Croup: Straight To The Point of Care

Croup
Straight to the point of care
Last updated: Nov 15, 2019

Table of Contents
Overview 3
Summary 3
Definition 3
Theory 4
Epidemiology 4
Aetiology 4
Pathophysiology 4
Case history 4
Diagnosis 6
Approach 6
History and exam 6
Risk factors 8
Investigations 8
Differentials 9
Criteria 10
Management 12
Approach 12
Treatment algorithm overview 14
Treatment algorithm 15
Primary prevention 21
Secondary prevention 21
Patient discussions 21
Follow up 22
Monitoring 22
Complications 22
Prognosis 22
Guidelines 24
Diagnostic guidelines 24
Treatment guidelines 24
References 25
Disclaimer 34
Croup Overview
Summary
Common cause of acute respiratory distress in children.
Acute onset of seal-like barky cough in moderate to severe cases accompanied by stridor and sternal/
OVERVIEW
intercostal indrawing.
Careful history and physical examination sufficient for confirming clinical diagnosis and ruling out potentially
serious differentials.
Orally administered corticosteroids are the mainstay for all levels of severity, combined with nebulised
epinephrine (adrenaline) in moderate to severe croup to provide temporary relief of the symptoms of upper-
airway obstruction.
Definition
Croup, also known as laryngotracheobronchitis, is a common respiratory disease of childhood, characterised
by the sudden onset of a seal-like barky cough, often accompanied by stridor, voice hoarseness, and
respiratory distress. The symptoms are a result of upper-airway obstruction due to generalised inflammation
of the airways, as a result of viral infection (typically parainfluenza virus types 1 or 3).
This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Nov 15, 2019.
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3
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Croup Theory
Epidemiology
Croup is a frequent cause of acute respiratory distress in young children. Typically, it affects those between
6 months and 3 years of age, peaking in the second year of life. It has been reported to occur in infants
THEORY
younger than 6 months, in adolescents, and, more rarely, in adults.[1] [2] An observational study in a US
paediatric group practice found it to be the confirmed diagnosis in 15% of all cases of lower respiratory
infection.[1] Boys are more commonly affected, with a ratio of 1.4:1 compared with girls.[1] There is no
evidence to suggest variations in ethnicity prevalence. Admission rates peak in late autumn (September
through December), but cases occur all year round.[3] A peak in clinical presentations is correlated with
parainfluenza virus epidemics. These peaks typically occur in alternating years and result in a 50 % increase
in the number of children admitted with croup.[3]
Aetiology
The illness is due to viral infection (typically parainfluenza virus types 1 or 3).[3] Several other viral
pathogens have been recognised, including influenza A and B, adenovirus, respiratory syncytial virus,
metapneumovirus, coronavirus HCoV-NL63, and rarely measles.[1] [4] [5] [6] [7] [8] Distinctions have
been made between viral croup and spasmodic croup. However, it remains unclear as to whether these
entities represent different diseases or are merely a spectrum of the same disease. Clinically, it is difficult to
distinguish between the two, and is likely to be unnecessary as treatment decisions are based upon history
and clinical severity of the airway obstruction. Historically, laryngeal diphtheria was well known as a cause
of croup, but this is now rare in immunised populations. Reports of diphtheric croup have been published in
case series from India and Russia.[9] [10] [11] [12] A weak link between a history of previous intubation and
croup has been indicated.[13]
Pathophysiology
The symptoms result from upper-airway obstruction due to generalised inflammation and oedema of the
airways. At the cellular level this progresses to necrosis and shedding of the epithelium. The narrowed
subglottic region is responsible for the symptoms of seal-like barky cough, stridor (from increased airflow
turbulence), and sternal/intercostal indrawing. If the upper-airway obstruction worsens, respiratory failure can
result, leading to asynchronous chest and abdominal wall motion, fatigue, hypoxia, and hypercapnia.[14] [15]
[16]
Case history
Case history #1
A 2-year-old boy is brought to the emergency department by his parents in the middle of the night. He has
had mild symptoms of an upper respiratory infection for 48 hours, awoke with a sudden onset of seal-like
barky cough, and has had inspiratory stridor when crying. The stridor disappeared at rest, but the seal-
like barky cough has persisted.
4 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Nov 15, 2019.
Croup Theory
Case history #2
A 3-year-old boy is brought to the emergency department by his parents in the late evening. He has
developed a sudden onset of a seal-like barky cough, accompanied by clear nasal discharge. His parents
THEORY
became alarmed when he developed stridor, which persists throughout the trip to the hospital. On
examination, he has a seal-like barky cough and inspiratory stridor when at rest, which worsens with
agitation. Persistent sternal indrawing is also evident at rest.
5
Croup Diagnosis
Approach
The diagnosis of croup depends upon a careful history and physical examination. The key features are the
characteristic sudden-onset, seal-like barky cough, often accompanied by stridor and chest wall (intercostal)
or sternal indrawing. Symptoms are typically worse at night and increase with agitation.
There may be a history of prior non-specific upper respiratory tract symptoms (coryza, non-barky cough, mild
fever), although the seal-like barky cough may also present abruptly with no preceding illness. Although not
essential to the diagnosis, there is commonly a hoarse voice.
Clinical presentation
Presentations may range from mild symptoms to impending respiratory failure.[19] The physician should
look out for the following symptoms and signs according to severity:
• Mild: seal-like barky cough but no stridor or sternal/intercostal recession at rest

