Guideline for the management of Croup
Summary statement: How does the document support patient care? / The purpose of this policy is to provide evidence based guidance for staff in the assessment and management of croup
Staff/stakeholders involved in development:
Job titles only / Paediatric Consultant
Division: / Women & Child Health
Department: / Paediatrics
Responsible Person: / Chief of Service
Author: / Dr M. Linney
For use by: / All medical and nursing staff assessing and managing children who present with Croup
Purpose: / This guideline is to aid staff in the assessment and management of children presenting with Croup
This document supports:
Standards and legislation
Key related documents: / Croup Chart 2012
Approved by:
Divisional Governance/Management Group / Joint Paediatric Guidelines Group
Approval date: / October 2012
Ratified by Board of Directors/ Committee of the Board of Directors / No Applicable – Divisional ratification only required
Ratification Date: / No Applicable – Divisional ratification only required.
Expiry Date: / November 2015
Review date: / August 2015
If you require this document in another format such as Braille, large print, audio or another language please contact the Trusts Communications Team
Reference Number: / To be added by the Library
Version / date / Author / Status / Comment
1.0 / Oct 2012 / Dr M. Linney / Live
2.0
3.0
4.0

INDEX

Page No.
1.0 / Purpose / 4
2.0 / Key points / 4
3.0 / Assessment and Management / 5
App 1 / Paed Dept Croup Chart / 6
References / 8

1.0PURPOSE

To guide medical and nursing staff in the assessment and management of croup in A&E and on Howard Ward.

2.0KEY POINTS

Croup is common, affecting about 2% pre-school aged children annually. It mainly affects children aged 6-36 months and boys more than girls (3:2). The term ‘croup’ refers to a clinical syndrome of harsh barking cough and inspiratory stridor. It is most commonly caused by viral laryngotracheobronchitis and can cause significant, sometimes life-threatening, respiratory distress and upper airway obstruction.

The condition is usually mild and self- limiting and often managed in primary care. Typically coryzal symptoms and croup develop over a few days and then upper airway obstruction resolves over 3-5 days. Symptoms are usually worst at night.

Other differential diagnoses should be considered and include epiglottitis (rare since introduction of Hib vaccine), inhalation of a foreign body, bacterial tracheitis and acute angioedema (usually other symptoms and signs of allergy). Spasmodic croup tends to occur in older, often atopic, children and can be treated in the same way as viral croup.

GUIDANCE

Determining the degree of upper airway obstruction is the most important consideration when assessing children with croup. This is based on history and clinical assessment using the ‘croup score’ (see attached) based on respiratory effort, oxygen saturation, stridor, work of breathing and air entry. General appearance will also guide the clinician as to the severity of croup- an agitated or tiring child may rapidly deteriorate. Assessment should take place with the child in a calm environment, whether in A&E/CAU/CYPDU or on the Children’s Wards, ideally with the parent or carer as anxiety can worsen symptoms. Do not attempt to examine the throat of a child with upper airway compromise as this can precipitate complete obstruction.

3.0Assessment and Management.

(Croup Chart to be used as a guide to severity- see appendix.)

If you are concerned that the child is at risk of complete upper airway obstruction

  • Call for help
  • Put out a Paediatric crash call (anaesthetic and paediatric registrars)
  • Ask switchboard to fast bleep the Consultant Anaesthetist and Paediatrician.
  • Manage the situation in the nearest place available with the best monitoring (Paeds Resus in A&E or stabilisation areas on the Wards)
  • Let the child adopt a comfortable condition and do not upset them if possible.
  • Drug management as for croup score of 10+

Croup score 10+

  • Call Paediatric and Anaesthetic registrars.
  • Give nebulised adrenaline 5ml of 1/1000 . Beware of rebound symptoms as the effects can be short-lived. Dose can be repeated if necessary after 2hours.
  • Oral dexamethasone 150 mcg/kg (0.15mg/kg) if not tolerated give nebulised budesonide Give 2mg dose of budesonide
  • If there is no improvement these children may need stabilisation and transfer to PICU. Consultant Paediatric and Anaesthetic input is urgently required with possible intubation, iv fluids, hydrocortisone and empirical antibiotics in case of bacterial tracheitis or epiglottitis.

Croup score 8-10

Oral dexamethasone 150mcg/kg (0.15mg/kg) repeat after 12 hours

  • Only give nebulised budesonide if vomiting or refusing dexamethasone. Give initial 2mg stat then 1mg
  • Admit for observation

Croup score 3-7

  • Give oral dexamethasone 150 mcg/kg (0.15mg/kg) or nebulised budesonide if vomiting/refusing

Observation for at least 4 hours

Croup score 0-2 (mild croup)

Observation only required but dexamethasone can be given if felt a worsening condition. Can be discharged from ED if unlikely to worsen with advice.

PAEDIATRIC DEPARTMENT CROUP CHART

Name and Address

Patient Label / Date:......
Ward:......
Date / Time
Temperature
Pulse Rate
Respiratory rate
Saturation %
Saturation Score
Stridor Score
Air Entry Score
Recession Score
Resp. Distress Score
TOTAL SCORE
Respiratory Distress Score
/ Saturation (in air) Score
Nil / 0 / 95 – 100%
Child comfortable / 1 / 92 – 94%
Child agitated / 2 / 89 – 91%
Child exhausted / 3 / 86 – 88%
4 / Less than 86%
Stridor Score / Air Entry Score / Recession Score
No Stridor / 0 / Normal / 0 / Nil
Only when agitated / 1 / Reduced / 1 / Mild
Mild at rest / 2 / 2 / Moderate
Moderate at rest / 3 / Greatly reduced / 3 / Severe
Severe at rest / 4
STEP 1
Score 0 – 3
Observe. / STEP 2Score 4 – 7
Oral dexamethasone.
Observe. / STEP 3Score 8 – 10
Oral dexamethasone.
BudesonideNeb.
Observation. /
STEP 4
Score 10+
Call Help – Paeds Reg.
Nebulised adrenaline
Neb. Budesonide
Oral dexamethasone.
Close observation. /
STEP 5
Stabilise for PICU.
Consultant input.
Intubate
IV Fluids
IV Hydrocortisone
IV Antibiotics.
Oral Dexamethasone dose = 0.15 mg/kg/dose 12-hourly
Neb. Adrenaline dose = 5 ml of 1 in 1000 diluted with 3mls 0.9% NaC1
Neb. Budesonide dose = 2 mg stat then 1 mg 12-hourly
Also add nebulised Budesonide if there is no improvement in croup scores 12 hours following a dose of oral Dexamethasone.

Management of Croup Guideline

Version 1Page 1 of 9Oct 2012

References

Advanced Paediatric Life support guidelines.

Fitzgerald D, Kilham H. Croup: assessment and evidence-based management. Medical Journal of Australia 2003; 179 (7): 372-377

Macdonald W, Geelhoed G. Management of childhood croup. Thorax 1997;52:757-759

Geelhoed GC, Macdonald WB. Oral dexamethasone in the treatment of croup: 0.15 mg/kg versus 0.3 mg/kg versus 0.6 mg/kg. Pediatr Pulmonol. 1995;20(6):362-8

Johnson et al. NEJM:1998; Aug 20th

Management of Croup Guideline

Version 1Page 1 of 9Oct 2012