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Arch Dis Child: first published as 10.1136/adc.63.11.1305 on 1 November 1988. Downloaded from

Archives of Disease in Childhood, 1988, 63, 1305-1308

Management of croup

Those who turn to the current paediatric textbooks that hyperreactivity of the upper airway may be the for guidance on the management of croup may be underlying mechanism.5 6 forgiven if they are confused by what they read. Mist Bacterial , or pseudomembranous croup, treatment, tents, , nebulised is an uncommon but life threatening form of , , sedatives, intravenous croup.7 8 Infection of the tracheal mucosa with fluids, syrup of ipecacuanha (one drop per month of Staphyloccus aureus, streptococci, or Haemophilus age up to 2 years)' and endotracheal intubation are influenzae results in copious purulent secretions and advocated with enthusiasm or caution but with scant mucosal necrosis. The child appears toxic with a supportive evidence. Controversy about manage- high and the signs of progressive upper airway ment is fuelled by serious methodological deficien- obstruction. The croupy and absence of cies in published studies and failure to define clearly help distinguish this condition from acute the condition being studied.2 3 To some authors, . croup is synonymous with viral laryngotracheobron- Acute epiglottitis shares many of the clinical chitis, whereas others use the term to describe a features of croup but should be regarded as a symptom-complex which includes spasmodic croup, separate entity. B is the bacterial tracheitis, and acute epiglottitis, as well as causative pathogen in virtually all cases, but strepto- laryngotracheobronchitis. cocci can occasionally give a similar clinical picture. Although epiglottitis is a far less common cause of Definitions upper than croup, particularly in

infancy, it is important because without prompt copyright. Croup can be defined as an acute clinical syndrome recognition and appropriate treatment there is a with inspiratory , a barking cough, hoarse- high risk of death. Typically the child presents with a ness, and signs of respiratory distress due to varying history of a few hours of an intensely painful throat degrees of laryiigeal or tracheal obstruction. This and increasing difficulty in breathing. He is unable definition embraces several distinct disorders with to talk or drink and will be drooling saliva because different underlying pathophysiological processes, swallowing is so painful. A high fever and pallor are different clinical courses, and different responses to present and there may be signs of poor peripheral treatment. circulation. Characteristically, the child prefers to sit

upright rather than to lie down. General features of http://adc.bmj.com/ Acute laryngotracheobronchitis, the commonest upper airway obstruction such as sternal retraction, form of croup, is most frequently caused by the tachycardia, and tachypnoea, are present and may parainfluenza, , or respiratory syncytial worsen rapidly, particularly if the child is disturbed . The onset of barking cough, hoarseness, excessively. The stridor of epiglottitis is usually and stridor is usually preceded by rhinorrhoea, a quieter and less harsh than that of croup. The sore throat, and mild fever for one or two days. The absence of a croupy cough in any child with acute symptoms often begin, and are worse, at night but stridor and fever strongly suggests a diagnosis of normally disappear after two to seven days. Many epiglottitis. on September 24, 2021 by guest. Protected children have stridor with little or no respiratory , and difficulty but a few develop increasing tachycardia, laryngeal are uncommon causes of tachypnoea, sternal and subcostal recession, and acute stridor but may be fatal if not recognised. restlessness indicating severe upper airway obstruc- tion. The intensity of the stridor, like that of wheeze Treatment of croup in , is a poor indicator of the severity of obstruction.4 Accurate diagnosis, gentle handling, and careful Some children have repeated episodes of croup observation are the mainstays of good management. without fever or coryzal symptoms. Their symptoms As the distinction between viral laryngotracheo- are of sudden onset and at night, and often persist and recurrent croup, which together for only a few hours. The association of this account for most cases of croup, is often not made in recurrent or spasmodic croup with atopic disease and clinical practice or in published reports, the manage- an abnormal response to inhaled histamine, suggest ment of these two disorders will be considered 1305 Arch Dis Child: first published as 10.1136/adc.63.11.1305 on 1 November 1988. Downloaded from

