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Fifteen-minute consultation:
structured approach to management
of a child with recurrent croup
Vineeta Joshi,1 Vikas Malik,2 Omar Mirza,2 B Nirmal Kumar2
1Department of Paediatrics,Royal Albert Edward Infirmary,Wrightington, Wigan & LeighNHS Foundation Trust, Wigan,Lancashire, UK2Department of OtolaryngologyOtolaryngology and Head andNeck Surgery, Royal AlbertEdward Infirmary, Wrightington,Wigan & Leigh NHS Foundation
Trust, Wigan, Lancashire, UK
Correspondence toDr Vineeta Joshi, Department ofPaediatrics, Royal Albert EdwardInfirmary, Wrightington, Wigan& Leigh NHS Foundation Trust,Wigan, Lancashire WN1 2NN,UK; [email protected]
Received 25 April 2013Revised 1 October 2013Accepted 23 October 2013Published Online First14 November 2013
To cite:Joshi V, Malik V,Mirza O, et al. Arch Dis ChildEduc Pract Ed2014;99:9093.
ABSTRACT
Recurrent croup is a distinct clinical entity from
viral croup. It is not a specific diagnosis and its
presence should alert the clinician to explore the
underlying cause. We discuss an evidence-based
structured approach to management of a child
with recurrent croup.
INTRODUCTION
Croup is a relatively common viral infec-tion of larynx, trachea and/or bronchi thatis characterised by an acute onset ofbarking cough, hoarseness and stridor withor without dyspnoea, typically during Falland winter season. It is uncommon to havemore than one episode of croup in a yearin an immune competent child.1 Croupyepisodes which occur more frequently(more than two episodes per year) havebeen referred to as recurrent croup.2 3
Recurrent croup is not a specific diagnosisand its presence should alert the clinicianto explore what is the real diagnosis4
(table 1). Recurrent croup can be the pres-entation of an underlying intrinsic and/orextrinsic airway narrowing process (box 1).
A thorough history and physical exam-ination is an essential preliminary step inestablishing the primary or contributorycause of recurrent croup.
WHAT SHOULD YOU ASK IN
HISTORY?
1. Previous episodes: Age of onset, presence/
absence of viral upper respiratory tract
infection symptoms, duration of each
episode, interval between episodes, pres-
ence of wheeze and importantly the
response to treatment should be enquired.
Severity of previous episodes should be
assessed based on age of presentation, fre-
quency of episodes, need for urgent or
inpatient treatment and need for intub-
ation. Recurrent croup in a child age more
than 4 years has been suggested as a
marker of increased severity.5
2. Previous intubation:In the birth and neonatal
history, intubation may indicate acquired sub-
glottic stenosis or subglottic cysts, which pre-
dispose to recurrent croup symptoms.
3. Gastro-oesophageal reflux (GOR): Ask
about symptoms suggestive of GOR in
each case and if already on antireflux treat-ment, any subsequent improvement in fre-
quency or severity of croup episodes
should be enquired.
Studies report an evidence of gastro-
oesophageal reflux disease (GORD) in
47%100% of their patients with recurrent
croup.2 3 5 One study showed that children
with recurrent croup who had GOR pre-
sented at a younger age (mean age 6 months)
and had shorter interval between episodes
(mean interval period 3 months) as compared
with those who did not have reflux.5
GOR isnot a causative factor but may aggravate or
unmask pre-existing airway pathology.
4. Reactive airway disease (RAD) and atopy:
History of asthma, eczema and allergies
should be taken. Also, adequacy of treat-
ment with respect to symptom control
should be assessed.
Recurrent croup has been referred to as
spasmodic croup in a number of earlier
studies that postulate recurrent croup to be a
spectrum of airway hyper-reactivity like
asthma. These studies report RAD to be
present in 40.4%82% of patients with
recurrent croup.68 However, a cause and
effect relationship between RAD and
recurrent croup has not been established.
Kwonget al2 reported history of asthma in
76.5% (n=17) of their patients but failed to
note any improvement in croup symptoms
despite optimum management of asthma.
5. Foreign body aspiration: Laryngeal/
tracheal foreign body can masquerade as
recurrent croup leading to a delayed
diagnosis.911
BEST PRACTICE
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6. Hoarseness or weak cry: Persistent hoarse voice or weak
cry in between episodes may indicate vocal cord path-
ology such as vocal cord paralysis or recurrent respira-
tory papillomatosis.12
7. Chronic symptoms: Persistent cough, dyspnoea, dyspha-
gia and recurrent chest infections associated with recur-
rent stridor may suggest a pathology causing externalairway compression. Gormleyet al13 reported a delay of
6 weeks to 10 years in the diagnosis of congenital
cardiovascular abnormalities that present with such
chronic symptoms.
