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Clinical Practice Guidelines

Croup (Laryngotracheobronchitis)

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    PIC Endorsed

  • See also

    Acute upper airway obstruction 
    Inhaled foreign body

    Key Points

    1. Minimise distress to the child, as this can worsen upper airway obstruction. Note: Swabbing for COVID-19 or other viruses should not be performed until deemed safe to do so by a senior clinician
    2. Consider early transfer and involvement of senior staff if concerns regarding worsening upper airway obstruction
    3. For severe and life-threatening croup, use nebulised adrenaline
    4. Less severe cases can be managed with corticosteroids alone

    Background

    • Croup is inflammation of the upper airway, larynx and trachea, usually triggered by a virus
    • Occurs generally between the ages of 6 months and 6 years
    • Often worse at night
    • Alternative diagnoses include: bacterial tracheitis, inhaled foreign body, anaphylaxis. See Acute upper airway obstruction

    Assessment

    Children with croup should have minimal examination so as not to upset them further. Throat examination is rarely required

    Examination

    • Barking cough
    • Inspiratory stridor
    • Hoarse voice
    • May have associated widespread wheeze
    • Increased work of breathing
    • May have fever, but no signs of toxicity

    Risk factors for severe croup include:

    • pre-existing narrowing of upper airways
    • previous admissions with severe croup
    • young age: uncommon <6 months old, rare <3 months of age. Consider alternative diagnosis and causes of upper airway obstruction

    Assessment of severity

       Mild    Moderate    Severe
    Behaviour Normal  Intermittent mild agitation Increasing agitation, drowsiness
    Stridor* No stridor, or only when active or upset Intermittent stridor at rest Persistent stridor at rest
    Respiratory Rate Normal Increased respiratory rate  Marked increase or decrease
    Accessory Muscle Use None or minimal  Moderate chest wall retraction  Marked chest wall retraction
    Oxygen saturations** Hypoxia is a late sign which indicates life-threatening croup 

    * Loudness of stridor is not a good indicator of severity of obstruction. Soft stridor in the presence of worsening clinical picture may be a sign of imminent airway obstruction

    ** It is not necessary to measure oxygen saturations in children with mild to moderate croup 

    Management

    Investigations

    No investigations are needed in croup (including nasopharyngeal aspirate, X-rays and blood tests) and they may cause distress to the child and worsening of symptoms  

    Treatment

    • Minimal handling to avoid worsening symptoms — limited examination
    • Keep children with carers to reduce distress
    • Children will adopt a position of comfort that minimises airway obstruction, do not change this
    • Treat mild croup with steroids alone. Barking cough with no other symptoms does not always require steroids
    • Moderate croup is usually managed with steroids alone, consider adrenaline if persistent or worsening symptoms
    • Severe croup requires nebulised adrenaline and steroids. See flowchart
    • Supplemental oxygen is not usually required. If needed, treat for severe upper airway obstruction
    • Defer intravenous (IV) access
    • Consider a longer period of observation than 4 hours for a child who:
      • presents overnight
      • lives far from medical care
      • presents with stridor more than once during the same illness
      • has risk factors for severe croup

    croup

    * Consider nebulised Budesonide 2mg if oral corticosteroids not tolerated

    Consider consultation with local paediatric team when

    • Severe airway obstruction present
    • Child has risk factors or an atypical presentation
    • Child <3 months of age
    • No improvement with nebulised adrenaline

    Consider transfer when

    • No improvement following nebulised adrenaline
    • Child requiring repeated doses of nebulised adrenaline
    • Child requiring care above the level of comfort of the local hospital

    For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services

    Consider discharge when

    Stridor free at rest 

    AND

    • minimum of 4 hours post nebulised adrenaline (if this has been required)
      or 
    • 30 minutes post dose of oral steroids (and adrenaline not required)

    Parents should be advised to seek medical attention if recurrence of stridor at rest despite having received oral steroids     

