Clinical Practice Guidelines

Croup (Laryngotracheobronchitis)


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

  • See also       

    Acute upper airway obstruction 
    Inhaled foreign body

    Key Points

    1. Minimise distress to the child as this can worsen upper airway obstruction.
    2. Consider early transfer and involvement of senior staff if concerns regarding worsening upper airway obstruction.
    3. For severe and life-threatening croup use nebulised adrenaline.
    4. Less severe cases can be managed with corticosteroids alone.

    Background

    • Croup is inflammation of the upper airway, larynx and trachea usually triggered by a virus
    • Occurs generally between the ages of 6 months to 6 years.
    • Often worse at night
    • Alternative diagnoses include: Bacterial tracheitis, inhaled foreign body, anaphylaxis. See Acute upper airway obstruction

    Assessment

    Children with croup should have minimal examination so as not to upset the child further. Throat examination is rarely required. 

    Examination

    • Barking cough
    • Inspiratory stridor
    • Hoarse voice
    • May have associated widespread wheeze
    • Increased work of breathing
    • May have fever, but no signs of toxicity

    Risk factors for severe croup include:

    • pre-existing narrowing of upper airways
    • previous admissions with severe croup
    • young age:  uncommon < 6 months old, rare < 3 months of age. Consider alternative diagnosis and causes of upper airway obstruction

    Assessment of severity

       Mild    Moderate    Severe
    Behaviour Normal  Intermittent/ mild agitation Increasing agitation Drowsiness
    Stridor* No stridor, or only when active or upset Intermittent stridor at rest Persistent stridor at rest
    Respiratory Rate Normal Increased respiratory rate  Marked increase or decrease
    Accessory Muscle Use None or minimal  Moderate chest wall retraction  Marked chest wall retraction
    Oxygen saturations** Hypoxia is a late sign which indicates life-threatening croup 

    * Loudness of stridor is not a good indicator of severity of obstruction. Soft stridor in the presence of worsening clinical picture may be a sign of imminent airway obstruction

    ** It is not necessary to measure oxygen saturations in children with mild to moderate croup

    Management

    Investigations

    No investigations are needed in croup, including nasopharyngeal aspirate (NPA), x-rays and blood tests and may cause distress to the child and worsening of symptoms. 

    Treatment

    • Minimal handling to avoid worsening symptoms - limited examination.
    • Keep children with carers to reduce distress.
    • Children will adopt a position of comfort that minimises airway obstruction, do not change this.
    • Treat mild croup with steroids alone. Barking cough with no other symptoms does not always require steroids.
    • Moderate croup is usually managed with steroids alone, consider adrenaline if persistent or worsening symptoms.
    • Severe croup requires nebulised adrenaline and steroids. See flowchart.
    • Supplemental oxygen is not usually required. If needed, treat for severe upper airway obstruction.
    • Defer intravenous (IV) access.

    croup

    *Consider nebulised Budesonide 2mg if oral corticosteroids not tolerated

    Consider consultation with local paediatric team when:

    • Severe airway obstruction
    • Child has risk factors or an atypical presentation
    • No improvement with nebulised adrenaline

    Consider transfer when:

    • No improvement following nebulised adrenaline
    • Child requiring repeated doses of nebulised adrenaline
    • Child requiring care above the level of comfort of the local hospital. 

    For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services.

    Consider discharge when:

    Stridor free at rest 

    AND

    • four hours post nebulised adrenaline if this has been required
      or 
    • 30 minutes post oral steroids

    Parents should be advised to seek medical attention if re-occurrence of stridor at rest despite having received oral steroids.

    Parent information

    Kids Health Info 
    Croup

    Additional notes

    • Antibiotics have no role in uncomplicated croup as it has a viral aetiology.
    • Antitussives such has codeine, have no proven effect on the course or severity of croup, and may cause respiratory depression and increase sedation.
    • 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 May 2019