Croup can change from a barking cough to critical upper-airway obstruction. Viral inflammation narrows the larynx and subglottic trachea. Because a child's airway is small, even modest swelling greatly increases resistance. Agitation, crying and unnecessary examination can worsen obstruction. EMTs should keep the child calm, assess severity from a distance, give corticosteroid early when indicated, use nebulised adrenaline for severe stridor, prepare expert airway support and never force a throat examination. Follow Uganda paediatric protocols and senior supervision.
1. Learning objectives
- Define viral croup and explain why children deteriorate rapidly.
- Recognise barking cough, hoarseness, inspiratory stridor, retractions and life-threatening airway obstruction.
- Differentiate croup from epiglottitis, foreign body, anaphylaxis, bacterial tracheitis and bronchiolitis.
- Provide calm first aid, oxygen, corticosteroid, nebulised adrenaline and escalation.
- Plan observation, nursing care, discharge education and prevention.
2. Definition and causes
Croup, or acute laryngotracheobronchitis, is usually a viral infection causing swelling of the larynx, vocal cords and subglottic trachea. Parainfluenza viruses are common causes; influenza, RSV, adenovirus and other respiratory viruses may also be involved. It is most common in young children, especially around six months to six years, but older children can be affected.
| Pattern | Features | Risk |
|---|---|---|
| Mild croup | Barking cough, hoarse voice, no stridor at rest, normal feeding and colour. | Usually responds to one steroid dose and observation. |
| Moderate croup | Stridor at rest, retractions, agitation but alert, oxygenation usually preserved. | May progress; give steroid and consider nebulised adrenaline. |
| Severe/life-threatening | Marked retractions, persistent stridor, fatigue, cyanosis, reduced consciousness or poor air entry. | Impending complete obstruction; urgent airway/critical-care support. |
| Atypical/recurrent | Unusual age, recurrent episodes, poor response or prolonged symptoms. | Consider structural lesion, foreign body, allergy or bacterial disease. |
3. Clinical features
| Feature | Meaning | Danger sign |
|---|---|---|
| Barking cough | Brassy “seal-like” cough from laryngeal inflammation. | Rapidly worsening cough with stridor at rest. |
| Stridor | Harsh high-pitched sound, usually inspiratory. | Stridor at rest, biphasic stridor or a suddenly quieter sound with fatigue. |
| Work of breathing | Suprasternal/intercostal retractions, nasal flaring and tachypnoea. | Seesaw breathing, exhaustion, poor respiratory effort. |
| Voice/swallowing | Hoarse voice; croup usually allows swallowing. | Drooling, muffled voice or inability to swallow suggests epiglottitis/other emergency. |
| General state | Low fever, runny nose and anxiety are common. | Cyanosis, pallor, agitation turning to drowsiness or poor response. |
4. First contact: keep the child calm
- Allow the child to remain with the caregiver in the position of comfort; avoid forcing them supine.
- Observe breathing, colour, stridor and retractions before touching the child.
- Use a calm voice and minimal staff. Do not distress the child with repeated throat inspection, blood pressure cuffs or unnecessary venepuncture.
- Call paediatric/airway support early for stridor at rest, severe retractions, cyanosis or altered consciousness.
- Prepare oxygen, nebuliser, suction, bag-mask equipment and difficult-airway support while continuing observation.
5. ABCDE assessment
| Step | Assess | Action |
|---|---|---|
| A – Airway | Stridor, voice, drooling, swelling, secretions and consciousness. | Keep calm, call experts, avoid throat instrumentation and prepare advanced airway. |
| B – Breathing | Rate, effort, chest movement, SpO₂, colour and fatigue. | Oxygen if hypoxaemic, nebulised therapy for severe obstruction and assist ventilation if failing. |
| C – Circulation | Pulse, perfusion, dehydration and shock. | Monitor, obtain access only if safe/necessary and treat shock without agitating the child. |
| D – Disability | AVPU, agitation, lethargy, seizures and glucose. | Recognise hypoxia/fatigue and prepare resuscitation. |
| E – Exposure | Fever, rash, allergic trigger, trauma and hydration. | Look for alternative causes but keep the child warm and calm. |
6. Severity classification and actions
- Mild: barking cough without stridor at rest—give oral corticosteroid when prescribed, observe response and provide safety-net advice.
