2008 Update

Guideline for the

'LDJQRVLVDQG0DQDJHPHQWRI Administered by the

Croup
Alberta Medical Association

This clinical practice guideline was developed by an Alberta History

Clinical Practice Guideline Working Group. This guideline will be i Croup symptoms may occur either with or without
reviewed again as part of routine pracitce by the end of 2005. DQWHFHGHQWXSSHUUHVSLUDWRU\V\PSWRPVRIFRXJK
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DEFINITIONS
Croup is a childhood respiratory illness caused by a variety i Croup symptoms most commonly occur in the late
of viruses and is usually contracted in the autumn and HYHQLQJDQGDWQLJKWDQGKDYHDQDEUXSWRQVHW7KH\
ZLQWHUPRQWKV1 It is characterized by the abrupt onset of a LQFOXGH
EDUN\FRXJKDQGLVIUHTXHQWO\DVVRFLDWHGZLWKLQVSLUDWRU\ • VHDOOLNHEDUN\FRXJK
VWULGRUQRLV\EUHDWKLQJRQLQVSLUDWLRQKRDUVHQHVVDQG • inspiratory stridor
UHVSLUDWRU\GLVWUHVV2 Children with croup can be broadly • hoarseness
FDWHJRUL]HGDVKDYLQJIRXUOHYHOVRIVHYHULW\ • QRWRPRGHUDWHO\KLJKIHYHU

i &URXSV\PSWRPVIUHTXHQWO\LPSURYHHQURXWHWR
Mild±RFFDVLRQDOEDUN\FRXJKQRDXGLEOHVWULGRUDWUHVW
PHGLFDOFDUHDQGÀXFWXDWHVLJQL¿FDQWO\GHSHQGLQJRQ
DQGQRWRPLOGVXSUDVWHUQDODQGRULQWHUFRVWDOLQGUDZLQJ
ZKHWKHUWKHFKLOGLVFDOPRUDJLWDWHG
UHWUDFWLRQVRIWKHVNLQRIWKHFKHVWZDOO
i &URXSV\PSWRPVXVXDOO\LPSURYHGXULQJWKHGD\DQG
Moderate±IUHTXHQWEDUN\FRXJKHDVLO\DXGLEOHVWULGRUDW
RIWHQUHFXUDJDLQWKHIROORZLQJQLJKW4
UHVWDQGVXSUDVWHUQDODQGVWHUQDOZDOOUHWUDFWLRQDWUHVWEXW
QRRUOLWWOHGLVWUHVVRUDJLWDWLRQ i 7KHPDMRULW\RIFKLOGUHQUHVROYHWKHLUFURXSV\PSWRPV
ZLWKLQKRXUVEXWDVPDOOSURSRUWLRQRIFKLOGUHQ
Severe±IUHTXHQWEDUN\FRXJKSURPLQHQWLQVSLUDWRU\DQG
KDYHV\PSWRPVWKDWSHUVLVWIRUXSWRRQHZHHN4
RFFDVLRQDOO\H[SLUDWRU\VWULGRUPDUNHGVWHUQDOZDOO
UHWUDFWLRQVDQGVLJQL¿FDQWGLVWUHVVDQGDJLWDWLRQ i )ROORZLQJWKHUHVROXWLRQRIFURXSV\PSWRPVFKLOGUHQ
XVXDOO\KDYHW\SLFDOµ857,¶OLNHV\PSWRPVDQGRF-
Impending respiratory failure±EDUN\FRXJKRIWHQQRW
FDVLRQDOO\DVHFRQGDU\EDFWHULDOLQGXFHGRWLWLVPHGLD4-6
SURPLQHQWDXGLEOHVWULGRUDWUHVWRFFDVLRQDOO\KDUGWRKHDU
VWHUQDOZDOOUHWUDFWLRQVPD\QRWEHPDUNHGOHWKDUJ\RU
GHFUHDVHGOHYHORIFRQVFLRXVQHVVDQGRIWHQGXVN\DSSHDU-
DQFHZLWKRXWVXSSOHPHQWDOR[\JHQ
PRACTICE POINT
RECOMMENDATIONS VHH$OJRULWKP FEATURES SUGGESTING A DIFFERENT
DIAGNOSIS2,3
Diagnosis
• +LJKIHYHUWR[LFDSSHDUDQFHDQGSRRUUHVSRQVHWR
HSLQHSKULQHVXJJHVWVbacterial tracheitis
PRACTICE POINT • 6XGGHQRQVHWRIV\PSWRPVZLWKKLJKIHYHUDEVHQFH
RIEDUN\FRXJKG\VSKDJLDGURROLQJDQ[LRXVDS-
• Croup occurs most commonly in children between SHDUDQFHDQGVLWWLQJIRUZDUGLQ³VQLI¿QJSRVLWLRQ´
PRQWKVDQG\HDUVRIDJHEXWFDQDOVRRFFXULQ VXJJHVWVepiglottitis
FKLOGUHQDV\RXQJDVPRQWKVDQGDVROGDVWR • Other potential causes of stridor which are rare but
\HDUVRIDJH1 It has been reported very rarely in should be considered include foreign body lodged
DGXOWV3 in upper esophagus, retropharyngeal abscess,
• &URXSRFFXUVSUHGRPLQDQWO\LQODWHDXWXPQEXW and hereditary angioedema
FDQRFFXUGXULQJDQ\VHDVRQLQFOXGLQJVXPPHU1

