CROUP
Definition
common respiratory disease, typically occurs in children aged between 6 months and 3 years. commonly caused by virus, parainfluenza, type 1 or 3, characterised as onset, seal like barking cough, may be accompanied by hoarseness, stridor and or respiratory distress
Risk Factors
young age, between 6 months and 3 years
male
previous intubation
Diagnosis
diagnosis is made based of compatible history taking, examination findings
symptoms of onset seal like barking cough, hoarse voice is common
symptoms worse at night, and increased agitation
prodromal non specific upper respiratory tract symptoms maybe present for between 12 and 72 hours
progressive upper airway obstruction can result in the development of stridor and respiratory disease
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examining a child with croup*
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categorise of severity of symptoms
take care not to frighten the child as agitation may worsen symptoms
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ensure child is seated comfortably, do not reposition child from posture they have naturally adapted as this will be one that minimises airway obstruction
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 or little agitation or lethargy
severe - seal like barking cough with stridor and sternal/intercostal recession associated with agitation or lethargy
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impending respiratory failure - minimal barking cough, stridor may become harder to hear, 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 onset of respiratory failure as the child tries. a respiratory rate over 70 BPM
Differential diagnosis
bacterial tracheitis
Epiglottitis
foreign body in upper airway
retropharyngeal/peritonsillar abscess
angioneurotic oedema
allergic reaction
management
consider the need for hospital admission, admit all children with clinical features or moderate or severe illness or impending respiratory failure
consider hospital admission for children with resp rate over 60 BPM or who present with high fever or toxic appearance
consider admission for children with mild illness if these factors warrant a lower threshold for admission such as: chronic lung disease, congenital heart disease, neuromuscular disorder, immunodeficiency, age under 3 months, inadequate fluid intake,
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while waiting on admission
give controlled O2 therapy to all children with symptoms of severe illness or impending respiratory failure
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administer dose of dexamethasone, if child is too unwell to receive medication, inhaled budesonide or intramuscular dexamethasone as possible alternatives
If hospital admission is not indicated
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Px a single dose of oral dexamethasone
advise parents that expected course of croup, include that symptoms usually resolve with 48 hours
use paracetamol or ibuprofen for fever or pain
encourage fluids, continue to breastfed
attend hospital if stridor can be heard continuously
check child regularly including through the night
advise parent or care to call ambulance if the child is: pale, grey or blue, sleepy or unresponsive, having trouble sleeping - sinking in belly while breathing, upset while struggling to breathe and cannot be calmed down quickly, unable to talk or drooling, having trouble swallowing, or want to sit instead of lying down, arrange follow up, using clinical judgement to determine the appropriate interval