- Moderate: stridor at rest and retractions—give corticosteroid promptly, monitor closely and consider nebulised adrenaline if persistent/worsening.
- Severe: marked retractions, agitation, hypoxaemia or persistent stridor—nebulised adrenaline plus corticosteroid, oxygen and urgent senior/paediatric review.
- Life-threatening: cyanosis, exhaustion, altered consciousness, poor air entry or bradypnoea—resuscitation team, oxygen, nebulised adrenaline and expert airway/ICU transfer.
7. Medical treatment
7.1 Corticosteroid
Dexamethasone reduces airway oedema and symptoms. A single oral dose is often sufficient; IM/IV administration is used when swallowing is unsafe or vomiting prevents absorption. Follow the weight-based local protocol; commonly referenced regimens include 0.15–0.6 mg/kg depending on severity and guideline.
7.2 Nebulised adrenaline
Nebulised adrenaline provides rapid, temporary reduction in airway swelling for moderate-to-severe croup. It is an adjunct to corticosteroid, not a substitute. Common protocols use adrenaline 1:1000 at approximately 0.4 mL/kg to a maximum of 5 mL; check the Uganda/facility guideline, preparation and monitoring requirements before administration.
- Give oxygen-driven nebulisation when available and monitor heart rate, SpO₂, work of breathing and recurrence after the effect wears off.
- Repeat doses only under senior protocol; persistent symptoms require admission/escalation rather than repeated unsupervised nebulisers.
- Bronchodilator salbutamol is not a substitute for adrenaline because croup is upper-airway oedema, not lower-airway bronchospasm.
- Antibiotics are not routine viral-croup treatment; use them only when bacterial tracheitis or another bacterial source is suspected.
8. Oxygen and advanced airway support
- Give oxygen for cyanosis, hypoxaemia or severe distress, but do not force a mask onto a frightened child; use blow-by or a tolerated method while preparing definitive care.
- Call anaesthesia/paediatric airway experts before exhaustion. Intubation may be difficult because the airway is narrowed and swollen.
- If the child becomes unresponsive, open the airway, ventilate with bag-mask and follow paediatric resuscitation guidelines.
- Prepare smaller-than-usual endotracheal tubes and a backup plan; surgical airway is a rare last resort by an expert team.
9. Differential diagnosis
| Condition | Clues that differ from typical croup | Emergency action |
|---|---|---|
| Epiglottitis | High fever, toxic appearance, drooling, muffled voice, tripod position, no barking cough. | Do not examine the throat; keep calm, oxygen and urgent expert airway care. |
| Foreign body | Sudden onset during eating/play, choking episode, unilateral signs. | Foreign-body airway algorithm; bronchoscopy referral. |
| Anaphylaxis/angio-oedema | Rapid swelling, hives, wheeze, vomiting or hypotension after trigger. | IM adrenaline immediately for ABC compromise. |
| Bacterial tracheitis | High fever, toxic appearance, thick secretions, poor response to adrenaline. | Urgent airway, IV antibiotics and intensive care. |
| Retropharyngeal abscess | Neck stiffness, drooling, dysphagia and persistent fever. | Keep calm and obtain urgent ENT/paediatric review. |
10. Nursing and EMT care plan
| Problem | Interventions | Evaluate |
|---|---|---|
| Airway narrowing | Position of comfort, calm environment, oxygen, nebulised therapy and airway readiness. | Stridor at rest, retractions, speech/cry, SpO₂ and fatigue. |
| Anxiety/agitation | Keep caregiver present, minimise procedures and use reassuring communication. | Child settles, breathing effort reduces and treatment is tolerated. |
| Medication response | Check weight, preparation, dose, nebuliser flow and repeat observations. | Reduced stridor and stable cardiovascular status. |
| Risk of recurrence | Observe after nebulised adrenaline and document time of last dose. | No recurrent stridor at rest, safe feeding and stable observations. |
| Family education | Explain expected course, medicines, warning signs and follow-up. | Caregiver demonstrates understanding and has transport/access plan. |
11. Observation, admission and discharge
- Observe until stridor at rest, retractions and oxygen requirement have resolved and the child is drinking/feeding safely.
