Clinical Practice Guidelines

Croup (Laryngotracheobronchitis)

  • This guideline has been adapted for statewide use with the support of the Victorian Paediatric Clinical Network

     RCH: Consider Criteria Led Discharge

    See also:

    Acute upper airway obstruction
    Inhaled foreign body

    Background:

    - viral inflammation of upper airway, larynx, trachea and bronchi
    - worse at night - peak night two or three

    Differential Diagnoses see  Acute upper airway obstruction)

    - Inhaled foreign body
    - Epiglottitis
    - Bacterial tracheitis

    Assessment:

    Children with croup should have minimal examination. Do not examine throat. Do not upset child further.

    - barking cough
    - inspiratory stridor
    - may have associated widespread wheeze
    - increased  work of breathing
    - may have fever, but no signs of toxicity

    Risk Factors for severe croup

    - pre-existing narrowing of upper airways

    • subglottic stenosis (congenital or secondary to prolonged neonatal ventilation)
    • Down Syndrome

    - previous admissions with severe croup
    - uncommon <6 months, rare <3 months of age. Consider alternative diagnosis. Acute upper airway obstruction.

    Assessment of Severity

     

     MILD 

     MODERATE

     SEVERE

     Behaviour

     Normal 

     Some/intermittent irritability  

    Increasing irritability and/or lethargy

     

    Stridor*

    Barking cough

    Stridor only when active or upset

     Some stridor at rest

     Stridor present at rest

    Respiratory Rate

     Normal

    Increased Resp rate
    Tracheal Tug
    Nasal Flaring

    Marked increase or decrease
    Tracheal Tug
    Nasal Flaring

    Accessory Muscle Use

     None or minimal 

     Moderate chest wall retraction 

     Marked chest wall retraction

     Oxygen

    No oxygen requirement

     No oxygen requirement

    Hypoxemia is a late sign of significant upper airways obstruction

    * The loudness of the stridor is not a good guide to the severity of the obstruction.

    Investigations

    • investigations including NPA, CXR, blood tests are NOT usually indicated and may cause the child distress and worsening of symptoms

    Acute Management

    • Children with croup need minimal handling . This includes limiting examination, nursing with parents. Supplemental oxygen is not usually required. If needed consider severe airways obstruction.
    • Do not forcibly change a child's posture - they will adopt the posture that minimises airways obstruction.
    • Iv access should be deferred.
    • Avoid distressing the child further.

    Treatment:

    Children with cough only do not require treatment.

    Steroids have been shown to decrease the length of hospital stay, need for nebulised Adrenaline and other interventions. Drug Doses link

    Mild to Moderate Croup

    Prednisolone 1mg/kg, AND prescribe a second dose for the next evening.
     OR
     a single dose of Oral Dexamethasone 0.15mg/kg.
     
     (NB. Oral dexamethasone suspension ONLY available in hospitals, NOT available at commercial pharmacies)

    Observe for half an hour post steroid administration. Discharge once stridor-free at rest.

    Severe croup

    Nebulised adrenaline (1 mL of 1% adrenaline solution* plus 3ml Normal Saline, or 4ml of adrenaline 1:1000.)

    (*some hospitals stock bottles of 1% adrenaline solution, often for ophthalmic use. If not available use 1:1000 vials)

    AND

    Give 0.6mg/kg (max 12mg) IM/IV dexamethasone

    Improvement

    If good improvement, observe for 4 hours post adrenaline. Consider discharge once stridor free at rest.

    Improvement then deterioration

    Give further doses of adrenaline. Consider admission/transfer as appropriate.

    No improvement

    Reconsider diagnosis. Acute upper airway obstruction.

    Consider consultation with local paediatric team when:

    - Severe airways obstruction.
    - No improvement with nebulised adrenaline.
    - Child has risk factors (see above)

    Consider transfer when:

    - No improvement following nebulised adrenaline.
    - >2 doses of nebulised adrenaline are required.
    - Children requiring care above the level of comfort of the local hospital.

    For advice and inter-hospital (including ICU level) transfers ring the Sick Child Hotline: (03) 9345 7007

    Discharge requirements:

    - Four hours post nebulised adrenaline (if given) and/or half an hour post oral steroid, and stridor free at rest

    Parents should be advised and able to seek help if stridor at rest regardless of whether they have received steroids

    Parent information sheet:

     Information Specific to RCH

    Children with croup are usually admitted under the General Paediatric Team.

    Consider ICU review of any child admitted to RCH requiring frequent nebulised adrenaline, or treatment above to comfort level of the medical staff and/or ward. 

     

    Additional Notes

    Antibiotics have no role in uncomplicated croup as it has a viral aetiology
    Antitussives such as codeine, have no proven effect on the course or severity of croup and may increase sedation, thus interfering with assessment.
    Humidified air has not been proven to change the severity of croup
    Heliox has not been shown to be better than nebulised adrenaline in severe croup.

    Last updated April 2011