1. Croup + Stridor in Children
Caitriona Broderick
Source: PALS Guidelines

2. 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

3. 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

4. Initial Management? ABC

5. 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

6. 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
SpO %

7. 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

8. 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

9. 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 hourly reduces duration of intubation.

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