The above recommendations are systematically developed statements to assist practitioner and patient decisions about appropriate
KHDOWKFDUHIRUVSHFL¿FFOLQLFDOFLUFXPVWDQFHV7KH\VKRXOGEHXVHGDVDQDGMXQFWWRVRXQGFOLQLFDOGHFLVLRQPDNLQJ
Physical Examination • If laboratory tests are obtained they should be
Physicians should always be alert to the possibility of   ZHOOMXVWL¿HGDQGVKRXOGEHGHIHUUHGZKLOHWKH
RWKHUFDXVHVRIµFURXSOLNH¶V\PSWRPVDQGFRQVHTXHQWO\ patient is in respiratory distress
DFDUHIXOKLVWRU\DQGSK\VLFDOH[DPLVLPSRUWDQW.H\ • ,PDJLQJVWXGLHVDUHQRWUHTXLUHGLQSDWLHQWV
IHDWXUHVWRIRFXVRQLQFOXGH with a typical history that respond
  DSSURSULDWHO\WRWUHDWPHQWKRZHYHUODWHUDODQG
i $XGLEOHVHDOOLNHEDUN\FRXJK   DQWHURSRVWHULRU$3VRIWWLVVXHQHFN¿OPPD\
  EHKHOSIXOLQFODULI\LQJWKHGLDJQRVLVLQFKLOGUHQ
i Voice is often hoarse   ZLWKFURXSOLNHV\PSWRPV

i 9DU\LQJGHJUHHVRIVWULGRUpredominantly inspiratory &RQHVKDSHGQDUURZLQJ³VWHHSOLQJ´LQVWHDGRIWKH

QRUPDOVTXDUHGVKRXOGHUDSSHDUDQFHRIWKHVXEJORWWLF
i 9DU\LQJGHJUHHVRIUHWUDFWLRQVRIWKHFKHVWZDOO DUHDVXJJHVWVcroup7KH$3QHFNUDGLRJUDSKLVDOVR
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i 2IWHQDJLWDWHG SDWLHQWVZLWKDW\SLFDOGLVHDVH97KHIROORZLQJUDGLR-
ORJLFDO¿QGLQJVDUHFRQVLVWHQWZLWKWKHVHDOWHUQDWLYH
i $EVHQFHRIGURROLQJ GLVHDVHV
• $UDJJHGHGJHRUDPHPEUDQHVSDQQLQJWKH 
i Appears non-toxic  WUDFKHDVXJJHVWVbacterial tracheitis
• 7KLFNHQLQJRIHSLJORWWLVDQGDU\HSLJORWWLFIROGV
Other associated features that can be found on physical  VXJJHVWVepiglottitis
H[DPLQDWLRQLQFOXGH • %XOJLQJ SRVWHULRUSKDU\Q[VRIWWLVVXHVVXJJHVWV
retropharyngeal abcess
i )HEULOHXSWRƒ&
PRACTICE POINT
i 7DFK\FDUGLDZLWKPRUHVHYHUHREVWUXFWLYHV\PSWRPV
IF RADIOGRAPHS ARE OBTAINED
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health care personnel who are able to
i ,IWKHVXSUDJORWWLFUHJLRQLVYLVXDOL]HGLWDSSHDUV
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normal
Note this should not be routinely attempted in any child with
i Pulse oximetry is indicated in children with
respiratory distress
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PRACTICE POINT Pulse oximetry is not essential in patients with
 PLOGFURXS
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• &KDQJHLQPHQWDOVWDWXVVXFKDVIDWLJXHDQGOLVWOHVVQHVV i 9LUDOFXOWXUHVRUUDSLGDQWLJHQWHVWVGRQRWDLGLQ
• Pallor  WKHURXWLQHPDQDJHPHQWRISDWLHQWVHVSHFLDOO\
• 'XVN\DSSHDUDQFH  GXULQJWKHHSLGHPLFSHULRG
• Decreased retractions
• 'HFUHDVHGEUHDWKVRXQGVZLWKGHFUHDVLQJVWULGRU
Emergency Department Care

