Makindo Medical Notes

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

About

• Affects children aged 6 months to 3 years.

Aetiology

• Croup is an acute respiratory illness causing inflammation and narrowing of the subglottic region of the larynx, most often due to a viral infection.
• The most common causes are Parainfluenza virus, adenovirus, and respiratory syncytial virus (RSV).

Clinical Presentation

• Initial assessment should be minimally invasive if possible, allowing the child to settle.
• Encourage the child to sit on a caregiver’s lap; avoid forcing the child to lie down. Avoid throat examination and, if hypoxic, use a facemask for oxygen delivery.
• Signs and symptoms include rough, loud stridor, a barking cough, hoarseness, respiratory distress, and possible fever or coryza.

Assessing Severity

• Mild: Barking cough, no stridor or chest recession at rest.
• Moderate: Barking cough with stridor and chest recession, no agitation or lethargy.
• Severe: Barking cough with stridor, chest recession, agitation, or lethargy.
• Impending Respiratory Failure: Increasing airway obstruction, sternal/intercostal recession, asynchronous chest wall movement, fatigue, cyanosis, reduced consciousness, and tachycardia. Respiratory rate over 70 breaths/minute indicates severe distress.

Differential Diagnosis

• Acute epiglottitis: Rapid onset, minimal cough, fever > 38.5°C, drooling, quiet stridor.
• Diphtheria: Sore throat, bull neck, pseudomembrane, myocarditis. Rare in immunized individuals. Treatment: Antitoxin + IV Erythromycin.
• Acute tracheitis: Bacterial, high secretions. Managed like epiglottitis.
• Foreign body aspiration
• Anaphylaxis

Comparison of Croup, Epiglottitis, and Bacterial Tracheitis

Management

• Home Management: Suitable for mild viral croup cases.
  • Prescribe a single dose of oral dexamethasone (0.15 mg/kg).
  • Educate caregivers on the course of croup, which typically resolves within 48 hours.
  • Provide guidelines for emergency situations (e.g., continuous stridor, retractions, color changes).
• General Care:
  • Use paracetamol or ibuprofen to relieve fever-related distress.
  • Encourage fluid intake; continue breastfeeding for infants.
  • Check the child regularly, including through the night, and advise on signs of deterioration.
• Hospital Admission: For moderate, severe, or at-risk cases.
  • Admit if there is moderate or severe respiratory distress, or if respiratory rate exceeds 60/min.
  • Lower admission threshold if there are comorbid conditions or social concerns affecting care.
  • Provide controlled oxygen for severe cases or impending respiratory failure.
  • Administer oral dexamethasone (0.15 mg/kg). For severe cases, alternatives include inhaled budesonide or intramuscular dexamethasone.
  • Nebulized adrenaline may be used for urgent management; involve senior staff and PICU as necessary.

References

• Croup NICE guidance