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3.3 Croup

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					                                                           Paediatric Clinical Guideline
                                                                        Respiratory: 3.3
                                                                           October 2004
                                        CROUP


Croup is an acute clinical syndrome characterised by barking cough, inspiratory
stridor and hoarseness with or without fever. It most commonly occurs in children
aged from 6 months to 6 years. Symptoms are typically worse at night. Most croup
will be dealt with in primary care but up to 30% of cases will require hospitalisation,
of these less than 2% need intubation.

DIFFERENTIAL DIAGNOSIS
The main differential diagnosis of upper airway obstruction include:

1. Epiglottitis
This is now rare due to Hib vaccination but does still occur (check immunisation
history). Consider the diagnosis in a child who is drooling, agitated and who does not
have a cough. If you are unsure call for senior help.

2. Bacterial tracheitis.
Consider in a child with a croup like illness (barking cough and stridor) who has a
high fever and has not responded to treatment for croup. Tracheitis is usually caused
by Staphylococcus aureus (give flucloxacillin).

3. Inhaled foreign body.
Ask for history specifically especially if there is sudden onset of stridor in a well
child.

4. Angioedema
Associated swelling of the face and tongue, often with urticaria and wheeze. For
management see anaphylaxis protocol.

ASSESSMENT

The child should be assessed where they are most settled (e.g. on parents lap)

AVOID UNECESSARILY UPSETTING THE CHILD. DO NOT EXAMINE
THE THROAT. IV access should not be attempted. X rays are not required.

Assess the clinical severity of the airway obstruction (not the loudness of the stridor).

CALL SENIOR HELP IF CONCERNED




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                            Mild                  Moderate               Severe
Stridor              “Barking” cough,        Stridor at rest       Stridor may be
                     intermittent stridor,                         biphasic or quiet
                     worse when upset

Recession            No recession            Mild subcostal        Severe recession,
                                             recession, possible   marked use of
                                             tracheal tug          accessory muscles

Conscious level      Normal conscious        Agitated (this may    Drowsiness (may
                     level                   be a sign of          indicate impending
                                             hypoxia)              respiratory failure)

Heart rate and       Normal heart rate       Tachycardia,          Pronounced
respiratory rate     and respiratory rate    tachypnoea            tachycardia and
                     when settled                                  tachypnoea

Oxygen               SaO2>95% in air         SaO2 93-95% in air Bradycardia and
saturations                                                     desaturation occur
                                                                late and lead to
                                                                respiratory arrest if
                                                                airway obstruction
                                                                persists

Croup may present with other coincidental diagnosis e.g. asthma, pneumonia, otitis
media.

TREATMENT OF CROUP

Provide a calm reassuring atmosphere, keeping the child with parents if possible.

1) Mild to moderate croup.

a) Give one dose of 0.3mg/kg dexamethasone orally. Steroid treatment reduces the
   severity and duration of symptoms. Dexamethasone is cheaper, easier to give and
   as effective as nebulised budesonide.
b) Nebulised budesonide 2 mg as a single dose should be given in a vomiting child
   followed by oral dexamethasone once the child can tolerate it.
c) Assess the child hourly. Reassess at 4 hours, if improving consider discharge
   (see criteria for discharge).

2) Moderate to severe croup

a) Give humidified oxygen to keep the oxygen saturations >93%.
b) Give oral dexamethasone 0.6mg/kg (or nebulised budesonide 2mg if child is
   vomiting or too unwell to take oral medication)
c) Reassess in 1 hour if improving admit to ward and continue hourly assessment.
d) If poor response to steroid child should have senior review. Review diagnosis.
   Consider nebulised L-epinephrine – see management of severe croup.



