylaxis
-bacterial upper airway infection (epiglottitis, bacterial tracheitis)
Differentiation between croup, tracheitis, epiglottitis
Cause
CROUP
Viral
Age
Onset
Pyrexia
Abnormal
sounds
Swallowing
6M- 3yrs
Gradual
Mild
Barking cough,
stridor
Normal
TRACHEITIS
Staph Aureus
Streptococcus
Any age
Gradual
>38
Barking cough,
stridor
Difficult
Posture
Facies
Recumbent
Normal
Sitting
Anxious
EPIGLOTTITIS
Haem. Influenza B
2-6yrs
Sudden
>38
Muffled, guttural
cough
Very difficult with
drooling
Tripod position
Anxious,
distressed,
toxaemic
Bacterial tracheitis: infection of tracheal mucosa leading to copious secretions
and mucosual necrosis. Child is usually ‘toxic’ looking, high temp, and requires IV
antibiotics (usually cefotaxime and flucloxacillin).
Epiglottis is caused by haemophilus influenza B, and is intense swelling of
epiglottis and surrounding tissues leading to airway obstruction. . Cough is
usually minimal or absent. Child is toxic with a high fever and often drooling. IV
cefotaxime and anaesthetic assessment of airway is needed, avoid unnecessary
examination.
ASSESSING SEVERITY/SCORING:
Westley Croup scoring:
Inspiratory
stridor
Intecostal
recessions
Air entry
Cyanosis
0
points
Nil
Nil
1 point
When
At rest
agitated/active
Mild
Moderate
Normal Mildly
decreased
None
Level of
Normal
consciousnes
2 points
3
points
4 points
5
points
Severe
Severely
decreased
With
At rest
agitation/activity
Altered
<4 = Mild croup
4-6 = Moderate
>6 = Severe croup
INVESTIGATIONS
CBC may be non specific.
CXR: can exclude other causes if no improvement with initial management, or if
suspicious of inhaled foreign body, epiglottitis,
May reveal ‘steeple sign’ – subglottal narrowing of airway. But CXR findings not
specific, nor always present.
TREATMENT
Mild
Oral dexamethasone single dose of 0.6mg/kg
Can go home with croup advice (ie red flag signs of deterioration)
Do not need a period of observation
Moderate
Oral dexamethasone single dose of 0.6mg/kg
Observation needed for at least 2 hrs – home with advice if completely settled
If worsening – nebulized adrenaline 2mls of 1:1000 and further observation
needed
Can use nebulized budesonide 2mg.
Severe
PO/IV dexamethasone 0.6mg/kg
Oxygen by facemask/nasal cannula if child tolerates
Nebulised adrenaline 2ml of 1:1000 to be repeated as often as every hour if
needed but close monitoring required.
Repeated nebulized budesonide if responsive
Admission as inpatient.
Close monitoring
Consider anaesthetic review if deterioration and needing intubation/surgical
airway
Antibiotics do not need to be routinely started, unless there is doubt as to
diagnosis of croup (e.g. suspecting tracheitis/ epiglottitis) or poor response to
initial therapy.
Supportive care:
Need to keep the child calm, avoid disturbance as much as possible.
Encourage breastfeeding and oral fluids.
Avoid IV fluids/cannula if not necessary as this can cause the child more distress
and increase symptoms.
Dr Y Zhou Nov 2014.
References:
WHO Hospital care for children 2013 edition
NHS guidelines for management of croup
www.patient.co.uk