Croup: Approach to management
- Charles R Woods, MD, MS
Charles R Woods, MD, MS
- Professor of Pediatrics
- University of Louisville School of Medicine
- Section Editors
- Sheldon L Kaplan, MD
Sheldon L Kaplan, MD
- Editor-in-Chief — Pediatrics
- Section Editor — Pediatric Infectious Diseases
- Professor and Vice Chairman for Clinical Affairs
- Baylor College of Medicine
- Anna H Messner, MD
Anna H Messner, MD
- Section Editor — Pediatric Otolaryngology
- Professor of Otolaryngology/Head & Neck Surgery and Pediatrics
- Stanford University
Croup (laryngotracheitis) is a respiratory illness characterized by inspiratory stridor, barking cough, and hoarseness. It typically occurs in children six months to three years of age and is chiefly caused by parainfluenza virus. (See "Croup: Clinical features, evaluation, and diagnosis".)
Most children with croup who seek medical attention have a mild, self-limited illness and can be successfully managed as outpatients. The clinician must be able to identify children with mild symptoms, who can be safely managed at home, and those with moderate to severe croup or rapidly progressing symptoms, who require full evaluation and possible treatment in the office or emergency department setting. (See 'Severity assessment' below and 'Outpatient treatment' below.)
There is no definitive treatment for the viruses that cause croup. Pharmacologic therapy is directed toward decreasing airway edema, and supportive care is directed toward the provision of respiratory support and the maintenance of hydration. Corticosteroids and nebulized epinephrine are the cornerstones of therapy; their use is supported by substantial clinical evidence. (See 'Initial treatment' below and "Croup: Pharmacologic and supportive interventions".)
The approach to the management of croup will be discussed below. The clinical features and evaluation of croup, and the evidence supporting the use of the pharmacologic and supportive interventions included below are discussed separately. (See "Croup: Clinical features, evaluation, and diagnosis" and "Croup: Pharmacologic and supportive interventions".)
This initial step in the management of a child with croup is assessing severity of illness. The first contact with the healthcare system may occur by phone and the healthcare provider must be able to distinguish children with more severe symptoms who need immediate medical attention from those who can be managed at home. (See 'Telephone triage' below.)
- Westley CR, Cotton EK, Brooks JG. Nebulized racemic epinephrine by IPPB for the treatment of croup: a double-blind study. Am J Dis Child 1978; 132:484.
- Alberta Clinical Practice Guidelines Guideline Working Group. Guidelines for the diagnosis and management of croup. www.topalbertadoctors.org/download/252/croup_guideline.pdf (Accessed on March 13, 2015).
- Cherry JD. Clinical practice. Croup. N Engl J Med 2008; 358:384.
- Clarke M, Allaire J. An evidence-based approach to the evaluation and treatment of croup in children. Pediatric Emergency Medicine Practice 2012; 9:1.
- Fleisher G. Infectious disease emergencies. In: Textbook of Pediatric Emergency Medicine, 5th ed, Fleisher GR, Ludwig S, Henretig FM (Eds), Lippincott, Williams & Wilkins, Philadelphia 2006. p.783.
- Geelhoed GC, Turner J, Macdonald WB. Efficacy of a small single dose of oral dexamethasone for outpatient croup: a double blind placebo controlled clinical trial. BMJ 1996; 313:140.
- Bjornson CL, Klassen TP, Williamson J, et al. A randomized trial of a single dose of oral dexamethasone for mild croup. N Engl J Med 2004; 351:1306.
- Klassen TP, Craig WR, Moher D, et al. Nebulized budesonide and oral dexamethasone for treatment of croup: a randomized controlled trial. JAMA 1998; 279:1629.
- Paul RI. Oral dexamethasone for croup (commentary). AAP Grand Rounds 2004; 12:67.
- Duggan DE, Yeh KC, Matalia N, et al. Bioavailability of oral dexamethasone. Clin Pharmacol Ther 1975; 18:205.
- Johnson DW, Jacobson S, Edney PC, et al. A comparison of nebulized budesonide, intramuscular dexamethasone, and placebo for moderately severe croup. N Engl J Med 1998; 339:498.
- Russell KF, Liang Y, O'Gorman K, et al. Glucocorticoids for croup. Cochrane Database Syst Rev 2011; :CD001955.
- Bjornson C, Russell K, Vandermeer B, et al. Nebulized epinephrine for croup in children. Cochrane Database Syst Rev 2013; 10:CD006619.
- Prendergast M, Jones JS, Hartman D. Racemic epinephrine in the treatment of laryngotracheitis: can we identify children for outpatient therapy? Am J Emerg Med 1994; 12:613.
- Ledwith CA, Shea LM, Mauro RD. Safety and efficacy of nebulized racemic epinephrine in conjunction with oral dexamethasone and mist in the outpatient treatment of croup. Ann Emerg Med 1995; 25:331.
