It is unacceptably late at night and you are working in a delightfully appointed urgent treatment centre, complete with high end espresso machine and snacks in each clinical room. Of course, being a publicly funded service, the espresso machine is knackered and the snacks have all been snaffled but it’s nice to dream.
Anyway; your next patient is a 2 yo girl presenting with ‘barking cough’ according to the clinical case notes. Before your derrière has left your seat you hear what sounds like a seal lions rendition of the opening lines of Queen’s ‘Another One Bites the Dust’ (think about it, it makes sense). There are few diagnoses you can make from a hearing few seconds of coughing in a distant waiting room, but this is one them.
Additional history reveals a couple of days of fever and coryzal symptoms but symptoms got worse since she went to bed and the parents were abruptly woken from sleep by what they assumed to be the distressed sounds of a seal being kicked in an upstairs bedroom.
It’s been a long time since I released an AlfaMedCPD blog post, and quite frankly I needed something to do with my day off that wasn’t watching box sets on sky. This post will be a discussion about acute laryngo-tracheo-bronchitis, known to sane people as ‘Croup’.
What is Croup?
We hear a characteristic ‘seal bark’, or stridor cough because of oedema and inflammation of the larynx, and to a lesser extent the trachea and bronchi secondary to upper respiratory tract infection and most commonly occurs in young children between 6months and 3yrs old. It can occur in children of any age, but this is less common. In fact I saw a 12yo with croup a couple of years ago.
There is usually a prodromal period of cough and cold symptoms (although not exclusively) for a few days, that rapidly develops into stridor and associated cough. There is strong evidence to support the experience that you will nearly always see croupy kids at night. It isn’t fully understood why this happens but is theorised to be affected by the cooler air at night.
The cough is key really. If you hear it (or the parents have taken a video), you’ve made the diagnosis. Remember however, that a parent/ carers often use medical terms incorrectly and their description of ‘croupy cough’ may not be accurate. If in doubt, it is worth learning how to make a stridor/ stridor cough yourself in order to show what you mean (or use YouTube) i.e does their cough sound like this [insert stridor cough]? This will ensure that you are treating the right thing and that parents are empowered to recognise and manage this at home.
Assessment
Before you commit to a management plan that quickly improves symptoms and shows what an awesome clinician you are, there are a few things to consider that may sway your decision making.
Firstly. Is the child well and is their airway actually sufficiently patent for them to breathe adequately? What you need to be ascertaining here is that the child is well hydrated, well perfused and mentating normally (not floppy/ listless/ drowsy) and not working hard dragging breath in and out. In the absence of fever and coryzal symptoms, consider foreign body airway obstruction, especially in young children, those with swallow problems or those with neurodiversity with sensory chewing behaviours.
If they are drooling they are likely just drooling because they are snotty and full of cold. But, if they are drooling with the aforementioned ‘brown flag features’ then they may have epiglottis and they are likely to crash rapidly in the not too distant future and you should definitely call an ambulance. Epiglottis is thankfully exceptionally rare thanks to effective vaccine against Haemophilus Influenza B, and most cases these days occur in unvaccinated adults.
Secondly, can the parent/ carer readily access further health care support should things not go to plan or deteriorate further? Have they got ready access to transport or are they reliant on less immediate/ unreliable means such as public transport or reliance on others? This might lower your threshold to escalate to paediatrics , ensuring that the child either improves or remains stable prior to going back home.
Thirdly (and finally), have you explained the management plan and safety netting advice in such as way that enables the parent/ carer to be competent and confident to manage their child at home and to be able to recognise and respond to unanticipated change or deterioration. Again this may adjust your threshold for referral if you can’t achieve this.
Avoid pissing the child off (more than you have to)
In a child with croup, there is nothing that is more guaranteed to provoke a cycle of heightened stress = more cough + stridor = more stress = more cough…. and so on, until you get a lap full of vomit, than an over zealous clinician with a need to get hands on. The approach to adopt with acute paediatrics in general is to be as hands off as you can possibly be, since nearly everything you need to know can be gleaned from observing the Child’s demeanour and respiratory function with a fully exposed torso.
A child that is alert/ calm, well hydrated, well perfused, with mild or absent respiratory distress is likely to be one that we can safely manage in the community.
A note on respiratory distress and what is meant by this. i.e do they have any?
- Recession (sub/ intercostal or sternal)
- Tracheal tug
- Nasal flaring – infants and babies typically
- Accessory muscle use (head bobbing in infants)
- Grunting
Put the torch and tongue depressor away (sponsored by the previous section)
The calmer, the child, the calmer the parent/ carer and the less you will provoke stridor and coughing. Limit your examination to those aspects that might change your plan. Throat examination is a prime example, so leave your torch and tongue depressor out of sight. Trust me. The reason for looking in the throat would be to exclude severe throat swelling/ infection. If they are drinking, have no marked respiratory distress or continuous stridor, they are very unlikely to have are severely inflamed/ swollen throat. Similarly, if they do have any of these signs, you’d be arranging admission to hospital regardless of whether the throat looks ok or not. Right?
