Croup (laryngotracheobronchitis) is an upper respiratory illness characterised by a hoarse voice, barking cough, and stridor. The clinical symptoms are a result of inflammation and narrowing of the upper airway (larynx, trachea and bronchi).
Croup is usually caused by the Parainfluenza virus, but a variety of respiratory viruses may be responsible
Symptoms usually become more evident at night
Most cases are mild (and don’t require admission)
Severe cases can be life-threatening due to potential airway compromise
Don’t upset the child – this will exacerbate the symptoms
The severity of the stridor is not an indication of the severity of croup
Ask about the onset and duration of symptoms – cough, stridor, increased work of breathing.
Past history – previous episodes of croup, underlying upper airway abnormality, underlying neuromuscular conditions.
Possibility of inhaled foreign body, or anaphylaxis.
It is important not to exacerbate the symptoms by upsetting the child – keep your assessment short and as non-invasive as possible. Keep the child in their most comfortable position (eg: in parents arms).
Observations: heart rate, respiratory rate, temperature, SpO2 (and BP if severe).
Behaviour: child alert and interested in surroundings, or altered conscious state eg: irritable, lethargic.
Respiratory assessment: cyanosis (this is a very late sign), barking cough, stridor (when upset or at rest), air entry on auscultation, there may also be wheeze.
Work of breathing: degree (mild, moderate or severe) and type of recession (sternal, intercostal, subcostal, tracheal tug).
Watch for signs of impending respiratory exhaustion.
No stridor at rest
No sternal recession or tracheal tug
Audible stridor at rest
Mild sternal recession +/- trachael tug
May be irritable at times
Persistent stridor at rest
Pallor and mottling
Severe sternal recession +/- tracheal tug
Irritable or lethargic
Do not routinely test for viruses unless the child is being admitted to inpatient ward.
Chest X-Ray is not indicated (except for those in extremis, i.e. those considered for PICU admission).
Give high flow oxygen (15L/min via a non-rebreather mask)
Prepare for intubation.
Severe croup is treated as above with high flow oxygen and nebulised adrenaline. Adrenaline can be repeated 10 minutely as required. All severe and life threatening croup should be discussed with a Senior Doctor +/- Paediatric Intensive Care Unit and the child admitted under the General Paediatric Team.
Moderate croup will need observation (e.g.: ED observation ward) until there is no stridor at rest. All children requiring an adrenaline nebuliser should be observed for at least 3 hours.
Mild croup will not need observation and can be discharged home, after administration of oral steroid. All children presenting with any severity of croup, should receive corticosteroids.
Steroids start working by 30 minutes and reduce time in hospital, transfers to PICU, the chances of intubation for inpatients, and also reduce the likelihood of relapse after discharge home.
Steroid therapy is extremely successful in treating stridor, but does not resolve the underlying viral symptoms.
Usually a single dose of steroid is all that is required in mild to moderate croup.
ALL croup presentations should be treated with oral dexamethasone.
If oral dexamethasone is not available.
Rarely required. Can be given if oral steroids are not tolerated (e.g. vomited).
For severe cases of croup (PICU candidates)
The effect of adrenaline is short lived and is thought not to change the natural history of croup. It may be repeated after 10 minutes if necessary. Children receiving adrenaline need to be observed for a minimum of 3 hours afterwards.
Adrenaline – nebulised
Doses of 5mL can be given undiluted.
Doses < 5mL – dilute with 0.9% sodium chloride to 5mL
To be given with oxygen at 8 litres per minute via the nebuliser.
(Oxygen delivery at less than 8 litres per minute will not drive the nebuliser adequately).
As a “rule of thumb” children without stridor do not need to be admitted. This decision would be influenced by the distance parents live from the hospital, the reported severity of symptoms at home and past history of severe croup. The younger the child, the more conservative the approach.
The child must meet all of the following criteria:
No stridor at rest
No other clinical or social concerns
Health information (for carers)
Provide Health Facts Sheet – Croup
Minimal nursing intervention is encouraged to avoid distressing the child and increasing respiratory distress.
Patients should remain in a position of comfort
Children with croup require close observation
Baseline observations: heart rate, respiratory rate, SpO2 and temperature
The presence or absence of the following clinical features should be assessed and documented – stridor, barking cough, degree and type of recession (i.e. mild, moderate, severe, intercostal, subcostal, tracheal tug), air entry, cyanosis, conscious state (normal or altered)
Observations should be recorded at least hourly whilst in the emergency department
Any significant changes should be reported immediately to the medical team
SpO2 and ECG monitoring is recommended if adrenaline is given
Before applying consider whether the risk of distress negates the accuracy of monitoring
Children admitted to hospital with croup should be isolated
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