    Parent information

    Kids Health Info 
    Croup

    Additional notes

    • Antibiotics have no role in uncomplicated croup as it has a viral aetiology
    • Anti-tussives such has codeine, have no proven effect on the course or severity of croup, and may cause respiratory depression and increase sedation
    • Humidified air has not been proven to change the severity of croup 
    • Heliox has not been shown to be better than nebulised adrenaline in severe croup

    Last updated May 2020 

  • Reference List

    1. Amir, L., Hubermann, H., Halevi, A., Mor, M., Mimouni, M., Waisman, Y., 2006. Oral betamethasone versus intramuscular dexamethasone for the treatment of mild to moderate viral croup: a prospective, randomized trial. Pediatr. Emerg. Care 22, 541–544. https://doi.org/10.1097/01.pec.0000230552.63799.32
    2. Argent, A.C., Hatherill, M., Newth, C.J.L., Klein, M., 2008. The effect of epinephrine by nebulization on measures of airway obstruction in patients with acute severe croup. Intensive Care Med. 34, 138–147. https://doi.org/10.1007/s00134-007-0855-0
    3. Atkinson, P.R.T., Boyle, A.A., Lennon, R.S.P., 2014. Weather factors associated with paediatric croup presentations to an Australian emergency department. Emerg. Med. J. EMJ 31, 160–162. https://doi.org/10.1136/emermed-2012-201876
    4. Bjornson, C., Russell, K., Vandermeer, B., Klassen, T.P., Johnson, D.W., 2013. Nebulized epinephrine for croup in children. Cochrane Database Syst. Rev. CD006619. https://doi.org/10.1002/14651858.CD006619.pub3
    5. Bjornson, C.L., Johnson, D.W., 2008. Croup. The Lancet 371, 329–339. https://doi.org/10.1016/S0140-6736(08)60170-1
    6. Bjornson, C.L., Klassen, T.P., Williamson, J., Brant, R., Mitton, C., Plint, A., Bulloch, B., Evered, L., Johnson, D.W., 2004. A Randomized Trial of a Single Dose of Oral Dexamethasone for Mild Croup. N. Engl. J. Med. 351, 1306–1313. https://doi.org/10.1056/NEJMoa033534
    7. Cetinkaya, F., Tüfekçi, B.S., Kutluk, G., 2004. A comparison of nebulized budesonide, and intramuscular, and oral dexamethasone for treatment of croup. Int. J. Pediatr. Otorhinolaryngol. 68, 453–456. https://doi.org/10.1016/j.ijporl.2003.11.017
    8. Charles, J., Britt, H., Fahridin, S., 2010. Croup. Aust. Fam. Physician 39, 269.
    9. Cherry, J.D., 2008. Croup. N. Engl. J. Med. 358, 384–391. https://doi.org/10.1056/NEJMcp072022
    10. Chub-Uppakarn, S., Sangsupawanich, P., 2007. A randomized comparison of dexamethasone 0.15 mg/kg versus 0.6 mg/kg for the treatment of moderate to severe croup. Int. J. Pediatr. Otorhinolaryngol. 71, 473–477. https://doi.org/10.1016/j.ijporl.2006.11.016
    11. Corfield, A., Teece, S., 2003. Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. Type of oral cortiosteroid in mild to moderate croup. Emerg. Med. J. EMJ 20, 264.
    12. Dobrovoljac, M., Geelhoed, G.C., 2012. How fast does oral dexamethasone work in mild to moderately severe croup? A randomized double-blinded clinical trial. Emerg. Med. Australas. EMA 24, 79–85. https://doi.org/10.1111/j.1742-6723.2011.01475.x
    13. Dobrovoljac, M., Geelhoed, G.C., 2009. 27 years of croup: an update highlighting the effectiveness of 0.15 mg/kg of dexamethasone. Emerg. Med. Australas. EMA 21, 309–314. https://doi.org/10.1111/j.1742-6723.2009.01202.x