Observations won’t tell you much more than you’ve already determined either so don’t feel too precious about getting an SpO2 or temperature if the child doesn’t want to cooperate. A respiratory and pulse rate and a central capillary refill time along with an impression of their demeanour is sufficient to determine whether or not they have severe disease or no. If they are not drowsy, they are not hypoxaemic, hence spo2 unlikely to change your plan, and temperature, well, that won’t change your plan which ever way you look at it (if child has clear evidence of infection).
Management
Reduce stress and avoid anything that might scare the child.
Oral corticosteroids
Indicated and beneficial in all children with croup regardless of severity (6) and should be offered at the initial presentation. In the UK there are broadly 2 options, Dexamethasone or Prednisolone.
Dexamethasone 150mcg/kg orally is the preferred option, since it requires a single dose and demonstrates superiority when compared to prednisolone (1), with treatment failure in 7% vs 29% in those treated with prednisolone (1mg/kg).
If your local service / pharmacy doesn’t have oral dexamethasone, then Prednisolone1-2mg/kg, whilst not ideal, is better than nothing (go for higher dose unless good reason not to) but is usually more readily available that dexamethasone. It does require treatment for 2-3 days due to it’s shorter half-life and carries a greater incidence of vomiting and may need repeating in this case.
Nebulised Budesonide is an option if the child is too unwell to take anything orally but this needs to be balanced against the potential to distress them and worsen their symptoms.
Adrenaline
In severe or life threatening croup, along with oxygen and steroids (orally or parenterally if the child is really sick), nebulised adrenaline o.5ml/kg 1:1000 (max 5ml) can improve symptoms within 30 minutes and buy some time to get the child to senior support (2, 4, 5). The results are usually transient
Interestingly, if you are UK prehospital clinician, you may have noticed that JRCALC (3) (the body that produces clinical practice guidelines for UK Ambulance Clinicians) doesn’t recommend nebulised adrenaline on the basis that it is a low frequency occurrence, and that the stress of nebulisation can make the symptoms worse. The single study upon which this decision is based, demonstrated that 6% of children presenting with croup had critical airway obstruction and received nebulised adrenaline! Not exactly rare is it? Granted, clinicians are required to work within their services policies and procedures but I’d have to stress here that JRCALC are ‘GUIDELINES’ and that the majority of other international and national guidance supports the use of adrenaline nebuliser in this group of really sick children. Food for thought.
The flow chart above provides a really quick overview of the management, with children in the low risk category being the most common and straightforward. Amber features require a little more thought and may benefit from a period of observation within your setting after you’ve initiated treatment to ensure that they are not worsening. There may be a variety of decisions that could be made for those children in the amber category, depending on the factors that I touched on earlier, as well as your own experience and confidence. If in doubt phone a friend. From experience, most paediatricians will happily provide advice and objective opinion if you are uncertain, but avoid the temptation to defer to them to make the decision for you.
Admission/ follow up
Those with life threatening or severe disease or those with concerning features need onward referral to acute paediatrics whilst undertaking the management steps appropriate to the presentation. Take a look at the NICE CKS: Croup (6) or the fantastic RCEMLearning post (2) for further information.
Most children with mild- moderate symptoms can be safely managed at home, ensuring adequate oral hydration, adequate analgesia with paracetamol and/ or ibuprofen, along with careful safety netting advice to ensure that children who deteriorate unexpectedly don’t slip through the net and are presented to an appropriate setting in a timely manner. Specifically document what safety netting was provided, don’t just write ‘safety netted’. Healthier Together What 0-18 (7) provides some really good safety netting and advice sheets that you can print/ text to parents and carers in addition to clinical pathways for the non- paediatric specialist to support management and decision making strategies.
Summary
With unwell children, less is more (usually). Croup definitely benefits from steroid treatment and most children don’t require escalation in their treatment but if they have severe or life threatening symptoms, there is good evidence to support adjunctive therapy with nebulised adrenaline whilst arranging senior input or awaiting ambulance transfer into hospital.
It has been a while but I am hoping to make more of the short snippets of easily digestible CPD. Leave your comments below and start a discussion of your own.
References
- Sparrow H, Geelhoead GC. Prednisolone versus dexamethasone in croup: a randomised equivalence trial. Arch Dis Child 2006; 91: 580-83.
- https://www.rcemlearning.co.uk/reference/croup/#1568728785135-df3bff44-26c4
- https://jrcalc.org.uk/jrcalc-q-and-as/advice-on-nebulised-adrenaline-for-croup-at-home/#:~:text=Q%26A%3A%20JRCALC%20does%20not%20recommend,Subcommittee%20and%20supported%20by%20AACE.
- https://bnf.nice.org.uk/treatment-summaries/croup/
- https://www.childrens.health.qld.gov.au/__data/assets/pdf_file/0034/193669/Adrenaline-Use-Croup.pdf
- https://cks.nice.org.uk/topics/croup/
- https://www.what0-18.nhs.uk/parentscarers/worried-your-child-unwell/croup
