Croup: Approach to management
- Charles R Woods, MD, MS
Charles R Woods, MD, MS
- Professor of Pediatrics
- University of Louisville School of Medicine
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 caused by parainfluenza virus. (See "Croup: Clinical features, evaluation, and diagnosis".)
The treatment of croup has changed significantly since the 1980s. Corticosteroids and nebulized epinephrine have become the cornerstones of therapy. Substantial clinical evidence supports the efficacy of these interventions [1-5]. The impact also is evident in the decrease in annual hospital admissions for croup in children in the United States between 1979 and 1982, and 1994 and 1997 (from 2.8 to 2.1 per 1000 for children <1 year and from 1.8 to 1.2 per 1000 children for children 1 to 4 years) .
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".)
The treatment of croup and the setting in which the child is initially evaluated depend upon the severity of symptoms and the presence of risk factors for rapid progression. 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. (See "Croup: Pharmacologic and supportive interventions".)
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.
- 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.
- Fogel JM, Berg IJ, Gerber MA, Sherter CB. Racemic epinephrine in the treatment of croup: nebulization alone versus nebulization with intermittent positive pressure breathing. J Pediatr 1982; 101:1028.
- Kairys SW, Olmstead EM, O'Connor GT. Steroid treatment of laryngotracheitis: a meta-analysis of the evidence from randomized trials. Pediatrics 1989; 83:683.
- 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.
- Klassen TP, Feldman ME, Watters LK, et al. Nebulized budesonide for children with mild-to-moderate croup. N Engl J Med 1994; 331:285.
- Counihan ME, Shay DK, Holman RC, et al. Human parainfluenza virus-associated hospitalizations among children less than five years of age in the United States. Pediatr Infect Dis J 2001; 20:646.
- Bjornson CL, Johnson DW. Croup. Lancet 2008; 371:329.
- Alberta Clinical Practice Guidelines Guideline Working Group. Guidelines to the diagnosis and management of croup. www.albertadoctors.org/bcm/ama/ama-website.nsf/AllDoc/87256DB000705C3F87256E05005534E2/$File/CROUP.PDF (Accessed on January 28, 2008).
- Cherry JD. Clinical practice. Croup. N Engl J Med 2008; 358:384.
- 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.
- Bhende MS. End-tidal carbon dioxide monitoring in pediatrics - clinical applications. J Postgrad Med 2001; 47:215.
- Sendi K, Crysdale WS, Yoo J. Tracheitis: outcome of 1,700 cases presenting to the emergency department during two years. J Otolaryngol 1992; 21:20.
- 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.
- Wagener JS, Landau LI, Olinsky A, Phelan PD. Management of children hospitalized for laryngotracheobronchitis. Pediatr Pulmonol 1986; 2:159.
- Tan AK, Manoukian JJ. Hospitalized croup (bacterial and viral): the role of rigid endoscopy. J Otolaryngol 1992; 21:48.
- Russell KF, Liang Y, O'Gorman K, et al. Glucocorticoids for croup. Cochrane Database Syst Rev 2011; :CD001955.
- Kristjánsson S, Berg-Kelly K, Winsö E. Inhalation of racemic adrenaline in the treatment of mild and moderately severe croup. Clinical symptom score and oxygen saturation measurements for evaluation of treatment effects. Acta Paediatr 1994; 83:1156.
- Taussig LM, Castro O, Beaudry PH, et al. Treatment of laryngotracheobronchitis (croup). Use of intermittent positive-pressure breathing and racemic epinephrine. Am J Dis Child 1975; 129:790.
- 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.
- 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.
- Brown JC. The management of croup. Br Med Bull 2002; 61:189.
- Kaditis AG, Wald ER. Viral croup: current diagnosis and treatment. Pediatr Infect Dis J 1998; 17:827.
- 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.
- Dawson KP, Mogridge N, Downward G. Severe acute laryngotracheitis in Christchurch 1980-90. N Z Med J 1991; 104:374.
- 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.
- Rosekrans JA. Viral croup: current diagnosis and treatment. Mayo Clin Proc 1998; 73:1102.
- Severity assessment
- - Westley croup score
- - Respiratory failure
- PHONE TRIAGE
- MILD CROUP
- Home treatment
- Outpatient treatment
- MODERATE TO SEVERE CROUP
- Supportive care
- - Monitoring
- - Fluids
- - Intubation
- Discharge to home
- - Indications
- - Interventions
- - Infection control
- - Discharge criteria
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS
- Mild symptoms
- Moderate to severe symptoms