    14. Donaldson, D., Poleski, D., Knipple, E., Filips, K., Reetz, L., Pascual, R.G., Jackson, R.E., 2003. Intramuscular versus oral dexamethasone for the treatment of moderate-to-severe croup: a randomized, double-blind trial. Acad. Emerg. Med. Off. J. Soc. Acad. Emerg. Med. 10, 16–21.
    15. Duman, M., Ozdemir, D., Atasever, S., 2005. Nebulised L-epinephrine and steroid combination in the treatment of moderate to severe croup. Clin. Drug Investig. 25, 183–189.
    16. Eboriadou, M., Chryssanthopoulou, D., Stamoulis, P., Damianidou, L., Haidopoulou, K., 2010. The effectiveness of local corticosteroids therapy in the management of mild to moderate viral croup. Minerva Pediatr. 62, 23–28.
    17. Eghbali, A., Sabbagh, A., Bagheri, B., Taherahmadi, H., Kahbazi, M., 2016. Efficacy of nebulized L-epinephrine for treatment of croup: a randomized, double-blind study. Fundam. Clin. Pharmacol. 30, 70–75. https://doi.org/10.1111/fcp.12158
    18. Faraji-Goodarzi, M., Taee, N., Mohammadi-Kamalvand, M., 2018. Comparison of the Effect of Cold Drink and Dexamethasone, and their Combined Effect on Children with Croup. Drug Res. 68, 185–188. https://doi.org/10.1055/s-0043-118537
    19. Fifoot, A.A., Ting, J.Y., 2007. Comparison between single-dose oral prednisolone and oral dexamethasone in the treatment of croup: a randomized, double-blinded clinical trial. Emerg. Med. Australas. EMA 19, 51–58. https://doi.org/10.1111/j.1742-6723.2006.00919.x
    20. Garbutt, J.M., Conlon, B., Sterkel, R., Baty, J., Schechtman, K.B., Mandrell, K., Leege, E., Gentry, S., Stunk, R.C., 2013. The comparative effectiveness of prednisolone and dexamethasone for children with croup: a community-based randomized trial. Clin. Pediatr. (Phila.) 52, 1014–1021. https://doi.org/10.1177/0009922813504823
    21. Gates, A., Gates, M., Vandermeer, B., Johnson, C., Hartling, L., Johnson, D.W., Klassen, T.P., 2018. Glucocorticoids for croup in children. Cochrane Database Syst. Rev. https://doi.org/10.1002/14651858.CD001955.pub4
    22. Geelhoed, G.C., 2005. Budesonide offers no advantage when added to oral dexamethasone in the treatment of croup. Pediatr. Emerg. Care 21, 359–362.
    23. Geelhoed G.C, Macdonald, W.B.,1995. Oral dexamethasone in the treatment of croup: 0.15mg/kg versus 0.3mg/kg versus 0.6mg/kg. Pediatr Pulmonol.20, 362-368
    24. Gelbart, B., Parsons, S., Sarpal, A., Ninova, P., Butt, W., 2016. Intensive care management of children intubated for croup: a retrospective analysis. Anaesth. Intensive Care 44, 245–250.
    25. Gupta, V.K., Cheifetz, I.M., 2005. Heliox administration in the pediatric intensive care unit: an evidence-based review. Pediatr. Crit. Care Med. J. Soc. Crit. Care Med. World Fed. Pediatr. Intensive Crit. Care Soc. 6, 204–211. https://doi.org/10.1097/01.PCC.0000154946.62733.94
    26. Hansen, M., Meckler, G., Lambert, W., Dickinson, C., Dickinson, K., Guise, J.-M., 2016. Paramedic assessment and treatment of upper airway obstruction in pediatric patients: an exploratory analysis by the Children’s Safety Initiative-Emergency Medical Services. Am. J. Emerg. Med. 34, 599–601. https://doi.org/10.1016/j.ajem.2015.12.082
