Official reprint from UpToDate www.uptodate.com.sci­hub.org ©2015 UpToDate

AuthorCharles R Woods, MD, MS

Section EditorSheldon L Kaplan, MD

Deputy EditorCarrie Armsby, MD, MPH

Croup: Approach to management

All topics are updated as new evidence becomes available and our peer review process is complete.Literature review current through: Dec 2014. | This topic last updated: Dec 14, 2013.

INTRODUCTION — Croup (laryngotracheitis) is a respiratory illness characterized by inspiratory stridor, barkingcough, and hoarseness. It typically occurs in children six months to three years of age and is caused byparainfluenza virus. (See "Croup: Clinical features, evaluation, and diagnosis".)

The treatment of croup has changed significantly since the 1980s. Corticosteroids and nebulized epinephrine havebecome the cornerstones of therapy. Substantial clinical evidence supports the efficacy of these interventions [1­5]. The impact also is evident in the decrease in annual hospital admissions for croup in children in the UnitedStates between 1979 and 1982, and 1994 and 1997 (from 2.8 to 2.1 per 1000 for children <1 year and from 1.8 to1.2 per 1000 children for children 1 to 4 years) [6].

The approach to the management of croup will be discussed below. The clinical features and evaluation of croupand the evidence supporting the use of the pharmacologic and supportive interventions included below arediscussed separately. (See "Croup: Clinical features, evaluation, and diagnosis" and "Croup: Pharmacologic andsupportive interventions".)

OVERVIEW — The treatment of croup and the setting in which the child is initially evaluated depend upon theseverity of symptoms and the presence of risk factors for rapid progression. There is no definitive treatment for theviruses that cause croup. Pharmacologic therapy is directed toward decreasing airway edema, and supportive careis directed toward the provision of respiratory support and the maintenance of hydration. (See "Croup:Pharmacologic and supportive interventions".)

Most children with croup who seek medical attention have a mild, self­limited illness and can be successfullymanaged as outpatients. The clinician must be able to identify children with mild symptoms, who can be safelymanaged at home, and those with moderate to severe croup or rapidly progressing symptoms, who require fullevaluation and possible treatment in the office or emergency department setting.

Severity assessment — The severity of croup is often determined by the clinical scoring systems. Although thereare a number of validated croup scoring systems, the Westley croup score [1] has been the most extensivelystudied; it is described below. No matter which system is used to assess severity, the presence of chest wallretractions and stridor at rest are the two most critical clinical features [7].

Westley croup score — The elements of the Westley croup score describe key features of the physicalexamination [1]. Each element is assigned a score, as illustrated below:

The total score ranges from 0 to 17.

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Level of consciousness: Normal, including sleep = 0; disoriented = 5Cyanosis: None = 0; with agitation = 4; at rest = 5Stridor: None = 0; with agitation = 1; at rest = 2Air entry: Normal = 0; decreased = 1; markedly decreased = 2Retractions: None = 0; mild = 1; moderate = 2; severe = 3

Mild croup is defined by a Westley croup score of ≤2. Typically these children have a barking cough, hoarsecry, but no stridor at rest. Children with mild croup may have stridor when upset or crying (ie, agitated) andeither no, or only mild, chest wall/subcostal retractions [8,9].

Respiratory failure — Croup occasionally results in significant upper airway obstruction with impendingrespiratory failure, heralded by the following signs [8,10]:

PHONE TRIAGE — The first contact with the health­care system regarding a child with symptoms of croup mayoccur by phone. When assessing patients by phone, the health­care provider must distinguish children who needimmediate medical attention or further evaluation from those who can be managed at home. Children who needfurther evaluation include those who have:

Patients who are assessed by phone and determined to have mild symptoms and none of the above indications forfurther evaluation can be managed at home. (See 'Home treatment' below.)

MILD CROUP — Children with mild symptoms, defined by a Westley croup score of ≤2, should be treatedsymptomatically with humidity, fever reduction, and oral fluids. Many such children can be managed by phone,provided that none of the criteria for further evaluation described above are present.

Home treatment — The caregivers of children with mild croup who are managed at home should be instructed inprovision of supportive care including mist, antipyretics, and encouragement of fluid intake.

