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This article is about the respiratory condition. For the part of a quadruped, see rump (animal). For
the crop of a bird, see crop (anatomy). For the type of casino employee, see croupier.


The steeple sign as seen on an AP neck X-ray of a child with croup

Classification and external resources












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Patient UK




Croup (or laryngotracheobronchitis) is a respiratory condition that is usually triggered by an acute

viral infection of the upper airway. The infection leads to swelling inside the throat, which interferes
with normal breathing and produces the classical symptoms of a "barking" cough, stridor,
and hoarseness. It may produce mild, moderate, or severe symptoms, which often worsen at night. It
is often treated with a single dose of oral steroids; occasionally inhaled epinephrine is used in more
severe cases. Hospitalization is rarely required.
Croup is diagnosed on clinical grounds, once potentially more severe causes of symptoms have
been excluded (i.e. epiglottitis or anairway foreign body). Further investigationssuch as blood
tests, X-rays, and culturesare usually not needed. It is a relatively common condition that affects
about 15% of children at some point, most commonly between 6 months and 56 years of age. It is
almost never seen in teenagers or adults.
Before the advent of vaccination, croup was frequently caused by diphtheria, and was often fatal.
This cause is now a historical one in the Western world due to the success of the diphtheria
vaccine and improved hygiene and living standards.[1]

1 Signs and symptoms

2 Causes

2.1 Viral

2.2 Bacterial

3 Pathophysiology

4 Diagnosis

4.1 Severity

5 Prevention

6 Treatment

6.1 Steroids

6.2 Epinephrine

6.3 Other

7 Prognosis

8 Epidemiology

9 History

10 References

11 External links

Signs and symptoms[edit]



Inspiratory and expiratory

stridor in a 13-month child
with croup.

Problems playing this file? See media help.

Croup is characterized by a "barking" cough, stridor, hoarseness, and difficulty breathing which
usually worsens at night.[2] The "barking" cough is often described as resembling the call of
a seal or sea lion.[3] The stridor is worsened by agitation or crying, and if it can be heard at rest, it
may indicate critical narrowing of the airways. As croup worsens, stridor may decrease considerably.

Other symptoms include fever, coryza (symptoms typical of the common cold), and chest
wall indrawing.[2][4] Drooling or a very sick appearance indicate other medical conditions.[4]

Croup is usually deemed to be due to a viral infection.[2][5] Others use the term more broadly, to
include acute laryngotracheitis, spasmodic croup, laryngeal diphtheria, bacterial tracheitis,
laryngotracheobronchitis, and laryngotracheobronchopneumonitis. The first two conditions involve a
viral infection and are generally milder with respect to symptomatology; the last four are due to
bacterial infection and are usually of greater severity.[3]

Viral croup or acute laryngotracheitis is caused by parainfluenza virus, primarily types 1 and 2, in
75% of cases.[6] Other viral causes include influenza A and B, measles,adenovirus and respiratory
syncytial virus (RSV).[3] Spasmodic croup is caused by the same group of viruses as acute
laryngotracheitis, but lacks the usual signs of infection (such as fever, sore throat, and
increased white blood cell count).[3] Treatment, and response to treatment, are also similar.[6]


Bacterial croup may be divided into laryngeal diphtheria, bacterial tracheitis,

laryngotracheobronchitis, and laryngotracheobronchopneumonitis. [3] Laryngeal diphtheria is due
toCorynebacterium diphtheriae while bacterial tracheitis, laryngotracheobronchitis, and
laryngotracheobronchopneumonitis are usually due to a primary viral infection with secondary
bacterial growth. The most common bacteria implicated are Staphylococcus aureus, Streptococcus
pneumoniae, Hemophilus influenzae, and Moraxella catarrhalis.[3]

The viral infection that causes croup leads to swelling of the larynx, trachea, and large bronchi[5] due
to infiltration of white blood cells (especially histiocytes, lymphocytes, plasma cells, and neutrophils).
Swelling produces airway obstruction which, when significant, leads to dramatically increased work
of breathing and the characteristic turbulent, noisy airflow known as stridor.[5]

The Westley Score: Classification of croup severity[6][7]

Number of points assigned for this feature


Chest wall








At rest



Level of


Air entry



At rest



Markedly decreased

Croup is a clinical diagnosis.[5] The first step is to exclude other obstructive conditions of the upper
airway, especiallyepiglottitis, an airway foreign body, subglottic
stenosis,angioedema, retropharyngeal abscess, and bacterial tracheitis.[3][5]