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can be reliably made based on the clinical presentation
in combination with a careful history and physical
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Note that mist therapy has not been shown to have any meas- i Sedation is contraindicated26
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Indications for Admission
i Epinephrine is indicated in patients with severe res-
SLUDWRU\GLVWUHVVDVLQGLFDWHGE\PDUNHGVWHUQDOZDOO 7KRXJKWKHYDVWPDMRULW\RIFKLOGUHQFDQEHPDQDJHGDV
LQGUDZLQJDQGDJLWDWLRQ RXWSDWLHQWVUHODWLYHO\OLWWOHHYLGHQFHKDVEHHQSXEOLVKHG
• ,PSURYHPHQWRFFXUVZLWKLQPLQXWHVDQGEHJLQVWR WKDWDGGUHVVHVH[DFWO\ZKLFKFKLOGUHQVKRXOGEHDGPLWWHG
ZHDURIIDIWHURQHKRXU12 Therefore these recommendations should be applied with
• Treatment does not alter disease symptoms beyond FDXWLRQ
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• /HSLQHSKULQHLVDVHIIHFWLYHDVUDFHPLF Absolute
epinephrine and institutional preference may i 6LJQL¿FDQWUHVSLUDWRU\FRPSURPLVHSHUVLVWLQJIRXURU
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more hours after treatment with corticosteroids
• Nebulized epinephrine therapy does not mandate
(If possible physicians should wait at least 4 hours
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after treatment with dexamethasone before deciding
i 'H[DPHWKDVRQHLVLQGLFDWHGLQDOOFKLOGUHQGLDJQRVHG to admit a child to hospital
WRKDYHFURXSLQFOXGLQJWKRVHZLWKRQO\DEDUN\ • 6WHUQDOZDOOLQGUDZLQJ
FRXJKZLWKRXWDQ\RWKHUVLJQVRIUHVSLUDWRU\GLVWUHVV • Easily audible stridor at rest
• ,PSURYHPHQWEHJLQVZLWKLQWRKRXUVDIWHU
 DGPLQLVWUDWLRQDQGSHUVLVWVIRUWRKRXUV Relative*
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• A potential exception is the rare child with a
 NQRZQLPPXQHGH¿FLHQF\RUUHFHQWH[SRVXUH i 6LJQL¿FDQWSDUHQWDODQ[LHW\H[LVWV
 WRYDULFHOOD
• Dexamethasone may be administered orally in i Recurrent ED visits within 24 hours
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may be mixed with epinephrine and administered
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Complications
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* Based on consensus opinion

i Bacterial tracheitis can cause a precipitous deteriora- BACKGROUND
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Epidemiology
i Cardiopulmonary arrest can occur in patients who are
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of upper airway obstruction in children and has an annual
i Pneumonia is a rare complication of croup33 LQFLGHQFHLQ$OEHUWDRILQFKLOGUHQXQGHUWKHDJHRI
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enza and is most prevalent in the late fall to early winter
Criteria for Discharge from ED
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i The presence of mild symptoms either on initial evalu- Croup occurs most commonly in children between 6
ation or after a period of observation  PRQWKVDQG\HDUVRIDJHEXWFDQDOVRRFFXULQFKLOGUHQDV
\RXQJDVPRQWKVDQGDVROGDV\HDUV1 It has been
i &KLOGUHQVKRXOGQRWEHGLVFKDUJHGHDUOLHUWKDQWZR UHSRUWHGUDUHO\LQDGXOWV3 Boys are affected more often
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Differential Diagnosis
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• ,IFKLOGGHYHORSVPLOGUHVSLUDWRU\GLVWUHVV of upper airway obstruction characterized by stridor and
 H[SRVXUHWRFRROQLJKWDLUPD\SURYLGH  LQGUDZLQJKDYHFURXS,QJHQHUDOWKHGLDJQRVLVRIFURXS
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• ,IFKLOGGHYHORSVPRUHVLJQL¿FDQWUHVSLUDWRU\ RIVWULGRUPXVWEHFRQVLGHUHGDQGH[FOXGHG7KHPRVW
distress but is not severely agitated or cyanotic FRPPRQDOWHUQDWLYHGLDJQRVLVLVEDFWHULDOWUDFKHLWLV
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 QHDUHVWHPHUJHQF\GHSDUWPHQWIRUFDUH FURXS,QIDFWEDFWHULDOWUDFKHLWLVLVWKRXJKWWREHDVXSHU
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 WKHSDUHQWVFDUHWDNHUVVKRXOGFDOO IURPFURXSE\WKHSUHVHQFHRIKLJKIHYHUWR[LFDSSHDU-
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Follow-up bacterial tracheitis includes intravenous antibiotics and
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physician should occur in patients who have had pro- HQ]DHZDVRQFHUHODWLYHO\FRPPRQLQFKLOGUHQKRZHYHU
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³VQLI¿QJSRVLWLRQ´7KHUHLVDQabsenceRIDEDUN\FRXJK
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* Based on consensus opinion