• Moderate: seal-like barky cough with stridor and sternal recession at rest; no agitation or lethargy
• Severe: seal-like barky cough with stridor and sternal/intercostal recession, associated with
agitation or lethargy
• Impending respiratory failure: increasing upper airway obstruction, sternal/intercostal recession,
asynchronous chest wall and abdominal movement, fatigue, and signs of hypoxia (pallor or
cyanosis) and hypercapnia (decreased level of consciousness secondary to rising PaCO₂). The
degree of chest wall recession may diminish with the onset of respiratory failure as the child tires.
The clinician must consider the differential diagnosis during the physical examination. In particular, if
epiglottitis is suspected, examination of the oropharynx or manipulation of the neck is contraindicated as it
may precipitate further airway obstruction.
Work-up
Croup is largely a clinical diagnosis.[20] X-ray of the anteroposterior and lateral neck is not performed in
a child presenting with typical symptoms and signs of croup. The steeple sign (narrowed trachea) is a
DIAGNOSIS
classic finding on anteroposterior view, but is not always present. Radiological studies are contraindicated
if there is clinical suspicion of epiglottitis or bacterial tracheitis, as manipulation of the neck region and
agitation may precipitate further airway obstruction. If the clinical picture is atypical for these conditions,
soft-tissue radiographs of the neck may provide helpful information to support an alternative diagnosis.
Any x-ray should be performed with considerable care and personnel equipped to support the airway in
the event of worsening obstruction.
History and exam

Key diagnostic factors
symptoms increasing with agitation (common)
• Seen in all levels of severity.
distinctive seal-like bark y cough (common)

• Key feature, required to make a diagnosis of croup.
age 6 months to 6 years (common)
Croup Diagnosis
• Occurs in this age group. Typically, it affects children between 6 months and 3 years of age, peaking in
the second year of life.[1]
• Croup can be seen in infants as young as 3 months of age, and may also occur, although rarely, in
older children, adolescents, and adults.[1]
Other diagnostic factors

male sex (common)
• Male to female ratio: 1.4:1.[1]
peak season late autumn (common)

• Cases peak in late autumn (September to December), which correlates with the peak prevalence of
parainfluenza virus in the community.[3]
prodromal symptoms (common)

• Non-specific upper respiratory tract symptoms (coryza, non-barky cough, mild fever) for 12 to 48 hours
may be present. Not a key feature in all cases; seal-like barky cough may present abruptly with no
preceding illness.
abrupt onset of symptoms (common)

• Typical, but not essential to the diagnosis.
symptoms worse at night (common)

• Typical, but not essential to the diagnosis.
hoarse voice (common)

• Not essential to the diagnosis, but commonly seen.
respiratory distress (sternal/intercostal indrawing, stridor) (uncommon)

• In moderate/severe croup.
DIAGNOSIS
persistent agitation (uncommon)
• In severe croup.
lethargy (uncommon)
• In severe croup (more likely in impending respiratory failure).
asynchronous chest wall and abdominal movement (uncommon)

• Impending respiratory failure.
fatigue (uncommon)
signs of hypoxia (pallor or cyanosis) (uncommon)

signs of hypercapnia (decreased level of consciousness secondary to rising

PaCO₂) (uncommon)
7
Croup Diagnosis
Risk factors
Strong
age 6 months to 6 years
• Occurs in this age group. Typically, it affects those between 6 months and 3 years of age, peaking in
the second year of life.[1]
• Croup can be seen in infants as young as 3 months of age, and may also occur, although rarely, in
older children, adolescents, and adults.[1]
Weak
male sex
• Male to female ratio: 1.4:1.[1]
prior intubation
• Small observational study indicates a weak link between a history of previous intubation and croup.[13]
Investigations
1st test to order
Test Result
clinical exam typical features on
clinical exam
• Croup is largely a clinical diagnosis.
Other tests to consider