In acute situations and for short periods of time, caregivers may try sitting with the child in a bathroom filled withsteam generated by running hot water from the shower to improve symptoms. This may help reassure parents that"something" is being done to reverse the symptoms, and anecdotal evidence supports some value of thismeasure.

Exposure to cold night air also may lessen symptoms of mild croup, although this has never been systematicallystudied. If parents or caregivers wish to use humidifiers at home, only those that produce mist at roomtemperature should be used to avoid the risk of burns from steam or the heating element.

Patients who are managed at home should receive a follow­up phone call; caregivers should receive instructions

Moderate croup is defined by a Westley croup score of 3 to 7. Children with moderate croup have stridor atrest, at least mild retractions, and may have other symptoms or signs of respiratory distress, but little or noagitation [8,9].

Severe croup is defined by a Westley croup score of ≥8. Children with severe croup have significant stridorat rest, although stridor may decrease with worsening upper airway obstruction and decreased air entry [8,9].Retractions are severe (including indrawing of the sternum) and the child may appear anxious, agitated, orfatigued. Prompt recognition and treatment of children with severe croup are paramount.

Fatigue and listlessnessMarked retractions (although retractions may decrease with increased obstruction and decreased air entry)Decreased or absent breath soundsDepressed level of consciousnessTachycardia out of proportion to feverCyanosis or pallor

Stridor at restAn abnormal airway (eg, subglottic narrowing from care in the neonatal intensive care unit)Previous episodes of moderate to severe croupMedical conditions that predispose to respiratory failure (eg, neuromuscular disorders)Rapid progression of symptoms (ie, symptoms of upper airway obstruction after less than 12 hours of illness)Inability to tolerate oral fluidsParental concern that cannot be relieved by reassuranceProlonged symptoms (more than three to seven days) or an atypical course (perhaps indicating an alternativediagnosis) (see "Croup: Clinical features, evaluation, and diagnosis", section on 'Differential diagnosis')

regarding indications to seek medical attention, including [8]:

Caregivers also should be provided with some guidance regarding when it is safe for them to drive the child to theemergency department and when to call for emergency medical services. Emergency medical services shouldprovide transportation for children who are severely agitated, cyanotic, struggling to breathe, or lethargic [8].

Outpatient treatment — Children who are seen in the office or emergency department with mild croup may requirelittle or no therapy, or may have improvement with humidified air. (See "Croup: Pharmacologic and supportiveinterventions", section on 'Mist therapy'.) Randomized controlled trials have demonstrated that treatment with asingle dose of oral dexamethasone (0.15 to 0.6 mg/kg, maximum dose 10 mg) may reduce the need forreevaluation, shorten the course, improve duration of the child's sleep, and reduce parental stress [11,12].

We suggest that children with mild croup who are seen in the outpatient setting be treated with a single dose oforal dexamethasone (0.6 mg/kg). Treatment of such children in the late morning or early afternoon hours mayprevent worsening of symptoms as evening approaches. However, anticipatory guidance about potentialworsening and when to seek care or return for follow­up also is reasonable. (See "Croup: Pharmacologic andsupportive interventions", section on 'Dexamethasone'.)

Children with mild croup who are tolerating fluids and have not received nebulized epinephrine can be sent homeafter specific follow­up (which may occur by phone) has been arranged and the caregiver has received instructionsregarding home care and indications to seek medical attention as described above. (See 'Home treatment' above.)

MODERATE TO SEVERE CROUP — Children with moderate croup (Westley croup score 3 to 7, stridor andretractions at rest without agitation) should be evaluated in the emergency department or office (provided the officeis equipped to handle acute upper airway obstruction). Children with severe croup (Westley croup score ≥8, stridorand retractions at rest with agitation, lethargy, or cyanosis, marked sternal wall indrawing) should be evaluated inthe emergency department. Such children require aggressive therapy, monitoring, and supportive care.

Supportive care — Supportive care for children with moderate/severe croup includes administration of humidifiedair or humidified oxygen as indicated for hypoxemia (oxygen saturation <92 percent in room air) or respiratorydistress. (See "Croup: Pharmacologic and supportive interventions", section on 'Oxygen'.)