A frontal X-ray of the neck is not routinely performed,[5] but if it is done, it may show a characteristic
narrowing of the trachea, called the steeple sign, because of the subglottic stenosis, which is similar
to a steeple in shape. The steeple sign is suggestive of the diagnosis, but is absent in half of cases. [4]
Other investigations (such as blood tests and viral culture) are discouraged, as they may cause
unnecessary agitation and thus worsen the stress on the compromised airway.[5] While viral cultures,
obtained via nasopharyngeal aspiration, can be used to confirm the exact cause, these are usually
restricted to research settings.[2] Bacterial infection should be considered if a person does not
improve with standard treatment, at which point further investigations may be indicated. [3]

The most commonly used system for classifying the severity of croup is the Westley score. It is
primarily used for research purposes rather than in clinical practice. [3] It is the sum of points assigned
for five factors: level of consciousness, cyanosis, stridor, air entry, and retractions. [3] The points given
for each factor is listed in the table to the right, and the final score ranges from 0 to 17. [7]

A total score of 2 indicates mild croup. The characteristic barking

cough and hoarseness may be present, but there is no stridor at

A total score of 35 is classified as moderate croup. It presents with

easily heard stridor, but with few other signs.[6]

A total score of 611 is severe croup. It also presents with obvious

stridor, but also features marked chest wall indrawing.[6]

A total score of 12 indicates impending respiratory failure. The

barking cough and stridor may no longer be prominent at this stage.

85% of children presenting to the emergency department have mild disease; severe croup is rare

Many cases of croup have been prevented by immunization for influenza and diphtheria.[3] At one
time, croup referred to a diphtherial disease, but with vaccination, diphtheria is now rare in the
developed world.[3]

Children with croup are generally kept as calm as possible.[5] Steroids are given routinely,
with epinephrine used in severe cases.[5] Children with oxygen saturations under 92% should receive
oxygen,[3] and those with severe croup may be hospitalized for observation.[4] If oxygen is needed,
"blow-by" administration (holding an oxygen source near the child's face) is recommended, as it
causes less agitation than use of a mask.[3] With treatment, less than 0.2% of people
require endotracheal intubation.[7]

Corticosteroids, such as dexamethasone and budesonide, have been shown to improve outcomes in
children with all severities of croup.[8] Significant relief is obtained as early as six hours after
administration.[8] While effective when given orally, parenterally, or by inhalation, the oral route is

preferred.[5] A single dose is usually all that is required, and is generally considered to be quite safe.
Dexamethasone at doses of 0.15, 0.3 and 0.6 mg/kg appear to be all equally effective.[9]

Moderate to severe croup may be improved temporarily with nebulized epinephrine.[5] While
epinephrine typically produces a reduction in croup severity within 1030 minutes, the benefits last
for only about 2 hours.[2][5] If the condition remains improved for 24 hours after treatment and no
other complications arise, the child is typically discharged from the hospital. [2][5]

While other treatments for croup have been studied, none have sufficient evidence to support their
use. Inhalation of hot steam or humidified air is a traditional self-caretreatment, but clinical studies
have failed to show effectiveness[3][5] and currently it is rarely used.[10] The use of cough medicines,
which usually contain dextromethorphan and/orguiafenesin, are also discouraged.[2] While
breathing heliox (a mixture of helium and oxygen) to decrease the work of breathing has been used
in the past, there is very little evidence to support its use.[11] Since croup is usually a viral
disease, antibiotics are not used unless secondary bacterial infection is suspected.[2] In cases of
possible secondary bacterial infection, the antibiotics vancomycin and cefotaxime are
recommended.[3] In severe cases associated with influenza A or B, the antiviral neuraminidase
inhibitors may be administered.[3]

Viral croup is usually a self-limited disease,[2] with half of cases going away in a day and 80% of
cases in two days.[12] It can very rarely result in death from respiratory failureand/or cardiac arrest.
Symptoms usually improve within two days, but may last for up to seven days.[6] Other uncommon
complications include bacterial tracheitis, pneumonia, and pulmonary edema.[6]

Croup affects about 15% of children, and usually presents between the ages of 6 months and 56
years.[3][5] It accounts for about 5% of hospital admissions in this population. [6]In rare cases, it may
occur in children as young as 3 months and as old as 15 years.[6] Males are affected 50% more
frequently than are females, and there is an increasedprevalence in autumn.[3]

The word croup comes from the Early Modern English verb croup, meaning "to cry hoarsely"; the
name was first applied to the disease in Scotland and popularized in the 18th century.[13] Diphtheritic
croup has been known since the time of Homer's Ancient Greece and it was not until 1826 that viral
croup was differentiated from croup due to diphtheriaby Bretonneau.[10][14] Viral croup was then called
"faux-croup" by the French and often called "false croup" in English,[15][16] as "croup" or "true croup"
then most often referred to the disease caused by the diphtheria bacterium.[17][18] False croup has also
been known as pseudo croup or spasmodic croup.[19] Croup due to diphtheria has become nearly
unknown in affluent countries in modern times due to the advent of effective immunization.[1][14]


^ Jump up to:a b Vanderpool, Patricia (December 2012). "Recognizing

croup and stridor in children".American Nurse Today 7 (12).
Retrieved 15 April 2014.