- Admit after repeated nebulised adrenaline, persistent stridor, severe features, poor access to care, atypical age or diagnostic uncertainty.
- Discharge only with caregiver supervision, written advice, medication instructions and reliable return access.
- Return immediately for stridor at rest, chest indrawing, blue lips, drooling, inability to drink, exhaustion, drowsiness or worsening after initial improvement.
12. Prevention and family teaching
- Hand hygiene, ventilation, respiratory etiquette and avoiding sick contacts reduce viral spread.
- Keep the child hydrated and comfortable; avoid smoke, strong fumes and unnecessary cough medicines.
- Teach caregivers that steam inhalation can burn children and is not a substitute for medical assessment.
- Explain the difference between a barking cough and dangerous stridor at rest.
- Review recurrent/atypical croup for structural airway disease, reflux, allergy or other causes.
13. Clinical scenarios
Scenario 1 – mild croup. A 2-year-old has a barking cough at night but no stridor at rest and is drinking. Keep calm, assess, give prescribed oral steroid, observe and provide clear return precautions.
Scenario 2 – moderate croup. A child has stridor at rest, suprasternal recession and anxiety. Give corticosteroid promptly, keep the child with the caregiver, monitor continuously and involve a senior clinician; nebulised adrenaline may be required.
Scenario 3 – severe croup. A child becomes cyanosed with marked retractions and reduced air entry. Call the airway team, give oxygen and nebulised adrenaline, administer steroid, prepare ventilation and transfer to critical care.
Scenario 4 – epiglottitis mimic. A febrile child is drooling, sitting forward and refusing to lie down without a barking cough. Do not inspect the throat or force the child supine; keep calm and arrange urgent expert airway care.
14. Common errors to avoid
- Forcing a distressed child to lie down or repeatedly examining the throat.
- Assuming stridor at rest is mild because the child is still alert.
- Using salbutamol for upper-airway croup or delaying steroid.
- Discharging immediately after nebulised adrenaline without observation.
- Missing epiglottitis, foreign body, anaphylaxis or bacterial tracheitis.
- Using steam, antibiotics or cough mixtures as substitutes for assessment.
CROUP emergency check – “CALM”
C – Calm child and caregiver
A – Assess stridor and airway severity
L – Laryngeal steroid early; nebulised adrenaline when severe
M – Monitor, minimise handling and escalate early
C – Calm child and caregiver
A – Assess stridor and airway severity
L – Laryngeal steroid early; nebulised adrenaline when severe
M – Monitor, minimise handling and escalate early
15. Revision questions
- Explain why children with croup deteriorate rapidly when agitated.
- List features of mild, moderate and severe croup.
- When is nebulised adrenaline indicated?
- Why should a suspected epiglottitis patient not have a forced throat examination?
- List five croup discharge warning signs.
- Differentiate croup from foreign body and anaphylaxis.
16. Key take-home points
- Keep the child calm and assess stridor at rest, work of breathing, colour and mental state.
- Corticosteroid is the core treatment; nebulised adrenaline gives temporary relief in severe obstruction.
- Do not force examination or delay airway support in a deteriorating child.
- Stridor with drooling, toxic appearance or sudden choking suggests another airway emergency.
- Observe after nebulised adrenaline and discharge only with reliable safety-netting.
Safety note: This is educational content for EMT students. Dexamethasone dose, nebulised adrenaline preparation, oxygen delivery, intubation and admission decisions must follow the current Uganda paediatric protocol and senior supervision.