DIAGNOSIS
Test Result
x-ray anteroposterior and lateral neck steeple sign in
anteroposterior view or
• Croup is largely a clinical diagnosis.Therefore, x-ray should not be
normal
performed in a child presenting with typical symptoms and signs of
croup. The steeple sign (narrowed trachea) is a classic finding on
anteroposterior view, but is not always present.
• Radiological studies are contraindicated if there is clinical suspicion of
epiglottitis or bacterial tracheitis, as manipulation of the neck region
and agitation may precipitate further airway obstruction. If the clinical
picture is atypical for these conditions, soft-tissue radiographs of
the neck may provide helpful information to support an alternative
diagnosis. Any x-ray should be performed with considerable care and
personnel equipped to support the airway in the event of worsening
obstruction.
Croup Diagnosis
Differentials
Condition Differentiating signs / Differentiating tests

symptoms
Bacterial tracheitis • May or may not have • Radiological studies are
antecedent symptoms contraindicated if there is
consistent with croup; clinical suspicion of bacterial
sudden deterioration tracheitis, as manipulation of
following 2 to 7 days of a the neck region and agitation
mild to moderate croup or may precipitate further
other mild viral illness;[14] airway obstruction.
fever, toxic appearance (child • Bronchoscopy, performed at
appears unwell and does the time of intubation, shows
not interact normally with erythematous tracheal
his/her surroundings) may mucosa, with thick, purulent
be present; painful cough; tracheal secretions.[25]
poor response to treatment • The most frequently
with nebulised epinephrine isolated pathogens
(adrenaline).[21] [22] [23] from tracheal secretions
[24] include Staphylococcus
aureus , group A
streptococcus, Moraxella
catarrhalis , Streptococcus
pneumoniae , Haemophilus
influenzae , and anaerobic
organisms.[14] [22] [23] [26]
[27] [28]
Epiglot titis • Rarely seen since • Radiological studies are

widespread immunisation contraindicated if there
against Haemophilus is clinical suspicion of
influenzae B;[29] [30] epiglottitis, as manipulation
[31] sudden onset of high of the neck region and
fever, dysphagia, drooling, agitation may precipitate
DIAGNOSIS
and anxiety; preferred further airway obstruction.
posture: sitting upright with • Visualisation of the
head extended; non-barky airway (prior to controlled
cough.[14] endotracheal intubation)
confirms the diagnosis
showing an oedematous,
erythematous epiglottis,
often obstructing the view of
the vocal cords.
Foreign body in the upper • Sudden onset of dyspnoea • Many foreign bodies are
airway and stridor; usually a clear not radio-opaque, thus x-
history of foreign body rays may not confirm the
inhalation or ingestion;[14] diagnosis.
no prodrome or symptoms of • Direct visualisation and
viral illness; no fever (unless removal of foreign body in
secondary infection).[32] the operating room confirms
the diagnosis.
Retropharyngeal abscess • Dysphagia, drooling, • Lateral neck radiograph may

occasionally stridor, demonstrate retroflexion
dyspnoea, tachypnoea, of cervical vertebrae and
9
Croup Diagnosis
Condition Differentiating signs / Differentiating tests

symptoms
neck stiffness, unilateral posterior pharyngeal
cervical adenopathy; onset is oedema.[33]
typically more gradual, often
accompanied by fever.[32]
Peritonsillar abscess • Dysphagia, drooling, • No differentiating tests.

occasionally stridor,
dyspnoea, tachypnoea,
neck stiffness, unilateral
cervical adenopathy; onset is
typically more gradual, often
accompanied by fever.[32]
Angioneurotic oedema • May present at any age; • No differentiating tests.

acute swelling of the upper
airway may cause dyspnoea
and stridor; fever uncommon.
Swelling of face, tongue, or
pharynx may be present.
Allergic reaction • May present at any age; • Allergy testing (skin prick
rapid onset of dysphagia, or RAST) may determine
stridor, and possible underlying allergen
cutaneous manifestations
(urticarial rash); often
personal or family history of
prior episodes or allergy.
Laryngeal diphtheria • Extremely rare clinical • No differentiating tests.

emergency. May present
at any age; history of
inadequate immunisation;
prodrome with symptoms
of pharyngitis for 2
DIAGNOSIS
to 3 days; low-grade
fever, voice hoarseness,
potentially barky cough;
dysphagia, inspiratory
stridor; characteristic
membranous pharyngitis on
examination.[32]
Congenital or acquired • Extremely rare. Usually • Upper airway endoscopy

tracheal or laryngeal presents at under 3 months or bronchoscopy will allow
abnormalities of age. direct visualisation of the
• Abnormally prolonged underlying abnormality.
or recurrent stridor. Poor However, these tests should
response to croup treatment. be delayed until after the
acute illness.
Criteria
Clinical classification of severity[19]
Croup Diagnosis
• Mild: seal-like barky cough but no stridor or sternal/intercostal recession at rest

• Moderate: seal-like barky cough with stridor and sternal recession at rest; no agitation or lethargy
• Severe: seal-like barky cough with stridor and sternal/intercostal recession associated with agitation or
lethargy
• Impending respiratory failure: increasing upper airway obstruction, sternal/intercostal recession,
asynchronous chest wall and abdominal movement, fatigue, and signs of hypoxia (pallor or cyanosis)
and hypercapnia (decreased level of consciousness secondary to rising PaCO₂). The degree of chest
wall recession may diminish with the onset of respiratory failure as the child tires.
Westley croup score: research classification