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3) Severe life threatening croup

a)   Think “ABC”
b)   Give 100% oxygen with continuous cardiac and oxygen saturation monitoring.
a)   Call anaesthetic and senior paediatric help urgently.
b)   Give nebulised L-epinephrine 1 in 1000 solution.
     Age< 1yr: 2.5mls L-epinephrine, diluted with 2.5mls normal saline.
     Age> 1yr: 5mls L-epinephrine undiluted.
     Effective at 10-30 minutes, but can get “rebound” with worsening obstruction as
     effect wears off after 60 – 90 minutes. Can be given continuously if necessary.
c)   Give nebulised budesonide 2mg if this will not delay airway management.
d)   Transfer to high dependency/ ITU. Nebulised epinephrine should be given on
     general paediatric wards only as a holding measure in a child being transferred to
     ITU.
e)   Intubation.
     Ideally by a senior paediatric anaesthetist with gas induction, in a controlled
     environment.
     If child is in extremis, intubation by the most experienced person present. The
     cords will be swollen, an ETT several sizes smaller than predicted may be
     necessary. Do not cut the tube.
f)   Give dexamethasone 0.6 mg/kg IV. Do not attempt to gain IV access until
     airway is secure.
g)   Give antibiotics only if bacterial tracheitis suspected.


CRITERIA FOR DISCHARGE WITH CROUP

1) Parents confident they can manage child’s symptoms and are able to bring the
   child back if necessary.

2) Mild or intermittent stridor only with minimal recession. Sat O2 in air> 93%.

3) Dexamethasone given (in all cases even if child only has barking cough).

4) Certain of diagnosis i.e. foreign body, epiglottits etc excluded.

5) Children with pre-existing narrowing of the upper airways (e.g. subglottic
   stenosis) and children with Down’s syndrome are prone to more severe croup.
   Admission should be considered even with mild symptoms.

6) Never discharge within 3 hours of giving epinephrine.




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REFERENCES

Oral dexamethasone in the treatment of croup, 0.15 vs 0.3 vs 0.6mg/kg
Paediatric pulmonolgy. 1995 Dec; 20(6): 362-8 Geelhoed GC, Macdonald WB

Nebulised steroid in the treatment of croup: a systematic review of randomised
controlled trials.
Griffin S, Ellis S, Fitzgerald-Barron A, Rose J, Egger M. Br J Gen Prac Feb 2000,
50(451): 135-141.

The effectiveness of glucocorticoids in treating croup: meta analysis.
Ausejo M, Saenz A, Pham B, Kellner JD, Johnson DW, Moher D, Klassen TP.
BMJ 1999 Sep 4; 319(7210): 595-600 (Cochrane library)

Nebulised budesonide vs oral dexamethasone for the treatment of croup.
Klassen T, Craig W, Moher D, et al
JAMA 279: 1629-1632, 1998

A comparison of nebulised budesonide, im dexamethasone and placebo in moderately
severe croup.
Johnson et al
New Engl J Med 1998 Aug 20; 339(8):498-503.

Case report – Paediatric myocardial infarction after epinephrine
Pediatrics 104(1) e9 July 1999

The disposition of children with croup treated with racemic epinephrine and
dexamethasone in the emergency dept
J Emerg Med. 1998 Jul-Aug; 16(4):535-9

A randomised trial of a single dose of oral dexamethasone for mild croup. Bjorsen CL
et al. N Engl J Med 2004;351:1306-13

Breathing difficulties: An evidence based guideline for the management of children
presenting with acute breathing difficulty (Children Nationwide – January 2002)

Guideline: Acute Laryngo-tracheo-bronchitis (LTB) (Croup)
Authors: S Jothimurugan, D Luyt
Source: University Hospitals of Leicester NHS Trust
Date: 1999

Guideline: Management of Croup
Author: Dr Anu Shankar
Source: King’s College Hospital
Date: March 2001

Guideline: Croup (Laryngotracheobronchitis)
Source: Royal Children’s Hospital Melbourne, Australia
Date: Nov 2001


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MEDICAL GUIDELINES POLICY

ISSUE: 3       VERSION: Final


Title: CROUP

Author: Carol Bertenshaw
Job Title: Paediatric Specialist Registrar

First issued: July 1997               Date Revised: October 2004
                                      Review Date: October 2007




Document Derivation: Included in guideline                Consultation Process:
References: Included in guideline                         Paediatric Respiratory
                                                          Consultants
                                                          Paediatric Pharmacy

Ratified by: Paediatric Guidelines Committee
Chaired by: Dr Louise Wells
Consultant with Responsibility: Dr Stephanie Smith

Distribution: All wards QMC & CHN


MANUAL AMENDMENTS RECORD
(please complete when making any handwritten changes/amendments to protocol and
not processed through protocol committee)
Date                        Author                    Description




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