The child with severe croup must be approached cautiously, as any increase in anxiety may worsen airwayobstruction. The parent or caregiver should be instructed to hold and comfort the child and to administer humidifiedoxygen. Nebulized epinephrine should be added as quickly as possible, as described below. In the meantime,health­care providers should continuously observe the child and be prepared to provide bag mask ventilation andadvanced airway techniques if the condition worsens. (See "Emergent endotracheal intubation in children".)

Monitoring — Monitoring should include pulse oximetry and close observation of respiratory status, includinglevel of consciousness, stridor, cyanosis, air entry, and retractions. Trends in ventilation can be monitorednoninvasively with capnography if capnography is available and the child will tolerate the nasal prongs [13].

Fluids — Administration of intravenous fluids may be necessary in some children. Fever and tachypnea may

Difficulty breathingPallor or cyanosisSevere coughing spellsDrooling or difficulty swallowingFatigueWorsening courseFever (>38.5ºC)Prolonged symptoms (longer than seven days)Stridor at restSuprasternal retractions

increase fluid requirements, and respiratory difficulty may prevent the child from achieving adequate oral intake.(See "Maintenance fluid therapy in children".)

Intubation — Endotracheal intubation is required in less than 1 percent of those who are seen in theemergency department and 2 to 6 percent of those who are hospitalized [14­17]. The need for intubation should beanticipated in children with progressive respiratory failure so that the procedure can be performed in as controlled asetting as possible. A tracheal tube that is 0.5 to 1 mm smaller than would typically be used may be required. (See'Respiratory failure' above and "Emergent endotracheal intubation in children", section on 'Endotracheal tube'.)

Pharmacotherapy — The benefits of corticosteroids and nebulized epinephrine for moderate to severe croup havebeen demonstrated in meta­analysis and randomized controlled trials, respectively [1,18­20]. Specificpharmacologic intervention depends upon the severity of symptoms:

Nebulized epinephrine can be repeated every 15 to 20 minutes. The administration of three or more doses within atwo­ to three­hour time period should prompt initiation of close cardiac monitoring if this is not already underway.(See "Croup: Pharmacologic and supportive interventions", section on 'Nebulized epinephrine'.)

Children who receive nebulized epinephrine should also receive dexamethasone by the least invasive route thatcan be accomplished, as described above. (See "Croup: Pharmacologic and supportive interventions", section on'Glucocorticoids'.)

Although it is not routinely indicated in the treatment of croup, a single dose of nebulized budesonide (2 mg [2 mLsolution] via nebulizer) may provide an alternative to IM or IV dexamethasone for children with vomiting or severerespiratory distress [8]. In children with severe respiratory distress, budesonide may be mixed with epinephrineand administered simultaneously [8]. (See "Croup: Pharmacologic and supportive interventions", section on'Budesonide'.)

Observation — Children with moderate/severe croup should be observed after pharmacologic intervention. Duringthe observation period, children should be encouraged to drink.

For children with moderate stridor at rest and moderate retractions or more severe symptoms, werecommend administration of dexamethasone (0.6 mg/kg, maximum of 10 mg) by the least invasive routepossible: oral if oral intake is tolerated, intravenous if IV access has been established, IM if oral intake is nottolerated and IV access has not been established. The oral preparation of dexamethasone (1 mg per mL) hasa foul taste. The intravenous preparation is more concentrated (4 mg per mL) and can be given orally mixedwith syrup [8,21­23]. A single dose of nebulized budesonide (as described below) is another option,particularly for children who are vomiting. (See "Croup: Pharmacologic and supportive interventions", sectionon 'Glucocorticoids'.)

For children with moderate stridor at rest and moderate retractions, or more severe symptoms, werecommend nebulized epinephrine in addition to dexamethasone:

Racemic epinephrine is administered as 0.05 mL/kg per dose (maximum of 0.5 mL) of a 2.25 percentsolution diluted to 3 mL total volume with normal saline. It is given via nebulizer over 15 minutes.

•

L­epinephrine is administered as 0.5 mL/kg per dose (maximum of 5 mL) of a 1:1000 dilution. It is givenvia nebulizer over 15 minutes.

•

Children who have received nebulized epinephrine and dexamethasone with good response should beobserved for at least three to four hours [24­27]. Croup symptoms usually improve within 30 minutes ofadministration of nebulized epinephrine [28,29] but may return to baseline as the effects of epinephrine wearoff (usually by two hours).

