Laryngotracheitis and laryngotracheobronchitis (croup)

Select language:
Permalink
On this page

    Viral infection in children aged 3 months to 4 years.

    Clinical features

    • Typical barking cough, hoarse voice or cry.
    • Inspiratory stridor (abnormal high pitched sound on inspiration):
      • Croup is considered mild or moderate if the stridor only occurs with agitation;
      • Croup is considered severe if there is stridor at rest, especially when it is accompanied by respiratory distress.
    • Wheezing may also be present if the bronchi are involved.

    Treatment

    • In the absence of inspiratory stridor or retractions, treat symptomatically: ensure adequate hydration, seek medical attention if symptoms worsen (e.g. respiratory difficulty, noisy breathing and inability to tolerate oral fluids).

     

    • If stridor is only present with agitation (moderate croup):
      • Hospitalize for treatment and observation (risk of worsening).
      • Assure adequate hydration.
      • dexamethasone a Citation a. Administer orally if possible in order to avoid causing agitation in the child as this may worsen symptoms.  PO (use IV preparation flavoured with sugar water, 10% or 50% glucose or juice) or IM if child is vomiting: 0.6 mg/kg single dose (see table).

     

    • If danger signs are present (stridor at rest, respiratory distress), admit in intensive care:
      • Oxygen continuously: at least 5 litres/minute or to maintain the SpO2 between 94 and 98%.
      • Insert a peripheral IV line and provide IV hydration.
      • epinephrine (adrenaline) via nebulizer (1 mg/ml, 1 ml ampoule): 0.5 mg/kg (max. 5 mg) to be repeated every 20 minutes if danger signs persist.
        Monitor heart rate during nebulization (if heart rate greater than 200, stop the nebulization).

     

    Age

    3 months

    4-6 months

    7-9 months

    10-11 months

    1-4 years

    Weight

    6 kg

    7 kg

    8 kg

    9 kg

    10-17 kg

    Dose in mg

    3 mg

    3.5 mg

    4 mg

    4.5 mg

    5 mg

    Dose in ml

    3 ml

    3.5 ml

    4 ml

    4.5 ml

    5 ml

    NaCl 0.9% (a) Citation a. Add sufficient NaCl 0.9% to obtain a total volume of 4 to 4.5 ml in the nebulizing chamber.

    1 ml

    1 ml

     
    Epinephrine is intended exclusively for nebulized administration and should not be given IV or IM in croup.

     

    • dexamethasone a Citation a. Administer orally if possible in order to avoid causing agitation in the child as this may worsen symptoms.  (4 mg/ml, 1 ml ampoule) IM or IV: 0.6 mg/kg single dose

    Age

    3-11 months

    1-2 years

    3-4 years

    Weight

    6-9 kg

    10-13 kg

    14-17 kg

    Dose in mg

    4 mg

    8 mg

    10 mg

    Dose in ml

    1 ml

    2 ml

    2.5 ml

     

    Suspect bacterial tracheitis in a critically ill appearing child b Citation b. Critically ill appearing child: weak grunting or crying, drowsiness, difficult to arrouse, does not smile, unconjugate or anxious gaze, pallor or cyanosis, general hypotonia. with croup who does not improve with the above treatment.

     

    • If wheezing is present:

    salbutamol aerosol (using a spacer): 2 to 3 puffs every 20 to 30 minutes as needed

     

    • If the patient has a complete airway obstruction, intubation if possible or emergency tracheotomy.

     

    Footnotes
    • (a) Administer orally if possible in order to avoid causing agitation in the child as this may worsen symptoms. 
    • (b)Critically ill appearing child: weak grunting or crying, drowsiness, difficult to arrouse, does not smile, unconjugate or anxious gaze, pallor or cyanosis, general hypotonia.
    • (a)Add sufficient NaCl 0.9% to obtain a total volume of 4 to 4.5 ml in the nebulizing chamber.