Croup

Disclaimer

These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline.

Read the full PCH Emergency Department disclaimer.

Aim

To guide PCH ED staff with the assessment and management of croup.

Definition

Croup (laryngotracheobronchitis) is an upper respiratory illness characterised by a hoarse voice, barking cough, and stridor. The clinical symptoms are a result of inflammation and narrowing of the upper airway (larynx, trachea and bronchi).

Background

Croup is usually caused by the Parainfluenza virus, but a variety of respiratory viruses may be responsible
Symptoms usually become more evident at night
Most cases are mild (and don’t require admission)
Severe cases can be life-threatening due to potential airway compromise

Assessment

Don’t upset the child – this will exacerbate the symptoms
The severity of the stridor is not an indication of the severity of croup

History

Ask about the onset and duration of symptoms – cough, stridor, increased work of breathing.
Past history – e.g. previous episodes of croup, underlying upper airway, abnormality, underlying neuromuscular conditions.
Possibility of inhaled foreign body, or anaphylaxis

Examination

It is important not to exacerbate the symptoms by upsetting the child – keep your assessment short and as non-invasive as possible. Keep the child in their most comfortable position (e.g.: in parent’s arms)
Observations: heart rate, respiratory rate, temperature, SpO₂ (and BP if severe)
Behaviour: child alert and interested in surroundings, or altered conscious state e.g. irritable, lethargic
Respiratory assessment: cyanosis (this is a very late sign), barking cough, stridor (when upset or at rest), air entry on auscultation, there may also be wheeze.
Work of breathing: degree (mild, moderate or severe) and type of recession (sternal, intercostal, subcostal, tracheal tug).
Watch for signs of impending respiratory exhaustion.

Mild symptoms	Moderate symptoms	Severe symptoms
Barking cough No stridor at rest No sternal recession or tracheal tug Normal behaviour	Barking cough Audible stridor at rest Mild sternal regression +/- tracheal tug May be irritable at times	Persistent stridor at rest Pallor and mottling Severe sternal recession +/- tracheal tug Drooling Irritable or lethargic

Investigations

Do not routinely test for viruses
Chest X-Ray is not indicated (except for those in extremis, i.e. those considered for PCC admission).

Differential diagnoses

Underlying congenital abnormality eg: laryngomalacia, tracheomalacia
Inhaled foreign body
Anaphylaxis
Epiglottitis
Bacterial tracheitis

Management

All children with croup receive corticosteroids
Additional treatments depend on the severity and may include nebulised adrenaline.

Resuscitation

Life threatening croup:

Transfer the child to the resuscitation room, activate the resuscitation team
Give nebulised adrenaline immediately (5mLs of 1:1000, undiluted)
Give high flow oxygen (15L/min via a non-rebreather mask)
Prepare for intubation with support from ENT and anaesthetics.

Initial management

Severe croup is treated as above with high flow oxygen and nebulised adrenaline. Adrenaline can be repeated 10 minutely as required

All severe and life threatening croup should be discussed with a Senior Doctor +/- Paediatric Critical Care Unit and the child admitted under the General Paediatric Team.

Moderate croup will need observation (e.g. ED short stay unit) until there is no stridor at rest. All children requiring an adrenaline nebuliser should be observed for at least 3 hours.

Mild croup will not need observation and can be discharged home, after administration of oral steroid. All children presenting with any severity of croup, should receive corticosteroids.

Medications

Steroids

Steroids start working by 30 minutes and reduce time in hospital, transfers to PICU, the chances of intubation for inpatients, and also reduce the likelihood of relapse after discharge home.
Steroid therapy is extremely successful in treating stridor, but does not resolve the underlying viral symptoms.
Usually a single dose of steroid is all that is required in mild to moderate croup.

Medication	Dose	Route	Treatment
Dexamethasone	0.15mg/kg	PO	All croup presentations should be treated with oral dexamethasone.
Prednisolone	1mg/kg	PO	If oral dexamethasone is not available.
Dexamethasone	0.15mg/kg	IM	Rarely required. Can give if oral steroids are not tolerated (e.g. vomited).
Dexamethasone	0.6mg/kg	IV	For severe cases of croup (PCC candidates).