    27. Hiebert, J.C., Zhao, Y.D., Willis, E.B., 2016. Bronchoscopy findings in recurrent croup: A systematic review and meta-analysis. Int. J. Pediatr. Otorhinolaryngol. 90, 86–90. https://doi.org/10.1016/j.ijporl.2016.09.003
    28. Hoa, M., Kingsley, E.L., Coticchia, J.M., 2008. Correlating the clinical course of recurrent croup with endoscopic findings: a retrospective observational study. Ann. Otol. Rhinol. Laryngol. 117, 464–469. https://doi.org/10.1177/000348940811700610
    29. Hodnett, B.L., Simons, J.P., Riera, K.M., Mehta, D.K., Maguire, R.C., 2015. Objective endoscopic findings in patients with recurrent croup: 10-year retrospective analysis. Int. J. Pediatr. Otorhinolaryngol. 79, 2343–2347. https://doi.org/10.1016/j.ijporl.2015.10.039
    30. Johnson, D.W., 2009. Croup. BMJ Clin. Evid. 2009.
    31. Kawaguchi, A., Joffe, A., 2015. Evidence for Clinicians: Nebulized epinephrine for croup in children. Paediatr. Child Health 20, 19–20.
    32. Klassen, T.P., Craig, W.R., Moher, D., Osmond, M.H., Pasterkamp, H., Sutcliffe, T., Watters, L.K., Rowe, P.C., 1998. Nebulized budesonide and oral dexamethasone for treatment of croup: a randomized controlled trial. JAMA 279, 1629–1632.
    33. Kline-Krammes, S., Reed, C., Giuliano, J.S., Schwartz, H.P., Forbes, M., Pope, J., Besunder, J., Gothard, M.D., Russell, K., Bigham, M.T., 2012. Heliox in children with croup: a strategy to hasten improvement. Air Med. J. 31, 131–137. https://doi.org/10.1016/j.amj.2011.08.004
    34. Knapp, J.F., Hall, M., Sharma, V., 2010. Benchmarks for the emergency department care of children with asthma, bronchiolitis, and croup. Pediatr. Emerg. Care 26, 364–369. https://doi.org/10.1097/PEC.0b013e3181db2262
    35. Kwong, K., Hoa, M., Coticchia, J.M., 2007. Recurrent croup presentation, diagnosis, and management. Am. J. Otolaryngol. 28, 401–407. https://doi.org/10.1016/j.amjoto.2006.11.013
    36. Leung, K., Newth, C.J.L., Hotz, J.C., O’Brien, K.C., Fink, J.B., Coates, A.L., 2016. Delivery of Epinephrine in the Vapor Phase for the Treatment of Croup. Pediatr. Crit. Care Med. J. Soc. Crit. Care Med. World Fed. Pediatr. Intensive Crit. Care Soc. 17, e177-181. https://doi.org/10.1097/PCC.0000000000000666
    37. Lin, S.-C., Lin, H.-W., Chiang, B.-L., 2017. Association of croup with asthma in children. Medicine (Baltimore) 96. https://doi.org/10.1097/MD.0000000000007667
    38. Mazza, D., Wilkinson, F., Turner, T., Harris, C., Health for Kids Guideline Development Group, 2008. Evidence based guideline for the management of croup. Aust. Fam. Physician 37, 14–20.
    39. Moore, M., Little, P., 2006. Humidified air inhalation for treating croup. Cochrane Database Syst. Rev. CD002870. https://doi.org/10.1002/14651858.CD002870.pub2
    40. Moraa, I., Sturman, N., McGuire, T., van Driel, M.L., 2013. Heliox for croup in children. Cochrane Database Syst. Rev. CD006822. https://doi.org/10.1002/14651858.CD006822.pub4
    41. Muñoz-Osores, E., Arenas, D., 2017. What is the effectiveness of systemic corticosteroids in children with croup? Medwave 17, e6965.
    42. Narayanan, S., Funkhouser, E., 2014. Inpatient hospitalizations for croup. Hosp. Pediatr. 4, 88–92. https://doi.org/10.1542/hpeds.2013-0066
    43. Ortiz-Alvarez, O., 2017. Acute management of croup in the emergency department. Paediatr. Child Health 22, 166–169. https://doi.org/10.1093/pch/pxx019
