Croup + Stridor in Children Caitriona Broderick Source: PALS Guidelines

Stridor An abnormal, high-pitched sound produced by turbulent airflow through a partially obstructed airway at the level of the supraglottis, glottis, subglottis, or trachea. Inspiratory stridor; laryngeal obstruction Expiratory stridor; tracheobronchial obstruction Biphasic stridor; subglottic or glottic anomaly Symptom; not a diagnosis or disease Causes: Croup- viral laryngotracheitis Croup- recurrent or spasmodic Laryngeal foreign body Epiglottitis Croup- bacterial tracheitis Trauma Retropharyngeal abscess Viral croup; coryzal, barking cough, mild fever, hoarse voice Recurrent or spasmodic; sudden onset, recurrent, history of atopy Foreign body; sudden onset, history of chocking Epiglottitis; drooling, muffled voice, septic appearance incidence reduced since HIB vaccine. Bacterial tracheitis; harsh cough, chest pain, septic appearance Trauma; neck swelling crepitus, bruising Retropharyngeal abscess; drooling septic appearance

Definition: Croup: acute clinical syndrome with Commonest Cause (95%): Inspiratory stridor Barking cough Hoarseness Variable degrees of respiratory distress Preceded by fever, coryza for 1-3 days Symptoms often start and are worse at night Can deteriorate rapidly Commonest Cause (95%): Acute viral laryngotracheobronchitis (viral croup) Pathogens; Parainfluenza virus, RSV, adenoviruses Peak incidence; 2nd year of life Most hospital admissions; 6mths-5years

Initial Management? ABC

Chin lift or jaw thrust manoeuvre Responsiveness? Airway: Vocalisations Patency; chest movement +/- abdominal movement, symmetry, recession Listen for breathing sounds and stridor Feel for expired air Reassess after any airway manoeuvres Suction secretions Chin lift or jaw thrust manoeuvre Oro or nasopharyngeal airway device Intubation with senior help

Breathing: 10-15L/min; 100% O2 SpO2 94-98% Effort of breathing; Respiratory Rate Stridor Accessory muscle use Recession Wheeze Flaring of nostrils Grunting Gasping Efficacy of breathing; Chest expansion Breath sounds; reduced/absent/ Symmetry on ausculataion SpO2 10-15L/min; 100% O2 SpO2 94-98%

Fluid Bolus; 20ml/kg of 0.9% saline Circulation: Heart Rate Pulse Volume Capillary Refill Skin Temperature Disability: Mental status/ conscious level Posture Pupils Exposure: Rash or fever Fluid Bolus; 20ml/kg of 0.9% saline

Severe Respiratory Distress + Harsh Stridor + Barking Cough Nebulised Adrenaline 400mcg/kg 0.4ml/kg of 1:1000 With oxygen Via Face mask May need to be repeated Reduces the clinical severity of obstruction Does not improve arterial blood gases reduce the duration of hospitalisaion or eliminate the need for intubation Observe withcntinuous ECG and O2 sats Marked tachycadia can be produced with adrenaline It is best used to buy time to assemble an experienced team to treat a child with severe croup

Oral Dexamethasone 150mcg/kg Or Inhaled Nebulised Budesonide 2mg Both equally effective May be repeated after 12 hours if clinically indicated <5% require tracheal intubation; Tachycardia, tachypnoea, chest retraction, cyanosis, exhaustion or confusion. Tachycardia, tachypnoea, chest retraction, cyanosis, exhaustion or confusion. Median duration of intubation; 3 days, the younger the child the longer the intubation. Prednisolone 1mg/kg every 12 hours or dexamethasone 0.15mg/kg 12-24 hourly reduces duration of intubation.

Croup; Summary: ABC Nebulised Adrenaline Oral Dexamethasone or Inhaled Budesonide