Total score ranging from 0 to 17 points. Five component items make up the score: [34]
• Stridor (0 = none, 1 = with agitation only, 2 = at rest)

• Recession (0 = none, 1 = mild, 2 = moderate, 3 = severe)
• Cyanosis (0 = none, 4 = cyanosis with agitation, 5 = cyanosis at rest)
• Level of consciousness (0 = normal - including asleep, 5 = disorientated)
• Air entry (0 = normal, 1 = decreased, 2 = markedly decreased).
The Westley croup score has been used in numerous clinical research studies to classify croup into mild,
moderate, and severe categories. A total score ≤1 is typically considered mild, 2 to 4 is considered moderate,
and a score ≥5 is considered severe.[35] However, substantial inter-observer variability exists when the score
is used in clinical practice, thus limiting its use in the clinical setting.[36]
DIAGNOSIS
11
Croup Management
Approach
In mild and moderate croup, the main goals of treatment are symptomatic relief; this is achieved with
supportive care and oral or nebulised corticosteroids. In moderate croup these should be combined
with nebulised epinephrine (adrenaline). Children may be safely discharged home after 2 to 4 hours of
observation following epinephrine administration.[37] [38] [39] [40] [41] [42] [43]
In severe croup, the main treatment aim is to prevent further airway compromise. In addition to the
combination treatment of nebulised or parenteral corticosteroids plus nebulised epinephrine, oxygen is
given to children demonstrating marked respiratory distress.[19] [44] [45] [46] [47] Intubation is indicated for
impending respiratory failure.[48] [49] [50] [51]
General care
Care should be taken to avoid frightening the child, as agitation may cause worsening of symptoms.[19]
To ensure comfort, the child should be seated comfortably in the carer's lap during assessment and
treatment. Although there is little research regarding the use of oxygen in croup, the clinical rationale is
clear in a child with significant respiratory distress. The mechanism by which patients with severe croup
become hypoxic is secondary to relative hypoventilation. Therefore, close monitoring and re-assessment
should occur continuously. Humidified oxygen may be administered via a plastic hose with the opening
held within a few centimetres of the nose or mouth to minimise the chance of causing agitation.[19] [44]
[45] [46] [47]
Especially in mild croup, parental assurance and education to the self-limited nature of the illness is
important.
Corticosteroids
Corticosteroids are the mainstay of medical treatment in mild, moderate, and severe croup.[38] [53]
[54] [55] [56] [57] [52] [58] In a systematic review, corticosteroids were found to improve symptoms of
moderate to severe croup within 2 hours, with the effect lasting for at least 24 hours.[59] Corticosteroid
were associated with an average 15-hour reduction in length of stay in hospital or emergency department,
and a 50% reduction in number of admissions for treatment and return visits.[59] However, most studies
were at high or unclear risk of bias.[59]
The usual administration is a single oral dose of dexamethasone, with treatment effect evident within
2 hours, and further beneficial effects noted up to 10 hours following initial dose.[38] Traditionally, a
dose of 0.6 mg/kg/dose was used for croup; however, evidence now supports the use of a smaller
dose of 0.15 mg/kg/dose. Adding inhaled budesonide does not appear to provide additional benefit.[64]
There is inadequate evidence comparing single versus multiple doses of corticosteroids. With most
croup symptoms showing resolution within 3 days of the onset, and the anti-inflammatory effect of
dexamethasone thought to last between 2 to 4 days, a second dose is unlikely to be beneficial in the
majority of children with croup.[65]
Both oral and intramuscular routes of administration have been shown to be equivalent or superior
MANAGEMENT
to inhaled corticosteroids in moderate to severe croup.[38] [55] [66] [67] [68] Alternative routes of
administration will be necessary in children who do not tolerate or absorb oral medicine (e.g., children
with persistent vomiting or severe respiratory distress). Inhaled budesonide may be preferable in children
with severe hypoxia, in whom reduced gut and tissue perfusion can impair oral and intramuscular
Croup Management
absorption. Establishing intravenous access can increase distress and potentially precipitate respiratory
failure. Extreme care should be taken when considering intravenous administration.
To date, no adverse effects have been attributed to the use of corticosteroids in children with croup.
Theoretical concerns include a possible increased risk of complications of varicella (bacterial
superinfection, disseminated varicella) in a child with recent exposure.
Adding nebulised epinephrine (adrenaline)

