Cause
- Viral (laryngotracheobronchitis)
- Bacterial infection
- Acute epiglottitis
- Inflammatory obstruction
- Inhalation of hot fumes e.g. in fire outbreaks
- Angioneurotic oedema
- Retropharyngeal abscess
- Inhalation of a foreign body
- Congenital malformation of the larynx e.g. laryngomalacia
Symptoms
- Low grade fever
- Hoarse voice
- Barking cough
- Breathing difficulty
- Restlessness
Signs
- Stridor
- Low grade fever
- Restless apprehensive child when obstruction is severe
- Hoarse voice
- Barking cough
- Laboured breathing e.g. suprasternal, supraclavicular, substernal and intercostals retractions
- Tachypnoea
- Cyanosis in severe obstruction
- Reddened throat
Investigations
- Sputum culture
- Lateral soft tissue X-ray of neck
- Chest X-ray
TreatmentTreatment Objectives
- To avoid aggravation of the obstruction with thick or crusted secretions
- To ensure early and timely relief of obstruction
Non-pharmacological treatment
- Ensuring good hydration including liberal oral fluids
- Ensure maximum rest for the child
- Establish the airway by intubation or tracheostomy in severe obstruction
Pharmacological treatment
For hydration of very sick patients who cannot drink
1st Line Treatment
Evidence Rating: [C]
- Dextrose saline, IV, 5%
For restless and distressed children who require oxygen
- Oxygen, 1-6 L as required (based on oxygen saturation level)
For steroid therapy
- Dexamethasone, oral/IM/IV,
Children
0.6 mg/kg stat.
Or
- Budesonide, nebulised,
Children
2 mg stat.
Or
- Prednisolone, oral,
Children
1-2 mg/kg stat.
Or
- Hydrocortisone, IV,
Children
4 mg/kg 6 hourly for 2-3 days
Note: Steroids are most useful when given within 6 hours of onset of symptoms. Antibiotics should be given in suspected secondary bacterial infection. Cough syrups containing opiates and atropine are contraindicated
In superimposed bacterial infection
1st Line Treatment
Evidence Rating: [C]
- Cloxacillin, IV,
Children
5-12 years; 250 mg 6 hourly for 7 days
1-5 years; 125 mg 6 hourly for 7 days
< 1 year; 62.5 mg 6 hourly for 7 days
And
- Gentamicin, IV,
Children
1-12 years; 2.5 mg/kg 8 hourly for 7 days
< 1 year; 2.5 mg/kg 12 hourly for 7 days
And
- Metronidazole, IV,
Children
7.5 mg/kg 8 hourly for 7 days
2nd Line Treatment
Evidence Rating: [C]
- Cefuroxime, IV,
Children
20 mg/kg 8 hourly
And
- Metronidazole, IV,
Children
7.5 mg/kg 8 hourly for 7 days
For severe Croup
- Adrenaline, 1:1000 solution, nebulised, 2 ml stat.
Then
Repeat hourly if effective
Referral Criteria
Refer cases with severe obstruction and complications in children to a Paediatrician or ENT specialist. Also refer all cases of stridor if there is no expertise to intubate or perform tracheostomy to a specialist.