Children who received dexamethasone and remain symptomatic should be observed for at least four hoursbefore deciding whether they require hospital admission (as the effect of dexamethasone may not beapparent for several hours) [8].

Discharge to home — Many children with moderate/severe croup have symptomatic improvement after treatmentwith nebulized epinephrine and/or corticosteroids.

After three to four hours of observation, children who remain comfortable may be discharged home if they meet thefollowing criteria [24­27]:

Before discharge, follow­up with the primary care provider should be arranged within the next 24 hours.Instructions regarding home treatment should be provided. (See 'Home treatment' above.)

About 5 percent of children well enough for discharge from the emergency department after receivingcorticosteroids and nebulized epinephrine treatments may be expected to return for care. Relapse within 24 hoursis unlikely in those who have minimal symptoms at the time of discharge [30].

Hospitalization

Indications — Children with moderate/severe croup whose condition worsens or fails to improve as expectedafter treatment with nebulized epinephrine and corticosteroids should be admitted to the hospital for repeateddoses of nebulized epinephrine, observation, and supportive care. Poor response to nebulized epinephrine inconjunction with high fever and toxic appearance should prompt consideration of bacterial tracheitis (picture 1) [8].(See "Croup: Clinical features, evaluation, and diagnosis", section on 'Bacterial tracheitis' and "Bacterial tracheitisin children: Clinical features and diagnosis", section on 'Clinical features'.)

Additional factors that influence the decision regarding admission include [8,31]:

Interventions — Children who are admitted to the hospital should continue to be monitored for heart rate andoxygen saturation and to receive humidified oxygen as necessary. Capnography, if it is available, is a usefultechnique for monitoring ventilation if the child will tolerate nasal prongs. If the child is unable to tolerate oralintake, maintenance intravenous fluids should be administered.

Pharmacologic interventions for hospitalized patients may include nebulized epinephrine for persisting severerespiratory distress. Nebulized epinephrine can be repeated every 15 to 20 minutes, as described above. (See'Pharmacotherapy' above.)

However, children who require repeated doses of epinephrine (eg, three or more doses within two to three hours, or

No stridor at restNormal pulse oximetryGood air exchangeNormal colorNormal level of consciousnessDemonstrated ability to tolerate fluids by mouthCaregivers understand the indications for return to care and would be able to return if necessary

Need for supplemental oxygenModerate retractions and tachypnea, indicating increased work of breathing, which may lead to respiratoryfatigue and failure

Degree of response to initial therapies"Toxicity" or clinical picture suggesting serious secondary bacterial infectionPoor oral intake and degree of dehydrationYoung age, particularly younger than six monthsAbility of the family to comprehend the instructions regarding recognition of features that indicate the need toreturn for care

Ability of the family to return for care (eg, distance from home to care site, weather/travel conditions)Recurrent visits to the ED within 24 hours

ongoing administration more frequently than every one to two hours) should be admitted/transferred to an intensivecare unit or other setting where appropriately close monitoring can be accomplished.

Repeat doses of corticosteroids are not necessary on a routine basis and may have adverse effects. Moderate tosevere symptoms that persist for more than a few days should prompt investigation for other causes of airwayobstruction. (See "Croup: Clinical features, evaluation, and diagnosis", section on 'Differential diagnosis'.)

Infection control — Children who are admitted to the hospital with croup should be managed with contactprecautions (ie, gown and gloves for contact), particularly if parainfluenza or respiratory syncytial virus is thesuspected etiology. If influenza is suspected, droplet isolation measures (ie, respiratory mask within three feet)also should be followed. (See "General principles of infection control".)

Discharge criteria — Children who require hospital admission may be discharged when they meet thefollowing criteria:

FOLLOW­UP — Any patient who was admitted to the hospital, received nebulized epinephrine, or had a prolongedoutpatient visit should have follow­up scheduled with the primary care provider within 24 hours or as soon as canbe arranged. Although some children may continue to have mild to moderate symptoms at the time of follow­up,there are no studies that support the routine use of corticosteroid therapy beyond 24 hours.