In moderate and severe croup, nebulised epinephrine should be administered with dexamethasone as
it provides temporary relief of symptoms of airway obstruction. [71] [72] A clear reduction in stridor and
sternal/intercostal recession should be evident within 10 to 30 minutes following administration.[38] The
clinical effects of nebulised epinephrine last on average at least 1 hour, but usually subside 2 hours
after administration.[34] On average, symptoms return to their baseline, without evidence of a rebound
effect.[74] [34] [75] [76] [77] [78]
Although racemic epinephrine has traditionally been used to treat children with croup, L-epinephrine is
as effective in moderate to severe croup.[79] In some countries, L-epinephrine availability may be limited.
The same dose of nebulised epinephrine is used regardless of weight, as the effective dose of drug
delivered to the airway is regulated by individual tidal volume.[80] [81] [82] [83] No adverse effects have
been noted when given one dose at a time.[79] [73] [74] [84] [60] [85] [86] Caution should be used with
multiple doses of nebulised epinephrine. There have been no reports of complications associated with the
use of L-epinephrine in children with known cardiac conditions. However, careful observation is advisable
if epinephrine treatment is deemed necessary.
In children who do not respond to combination treatment within a few hours following administration, a
refocused assessment should take place to rule out alternate diagnoses.
Impending respiratory failure

In children progressing to asynchronous chest wall and abdominal movement, fatigue, and signs of
hypoxia (pallor or cyanosis) and hypercapnia (decreased level of consciousness secondary to rising
PaCO₂), endotracheal intubation may be necessary to secure the airway.
Treatments with no added benefit

Historically mist or humidified air have been widely employed, but there is now convincing evidence that
these are ineffective[19] [88] [89] [90] [91] [92] [93] and even harmful in some instances. For example,
hot humidified air carries an increased risk of scald injuries[94] and mist tents promote mould growth if
improperly cleaned.[93] Additionally, being enclosed in a cold, wet space separated from the carer may
increase a child's agitation.
Antibiotics, beta-2 agonists, and decongestants have not been studied and their use should be
discouraged.[19] [44] [45] [46] [47]
Heliox (a defined mixture of helium and oxygen) has been studied as an adjunctive therapy in severe
airway obstruction.[85] [95] Helium is an inert gas that has no recognised pharmaceutical properties.
MANAGEMENT
Heliox usually contains 70% helium, limiting the fractional concentration of oxygen to maximal 30%.
Compared with nitrogen, the major gas found in room air, the lower-density helium gas decreases the
turbulence of airflow over the narrowed airways, which theoretically should result in decreased work of
breathing. However, heliox has not yet been shown to confer improvements over standard therapies,[96]
13
Croup Management
limits the fractional concentration of inhaled oxygen that can be provided and can be challenging to use in
unskilled hands.[85] [95] [97] [98] [99] [100] [101] [102] It is not currently recommended for use in children
with severe croup.
Tracheostomy is a rare intervention reserved for cases of unsuccessful endotracheal intubation (e.g.,
in severe epiglottitis) and is not indicated in croup. Its complications include risk of bleeding, damage
to adjacent structures in the neck, air leak (pneumomediastinum or pneumothorax), obstruction of the
tracheotomy tube, infection, and tracheal injury.
Treatment algorithm overview

Please note that formulations/routes and doses may differ between drug names and brands, drug
formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
Acute ( summary )
mild (no stridor at rest)
1st corticosteroids + supportive care
moderate (stridor at rest; no agitation

or lethargy)
plus nebulised adrenaline (epinephrine)
severe (stridor at rest with agitation

or lethargy)
plus supplemental ox ygen
with impending adjunct intubation

respiratory failure
MANAGEMENT
Croup Management
Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug
formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
MANAGEMENT
15
Croup Management
Acute
mild (no stridor at rest)

Primary options
» dexamethasone: 0.15 to 0.6 mg/kg orally as

a single dose
» A single dose of oral dexamethasone is given

as soon as the clinical diagnosis of croup has
been made. Its effect in reducing the clinical
signs of croup is seen within 2 hours, with further
beneficial effects noted up to 10 hours following
administration.[38]
» Traditionally, a dose of 0.6 mg/kg/dose was

used for croup; however, evidence now supports
the use of a smaller dose of 0.15 mg/kg/dose.
» Care should be taken to avoid frightening

the child, as agitation may cause worsening of
symptoms.[19] Especially in mild croup, parental
assurance and education to the self-limited
nature of the illness is important.
» Historically mist or humidified air have been

widely employed, but there is now convincing
evidence that these are ineffective[19] [88] [89]
[90] [91] [92] [93] and even harmful in some
instances.
moderate (stridor at rest; no agitation
or lethargy)

Primary options

a single dose
OR
» budesonide inhaled: 2 mg nebulised as a

single dose
OR
» dexamethasone: 0.6 mg/kg intramuscularly

as a single dose

MANAGEMENT

signs of croup is seen within 2 hours, with further
beneficial effect noted up to 10 hours following
administration.[38]
Croup Management
Acute
» Nebulised budesonide is preferable in severe

hypoxia, persistent vomiting, or respiratory
distress preventing administration of an oral
dose.
» Intramuscular dexamethasone is another

alternative.
» Care should be taken to avoid frightening

the child, as agitation may cause worsening of
symptoms.[19] Historically mist or humidified
air have been widely employed, but there
is now convincing evidence that these are
ineffective[19] [88] [89] [90] [91] [92] [93] and
even harmful in some instances.
Treatment recommended for ALL patients in
selected patient group
Primary options
» adrenaline inhaled: (1:1000 solution of L-

adrenaline) 5 mL undiluted nebulised as a
single dose
OR
» adrenaline inhaled: (2.25% racemic

solution) 0.5 mL diluted to 2-4 mL with normal
saline nebulised as a single dose
» In children presenting with stridor, sternal

indrawing at rest, and persistent or increasing
agitation, nebulised adrenaline (epinephrine)
should be administered in addition to
dexamethasone. It provides temporary relief of
the airway obstruction while awaiting the effects
of corticosteroid treatment.[72]
» The clinical effects of nebulised adrenaline

