History

Fact Explanation
Non-specific respiratory symptoms Most of the time symptoms consist of abrupt onset rhinorrhea, sore throat and cough especially at night. Common in the age group of 3 months to 5 years [1],[2]
Inspiratory stridor [2] The inflamed and swollen trachea is narrowed immediately below the vocal cords. [3]
Spasmodic croup (Recurrent croup) Recurrent symptoms of croup occurs due to non-inflammatory edema of the vocal cords. [4]
Barking cough [2] Due to the irritation of trachea and glottis. [5]
Fever Generally low grade fever, may rarely exceed 40°C.
Poor feeding Mostly in young children.
Hoarseness of voice Edema of the trachea and the throat. [6]
References
  1. NELSON. ed. Robert M. Kliegman. Bonita F. Stanton, Joseph W. St. Geme III, Nina F. Schor, Richard E. Behrman. Nelson Textbook of Pediatrics. 19th ed. London. Elsevier, 2011.
  2. CANDICE L BJORNSON, DAVID W JOHNSON. Croup. The Lancet, Volume 371, Pages 329 - 339, 26 January 2008. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(08)60170-1/abstract
  3. DAVISON FW. Acute laryngeal obstruction in children. JAMA 1959;171:1301-1305
  4. JAMES D. CHERRY, Croup. N Engl J Med 2008; 358:384-391 http://www.nejm.org/doi/full/10.1056/NEJMcp072022
  5. M D SHIELDS, A BUSH, M L EVERARD, S MCKENZIED, R PRIMHAK. Recommendations for the assessment and management of cough in children. BTS guidelines. Thorax 2008;63:iii1-iii15 http://thorax.bmj.com/content/63/Suppl_3/iii1.full
  6. Croup. Viral croup; Laryngotracheobronchitis - acute; Spasmodic croup. May 16, 2012 http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001955/

Examination

Fact Explanation
Fever The child is febrile due to the infection.
Inspiratory stridor Inflammation leading to narrowing of the airway below the vocal cords. [1]
Expiratory wheezing Usually mild.
Features of labored breathing Suprasternal, intercostal and subcostal recessions can be seen. [1]
Reduced air entry to the lungs Due to the narrowed airway.
Cyanosis Increased desaturated hemoglobin in the blood causes peripheral cyanosis, later leading to central cyanosis. [2]
Respiratory failure Due to the narrowed airway leading to labored breathing. [3]
References
  1. CANDICE L BJORNSON, DAVID W JOHNSON. Croup. The Lancet [Online], Volume 371, Issue 9609, Pages 329 - 339, 26 January 2008 [viewed on 28 April 2014]. Available from: doi:10.1016/S0140-6736(08)60170-1
  2. JAMES D. CHERRY, Croup. N Engl J Med [Online] 2008; 358:384-391 [viewed on 28 April 2014]. Available from: DOI: 10.1056/NEJMcp072022
  3. JOHNSON D. Croup. Clin Evid [Online]. Mar 10 2009. [viewed on 28 April 2014]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19445760

Differential Diagnoses

Fact Explanation
Inhaled foreign body [1] This does not cause fever or any signs of infection; and it is of sudden onset with no preceding symptoms. [1]
Peritonsillar Abscess [2] Compression of the upper airway results in stridor.
Angioedema [3] Allergic angioedema is of acute onset.
Acute epiglottitis This is of acute onset. Child is febrile, toxic and drooling saliva. [4]
Laryngomalacia Causes chronic stridor.
Allergic reaction [5] Swelling of face and neck may be seen. [6]
Laryngeal web Causes chronic stridor. [2]
Gastroesophageal reflux Stridor occurs due to transient laryngospasm and laryngeal edema. [2]
References
  1. CANDICE L BJORNSON, DAVID W JOHNSON. Croup. The Lancet, Volume 371, Pages 329 - 339, 26 January 2008
  2. NELSON. ed. Robert M. Kliegman. Bonita F. Stanton, Joseph W. St. Geme III, Nina F. Schor, Richard E. Behrman. Nelson Textbook of Pediatrics. 19th ed. London. Elsevier, 2011.
  3. FEIGIN RD, CHERRY JD, DEMMLER GJ, KAPLAN S. Textbook of pediatric infectious diseases. 5th ed. Philadelphia: W.B. Saunders, 2004:252-66.
  4. REMINGTON JS, SWARTZ MN, Current clinical topics in infectious diseases. New York: McGraw-Hill, 1981:1-30.
  5. J. A. FORBES, Croup and its management, Br Med J [Online]. Feb 11, 1961; 1(5223): 389–392.[viewed on 28 April 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1953274/pdf/brmedj02880-0041.pdf
  6. ROGER ZOOROB, MOHAMAD SIDANI, JOHN MURRAY, Croup: An Overview. Am Fam Physician. 2011 May 1;83(9):1067-1073.

Investigations - for Diagnosis

Fact Explanation
None Croup is a clinical diagnosis. [1]
Full blood count This helps to differentiate a viral etiology from a bacterial etiology.
X-Ray of the neck When there is a doubt in diagnosis, “Steeple sign” (pencil-point sign) might be visible on the X-ray, which refers to subglottic narrowing. [2]
Nasal swab and viral studies Not routinely done, but helps in determining the antiviral treatment. [1]
Bronchoscopy To detect anatomical abnormalities in recurrent croup. [3,4]
References
  1. JAMES D. CHERRY, Croup. N Engl J Med [Online] 2008; 358:384-391 [viewed on 28 April 2014]. Available from: DOI: 10.1056/NEJMcp072022
  2. NELSON. ed. Robert M. Kliegman. Bonita F. Stanton, Joseph W. St. Geme III, Nina F. Schor, Richard E. Behrman. Nelson Textbook of Pediatrics. 19th ed. London. Elsevier, 2011.
  3. CHUN R, PRECIADO DA, ZALZAL GH, SHAH RK. Utility of bronchoscopy for recurrent croup. Ann Otol Rhinol Laryngol. Jul 2009;118(7):495-9.
  4. KWONG K, HOA M, COTICCHIA JM. Recurrent croup presentation, diagnosis, and management. Am J Otolaryngol. 2007 Nov-Dec;28(6):401-7.