    44. Port, C., 2009. Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. BET 4. Dose of dexamethasone in croup. Emerg. Med. J. EMJ 26, 291–292. https://doi.org/10.1136/emj.2009.072090
    45. Rajapaksa, S., Starr, M., 2010. Croup - assessment and management. Aust. Fam. Physician 39, 280–282.
    46. Rankin, I., Wang, S.M., Waters, A., Clement, W.A., Kubba, H., 2013. The management of recurrent croup in children. J. Laryngol. Otol. 127, 494–500. https://doi.org/10.1017/S0022215113000418
    47. Rosychuk, R.J., Klassen, T.P., Metes, D., Voaklander, D.C., Senthilselvan, A., Rowe, B.H., 2010. Croup presentations to emergency departments in Alberta, Canada: a large population-based study. Pediatr. Pulmonol. 45, 83–91. https://doi.org/10.1002/ppul.21162
    48. Rosychuk, R.J., Klassen, T.P., Voaklander, D.C., Senthilselvan, A., Rowe, B.H., 2011. Seasonality patterns in croup presentations to emergency departments in Alberta, Canada: a time series analysis. Pediatr. Emerg. Care 27, 256–260. https://doi.org/10.1097/PEC.0b013e31821314b0
    49. Russell, K.F., Liang, Y., O’Gorman, K., Johnson, D.W., Klassen, T.P., 2011. Glucocorticoids for croup. Cochrane Database Syst. Rev. CD001955. https://doi.org/10.1002/14651858.CD001955.pub3
    50. Scolnik, D., Coates, A.L., Stephens, D., Da Silva, Z., Lavine, E., Schuh, S., 2006. Controlled delivery of high vs low humidity vs mist therapy for croup in emergency departments: a randomized controlled trial. JAMA 295, 1274–1280. https://doi.org/10.1001/jama.295.11.1274
    51. Sharma, B.S., Shekhawat, D.S., Sharma, P., Meena, C., Mohan, H., 2015. Acute Respiratory Distress in Children: Croup and Acute Asthma. Indian J. Pediatr. 82, 629–636. https://doi.org/10.1007/s12098-014-1559-4
    52. Smith, N., Giordano, K., Thompson, A., DePiero, A., 2018. Failure of Outpatient Management With Different Observation Times After Racemic Epinephrine for Croup. Clin. Pediatr. (Phila.) 57, 706–710. https://doi.org/10.1177/0009922817737075
    53. Sparrow, A., Geelhoed, G., 2006. Prednisolone versus dexamethasone in croup: a randomised equivalence trial. Arch. Dis. Child. 91, 580–583. https://doi.org/10.1136/adc.2005.089516
    54. Tibballs, J., Watson, T., 2011. Symptoms and signs differentiating croup and epiglottitis. J. Paediatr. Child Health 47, 77–82. https://doi.org/10.1111/j.1440-1754.2010.01892.x
    55. Tyler, A., McLeod, L., Beaty, B., Juarez-Colunga, E., Birkholz, M., Hyman, D., Kempe, A., Todd, J., Dempsey, A.F., 2017. Variation in Inpatient Croup Management and Outcomes. Pediatrics 139. https://doi.org/10.1542/peds.2016-3582
    56. Wright, M., Bush, A., 2016. Assessment and management of viral croup in children: Viral croup. Prescriber 27, 32–37. https://doi.org/10.1002/psb.1490
    57. Wright, R.B., Rowe, B.H., Arent, R.J., Klassen, T.P., 2005. Current pharmacological options in the treatment of croup. Expert Opin. Pharmacother. 6, 255–261. https://doi.org/10.1517/14656566.6.2.255
    58. Yang, W.-C., Lee, J., Chen, C.-Y., Chang, Y.-J., Wu, H.-P., 2017. Westley score and clinical factors in predicting the outcome of croup in the pediatric emergency department. Pediatr. Pulmonol. 52, 1329–1334. https://doi.org/10.1002/ppul.23738