Clinical case 041: Classic croup – or is it?

I caught this audio last week at about 4 AM when the ambos rushed this 3 1/2 year old boy in with his mother to ED.  The story was classical croup – a day of URTI sxs, coryza, low grade fever followed by the early AM wake up with stridor, the “seal barking” cough and marked dyspnoea.  So it was a slam dunk for diagnosis.  Also the medical students never get to hear a good croup bark – because they are always safely tucked up in bed at 4 AM – so I produce this video to share….Croup (click to view)

Now this kid was sick:  RR 60, marked chest wall recession, biphasic stridor and looking very scared.  Of course his SpO2 was 99% – as it often is in early, severe upper airway obstruction.  The Ambo team had given 2 x salbutamol nebs in transit without any change in his dyspnoea.

On examination his chest was ‘clear’ aside from transmitted stridor.  No wheeze, creps etc.  So it had to be croup.

Given how severe his dyspnea, we went in with an adrenaline neb immediately – which worked really well – he lost the stridor after 5 minutes and his work of breathing improved dramatically.  We got an IV access and gave a dose of oral dexamethasone. Yes, I use dexamethasone – not prednisolone.  I guess you could argue for IV hydrocortisone – no problem with that.  I do not use prednisolone for the following reasons:

  1. It tastes terrible, whereas dex is sweet and kids tend to swallow it better
  2. The trials done right here in WA used dexamethasone – see Geelhoed et al these trials showed in summary –
    1. Paed Pulmonology 2005:  0.15 mg/kg of oral dex was as good as 0.3 mg, and 0.6 mg in treating croup
    2. BMJ 1996.  A single dose of 0.15 mg/kg dramatically reduced recurrence / representation in mild outpatient croup
    3. Arch of Dis in Childhood 2006.  Dexamethasone as above was superior to prednisolone in preventing recurrence and other markers of severity for managing mild – moderate outpatient croup.
  3. Prednisolone has some mineralocorticoid activity which is just unecessary in this clinical context – dex is a bit cleaner.
So anyway back to our kid in ED.  He settles with the adrenaline, the dex has time to kick in and he looks like a mild croup and hour later – the sun is coming up, so the paraflu is running back to cover!  We admit him to the ward and ask the friendly Paeds to review him on their round.  I head off to bed…
Around 10 AM I stumble out of the on-call room and pop onto the ward to check on the little guy.  The Paediatrician says:  “Oh that kid isn’t croup -he has asthma!  He has a good going wheeze and is responding to salbutamol…”
So I say: “Nah, mate.  He was croup – classic!” and I show her the video clip above. We agree that we are both right.
Back the truck up and look at the previous history – there was a strong family history of asthma / atopy, smoke exposure and one possible previous episode of asthma after a viral illness. So – he probably has another bout of viral-induced asthma, the virus [maybe paraflu]also caused the croup.  Of course the adrenaline neb did a great job of masking any wheeze / bronchospasm signs he might have had.
1. There can be 2 disease processes taking place in the same patient.      2. Examine, then re-examine kids before and after interventions      3. After an emergency – you still have to go back and take a thorough history

 

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