Diagnosis and Management of Croup

Summary of the Alberta Clinical Practice Guideline, March 2003

Diagnosis The characteristic clinical features of a child with croup are a seal-like barky cough, hoarseness, and
often include fever, irritability, stridor and chest wall indrawing of varying severity. Children with croup
should not drool or appear toxic.
FEATURES SUGGESTING A DIFFERENT DIAGNOSIS
High fever, toxic appearance, and poor response to epinephrine suggest bacterial tracheitis
Sudden onset of symptoms with high fever, absence of barky cough, dysphagia, drooling, anxious appearance, and sitting
forward in sniffng position suggest epiglottitis
Other potential causes of stridor which are rare but should be considered include foreign body lodged in upper esopha-
gus, retropharyngeal abcess, and hereditary angioedema
The vast majority of children with croup can be diagnosed based on a careful history and physical
examination, and do not require either laboratory or radiological assesssment to accurately establish a
diagnosis.
1,2

Make children with croup comfortable and avoid agitating with unnecessary procedures. Provide blow-by
oxygen to children in respiratory distress.
Also administer epinephrine

via nebulization to children with severe respiratory distress (as evidenced
by sternal wall indrawing and agitation).
3
Administer one oral dose of dexamethasone to all children diagnosed with croup. Consider nebulized
budesonide in children who are too sick to tolerate oral administration of medications.
4
Antibiotics, sedatives and oral decongestants are not recommended.
Mist tents, wanes, or steamers should not be used.
Admit children who have signifcant respiratory compromise (sternal wall indrawing, easily audible
stridor at rest) persisting 4 or more hours after corticosteroid administration. Consider admission if sig-
nifcant parental anxiety exists; if the parents have brought the child to the ED repeatedly for croup
symptoms; if the childs family resides a long distance from hospital or has inadequate transportation;
or if there are other reasons that might result in inadequate follow-up.
Children admitted to hopsital should have frequent monitoring of their respiratory status. Intravenous
fuids are usually only required in children with severe respiratory distress. Administer epinephrine if
severe respiratory distress reoccurs. Contact the closest pediatric intensive care unit if epineprhine is
administered more than every two hours.
Intubation may be necessary in a small number of hospitalized patients. Cardiopulmonary arrest can occur
in patients not adequately monitored and managed. Bacterial tracheitis can cause precipitous deterioration.
Pneumonia is a rare complication.
The majority of children can be managed as outpatients. Children may be safely discharged home if they
have not been treated with epinephrine in the past two hours, they do not have stridor at rest, they do not
have signifcant chest wall indrawing, and the parent or caregiver can easily return for care if respiratory
distress reoccurs at home.
Provide parents/caregivers with written instructions and provide advice on when to return for medical care.
Most children with croup do not require specifc follow-up. Follow-up with a primary care provider should
occur in patients who have had stridor > 1 week.
Investigations

ED Care
(for drug
dosages see
over)
Admissions
Complications

Discharge
Supportive Care
Follow-up
Notes:
1. If laboratory tests are obtained, they should be deferred while patient is in respiratory distress and should be well justifed.
2. Lateral and anteroposterior (AP) soft tissue neck flm may be helpful in establishing an alternative diagnosis in patients with atypical disease.
3. Administration of epinephrine does not mandate admission to hospital.
4.. Although nebulized budesonide has been shown to be equivalent to oral dexamethasone, it is substantially more expensive. Potential exceptions include a
child who has persistent vomiting or a child with severe respiratory distress.
Administered by the Alberta
Medical Association
For complete guideline refer to the TOP Website: www.topalbertadoctors.org
July 2003
Reviewed January 2008
2008 Update
ALGORITHM: CROUP IN THE OUT-PATIENT SETTING
Based on severity at time of initial assessment
MILD
(without stridor or signifcant
chest wall indrawing at rest)
MODERATE
(stridor and chest wall indrawing
at rest without agitation)
SEVERE
(stridor and indrawing of the
sternum associated with
agitation or lethargy)
Give oral dexamethasone
0.6mg/kg of body weight
Educate parents
- Anticipated course of illness
- Signs of respiratory distress
- When to seek medical
assessment
Minimize intervention
Place child on parents lap
Provide position of comfort
Give oral dexamethasone
0.6mg/kg of body weight
Observe for improvement
Patient improves as evidenced
by no longer having:
- Chest wall indrawing
- Stridor at rest
Educate parents (as for mild
croup)
Discharge home
May discharge home without
further observation
Minimize intervention (as for
moderate croup)
Provide blow- by oxygen
(optional unless cyanosis is
present)
Nebulize epinephrine
- Racemic epinephrine 2.25%
(0.5 mL in 2.5 mL saline)
or
- L-epinephrine 1:1,000 (5ml)
Give oral dexamethasone
(0.6 mg/kg of body weight);
may repeat once
- If vomiting, consider
administering budesonide
(2mg) nebulized with
epinephrine
- If too distressed to take
oral medication, consider
administering budesonide
(2mg) nebulized with
epinephrine
Poor response to nebulized
epinephrine
Good response to nebulized
epinephrine
Observe for 2 hours?
Repeat nebulized epinephrine
Contact pediatric ICU for
further management
Persistent mild symptoms.
No recurrences of:
- Chest wall indrawing
- Stridor at rest
Provide education (as for mild
croup)
Discharge Home
Reocurrence of severe respira-
tory distress:
Repeat nebulized epinephrine
If good response continue to
observe
* Consider hospitalization (general ward) if:
Received steroid 4 hours ago
Continued moderate respiratory distress (without agitation or lethargy)
- Stridor at rest
- Chest wall indrawing
(If the patient has recurrent severe episodes of agitation or lethargy
contact pediatric ICU)
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No or minimal improve-
ment by 4 hours,
consider hospitalization
(see below)*
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