1. CROUP
IN
CHILDREN

2. PATHOPHYSIOLOGY
 The viral pathogen is inhaled and infects the cells of the respiratory epithelium.
Consequently leading to localized inflammatory response including
 Inflammation of the subglottic area
 Mucosal oedema
 Increased mucous production
 Swelling of the involved airway particularly involving the lateral walls of the
trachea just below the vocal cords
 The combination of swelling, oedema and excess mucous production leads to
narrowing of the internal airway lumen- this is aggravated by inspiration where
further inflammation can results from walls of the subglottic space are drawn in
during inspiration

3. DIFFERENTIAL DIAGNOISIS
 Peritonsillar or retropharengeal abcess
Signs and symptoms
Muffled voice, fever, ill appearance, stiff neck, dysphagia
 Foreign body aspiration
Signs and symptoms
Sudden onset of stridor in a previously well child- can be associated
with coughing or choking. Child playing with small objects
 Anaphylaxis
Signs and symptoms
History of allergy. Itching, facial swelling, Urticaria, wheeze, flushing and shock
(Hammer, 2004) ( Dykes, 2005)

4. SIGNS AND SYMPTOMS
• Runny nose
• Sore throat
• Mild fever
• Barking cough
• Hoarseness
• Stridor- due to narrowing of the upper airway
• Increase heart and respiratory rate
• Subcostal, intercostal, suprasternal and sternal
recession
• Pallor
• Fatigue
• Restlessness
(Hammer, 2004 & Dykes, 2005)

5. NURSING ASSESSMENT
 Children with croup need minimal handling . This includes limiting
examination, nursing with parents. Supplemental oxygen is not usually
required. If needed consider severe airways obstruction.
 Do not forcibly change a child's posture - they will adopt the posture that
minimises airways obstruction.
 Avoid distressing the child further.
 Auscultation not require if stridor heard at rest
 Assess child's ability to demonstrate a cough to hear ‘barking’
 Visualise trachi, chest wall and abdo for signs of increase work of breathing.
 SaO2 above 92% on room air, O2 not normally required
 Other investigations not normally required

6. TREATMENT
 Mild-moderate croup
Can be managed using Dexametasone
This systematic review has shown that treatment with
glucocorticoids is effective in improving symptoms of
croup in children as early as six hours and for up to at
least 12 hours after treatment.
(Russell et al, 2004)
• A single dose of oral Dexametasone can shorten the
duration and severity of Croup as early as 6 hours after
treatment (Hammer, 2004)
• Recommend dose of oral Dexametasone between
0.15-0.6 mg/kg. Fremantle hospital currently uses .
15mg/kg

7.  Adrenaline (nebulised) is used for those children with
severe upper airway obstruction
 For severe croup not effectively controlled with
corticosteroid treatment, nebulised adrenaline solution
1 in 1000 (1 mg/mL) can be given with close clinical
monitoring in a dose of 400 micrograms/kg (max.
5 mg) repeated after 30 minutes if necessary
 The effect last for appropriately 2 hours- staff need to
be aware of potential `rebound`- where symptoms can
reoccur once the Adrenaline has worn off. Taussig &
Landau (1999) recommend that children who have
received nebulised Adrenaline should be observed for 6
hours after dose

8. SIDE EFFECTS
 Upset stomach
 Muscle atrophy, negative protein balance
 Cushing syndrome resembling hyperactive
adrenal cortex with increase in adiposity,
hypertension, bone demineralization
 Hypertension, fluid and sodium retention,
oedema, worsening of heart insufficiency (due to
mineral corticoid activity)
 Allergic reactions

9. MECHANISIM OF ACTION
 Action- Dexamethasone is a glucocorticoid
agonist. Unbound dexamethasone crosses cell
membranes and binds with high affinity to
specific cytoplasmic glucocorticoid receptors.
This complex binds to DNA elements
(glucocorticoid response elements) which results
in a modification of transcription and, hence,
protein synthesis in order to achieve inhibition of
leukocyte infiltration at the site of inflammation,
interference in the function of mediators of
inflammatory response, suppression of humoral
immune responses, and reduction in oedema or
scar tissue.

10. NURSE MANAGEMENT PRIOR
TO DISCHARGE
 Oxygen saturations > 95 % in air
 No sternal recession
 No audible stridor
 Observations within age appropriate ranges
 Good colour
 Parents happy to discharge

11. EVIDENCE BASED PRACTISE
How fast does oral dexamethasone work in mild to
moderately severe croup? A randomized double-
blinded clinical trial.
For children with croup an oral dose of 0.15 mg/kg dexamethasone offers
benefit by 30 min, much earlier than the 4 hrs suggested by the Cochrane
Collaboration. This result might encourage doctors to treat more children
with all severities of croup being less worried about potential side-effects and
delayed benefit.
2012 Feb;24(1):79-85. doi: 10.1111/j.1742-6723.2011.01475.x. Epub 2011
Sep 4.
Dobrovoljac M, Geelhoed GC
 Emergency Department, Princess Margaret Hospital
for Children, Perth, Western Australia, Australia.

12. REFERENCES
 Deny, FW. Murphy, TF. Cylde, WA Jnr. Collier, AM
& Henderson, FW.
Croup: an 11 year study in pediatric practice.
Pediatrcs, 1983, vol 71, p.871-876.
 Dykes, J (2005) Managing children with Croup in
emergency departments.
Emergency Nurse, vol.13, no. 6, p. 14-19
 Hammer, J (2004) Acquired upper airway obstruction
Paediatric Respiratory Reviews, vol. 5, p. 25-33.
 Klassen, TP. Croup: a current perspective. Emergencymedicine.
Paediatric Clinics of North America, 1999, vol. 14, no. 6, p.
1167-1178
• Moore M, Little P. Humidified air inhalation for treating croup. Cochrane
Database of Systematic Reviews 2006, Issue 3. Art. No.: CD002870. DOI:
10.1002/14651858.CD002870.pub2
• Russell K, Wiebe N, Saenz A, Ausejo Segura M, Johnson D, Hartling L,
Klassen TP. Glucocorticoids for croup. Cochrane Database of Systematic
Reviews 2004, Issue 1. Art. No.: CD001955. DOI:
10.1002/14651858.CD001955.pub2
• Taussig, L & Landau, L (1999) Paediatric Respiratory Medicine. Mosby. St
Louis MO