1306 Couriel together. The treatment of bacterial tracheitis is OXYGEN described separately. Hypoxaemia, due to impaired alveolar ventilation The diagnosis and assessment of the severity of and ventilation-perfusion imbalance, is common in croup are based on the history and clinical examina- children admitted with croup." The degree of tion. Investigations such as the white cell count and hypoxaemia correlates poorly with clinical signs: the microbiological cultures rarely influence manage- respiratory rate is the best indicator of a lowered ment and should not be performed as a routine. arterial oxygen tension. Although oxygen treatment Lateral radiographs of the are not a reliable may delay the appearance of and agitation indicator of the severity of airway obstruction.9 The due to hypoxia, other clinical signs such as increas- procedure is disturbing to the child and can precipi- ing sternal retraction, tachypnoea, and tachycardia tate acute obstruction and therefore should be are not alleviated by oxygen and allow recognition avoided. of increasing obstruction. The measurement of oxygen saturation with pulse oximetry may be a to clinical assessment. Not all GENERAL SUPPORTIVE MEASURES valuable adjunct Children with croup are often frightened, miserable, croupy children admitted to,hospital need oxygen and uncomfortable. Crying increases their oxygen but it may help those with moderate or pronounced demand, accelerates respiratory muscle , and dyspnoea. It is difficult to achieve an oxygen may increase laryngeal swelling. Gentle confident concentration above 40% in a tent and few children handling helps reassure the child (and parents). will tolerate face masks. They may, however, accept Children are often more peaceful on their mother's a mask which is held a short distance above their lap than in a strange cot. Occasionally a sedative face, but the efficacy of this method of delivering such as chloral hydrate may be needed if the child oxygen is uncertain. that can cause repiratory remains agitated, but drugs NEBULISED ADRENALINE depression must be avoided. Nursing and medical In 1971, Adair et al reported 10 years' experience of staff must recognise that restlessness and agitation the use of racemic adrenaline delivered by intermit- may indicate serious hypoxaemia and not simply tent positive pressure breathing in 550 children with copyright. anxiety. Adequate hydration can usually be laryngotracheobronchitis.'2 (Racemic adrenaline is achieved by encouraging small frequent drinks. an equal mixture of the L- and R- isomers, but Children with severe dyspnoea may need intra- L-adrenaline is the active component.) Adair venous fluids. Nasogastric tubes cause discomfort claimed that this treatment improved airway pat- and increase respiratory distress, and should be ency and reduced or abolished the need for tracheo- avoided. stomy or intubation. Several small prospective controlled studies have failed to confirm Adair's

MIST TREATMENT retrospective observations. Although inhalation of http://adc.bmj.com/ Warm mist or water vapour is still used in the nebulised racemic adrenaline produced improve- treatment of croup. In hospital, humidifiers or ment of clinical signs'3-16 and a fall in respiratory nebulisers are used to increase the water content of resistance,l4 these effects were shortlived (30-60 air or oxygen, which may be delivered into a plastic minutes) and were not associated with improvement tent or via a face mask held a few inches from the in arterial blood gas tensions.13 A similar change child's mouth. Mist tents are uncomfortable and can occurred when adrenaline was delivered by simple be frightening, and they make observation more nebulisation without intermittent positive pressure difficult. Although there is anecdotal support for the breathing.'5 The duration of hospitalisation and the on September 24, 2021 by guest. Protected use of mist in croup, there is no objective evidence need for an artificial airway were not reduced in of benefit and it is unclear how mist might reduce these studies. respiratory obstruction. Bourchier and colleagues Racemic adrenaline is not available in this country showed no significant differences over a 12 hour but adrenaline 1:1000 BP is equally effective.'6 The period in the physical signs or transcutaneous dose of 5 ml, delivered from a nebuliser via face oxygen and carbon dioxide concentrations between mask, can be repeated every two to four hours. two groups of children with viral croup, who were Significant side effects have not been reported but randomly allocated to high or normal humidity.'0 all children receiving the drug need careful observa- The small numbers of patients (eight in each group), tion, preferably in an intensive care unit with however, and the wide variance of most of the continuous electrocardiographic monitoring. This parameters measured, precludes a firm conclusion form of treatment should be reserved for children about this negative result. There are no other with severe obstruction. Children who have no controlled studies of humidity in croup. improvement or who require repeated inhalations Arch Dis Child: first published as 10.1136/adc.63.11.1305 on 1 November 1988. Downloaded from