- Kunkel NC, Baker MD. Use of racemic epinephrine, dexamethasone, and mist in the outpatient management of croup. Pediatr Emerg Care 1996; 12:156.
- Rizos JD, DiGravio BE, Sehl MJ, Tallon JM. The disposition of children with croup treated with racemic epinephrine and dexamethasone in the emergency department. J Emerg Med 1998; 16:535.
- Waisman Y, Klein BL, Boenning DA, et al. Prospective randomized double-blind study comparing L-epinephrine and racemic epinephrine aerosols in the treatment of laryngotracheitis (croup). Pediatrics 1992; 89:302.
- Fitzgerald D, Mellis C, Johnson M, et al. Nebulized budesonide is as effective as nebulized adrenaline in moderately severe croup. Pediatrics 1996; 97:722.
- Rosychuk RJ, Klassen TP, Metes D, et al. Croup presentations to emergency departments in Alberta, Canada: a large population-based study. Pediatr Pulmonol 2010; 45:83.
- Brown JC. The management of croup. Br Med Bull 2002; 61:189.
- Petrocheilou A, Tanou K, Kalampouka E, et al. Viral croup: diagnosis and a treatment algorithm. Pediatr Pulmonol 2014; 49:421.
- Dobrovoljac M, Geelhoed GC. 27 years of croup: an update highlighting the effectiveness of 0.15 mg/kg of dexamethasone. Emerg Med Australas 2009; 21:309.
- Narayanan S, Funkhouser E. Inpatient hospitalizations for croup. Hosp Pediatr 2014; 4:88.
- Moore M, Little P. Humidified air inhalation for treating croup. Cochrane Database Syst Rev 2006; :CD002870.
- Moraa I, Sturman N, McGuire T, van Driel ML. Heliox for croup in children. Cochrane Database Syst Rev 2013; 12:CD006822.
- Thompson M, Vodicka TA, Blair PS, et al. Duration of symptoms of respiratory tract infections in children: systematic review. BMJ 2013; 347:f7027.
- Cherry JD. Croup (laryngitis, laryngotracheitis, spasmodic croup, laryngotracheobronchitis, bacterial tracheitis, and laryngotracheobronchopneumonitis) and epiglottitis (supraglottitis). In: Feigin and Cherry’s Textbook of Pediatric Infectious Diseases, 7th ed, Cherry JD, Harrison GJ, Kaplan SL, et al (Eds), Elsevier Saunders, Philadelphia 2014. p.241.
- Johnson D. Croup. Clin Evid 2005; :310.
- McEniery J, Gillis J, Kilham H, Benjamin B. Review of intubation in severe laryngotracheobronchitis. Pediatrics 1991; 87:847.
- Travis KW, Todres ID, Shannon DC. Pulmonary edema associated with croup and epiglottitis. Pediatrics 1977; 59:695.
- Fisher JD. Out-of-hospital cardiopulmonary arrest in children with croup. Pediatr Emerg Care 2004; 20:35.
- Sofer S, Dagan R, Tal A. The need for intubation in serious upper respiratory tract infection in pediatric patients (a retrospective study). Infection 1991; 19:131.
- Rosekrans JA. Viral croup: current diagnosis and treatment. Mayo Clin Proc 1998; 73:1102.
- Cooper T, Kuruvilla G, Persad R, El-Hakim H. Atypical croup: association with airway lesions, atopy, and esophagitis. Otolaryngol Head Neck Surg 2012; 147:209.
- Duval M, Tarasidis G, Grimmer JF, et al. Role of operative airway evaluation in children with recurrent croup: a retrospective cohort study. Clin Otolaryngol 2015; 40:227.
- Delany DR, Johnston DR. Role of direct laryngoscopy and bronchoscopy in recurrent croup. Otolaryngol Head Neck Surg 2015; 152:159.
- Rankin I, Wang SM, Waters A, et al. The management of recurrent croup in children. J Laryngol Otol 2013; 127:494.
- Jabbour N, Parker NP, Finkelstein M, et al. Incidence of operative endoscopy findings in recurrent croup. Otolaryngol Head Neck Surg 2011; 144:596.
- Chun R, Preciado DA, Zalzal GH, Shah RK. Utility of bronchoscopy for recurrent croup. Ann Otol Rhinol Laryngol 2009; 118:495.
- SEVERITY ASSESSMENT
- Telephone triage
- Croup severity score
- MILD CROUP
- Home treatment
- Outpatient treatment
- MODERATE TO SEVERE CROUP
- Setting and pace of treatment
- Initial treatment
- Observation and disposition
- - Discharge to home
- - Indications for hospital admission
- Inpatient management
- - Supportive care
- - Respiratory care
- - Repeated corticosteroid dosing
- - Monitoring
- - Infection control
- - Discharge criteria
- - Atypical course
- Recurrent symptoms
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS