1. Dr Jonny Taitz Sydney Children’s Hospital, Randwick April 2003
CROUP
Dr Jonny Taitz
Sydney Children’s Hospital, Randwick
April 2003

2. Introduction
Croup or LTB laryngo tracheo bronchitis is a clinical syndrome
Hoarse voice
Barking cough
Inspiratory stridor
COMMON cause of upper airway obstruction usually mild & self limiting
BUT is also the commonest cause of potentially life threatening airway obstruction in childhood

3. Anatomically Viral infection of upper airway
Inflammation of larynx, trachea & bronchi
Compromises airflow through proximal airway

4. Causes & Differential Commonest cause is viral (parainfluenza, RSV)
Very rarely  diphtherial croup (non immunized)

5. Causes & Differential Foreign Body Inhalation Structural Sudden onset
May have unilateral signs
Exp wheeze > insp stridor
Structural
Children < 3/12
Combination insp & exp stridor
(eg. Subglotic stenosis, laryngomalacia, laryngeal cysts, webs, thermal, chemical injury)

6. Causes & Differential Toxic Exclude bacterial tracheitis Epigloltitis
Retropharyngeal abscess

7. Assessment of Severity
Remember it is the severity of the airway obstruction NOT the stridor that is assessed
Worsening obstruction may lead to softer stridor !!!
Repeated clinical assessment is the key

8. Airway Obstruction
Mild
Moderate
Moderate progressing to severe
Severe

9. Danger Signs General: agitated, tiring,  LOC  observe closely
Resp distress: stridor at rest, tracheal tug, retractions pulsus Paradoxus  will need RX
Cyanosis / extreme pallor  RX immediately
Oxymetry is a late sign
Do not wait for desaturation to commence RX

10. Mild Airway Obstruction
Happy child, playful, tolerating fluids
Mild chest wall retractions, tachycardia
NO stridor at rest MX
Reassure parents
Counsel parents re: warning signs
No medication required

11. Moderate Airway Obstruction
Characterised by
Stridor at rest
Accessory muscle use, chest wall retractions
 HR,  RR
Child is interactive & can be placated MX
Will require corticosteriods
Observation for a minimum of 4 hours
Further RX if child progresses to severe obstruction

12. Progression from Moderate to Severe Airway Obstruction
Child will need admission
Child becomes preoccupied, tired, sleepy
Close monitoring
Regular review every mins MX
Corticosteriods
Nebulized Adrenaline

13. Severe Airway Obstruction
Characterised by
Tiredness, exhaustion, tachycardia
Restless, agitated
 LOC
Hypotonic, pale & cyanosed MX
Do not disturb unnecessarily
O2 via face mask
Nebulized Adrenaline
Intubation (under anaesthetic) & ventilation
Systemic steroids when airway secure }
Late signs indicating imminent airway obstruction

14. What Evidence is there for Current Rx Options
Non pharmacologic
Steam
2 large RCT’s looked at steam Rx in croup
No evidence that it is beneficial
Oxygen
Initial treatment of choice for children with moderate to severe viral croup

15. What Evidence is there for Current Rx Options
Drugs
Steroids
Precise mechanism in croup unclear
? Ante-inflammatry
? Vasoconstricts upper airway
Oral preferred route
Dexamethazone 0.3 mg/kg
Prednisore 1 mg/kg
Steriods have led to
 intubation
 Duration of ventilation
nebulized budesonide vs oral dexamethazone

16. Drugs (continued) Nebulized Adrenaline
Moderate to severe croup (i.e stridor at rest) needs nebulized adrenaline
Dose 0.5 mg/kg 1:1000 (max 5 mls)
Administered neat via neb
Effect
 Bronchial & tracheal epithelial vascular permeability
 Airway oedema
Onset is rapid  30 minutes
Duration is approx 2 hrs
Severe croup may need repeated doses

17. Drugs (continued) Ongoing requirements for Nebulized Adrenaline
Consider intubation and/or transfer to Paediatric ICU
Other factors to consider for transfer
Age of child
Severity of illness
Underlying anatomic problems
Level of exposure at hospital

18. Questions