🫁 Chapter 34: Croup and Croup-Like Illnesses

Viral croup (laryngotracheobronchitis) · Epiglottitis · Spasmodic croup · Bacterial tracheitis · Retropharyngeal abscess · Croup score · Steroids · Nebulised adrenaline · Heliox · Indications for intubation · Differential diagnosis

🔍 Core Concepts: Croup & Croup-Like Illnesses

📌 Viral Croup (Laryngotracheobronchitis)
Classic: barking cough, inspiratory stridor, hoarse voice. Viral prodrome. Croup score guides severity. X-ray: steeple sign (subglottic narrowing).
💊 Croup Management
Mild: dexamethasone 0.6 mg/kg (single dose). Moderate-severe: nebulised adrenaline (1:1000, 0.5 mL/kg) + steroids. Heliox (80/20) for severe. Intubation if impending failure.
⚠️ Epiglottitis (Supraglottitis)
Haemophilus influenzae type b (vaccine preventable). Toxic, drooling, tripod, high fever. Thumb sign on X-ray. DO NOT examine throat. Immediate airway control in OR.
🦠 Bacterial Tracheitis
Purulent exudates, poor response to adrenaline. Staph aureus, H. influenzae. Requires bronchoscopy, IV antibiotics, often intubation.
🦴 Retropharyngeal Abscess
Neck stiffness, torticollis, bulging posterior pharynx. Lateral neck X-ray: widened prevertebral space. CT diagnosis. IV antibiotics ± drainage.
📊 Croup Score (0-12)
Stridor, air entry, retractions, colour, consciousness. Score >7 needs ICU admission and close monitoring for intubation.

🩺 Stepwise Approach: Croup & Croup-Like Illnesses

1
Assess severity (croup score)
Score stridor (none/inspiratory/both), air entry (normal/decreased/minimal), retractions, colour, consciousness. Mild (≤2), moderate (3-5), severe (6-11), impending failure (≥12 or any hypoxia).
2
Mild croup
Dexamethasone 0.6 mg/kg PO/IM (single dose). Observe for 2-4 hours. Discharge if improved.
3
Moderate croup (stridor at rest, retractions)
Admit. Nebulised adrenaline (1:1000, 0.5 mL/kg, max 5 mL) + dexamethasone. Monitor for rebound. Heliox if available.
4
Severe croup / impending failure
Give adrenaline and steroids. Prepare for intubation in OR with ENT backup. Use inhalational anaesthesia (sevoflurane). Avoid muscle relaxants. Smaller ETT.
5
Differential diagnosis red flags
Toxic appearance, drooling, high fever → epiglottitis (don't examine throat). Poor response to adrenaline → bacterial tracheitis. Neck stiffness, torticollis → retropharyngeal abscess.
6
Post-intubation & discharge
Leak test before extubation (if cuffed ETT). Extubate when stridor resolves (usually 36-48h). Discharge when no respiratory distress, feeding well, no oxygen requirement.