(epinephrine) last on average at least 1 hour, but
usually subside 2 hours after administration.[34]
» The use of one dose at a time of nebulised

adrenaline (epinephrine) has not been
associated with any clinically significant
increases in BP or heart rate, neither has it been
MANAGEMENT
associated with any adverse events.[79] [73]

[74] [84] [60] [85] [86] Caution should be used
with multiple doses of nebulised adrenaline
(epinephrine). Careful observation is advisable
if adrenaline (epinephrine) treatment is deemed
necessary.
17
Croup Management
Acute
» Although racemic adrenaline (epinephrine)
has traditionally been used to treat children
with croup, L-adrenaline (epinephrine) is as
effective in moderate to severe croup.[79] In
some countries, L-adrenaline (epinephrine)
availability may be limited. The same dose is
used regardless of weight, as the effective dose
of drug delivered to the airway is regulated by
individual tidal volume.[80] [81] [82] [83]
severe (stridor at rest with agitation
or lethargy)

Primary options

a single dose
OR
» budesonide inhaled: 2 mg nebulised as a

single dose
OR
» dexamethasone: 0.6 mg/kg intramuscularly

as a single dose
Secondary options
» dexamethasone: 0.15 to 0.6 mg/kg

intravenously as a single dose

signs of croup is seen by 2 hours, with further
beneficial effect noted up to 10 hours following
administration.[38]

» Nebulised budesonide is preferable in severe

hypoxia, persistent vomiting or respiratory
distress preventing administration of an oral
dose.
» Intramuscular or intravenous dexamethasone

MANAGEMENT
is another alternative. However, there is

significant potential to increase agitation and
respiratory distress when an intravenous line is
inserted in a child with severe croup.
Croup Management
Acute
» Wherever possible, the child should be kept
in a calm environment with his/her caregiver.
Care should be taken to minimise interventions
that would increase the child’s agitation.
Historically mist or humidified air have been
widely employed, but there is now convincing
evidence that these are ineffective[19] [88] [89]
[90] [91] [92] [93] and even harmful in some
instances.
Primary options
» adrenaline inhaled: (1:1000 solution of L-

adrenaline) 5 mL undiluted nebulised as a
single dose
OR
» adrenaline inhaled: (2.25% racemic

solution) 0.5 mL diluted to 2-4mL with normal
saline nebulised as a single dose
» In children presenting with stridor, sternal/

intercostal indrawing at rest, and persistent
or increasing agitation, nebulised adrenaline
(epinephrine) should be administered in addition
to dexamethasone. It provides temporary relief of
the airway obstruction while awaiting the effects
of corticosteroid treatment.[72]
» The clinical effects of nebulised adrenaline

(epinephrine) last on average at least 1 hour, but
usually subside 2 hours after administration.[34]
» The use of one dose at a time of nebulised

adrenaline (epinephrine) has not been
associated with any clinically significant
increases in BP or heart rate; neither has it been
associated with any adverse events.[79] [73]
[74] [84] [60] [85] [86] Caution should be used
with multiple doses of nebulised adrenaline
(epinephrine).Careful observation is advisable
if adrenaline (epinephrine) treatment is deemed
necessary.
» Although racemic adrenaline (epinephrine)

has traditionally been used to treat children
with croup, L-adrenaline (epinephrine) is as
MANAGEMENT
effective in moderate to severe croup.[79] In

some countries, L-adrenaline (epinephrine)
availability may be limited. The same dose is
used regardless of weight, as the effective dose
of drug delivered to the airway is regulated by
individual tidal volume.[80] [81] [82] [83]
19
Croup Management
Acute
plus supplemental ox ygen
Primary options
» oxygen: 8 to 10 L/min blow-by
Secondary options
» oxygen: 100% by non-re-breather mask
» Humidified oxygen is given to children

demonstrating significant signs and symptoms
of respiratory distress, preferably as blow-by
oxygen via tubing held a few centimetres from
the child's nose and mouth.
» In the event that oxygenation is insufficient

using this method, 100% oxygen via a non-
re-breather mask is administered. However,
the application of the mask to the face carries
the potential for increasing agitation and
preparations (experienced personnel, intubation
equipment, medications) should be made to
secure the airway if the clinical situation worsens
to impending respiratory failure.
» Oxygen saturation monitoring should occur,

providing this does not increase the child's level
of agitation.
with impending adjunct intubation
respiratory failure
Treatment recommended for SOME patients in
» Indicated in children progressing to
asynchronous chest wall and abdominal
movement, fatigue, and signs of hypoxia (pallor
or cyanosis) and hypercapnia (decreased level
of consciousness secondary to rising PaCO₂).
» Becoming increasingly uncommon (in only