 TABLE 1
PHARMACOTHERAPY

Drug Category Dose and Duration Comments

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ƒ Epinephrine ƒ Racemic epineprhine ƒRacemic epinephrine & L epinephrine are
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diluted in 3mL of NS or ƒThe duration of effect of epinephrine does
sterile water via nebulizer QRWH[FHHGKRXUV7KLVSDWLHQWVVKRXOG
ƒ L Epinephrine QRWEHGLVFKDUJHGIURPPHGLFDOFDUHIRU
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severe respiratory distress

Corticosteroids ƒ PJNJ32,0RQFH ƒOral dexamethasone is well-absorbed and

ƒ Dexamethasone ƒ 0D\UHSHDWGRVHLQWR DFKLHYHVSHDNVHUXPFRQFHQWUDWLRQVDV
24 hours rapidly as with intramuscular administration
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intramuscular administration yield
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treatment
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dose
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toms

ƒ Budesonide ƒ PJYLDQHEXOL]HU ƒ ,QWKHYDVWPDMRULW\RIFDVHVEXGHVRQLGH

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 DSSURSULDWHVROXWLRQ and is substantially more expensive
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severe respiratory distress; budesonide
and epinephrine can be administered
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DQRFFXOWIRUHLJQERG\PRVWFRPPRQO\ORGJHGLQWKHXSSHU op respiratory failure; failure typically occurs over several
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abscess can present with stridor (most children with these
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HQWDWLRQVDUHYHU\UDUH2WKHUH[WUHPHO\UDUHFDXVHVRI The most common distinction made is between acute
acute onsetRIVWULGRULQFOXGHWUDXPDGLSWKHULDKHUHGLWDU\ ODU\QJRWUDFKHREURQFKLWLV/7%DQGVSDVPRGLFFURXS
DQJLRHGHPDK\SRFDOFHPLFWHWDQ\DQGLQJHVWLRQRIFRUURVLYHV 39
Acute LTB is described as an illness in which children
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Pathogenesis and Pathophysiology DQGIHYHUIRUWRKRXUVZKHUHDVVSDVPRGLFFURXS
is described as an illness in which symptoms occur
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Reviewed January 2005
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ALGORITHM: CROUP IN THE OUT-PATIENT SETTING
Based on severity at time of initial assessment

MILD MODERATE SEVERE

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APPENDIX 1:
INSTRUCTIONS FOR PARENTS OF A CHILD WITH CROUP

What is Croup?

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What can I do to make my child more comfortable?

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• Most importantly - if your child is upset - comfort him/her, and speak calmly and in quiet tones. This will
help more than anything to reduce breathing problems.

How can I monitor my child to be sure they are okay?

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The croup guideline for physicians and this patient hand-out were developed by a Clinical Practice Guideline
working group which promotes appropriate, effective and quality medical care in Alberta. July 2003. Reviewed
2007
This information is also available on the Alberta Medical Association web site:
www.albertadoctors.org
Should I call 911?

Ƈ Call if:
• Your child’s face is bluish-grey in color for more than a few seconds; or
• Your child becomes unusually sleepy or ‘glassy-eyed’ while making croupy sounds; or
• Your child is really stressed, is struggling to breathe, and you can not calm them within a few minutes.
Ƈ Remember that ambulance paramedics can start treatment for your child immediately, so that, if your child
has very severe symptoms, it is safer to call ‘911’ than to drive to the nearest hospital in your car.

Should I seek medical care right away?

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What medical treatment improves croup?

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Is it safe for my child to come home (or should they stay in the hospital)?

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Can I prevent my child from getting croup?

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