Investigations - Followup

Fact Explanation
Arterial Blood Gas Analysis (ABGA) If the patient deteriorates, ABGA helps to assess the acid base status and for the early detection of type two respiratory failure. [1]
Pulse oximetry Helpful in assessing the severity of the disease so to decide on treatment options. [2]
References
  1. WESLEY AG, BRUCE R, HOLLOWAY R. Arterial blood gases as a guide to management of infective croup. S Afr Med J. 1968 Nov 23;42(45):1237-9. http://www.ncbi.nlm.nih.gov/pubmed/5704996
  2. ROGER ZOOROB, MOHAMAD SIDANI, JOHN MURRAY, Croup: An Overview. Am Fam Physician. 2011 May 1;83(9):1067-1073. http://www.aafp.org/afp/2011/0501/p1067.html

Management - General Measures

Fact Explanation
Antypyretics As the child may be febrile.
Antibiotic treatment for secondary bacterial infection. Group A Haemolytic streptococci and staphylococci are known organisms. [1]
Intravenous fluids Correct dehydration.
References
  1. J. A. FORBES, Croup and its management, British medical journal, Feb. 11, 1961. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1953274/pdf/brmedj02880-0041.pdf

Management - Specific Treatments

Fact Explanation
Oxygen [1] 100% oxygen should be administered in severe croup.
Corticosteroids [2,3,4] Oral (prednisolone or dexamethasone), nebulized (budesonide), or intravenous can be used. [5] It has anti-inflammatory action and reduces the edema of the air way. [6] Usual dose is 0.6 mg/kg with maximum dose of 10mg as a single dose. [7]
Nebulized epinephrine Reduces the laryngeal edema, stimulates the beta-2 adrenergic receptors and causes bronchial smooth muscle relaxation and bronchodilation. The action lasts only for short period of time, therefore repeated doses are necessary. [2,8]
Inhaled ribavirin Ribavirin is an antiviral acting against Para influenza virus. This can be considered for immune compromised patients. [7]
Heliox therapy This is a mixture of oxygen and helium. Whereas some studies have proven no benefit [9], other studies have proven a clear benefit with inhaled heliox. [10,11]
References
  1. Guideline for the diagnosis and management of croup. Alberta Medical Association, 2007. http://www.topalbertadoctors.org/NR/rdonlyres/B072F5EF-1728-4BED-A88A-68A99341B98A/0/croup_guideline.pdf
  2. BJORNSON C, RUSSELL KF, VANDERMEER B, DUREC T, KLASSEN TP, JOHNSON DW. Nebulized epinephrine for croup in children. Cochrane Database Syst Rev. Feb 16 2011.
  3. MONICA AUSEJO,ANTONIO SAENZ, JAMES D KELLNER, DAVID W JOHNSON, DAVID MOHER, TERRY P KLASSEN. The effectiveness of glucocorticoids in treating croup: meta-analysis. BMJ 1999; 319. http://www.bmj.com/content/319/7210/595
  4. S GRIFFIN, S ELLIS, A FITZGERALD-BARRON, J ROSE, M EGGER. Nebulized steroids in the treatment of croup: A Systemic review of randomised controlled trials. Br J Gen Pract. Feb 2000; 50(451): 135–141. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1313634/
  5. LURIA JW, GONZALEZ-DEL-REY JA, DIGIULIO GA, et al. Effectiveness of oral or nebulized dexamethasone for children with mild croup. Arch Pediatr Adolesc Med2001; 155: 1340-1345
  6. DOMINIC A. FITZGERALD . The assessment and management of croup. Paediatric Respiratory Reviews. Volume 7 , Pages 73-81, March 2006.
  7. NELSON. ed. Robert M. Kliegman. Bonita F. Stanton, Joseph W. St. Geme III, Nina F. Schor, Richard E. Behrman. Nelson Textbook of Pediatrics. 19th ed. London. Elsevier, 2011.
  8. TAUSSIG LM, CASTRO O, BEAUDRY PH, FOX WW,BUREAU M. Treatment of laryngotracheobronchitis (croup): use of intermittent positive-pressure breathing and racemic epinephrine. Am J Dis Child 1975;129:790-793
  9. VORWERK C, COATS T. Heliox for croup in children. Cochrane Database Syst Rev. 2010 Feb 17. http://www.ncbi.nlm.nih.gov/pubmed/20166089
  10. KLINE-KRAMMES S, REED C, GLULIANO JS JR, SCHWARTZ HP, FORBES M, POPE J, BESUNDER J, GOTHARD, RUSSELL K, BIGHAM MT. Heliox in children with croup: a strategy to hasten improvement. Air Med J. 2012 May-Jun;31(3):131-7. http://www.ncbi.nlm.nih.gov/pubmed/22541348
  11. MORAA I, STURMAN N, MCGUIRE T, VAN DRIEL ML. Heliox for croup in children. Cochrane Database Syst Rev. 2013 Dec. http://www.ncbi.nlm.nih.gov/pubmed/24318607