1% to 3% of children admitted with croup) and
performed as rapid sequence induction in a
controlled setting with experienced personnel
and equipment.[48] [49] [50] [51]
» Advisable to have a selection of endotracheal

tubes of smaller sizes at hand, as subglottic
oedema may cause difficulty when intubating
with a standard sized endotracheal tube.
MANAGEMENT
Croup Management
Primary prevention
No strategies for primary prevention are currently recommended. Work continues into the development of
an effective vaccine against the parainfluenza virus.[17] [18] If a vaccine were to become available, this may
lead to a significant reduction in croup caused by parainfluenza viruses.
Secondary prevention
In developing nations, vitamin A has been used as a preventive therapy for croup caused by severe
measles.[7] [8]
Patient discussions
Parents should be made aware of the symptoms and signs of croup:
• Hoarse voice
• Seal-like barking cough
• Stridor (a high-pitched crowing sound heard as child breathes in)
• Fever (although not all children will have a fever).
Most children with mild croup can be observed at home.
Parents should be advised to go to the hospital if:
• The crowing sound (stridor) can be heard continually

• The skin between the ribs is pulling in with every breath
• The child is restless or agitated.
Parents should be instructed to call an ambulance if:
• The child's face is very pale, blue, or grey (includes blue lips) for more than a few seconds
• The child is unusually sleepy or is not responding
• The child is having a lot of trouble breathing (e.g., the belly is sinking in while breathing, or the skin
between the ribs or over the windpipe is pulling in with each breath; the nostrils may also be flaring
in and out)
• The child is upset (agitated or restless) while struggling to breathe and cannot be calmed down
quickly
• The child wants to sit instead of lie down
• The child cannot talk, is drooling, or having trouble swallowing.
MANAGEMENT
21
Croup Follow up
Monitoring
Monitoring
FOLLOW UP
Children with moderate to severe croup responding well to combination therapy with corticosteroids and
nebulised epinephrine (adrenaline) (plus oxygen) may be safely discharged home after 2 to 4 hours of
observation following epinephrine administration.
Children admitted to hospital with significant respiratory distress despite therapy require continuous
monitoring and observation of respiratory status and vital signs.
In children who have undergone intubation, there is no need for subsequent follow-up after extubation,
once the respiratory distress and symptoms of upper-airway obstruction have resolved.
In the rare case of a child with persistent symptoms of upper-airway obstruction, re-evaluation should
occur to assess for pre-existing upper-airway anatomical abnormalities.
Complications
Complications Timeframe Likelihood

bacterial tracheitis short term low
Postulated mechanism is bacterial super-infection related to previously unknown immune dysfunction,

requiring treatment with broad-spectrum intravenous antibiotics and, in severe cases, endotracheal
intubation.[104]
pneumonia short term low
Postulated mechanism is bacterial super-infection, requiring treatment with broad-spectrum antibiotics.
Prognosis
Although most children with the condition suffer a mild and self-limited illness of short duration, the stress
and disruption experienced by the child and family are well documented.[103]
Mild
Self-limited without treatment but shorter time to resolution with dexamethasone treatment.
Moderate
Reasonable outlook. While symptoms of obstruction may be frightening, symptoms resolve without significant
complications.
Croup Follow up
Severe
Before corticosteroids became standard treatment, children with severe croup were 5 times more likely
to receive endotracheal intubation,[52] and remained intubated for 30% longer.[53] Introduction of routine
FOLLOW UP
corticosteroid treatment has dramatically decreased numbers of children intubated, reduced number of days
spent in ICU, and shortened length of hospital stay.[56] Since combination treatment with dexamethasone
and nebulised epinephrine (adrenaline) became standard care, prognosis for severe croup has been
excellent.
Impending respiratory failure

Very rare, with intubation required in only 1% to 3% of all cases.[48] [49] [50] [51]
23
Croup Guidelines
Diagnostic guidelines
International
Management of the child with cough or difficult breathing: a guide for low-
income countries (ht tps://www.theunion.org/what-we-do/publications/
technical)
Published by: International Union Against TB and Lung Disease Last published: 2005
North America
Acute management of croup in the emergency department (ht tps://

www.cps.ca/en/documents/authors-auteurs/acute-care-commit tee)
Published by: Canadian Paediatric Society Last published: 2017
GUIDELINES
Guideline for the diagnosis and management of croup (ht tps://

act t.albertadoctors.org/CPGs/Pages/default.aspx)
Published by: Alberta Medical Association Last published: 2015
Treatment guidelines
International
Management of the child with cough or difficult breathing: a guide for

low-income countries (ht tp://www.theunion.org/what-we-do/publications/
technical)
Published by: International Union Against TB and Lung Disease Last published: 2005
North America
Acute management of croup in the emergency department (ht tps://

www.cps.ca/en/documents/authors-auteurs/acute-care-commit tee)
Published by: Canadian Paediatric Society Last published: 2017
Guideline for the diagnosis and management of croup (ht tps://

act t.albertadoctors.org/CPGs/Pages/default.aspx)
Published by: Alberta Medical Association Last published: 2015
Croup References
Key articles
• Johnson D, Klassen T, Kellner J. Diagnosis and management of croup: Alberta Medical Association
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33
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35
Contributors:
// Authors:
Candice Bjornson, MSc, MD, FRCPC