Adrenaline

The effect of adrenaline is short lived and is thought not to change the natural history of croup. It may be repeated after 10 minutes if necessary. Children receiving adrenaline need to be observed for a minimum of 3 hours afterwards.

Preparation	Dose	Maximum dose	Dilution volume	Route/delivery
1:1000 adrenaline	0.5mL/kg	5mL	Doses of 5mL can be given undiluted. Doses <5mL: dilute with 0.9% sodium chloride to make up to 5mL	To be given with oxygen at 8 litres per minute via nebuliser. (Oxygen delivery at less than 8 litres per minute will not drive the nebuliser adequately)

Admission criteria

As a 'rule of thumb' children without stridor do not need to be admitted
- This decision would be influenced by the distance parents live from the hospital, the reported severity of symptoms at home and past history of severe croup
- The younger the child, the more conservative the approach.

Isolation

Children admitted to hospital with croup should be isolated.

Discharge criteria

The child must meet all of the following criteria:

Clinically improved
Steroids received
No stridor at rest
No other clinical or social concerns

Nursing

Minimal nursing intervention is encouraged to avoid distressing the child and increasing respiratory distress.
Patients should remain in a position of comfort.
Children with croup require close observation.
Baseline observations: heart rate, respiratory rate, SpO₂ and temperature.
The presence or absence of the following clinical features should be assessed and documented:
- stridor,
- barking cough,
- degree and type of recession (i.e. mild, moderate, severe, intercostal, subcostal, tracheal tug)
- air entry
- cyanosis
- conscious state (normal or altered).
Observations should be recorded at least hourly whilst in the emergency department.
- Any significant changes should be reported immediately to the medical team.
SpO₂ and ECG monitoring is recommended if adrenaline is given.
- Before applying consider whether the risk of distress negates the accuracy of monitoring.

Bibliography

Kairys SW, Olmstead EM, O’Connor GT. Steroid treatment of laryngotracheitis: a meta‐analysis of the evidence from randomized trials. Pediatrics 1989;83:683‐93.
Tibballs J, Shann FA, Landau LI. Placebo‐controlled trial of prednisolone in children intubated for croup. Lancet 1992;340:745‐8.
Geelhoed GC, Macdonald WB. Oral dexamethasone in the treatment of croup: 0.15 mg/kg versus 0.3 mg/kg versus 0.6 mg/kg. Pediatr Pulmonol 1995;20:362‐8.
Klassen TP, Feldman ME, Watters LK, Sutcliffe T, Rowe PC. Nebulized budesonide for children with mild‐to‐moderate croup. N Engl J Med 1994;331:285‐9
Geelhoed GC, Macdonald WB. Oral and inhaled steroids in croup: a randomized, placebo‐controlled trial. Pediatr Pulmonol 1995;20:355‐61
Geelhoed GC, Turner J, MacDonald WB. Efficacy of a small single dose of oral dexamethasone for outpatient croup: a double blind placebo controlled clinical trial. Br Med J 1996;313:140‐2
Geelhoed GC. Sixteen years of croup in a Western Australian teaching hospital: effects of routine steroid treatment. Ann Emerg Med 1996;28:621‐6
Dobrovoljac M, Geelhoed GC How fast does oral dexamethasone work in mild to moderately severe croup? A randomised double blinded trial. Emergency Medicine Australasia. February 2012; 24(1);79‐85, 2012
Samuals M, Wieteska S (Ed) Advanced Paediatric Life Support Group. Advanced Paediatric Life Support The Practical Approach. 5th Edition. Australian Edition. Wiley‐Blackwell, Chichester. 2011. P.346. ISBN 978‐1‐4443‐3059‐5
Advanced Paediatric Life Support: The Practical Approach. 5th edition. Australian and New Zealand Version. Wiley-Blackwell, 2012
WA Health. Child and Adolescent Health Service. Pharmacy Manual: Adrenaline. Version 1, July 2014

Reviewer/Team:	Meredith Borland (ED Director), Dennis Chow (ED Consultant), Deirdre Speldewinde (ED Consultant), Gabrielle Anstey (ED CNS), Craig Hasler (ED CNM)	Last reviewed:	Apr 2018
		Review date:	Apr 2021
Endorsed by:	Director, Emergency Department	Date:	Apr 2018

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