Makindo Medical Notes.com

Related Subjects: |Acute Epiglottitis |Croup |Acute Tracheitis |Stridor

About

• Affects age group 6 months to 3 years.

Aetiology

• Croup is an acute respiratory illness causing inflammation and narrowing of the subglottic region of the larynx. It is most often caused by a viral infection.
• Most cases of croup are caused by Parainfluenza virus (which accounts for most cases), adenovirus, and respiratory syncytial virus (RSV).

Clinical

• Where appropriate (if severity allows) a minimally hands-off invasive approach allows best initial assessment– as children can look very different if allowed to settle for a few minutes
• If possible allow child to sit on carers lap – do not force child to lie down, Do not examine throat, If hypoxic try to give O₂ by facemask during assessment
• Affects age group 6 months to 3 years
• Rough loud Stridor, Barking cough, Hoarseness
• Respiratory distress +/- Fever +/- Coryza
• Severity based on
  • Respiratory rate
  • Heart rate
  • O₂ saturations
  • Respiratory distress
  • Exhaustion

Assessing Severity

• Mild: seal-like barking cough but no stridor or sternal/intercostal recession at rest.
• Moderate: seal-like barking cough with stridor and sternal recession at rest; no agitation or lethargy.
• Severe: seal-like barking cough with stridor and sternal/intercostal recession associated with agitation or lethargy. Impending respiratory failure – increasing upper airway obstruction, sternal/intercostal recession, asynchronous chest wall and abdominal movement, fatigue, pallor or cyanosis, decreased level of consciousness or tachycardia. The degree of chest wall recession may diminish with the onset of respiratory failure as the child tires.
• A respiratory rate of over 70 breaths/minute is also indicative of severe respiratory distress.

Differential

• Acute epiglottitis - comes on over hours, little if no cough, higher fever > 38.5 C, don't speak, drool saliva, quiet stridor
• Diphtheria - unusual in UK resident as immunised. Pyrexia, sore throat, dysphagia, bull neck due to enlarged cervical nodes, adherent pseudomembrane, myocarditis Rx Antitoxin + IV Erythromycin
• Acute tracheitis - bacterial. secretions ++. Manage as epiglottitis
• Acute foreign body aspiration
• Acute anaphylaxis

Comparison of Croup vs Epiglottitis and Tracheitis

Management

• Most cases of viral croup are mild and can be treated at home
  • Prescribe a single dose of oral dexamethasone (0.15 mg/kg) to be taken immediately.
  • Advise the parents/carers about the expected course of croup, including that symptoms usually resolve within 48 hours.
  • Advise them to take the child to hospital if stridor can be heard continually, the skin between the ribs is pulling in with every breath, and/or the child is restless or agitated.
  • Advise them to call an ambulance if the child is very pale, blue, or grey (includes blue lips) for more than a few seconds, is unusually sleepy or is not responding, is having a lot of trouble breathing (e.g., the belly is sinking in while breathing, or the skin between the ribs or over the windpipe is pulling in with each breath; the nostrils may also be flaring in and out), is upset (agitated or restless) while struggling to breathe and cannot be calmed down quickly, if they want to sit instead of lie down, and/or if they cannot talk, are drooling, or having trouble swallowing.
• General Care
  • Advise the parents/carers to use either paracetamol or ibuprofen to treat a child who is distressed due to fever.
  • Advise them to consider changing to the other agent if the child's distress is not alleviated, but not to give both agents simultaneously, and to only alternate these agents if the distress persists, or recurs before the next dose is due.
  • Advise them not attempt to reduce fever by under-dressing the child, or with use of tepid sponging.
  • Advise them to encourage the child to take fluids regularly. For infants that are breastfed, advise continued breastfeeding. Advise the parents/ carers to check on the child regularly, including through the night.
  • Arrange follow-up, using clinical judgment to determine the appropriate interval.
• Those who need Hospital
  • Admit all children with features of moderate or severe illness, or impending respiratory failure.
  • Children with a respiratory rate of over 60 breaths/minute or who have a high fever or 'toxic' appearance.
  • Children with mild illness may require admission if they have factors that warrant a lower threshold for admission, such as:
    • Chronic lung disease (including bronchopulmonary dysplasia).
    • Haemodynamically significant congenital heart disease.
    • Neuromuscular disorders.
    • Immunodeficiency.
    • Age under three months.
    • Inadequate fluid intake (50 to 75% of usual volume, or no wet nappy for 12 hours).
      • Factors that might affect a carer's ability to look after a child with croup, such as adverse social circumstances, or concerns about the skill and confidence of the carer in looking after a child with croup at home, or the carer being able to spot deteriorating symptoms or longer distance to healthcare in case of deterioration.
  • Give controlled O₂ to all children with symptoms of severe illness or impending respiratory failure.
  • Give oral dexamethasone (0.15 mg/kg). If the child is too unwell to receive medication, inhaled budesonide (2 mg nebulised as a single dose) or intramuscular dexamethasone (0.6 mg/kg as a single dose) are possible alternatives.
  • Nebulized adrenaline may be used. Involve Senior and PICU as needed

References

• Croup NICE guidance