Management of croup 1307 are likely to require intubation. The transient appropriate antibiotics. The median duration of improvement may be of value in the child who needs intubation in croup is four to five days. Nebulised endotracheal intubation, while waiting for an ex- adrenaline may reduce the stridor which follows perienced anaesthetist. extubation.18 Although tracheostomy is an equally effective way of alleviating obstruction, the morbid- ity and mortality are higher than with intubation. Over the last 20 years there have been more studies Tracheostomy should be reserved for the small to evaluate the role of corticosteroids in the manage- minority of children where endotracheal intubation ment of croup than any other form of treatment. cannot be achieved, where there is recurrent tube The results of these trials are confusing and conflict- blockage, or where prolonged intubation runs the ing because of major faults in their design.2 3 17 In risk of subglottic scarring. some studies there was no distinction between viral and spasmodic croup, and laryngotracheobronchitis Management of bacterial tracheitis often no allowance for the severity of the illness. Random assignment to treatment or non-treatment Early diagnosis and treatment of this potentially groups and double blind techniques were not always have been given in fatal infection are essential as the management is employed. Different steroids very different from that of other forms of croup. different doses by different routes. Patients usually Four fifths of children in reported series have received several other treatments, such as mist or adrenaline, concurrently with steroids. There have required intubation for severe tracheal obstruc- tion.7 8 At intubation, pus aspirated from the been no agreed criteria for assessing the effects of treatment. These deficiencies make interpretation should be sent for bacterial culture. Blood of the reported data impossible. It is difficult to cultures should also be taken, although bacteraemia is uncommon. Intravenous ampicillin and fluclox- justify the use of corticosteroids for a condition that acillin should be given for seven to 10 days unless almost always resolves without any specific treat- the results of bacterial culture indicate the use of ment. other antibiotics. Even with frequent endotracheal copyright. suction and careful humidification, blockage of the ENDOTRACHEAL INTUBATION endotracheal tube crusted secretions can occur About 2-5% of children admitted with croup by and tracheostomy may be required. There is no require an artificial airway.'8 The decision to intu- evidence that nebulised adrenaline or steroids are of bate is a clinical one based on increasing tachycar- benefit in bacterial tracheitis. dia, tachypnoea, and chest retraction, or the appear- ance of cyanosis, exhaustion, or confusion. The procedure should be performed under general Conclusions anaesthetic by an experienced anaesthetist, except http://adc.bmj.com/ where there has been a respiratory arrest. If there is With the exception of antibiotics in bacterial tra- doubt about the diagnosis, an ear, nose, and throat cheitis, there is no convincing evidence that any drug surgeon capable of performing a tracheostomy alters the natural history of croup. The brief duration should be present. Anaesthetic induction should be of the improvement produced in some patients by with oxygen and halothane through a face mask. nebulised adrenaline severely limits its clinical Intravenous induction agents and relaxants should value. and mist treatment cannot be recom- not pass an is be used. Many anaesthetists orotracheal mended on the basis of available data. Oxygen on September 24, 2021 by guest. Protected tube initially and then exchange this for a naso- almost certainly underused and saturation monitors tracheal tube after adequate oxygenation and thor- may be helpful in assessing the need for oxygen. ough tracheal suction have been achieved. Pulmon- In most children, croup is a self limiting disease ary oedema and or pneumomediasti- requiring only considerate handling, but in a minor- num are uncommon complications. ity there is life threatening airways obstruction. Children with an endotracheal tube need meticu- Deaths from croup still occur. Some of these deaths lous observation in an intensive care unit if poten- could be avoided by more careful diagnosis of the tially fatal complications such as tube blockage or cause of the upper airway obstruction, by earlier displacement are to be avoided. Thorough humidi- recognition of the clinical signs of severe obstruction fication of inspired gases using the humidifier of a and hypoxaemia, and by more prompt relief of ventilator circuit, and careful tracheal suction are severe obstruction by intubation. The crucial aspect essential to prevent concretion of secretions and of the efficient management of croup is the early tube blockage. Secondary infection with staphylo- recognition and alleviation of impending total re- coccus and haemophilus is common and may require spiratory obstruction. Arch Dis Child: first published as 10.1136/adc.63.11.1305 on 1 November 1988. Downloaded from