Follow­up should continue until the child's symptoms have begun to resolve. The child who does not improve asexpected (over the course of approximately seven days) may have an underlying airway abnormality or may bedeveloping a complication of croup. Further evaluation, particularly with a radiograph of the soft tissues of theneck, or consultation with otolaryngology, may be warranted. (See "Croup: Clinical features, evaluation, anddiagnosis", section on 'Differential diagnosis'.)

PROGNOSIS — Symptoms of croup resolve in most children within three days but may persist for up to oneweek [32,33]. Less than 5 percent of children with croup require hospital admission [34], and among those, 1 to 6percent require intubation [14­17,35]. Mortality is rare, occurring in <0.5 percent of intubated children [36].

Complications — Complications of croup are uncommon. Children with moderate to severe croup are at risk forhypoxemia (oxygen saturation <92 percent in room air) and respiratory failure. Other complications includepulmonary edema, pneumothorax, and pneumomediastinum [37]. These complications can be anticipated andmanaged by aggressive monitoring and intervention in the medical setting. Out­of­hospital cardiac arrest and deathalso have been reported [38].

Secondary bacterial infections may arise from croup. Bacterial tracheitis, bronchopneumonia, and pneumoniaoccur in a small number of patients [10,15,33,39]. In most instances, the child has been relatively stable orbeginning to improve after several days of illness but then suddenly worsens, with higher or recurrent fever,increased (and potentially productive) cough, and/or respiratory distress. (See "Bacterial tracheitis in children:Clinical features and diagnosis", section on 'Clinical features' and "Community­acquired pneumonia in children:Clinical features and diagnosis", section on 'Clinical presentation'.)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, “The Basics” and“Beyond the Basics.” The Basics patient education pieces are written in plain language, at the 5 to 6 gradereading level, and they answer the four or five key questions a patient might have about a given condition. Thesearticles are best for patients who want a general overview and who prefer short, easy­to­read materials. Beyond

No stridor at restNormal pulse oximetryGood air exchangeNormal colorNormal level of consciousnessDemonstrated ability to tolerate fluids by mouth

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the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are writtenat the 10 to 12 grade reading level and are best for patients who want in­depth information and are comfortablewith some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e­mail thesetopics to your patients. (You can also locate patient education articles on a variety of subjects by searching on“patient info” and the keyword(s) of interest.)

SUMMARY AND RECOMMENDATIONS

Overview

Mild symptoms

Moderate to severe symptoms

Nebulized epinephrine can be repeated every 15 to 20 minutes. The administration of three or more doses within atwo­ to three­hour time period should prompt initiation of close cardiac monitoring if this is not already underway.

th th

Basics topics (see "Patient information: Croup (The Basics)")

Beyond the Basics topics (see "Patient information: Croup in infants and children (Beyond the Basics)")

Children with croup who should be seen in the office or emergency department include those who havestridor at rest, an abnormal airway, previous episodes of moderate to severe croup, underlying conditions thatmay predispose to respiratory failure, rapid progression of symptoms, inability to tolerate fluids, prolongedsymptoms, or an atypical course. (See 'Phone triage' above.)

Children with mild symptoms can be managed at home. Families should be instructed in provision ofsupportive care and indications to seek medical attention. (See 'Home treatment' above.)

We suggest that a single dose of oral dexamethasone (0.6 mg/kg) be used when electing to treat childrenwith mild croup who are seen in the outpatient setting (Grade 2A). (See 'Outpatient treatment' above and"Croup: Pharmacologic and supportive interventions", section on 'Dexamethasone'.)

Children with moderate croup should be evaluated in the office or emergency department, and those withsevere croup should be evaluated in the emergency department. Children with severe croup must beapproached cautiously, as any increase in anxiety may worsen airway obstruction. (See 'Moderate to severecroup' above.)

Supportive care for the child with moderate or severe croup includes administration of humidified air oroxygen as indicated by hypoxemia and/or respiratory distress, provision of intravenous fluids, and monitoringfor worsening respiratory distress. (See 'Supportive care' above and "Croup: Pharmacologic and supportiveinterventions", section on 'Mist therapy'.)

We recommend that children with moderate to severe croup who have moderate stridor at rest, moderateretractions, and/or more severe symptoms be treated with nebulized epinephrine (Grade 1A) in addition todexamethasone. (See 'Pharmacotherapy' above and "Croup: Pharmacologic and supportive interventions",section on 'Nebulized epinephrine'.)