Associate Professor
University of Calgary, Calgary, Canada
DISCLOSURES: CB declares that she has no competing interests. CB is the author of several references in
this topic.
David Johnson, MD
Professor
Department of Pediatrics and Physiology and Pharmacology, University of Calgary, Calgary, Canada
DISCLOSURES: DJ declares that he has no competing interests. DJ is the author of several references in
this topic.
// Peer Reviewers:
Jeffrey Chapman, MD
Staff
Department of Pulmonary and Critical Care Medicine, Cleveland Clinic, Cleveland, OH
DISCLOSURES: JC declares that he has no competing interests.
Ken Farion, MD
Assistant Professor
Pediatrics and Emergency Medicine, University of Ottawa, Ottawa, Canada
DISCLOSURES: KF declares that he has no competing interests.
Doreen Matsui, MD, FRCPC

Associate Professor
Departments of Paediatrics and Medicine, Children's Hospital of Western Ontario, London, Ontario, Canada
DISCLOSURES: DM declares that she has no competing interests.
Jeremy Hull, MBBS

Consultant Paediatrician
Children's Hospital and West Wing, John Radcliffe Hospital, Oxford, UK
DISCLOSURES: JH declares that he has no competing interests.
Steve Cunningham, MBBS, PhD

Consultant Respiratory Paediatrician
Department of Respiratory & Sleep Medicine, Royal Hospital for Sick Children, Edinburgh, UK
DISCLOSURES: SC declares that he has no competing interests.

Croup: Straight To The Point of Care

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Croup

Straight to the point of care

Last updated: Nov 15, 2019

• Mild: seal-like barky cough but no stridor or sternal/intercostal recession at rest

History and exam

distinctive seal-like bark y cough (common)

age 6 months to 6 years (common)

Other diagnostic factors

peak season late autumn (common)

prodromal symptoms (common)

abrupt onset of symptoms (common)

symptoms worse at night (common)

hoarse voice (common)

respiratory distress (sternal/intercostal indrawing, stridor) (uncommon)

asynchronous chest wall and abdominal movement (uncommon)

signs of hypoxia (pallor or cyanosis) (uncommon)

signs of hypercapnia (decreased level of consciousness secondary to rising

Other tests to consider

Condition Differentiating signs / Differentiating tests

Epiglot titis • Rarely seen since • Radiological studies are

Retropharyngeal abscess • Dysphagia, drooling, • Lateral neck radiograph may

Condition Differentiating signs / Differentiating tests

Peritonsillar abscess • Dysphagia, drooling, • No differentiating tests.

Angioneurotic oedema • May present at any age; • No differentiating tests.

Laryngeal diphtheria • Extremely rare clinical • No differentiating tests.

Congenital or acquired • Extremely rare. Usually • Upper airway endoscopy

• Mild: seal-like barky cough but no stridor or sternal/intercostal recession at rest

Westley croup score: research classification

• Stridor (0 = none, 1 = with agitation only, 2 = at rest)

Adding nebulised epinephrine (adrenaline)

Impending respiratory failure

Treatments with no added benefit

Treatment algorithm overview

1st corticosteroids + supportive care

moderate (stridor at rest; no agitation

1st corticosteroids + supportive care

plus nebulised adrenaline (epinephrine)

severe (stridor at rest with agitation

1st corticosteroids + supportive care

plus nebulised adrenaline (epinephrine)

plus supplemental ox ygen

with impending adjunct intubation

1st corticosteroids + supportive care

» dexamethasone: 0.15 to 0.6 mg/kg orally as

» A single dose of oral dexamethasone is given

» Traditionally, a dose of 0.6 mg/kg/dose was

» Care should be taken to avoid frightening

» Historically mist or humidified air have been

1st corticosteroids + supportive care

» dexamethasone: 0.15 to 0.6 mg/kg orally as

» budesonide inhaled: 2 mg nebulised as a

» dexamethasone: 0.6 mg/kg intramuscularly

» A single dose of oral dexamethasone is given

as soon as the clinical diagnosis of croup has

» Nebulised budesonide is preferable in severe

» Intramuscular dexamethasone is another

» Care should be taken to avoid frightening

» adrenaline inhaled: (1:1000 solution of L-

» adrenaline inhaled: (2.25% racemic