^ Jump up to:a b c d e f g h i j k Rajapaksa S, Starr M (May 2010). "Croup

assessment and management". Aust Fam Physician 39 (5): 280
2. PMID 20485713.


^ Jump up to:a b c d e f g h i j k l m n o p q r s t Cherry JD (2008). "Clinical

practice. Croup". N. Engl. J. Med. 358 (4): 384
91. doi:10.1056/NEJMcp072022. PMID 18216359.


^ Jump up to:a b c d "Diagnosis and Management of Croup" (PDF). BC

Childrens Hospital Division of Pediatric Emergency Medicine Clinical
Practice Guidelines.


^ Jump up to:a b c d e f g h i j k l m n o p Everard ML (February 2009). "Acute

bronchiolitis and croup".Pediatr. Clin. North Am. 56 (1): 11933, x
xi. doi:10.1016/j.pcl.2008.10.007.PMID 19135584.


^ Jump up to:a b c d e f g h i j k l Johnson D (2009). "Croup". Clin Evid

(Online) 2009.PMC 2907784. PMID 19445760.


^ Jump up to:a b c Klassen TP (December 1999). "Croup. A current

perspective". Pediatr. Clin. North Am. 46 (6): 1167
78. doi:10.1016/S0031-3955(05)70180-2. PMID 10629679.


^ Jump up to:a b Russell KF, Liang Y, O'Gorman K, Johnson DW,

Klassen TP (2011). "Glucocorticoids for croup". Cochrane Database
Syst Rev 1 (1):
CD001955.doi:10.1002/14651858.CD001955.pub3. PMID 21249651.


Jump up^ Port C (April 2009). "Towards evidence based emergency

medicine: best BETs from the Manchester Royal Infirmary. BET 4.
Dose of dexamethasone in croup". Emerg Med J 26(4): 291
2. doi:10.1136/emj.2009.072090. PMID 19307398.

10. ^ Jump up to:a b Marchessault V (November 2001). "Historical review of

croup". Can J Infect Dis 12(6): 337
9. PMC 2094841. PMID 18159359.
11. Jump up^ Vorwerk C, Coats T (2010). "Heliox for croup in
children". Cochrane Database Syst Rev 2(2):
CD006822. doi:10.1002/14651858.CD006822.pub2. PMID 20166089.
12. Jump up^ Thompson, M; Vodicka, TA; Blair, PS; Buckley, DI;
Heneghan, C; Hay, AD; TARGET Programme, Team (Dec 11,
2013). "Duration of symptoms of respiratory tract infections in children:
systematic review.". BMJ (Clinical research ed.) 347:
f7027.doi:10.1136/bmj.f7027. PMC 3898587. PMID 24335668.
13. Jump up^ Online Etymological Dictionary, croup. Accessed 2010-0913.
14. ^ Jump up to:a b Feigin, Ralph D. (2004). Textbook of pediatric
infectious diseases. Philadelphia: Saunders. p. 252. ISBN 0-72169329-6.

15. Jump up^ Cormack, John Rose (8 May 1875). "Meaning of the Terms
Diphtheria, Croup, and Faux Croup". British Medical Journal 1 (749):
606. doi:10.1136/bmj.1.749.606.PMC 2297755. PMID 20747853.
16. Jump up^ Loving, Starling (5 October 1895). "Something concerning
the diagnosis and treatment of false croup". JAMA: The Journal of the
American Medical Association XXV (14): 567
573. doi:10.1001/jama.1895.02430400011001d. Retrieved 16
April 2014.
17. Jump up^ Bennett, James Risdon (8 May 1875). "True and False
Croup". British Medical Journal1 (749): 606
607. doi:10.1136/bmj.1.749.606-a. PMC 2297754. PMID 20747854.
18. Jump up^ Beard, George Miller (1875). Our Home Physician: A New
and Popular Guide to the Art of Preserving Health and Treating
Disease. New York: E. B. Treat. pp. 560564. Retrieved 15 April 2014.
19. Jump up^ Mandell, Douglas, and Bennett's Principles and Practice of
Infectious Diseases (8 ed.). Elsevier Health Sciences. 2014.
p. 762. ISBN 9780323263733.

External links[edit]
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Pathology of respiratory system (J, 460519), respiratory dis




Acute upper respiratory infections

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