8. Family history: Family history of croup, allergy and
atopy should be taken. Pruikkonen et al14 reported a
history of croup among parents and siblings to be the
most important predictive factor for croup and its recur-
rence in a child.Apart from the above focused history, a full paediatrichistory covering all aspects of growth and develop-ment should be taken to enable a comprehensivemanagement.
FOCUSED EXAMINATION OF A CHILD WITH
RECURRENT CROUP
1. Assessment of airway and breathing: In a child with acute
symptoms, immediately assess for severity of croup. Stridor
at rest, use of accessory muscles, chest wall retractions,
tachycardia, requirement of oxygen and increasing tiredness
suggest significant airway obstruction. Note the quality ofstridor, voice, cry, cough and presence of wheeze.
Type of stridor can help to localise the site of pathology.
Inspiratory stridor points towards a supraglottic problem,
for example, laryngomalacia; biphasic stridor points
towards a glottic or subglottic problem, for example, sub-
glottic stenosis or vocal cord paralysis; whereas expiratory
stridor points towards a tracheal pathology, for example,
external compression of trachea or tracheomalacia.
2. General examination: Check if the child is pyrexial or
has a toxic appearance. No response to standard treat-
ment of croup in an unwell child with pyrexia suggests
bacterial tracheitis.
Assess for failure to thrive. Presence of failure to thrive
may suggest an underlying significant GORD.
Look for any distinctive craniofacial features suggesting an
underlying genetic abnormality that may be associated
with an anatomic or functional airway abnormality.
Laryngospasm due to hypocalcaemia resulting in recur-
rent stridor has been reported in children with rickets.15
Look for presence of cutaneous haemangiomas.
Haemangioma particularly in the head and neck area
(beard distribution) may be associated with subglottic
haemangioma contributing to recurrent croup symp-
toms.16 Up to 50% of patients with subglottic
Box 1 Predisposing factors for recurrent croupin children
Congenital Congenital subglottic stenosis Congenital cardiovascular abnormality Tracheo-oesophageal fistula
Laryngotracheal cleft
Tracheobronchomalacia Vocal cord paralysis Congenital tracheal stenosis Congenital goitre
Traumatic Acquired subglottic stenosis Subglottic cysts Airway foreign body
Inflammatory Gastro-oesophageal reflux disease Asthma
Allergy
Infectious Viral Bacterial
Tumour Subglottic haemangioma Lymphangioma Thyroid neoplasm Recurrent respiratory papillomatosis Thymoma Lymphoma Mediastinal mass
Table 1 Croup versus recurrent croup
Croup Recurrent croup
Frequency Usually one episode per year Two or more episodes per year
Aetiology Parainfluenza type-1, influenza, RSV Possible underlying predisposing cause that may be unmasked by viralinfection (see box 1)
Age 6 Months to 3 years, peak incidence at 2 years Any age, can occur 3 years
Season During increased viral activityFall and winter season Throughout the year
Symptoms Usually a prodrome of URTI followed by hoarseness,
barking cough, stridor,respiratory distress
Hoarseness, barking cough, stridor, respiratory distress (usually no
prodrome but symptoms made worse if concurrent URTI)Course Short lasting, usually 12 days Relapsing, remitting course; episode can persist over weeks
Response totreatment
Symptoms completely resolve with standard treatment Some or no response to treatment
RSV, respiratory syncytial virus; URTI, upper respiratory tract infection.
Best practice
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haemangioma have a cutaneous haemangioma in the head
and neck area.17
3. Chest auscultation: Reduced air entry may be present
due to an airway foreign body or due to external tra-
cheal compression from a mediastinal mass.
4. Signs of allergy or atopy: Presence of nasal congestion,
mouth breathing, eczema and wheeze may suggest an
underlying atopy and airway reactivity predisposing to
recurrent croup.Apart from above focused examination, a detailedpaediatric general and systems examination should becarried out to complete the assessment.
WHAT MANAGEMENT SHOULD YOU PROVIDE?
1. Investigations: Appropriate investigation should be
carried out based on history and examination with the
aim of ruling out any underlying condition contributing
to the recurrence of croup symptoms.
