Croup + Stridor in Children

Caitriona Broderick

Source: PALS Guidelines

StridorAn 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

Definition:• Croup: acute clinical syndrome with

– 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

• 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:– 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%

• 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

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.

Croup; Summary:

• ABC• Nebulised Adrenaline• Oral Dexamethasone or Inhaled Budesonide