1308 Couriel References Newth CJL, Levison H, Bryan AC. The respiratory status of Forfar JO. Croup. In: Forfar JO, Arneil GC, eds. Textbook of children with croup. J Pediatr 1972;81:1068-73. paediatrics. 3rd ed. Edinburgh: Churchill Livingstone, 12 Adair JC, Ring WH, Jordan WS, et al. Ten year experience with 1984:536-8. IPPB in the treatment of acute laryngotrachobronchitis. Anesth 2 Cherry JD. The treatment of croup: continued controversy due Analg 1971;50:649-55. to failure of recognition of historic, etiologic and clinical 3 Taussig L, Castro 0, Beaudry P, Fox WF, Bureau M. perspectives. J Pediatr 1979;94:352-4. Treatment of laryngotracheobronchitis (croup): use of inter- 3 mittent positive pressure breathing and racemic . Tunnessen WW, Feinstein AR. The steroid-croup controversy: Am J Dis an analytical review of methodologic problems. J Pediatr Child 1975;129:790-3. 1980;%:75 1-6. 4 Lenney W, Milner AD. Treatment of acute viral croup. Arch 4 Dis Child 1978;53:704-6. Couriel JM. Acute stridor in the pre-school child. Br Med J 5 Fogel JM, Berg Gerber MA, Sherter CB. Racemic 1984;288:1 162. J, 5 epinephrine in the treatment of croup: nebulisation alone versus Zach M, Erben A, Olinsky A. Croup, recurrent croup, allergy nebulisation with IPPB. J Pediatr 1982;101:1028-31. and airways hyperreactivity. Arch Dis Child 1981;56:336-41. '6 Remington S, Meakin G. Nebulised adrenaline 1:1000 in the 6 Zach M, Schnall RP, Landau LI. Upper and lower airway treatment of croup. Anaesthesia 1986;41:923-6. hyperreactivity in recurrent croup. Am Rev Respir Dis 7 Koren G, Frand M, Barziley Z, SM. 1980;121 :979-83. Macloed 7 treatment of laryngotracheitis versus spasmodic croup in chil- Jones R, Santos JI, Overall JI. Bacterial tracheitis. JAMA dren. Am J Dis Child 1983;137:941-4. 1979;242:721-6. lx Wagener J, Landau LI, Olinsky A, Phelan PD. Management of Henry RL, Mellis CM, Benjamin B. Pseudomembranous croup. children hospitalised for laryngotracheobronchitis. Pediatr Pul- Arch Dis Child 1983;58:180-3. monol 1986;2:159-62. Mills JL, Spackman TJ, Borns P, Mandell GA, Schwartz MW. The usefulness of lateral neck roentgenograms in laryngo- tracheobronchitis. Am J Dis Child 1979;133:1140-2. J M COURIEL "' Bourchier D, Dawson KP, Ferguson DM. Humidification in Booth Hall Children's Hospital, viral croup: a controlled trial. Aust Paediatr J 1984;20:289-91. Blackley, Manchester M9 2AA copyright. http://adc.bmj.com/ on September 24, 2021 by guest. Protected