A. Radiological investigations:
X-ray chest/neck: may be helpful to identify a
mediastinal mass or a radio-opaque foreign body.
A normal frontal and lateral chest radiograph hasbeen shown virtually to exclude the diagnosis of a
vascular ring as a cause of stridor.18
Cardiac/chest CT/MR scan: may be required if
there is suspicion of external tracheal compres-
sion by a vascular ring or a mediastinal mass.
B. Direct laryngo-tracheo-bronchoscopy (DLTB):
DLTB is the most important investigation to
exclude anatomic airway abnormality predisposing
to recurrent croup such as subglottic cysts and sub-
glottic stenosis. It can also demonstrate findings
suggestive of GORD and extrinsic tracheal com-
pression from causes such as double aortic arch,innominate artery and mediastinal mass.
Anatomic airway abnormality has been reported in
25%100% of children with recurrent croup who under-
went bronchoscopy.2 3 5 1 9 20 Therefore, a careful con-
sideration of risk factors should be taken to guide
referral to otolaryngologist (box 2).
C Investigations for GOR: Testing for GOR will
depend on your own unit protocol.
D Blood tests: These are generally not helpful unless
bacterial tracheitis, mediastinal mass or hypo-
calcaemia is a consideration based on history,
examination and other investigations.
2. Treatment: Episodes of recurrent croup may or may not
respond to the standard treatment of viral croup that is,
oral dexamethasone with or without nebulised adren-
aline. No response or a partial response to standard
treatment warrants further investigation. Specific treat-
ment will depend on the underlying cause.
Bacterial tracheitis needs urgent attention andtreatment with broad-spectrum intravenous antibio-tics, as there is a high likelihood of the need forintubation.
Referral to a paediatric otolaryngologist is import-ant for airway assessment. Subglottic stenosis is acommon finding on DLTB in children with recurrentcroup. Subglottic stenosis is diagnosed by conven-
tional DLTB with the child breathing spontaneouslyand the airway is sized using endotracheal tubes ofincreasing diameter. Mild stenosis is found more com-monly and is usually managed conservatively whilethe higher grades require surgical intervention. Themost severe cases may even require laryngotrachealreconstruction. DLTB should ideally be performedwhen the child is free of respiratory tract infection.
A therapeutic trial of antireflux therapy can behelpful if there are supporting clinical features.Hoaet al reported a significant decline in the numberand duration of croup episodes in 87% of their
patients after 6
9 months of antireflux treatment.3
Even children who did not demonstrate reflux relatedchanges on endoscopy showed symptomatic improve-ment. Importantly, 50% of patients on antirefluxtherapy who had a second endoscopic examinationshowed clinically significant decrease in grading ofsubglottic stenosis.
Associated RAD and atopy should be appropriatelymanaged with bronchodilators, steroids, antihistamineand other specific drugs according to the condition. Itis suggested that if patients with recurrent croup areconsidered to have hyper-reactive airway, it would bejustified to treat them with inhaled corticosteroids,similar to patients with bronchial asthma.6 7
CONCLUSIONS
Recurrent croupy episodes should prompt a search foran underlying cause that may be unmasked by a viralinfection. A thorough history and examination shouldbe undertaken to investigate the underlying cause.Referral to paediatric otolaryngologist for DLTBshould be made after consideration of risk factors toassist in diagnosis and management.
Box 2 Indications for referral to an ENT surgeon
History of previous intubation Age less than 1 year or more than 4 years Multiple hospital admissions with croup No improvement in symptoms despite appropriate
treatment for gastro-oesophageal reflux or reactive
airway disease and atopy Suspicion of foreign body inhalation Patients with congenital anomalies Presence of cutaneous haemangioma Patients with a persistent weak cry or hoarse voice Patients who did not respond to standard treatment
of croup
Best practice
92 Joshi V,et al. Arch Dis Child Educ Pract Ed2014;99:9093. doi:10.1136/archdischild-2013-303846
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Contributors All the authors have helped in evidence-basedsearch and writing up the manuscript.
Competing interests None.
Provenance and peer review Commissioned; externally peerreviewed.
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Best practice
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recurrent croupapproach to management of a child withFifteen-minute consultation: structured
Vineeta Joshi, Vikas Malik, Omar Mirza and B Nirmal Kumar
doi: 10.1136/archdischild-2013-303846November 14, 2013
2014 99: 90-93 originally published onlineArch Dis Child Educ Pract Ed
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