A 3-year-old male presented to the emergency department (ED) with a 12 hour history of a barking cough.He had been running a low-grade temperature (37.5C) but had otherwise been his normal self. His parents had contacted their GP who had diagnosed ?croup and arranged ambulance transfer to the ED for further assessment.
A full history and careful clinical examination was undertaken and this likely diagnosis was confirmed.
Croup, or laryngotracheitis, is a condition producing swelling and erythema of the lateral walls of the trachea below the level of the vocal cords (Cherry 2008). It is both a common illness and presentation to ED’s, which generally affects children and infants <6 years old. During the second year of life up to 5% of children will develop this condition (Cherry 2008). The incidence of croup is 1.5 times higher in males than females (Cherry 2008).
In order to diagnose croup it is necessary to take a careful history and perform a full clinical examination to rule out other potential differential diagnosis for children presenting with similar symptoms (Zoorob et al 2011). An overview of some of the key conditions which need to be excluded are shown in table 1.
Table 1 – Differential diagnosis of children with respiratory symptoms (adapted from Zoorob et al 2011)
|Croup||Previously well child. Barking cough. Coryza.||Low-grade fever. May have nasal flaring, stridor or respiratory retractions.|
|Epiglottitis||Rapid onset of symptoms, sore throat, drooling and muffled voice.||High-grade fever, toxic appearance, “tripod” positioning or leaning forward.|
|Bacterial tracheitis||Mild to moderate presentation then rapid deterioration over 3-7 days.||High-grade fever, toxic appearance, copious secretions, productive cough and retractions. No drooling.|
|Foreign body aspiration||Sudden onset. History of choking.||Stridor. Potential wheeze.|
Croup is a benign condition associated with a low mortality rate and does not typically lead to high-grade fever, wheezing, drooling, difficulty swallowing or toxic appearance (Zoorob et al 2011).
Diagnosis of croup is based upon clinical assessment and the features shown in table 2 suggest the clinical findings, which are highly suggestive of this condition.
Table 2 – Clinical findings suggestive of croup (Zoorob et al 2011)
|Low grade fever|
|Absence of wheeze|
To determine the severity of the condition it is necessary to carefully undertake a full clinical examination, paying particular attention to the examination of the respiratory system and observing for respiratory rate, depth and the presence or absence of intercostal recession, tracheal tug, use of accessory muscles and stridor. It is thought that the most reliable findings to assess the severity are the severity of retractions and presence of stridor (Zoorob et al 2011).
To determine the severity of the croup it is commonplace to calculate the croup score, which provides a useful guide as to which treatment and management options should be utilised (Brown 2006). The croup score by Westley et al (1978) is shown in table 3 with management guidance shown in table 4.
Table 3 – Westley croup score (Westley et al 1978)
|Stridor||0 (none), 1 (when agitated), 2 (at rest)|
|Chest retractions||0 (none), 1 (mild), 2 (moderate), 3 (severe)|
|Air entry||0 (normal), 1 (decreased), 2 (markedly decreased)|
|Cyanosis in room air||0 (none), 4 (when agitated), 5 (at rest)|
|Conscious level||0 (normal), 5 (disorientated)|
– Score of 0-1 = mild croup.
– Score of 2-7 = moderate croup.
– Score of 8 or more = severe croup
Table 4 – Management of croup (Brown 2006)
|Mild (score 0-1)||– Can be managed at home- +/- dexamethasone 0.15mg/kg. Reassure parents and give advice on when to seek further medical attention.|
|Moderate croup (score 2-7)||– Do not distress child- +/- oxygen. Give 0.15mg/kg dexamethasone. Transfer for observation for 2-3 hours.|
|Severe croup (score >8)||– Do not distress child- Give oxygen. Give 0.15mg/kg dexamethasone. If not improving give nebulised adrenaline 1:1,000 0.4ml/kg (max 5mls). Admit to hospital|
The diagnosis of croup must reached by excluding the potentially severe differentials, through detailed history taking and full clinical examination.
Once this diagnosis has been reached it is possible to determine the severity of the disease through the use of the croup score and determine an appropriate management plan based on the findings.
Brown, S. (2006) GP guide to the assessment and management of croup. Prescriber. Volume 17, number 16, pp25-28.
Driscoll, J. (2007) Practicing clinical supervision: a reflective approach for healthcare professionals (2nd edition). Elsevier. Edinburgh.
Westley, C. R., Cotton, E. K & Brooks, J. C. (1978) Nebulised racemic epinephrine by IPPB for the treatment of croup: a double-blind study. The American Journal of Diseases of Childhood. Volume 132, pp484-487.