Croup Youtube vidoe Azza Elghonaimy 1 st May 2012

Case : A child with a loud barking cough : A 1 year old boy with a 2-day history of cough and noisy breathing. O/E: He has a loud barking cough. He has significant tracheal tug. and inspiratory stridor at rest. Temp.:38.1 C,RR:34/min. His parents have tried steam but there has been no improvement. Q1:What important causes must we consider ? Q2:What therapies do we think may be effective? Q3:When should we refer to hospital?

Differential diagnoses of acute stridor : Croup :most common cause of acute stridor. Acute epiglottitis ( rare) Foreign body Bacterial tracheitis (uncommon) Angioneurotic oedema Laryngomalacia. Structural abnormalities (uncommon). Diphtheria Peritonsillar abscess Retropharyngeal abscess Smoke inhalation Acute laryngeal fracture Burns / thermal injury

Croup : Viral croup (Laryngotracheobronchitis): Age 6 months -6 years Insidious onset over a few days. Lasts for 3 days on average. Often worse at night. Majority of cases will have mild illness. Spasmodic Croup : Recurrent short lived episodes particularly at nights. Sudden onset and Without the typical coryzal prodrome. History of Atopy and episodic stridor is common in children with spasmodic croup.

CroupEpiglottitis Time courseDaysHours ProdromecoryzaNone CoughBarkingslight if any Feedingcan drinkNo MouthclosedDrooling saliva ToxicNoYes Fever<38.5>38.5 StridorRaspingsoft VoiceHoarseWeak or silent

What therapies do we think may be effective? : Simple measures ; Keep the child and parents calm, sitting the child upright. Throat examination can be dangerous. Routine lateral neck xrays are no longer useful. Investigations in acute presentation may include: 1 -Neck xray: Steeple sign (PA view shows a narrowed column of subglottic air). 2-CT. 3.Pulse oximetry. Recurrent Croup: Bronchoscopy ;by chest physician /ENT surgeon.

The modified Westley clinical scoring system for croup Inspiratory stridor: Not present - 0 points. When agitated/active - 1 point. At rest - 2 points. Intercostal recession: Mild - 1 point. Moderate - 2 points. Severe - 3 points. Air entry: Normal - 0 points. Mildly decreased - 1 point. Severely decreased - 2 points. Cyanosis: None - 0 points. With agitation/activity - 4 points. At rest - 5 points. Level of consciousness: Normal - 0 points. Altered - 5 points. Possible score 0-17: 6 =severe croup

Humidification ; Steam inhalation (placebo effect/risk of scalding) Adrenaline : Nebulised Adrenaline(2mg STAT) Adrenalin 5mls of 1: mg/kg Max 5 mg. It is very effective in severe cases when intubation is considered. It reduces mucosal oedema. Duration of action is between 20 minutes and 3 hours. Contraindicated in Fallots Tetralogy (Ventricular outflow obstruction)

Steroids : Dose :(0.15mg/kg) Oral Dexamethasone OR Nebulised adrenaline. Intubation : Severe cases with worsening airway obstruction with signs of exhaustion or impending respiratory failure. Epiglottitis and Bacterial tracheitis.; Specialist care,ENT and anaesthetist. (Intubation and IV Antibiotics ) Steroids and Adrenaline have Minimal effect.

When to refer to Hospital : Most cases of acute stridor are viral croup. Mild croup : (no signs of respiratory distress)may be managed at home, with parental observation.( parents to receive Clear instructions when to return ). Cases with significant respiratory distress,stridor at rest or showing atypical features Low threshold for admission in children under age of 12 months. Emergency management in Primary care : If a child has croup that is severe or might cause complications then the child can be given either oral prednisolone 1-2mg/kg or oral dexamethasone (2mg/5mL oral solution) 150micrograms/kg, before transfer to hospital.

Worrying signs in children with stridor : High fever or signs of toxicity. Rapid onset. Drooling and dysphagia. Muffield voice and quiet stridor. Angioedema Age less than 4 months. Skin cavernous haemangioma. Previous ventilation as a neonate

References: MRCPCH Mastercourse. GP notebook. Oxford handbook of Paediatrics Local hospital guidelines Thank you Any question