Racemic epinephrine is administered as 0.05 mL/kg per dose (maximum of 0.5 mL) of a 2.25 percentsolution diluted to 3 mL total volume with normal saline. It is given via nebulizer over 15 minutes.

•

L­epinephrine is administered as 0.5 mL/kg per dose (maximum of 5 mL) of a 1:1000 dilution. It is givenvia nebulizer over 15 minutes.

•

We recommend that children with moderate to severe croup be treated with dexamethasone (0.6 mg/kg,maximum of 10 mg), by the least invasive route (Grade 1A). (See 'Pharmacotherapy' above and "Croup:

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Outcome

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REFERENCES

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Children with moderate to severe croup should be observed for three to four hours after intervention. Thosewho improve may be discharged home. (See 'Discharge to home' above.)

Children with moderate to severe croup whose condition worsens or fails to improve as expected aftertreatment with nebulized epinephrine and corticosteroids should be admitted to the hospital. (See'Hospitalization' above.)

We suggest not using repeated doses of corticosteroids. (Grade 2C). (See 'Hospitalization' above and"Croup: Pharmacologic and supportive interventions", section on 'Repeated dosing'.)

Other causes of upper airway obstruction should be investigated in children who have moderate to severesymptoms that persist for more than a few days. (See "Croup: Clinical features, evaluation, and diagnosis",section on 'Differential diagnosis'.)

Children who received nebulized epinephrine, had a prolonged outpatient visit, or were admitted to thehospital should have follow­up scheduled with the primary care provider within 24 hours of discharge or assoon as follow­up can be arranged. (See 'Follow­up' above.)

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epinephrine and dexamethasone in the emergency department. J Emerg Med 1998; 16:535.28. Waisman Y, Klein BL, Boenning DA, et al. Prospective randomized double­blind study comparing L­

epinephrine and racemic epinephrine aerosols in the treatment of laryngotracheitis (croup). Pediatrics 1992;89:302.

29. Fitzgerald D, Mellis C, Johnson M, et al. Nebulized budesonide is as effective as nebulized adrenaline inmoderately severe croup. Pediatrics 1996; 97:722.

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systematic review. BMJ 2013; 347:f7027.33. Cherry JD. Croup (laryngitis, laryngotracheitis, spasmodic croup, laryngotracheobronchitis, bacterial

tracheitis, and laryngotracheobronchopneumonitis) and epiglottitis (supraglottitis). In: Feigin and Cherry’sTextbook of Pediatric Infectious Diseases, 7th, Cherry JD, Harrison GJ, Kaplan SL, et al. (Eds), ElsevierSaunders, Philadelphia 2014. p.241.

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Pediatrics 1991; 87:847.37. Travis KW, Todres ID, Shannon DC. Pulmonary edema associated with croup and epiglottitis. Pediatrics

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39. Rosekrans JA. Viral croup: current diagnosis and treatment. Mayo Clin Proc 1998; 73:1102.

Topic 6004 Version 9.0

GRAPHICS

Bacterial tracheitis: Endoscopy

Note the adherent mucopurulent membranes within the trachea.

Courtesy of Glenn C Isaacson, MD, FAAP, FACS.

Graphic 55364 Version 2.0

Disclosures: Charles R Woods, MD, MS Other Financial Interest: Cerexa [Epiglottitis (Data SafetyMonitoring Board for pediatric trials of the antibiotic agent ceftaroline)]. Sheldon L Kaplan, MDGrant/Research/Clinical Trial Support: Pfizer [Pneumococcal surveillance studies (PCV13)]; Cubist [S.aureus skin and soft tissue infections (daptomycin pediatric studies)]; Optimer [fidaxomicin pediatricstudies]; Cerexa [ceftaroline pediatric studies]. Consultant/Advisory Boards: Pfizer [Pneumococcalsurveillance studies (PCV13)]. Carrie Armsby, MD, MPH Employee of UpToDate, Inc.Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these areaddressed by vetting through a multi­level review process, and through requirements for references to beprovided to support the content. Appropriately referenced content is required of all authors and mustconform to UpToDate standards of evidence.Conflict of interest policy

Disclosures