Beruflich Dokumente
Kultur Dokumente
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found,
these are addressed by vetting through a multi-level review process, and through requirements
for references to be provided to support the content. Appropriately referenced content is
required of all authors and must conform to UpToDate standards of evidence.
All topics are updated as new evidence becomes available and our peer review
process is complete.
Literature review current through: Mar 2015. | This topic last updated: Jan
30, 2014.
Treatment with glucocorticoids at various doses and by various routes has been
shown to improve croup scores and to decrease unscheduled medical visits,
length of stay in the emergency department or hospital, and the use
of epinephrine [7]. Among the available glucocorticoids, dexamethasone has
been used most frequently, is the least expensive, has the longest duration of
action, and is the easiest to administer.
Adverse effects Few serious adverse effects have been reported in the
studies evaluating the efficacy of asingle dose of glucocorticoids in croup [14].
However, most of these studies were too small to sufficiently evaluate rare (<1
percent) adverse effects [15,16].
Glucocorticoid use may exacerbate active varicella and tuberculosis and should
be avoided in children with these infections and in those recently exposed to,
and possibly incubating, varicella [18,19]. (See "Clinical features of varicella-
zoster virus infection: Chickenpox" and "Treatment of varicella-zoster virus
infection: Chickenpox".)
Agents
In one study, 100 children with mild croup were randomly assigned to
receive oral dexamethasone (0.15mg/kg) or placebo in the emergency
department [21]. Eight children in the placebo group, and none in the
dexamethasone group, returned for medical care (a statistically significant
difference).
In another study, 120 hospitalized children with croup were randomly
assigned to receive a single oral dose
of dexamethasone (0.15 mg/kg, 0.3 mg/kg, 0.6 mg/kg) or placebo [22].
There was no difference in duration of hospitalization, reduction in croup
score, or epinephrine use among the three groups receiving
dexamethasone.
The second study described above [22] included a small number of children
with relatively mild croup and consequently may have been underpowered
(unable) to detect a clinically important difference, particularly in children with
more severe symptoms [14].
Children with mild croup who can tolerate oral medications can be given
either dexamethasone 0.15 mg/kg or dexamethasone 0.6 mg/kg orally, to a
maximum total dose of 10 mg. Although the lower 0.15 mg/kg dose appears to
be efficacious [21], we continue to suggest the higher dose [23,24].
The oral preparation of dexamethasone (1 mg per mL) has a foul taste. The
intravenous preparation is more concentrated (4 mg per mL) and can be given
orally mixed with syrup [11,25,26].
Prednisolone Some authorities suggest that for children who are treated as
outpatients, oralprednisolone (2 mg/kg per day for three days) is an alternative
to oral dexamethasone [29]. The use of prednisolone in the treatment of croup
has been evaluated in a limited number of studies.
Administration of epinephrine does not alter the natural history of croup in the
short (>2 hours) or longer term (24 to 36 hours) [1,36,39].
Dose
OXYGEN Oxygen is not known to have any direct impact on the subglottic
edema or airway narrowing, but should be administered to children who are
hypoxemic (oxygen saturation of <92 percent in room air) and/or in moderate to
severe respiratory distress [14,24]. Supplemental oxygen should be humidified
to decrease drying effects on the airways, since drying may impede the
physiologic removal of airway secretions via mucociliary and cough
mechanisms. (See "Continuous oxygen delivery systems for infants, children,
and adults".)
Heliox Helium is inert, nontoxic, and of very low density. Heliox is a mixture
of helium (70 to 80 percent) and oxygen (20 to 30 percent). It can flow through
airways with less turbulence and resistance than pure oxygen.
(See "Physiology and clinical use of heliox".)
Heliox decreases the work of respiration in children with croup and theoretically
could be used as a temporizing measure, to prevent the need for intubation
while waiting for glucocorticoids to decrease airway edema [42]. However, in
clinical trials, heliox has not definitively been shown to be more effective than
humidified oxygen or racemic epinephrine in reducing croup scores [43-45]. A
2013 systematic review found only three methodologically limited trials (91
patients) evaluating heliox in children with croup and concluded that a larger
trial is needed before recommendations regarding the use of heliox in children
with croup can be made [45].
Although humidified air does not reduce subglottic edema, it may provide other
benefits. Inhalation of moist air, relative to dry air, may decrease drying of
inflamed mucosal surfaces and reduce inspissation of secretions [49]. In
addition, a mist source may provide a sense of comfort and reassurance to both
the child and family [50-52]. In medical settings, mist therapy may be provided
by blow-by or saline nebulization treatments. Croup tents should be avoided,
since they can aggravate a child's anxiety and make vital signs and other visual
assessments of the child more difficult. Some guidelines recommend against
the use of mist therapy for children who are hospitalized with croup [24].
Certainly if the child is agitated by the provision of mist, mist therapy should be
discontinued.
OTHER THERAPIES
Here are the patient education articles that are relevant to this topic. We
encourage you to print or e-mail these topics to your patients. (You can also
locate patient education articles on a variety of subjects by searching on
patient info and the keyword(s) of interest.)
1. 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.
2. 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.
3. Kairys SW, Olmstead EM, O'Connor GT. Steroid treatment of laryngotracheitis:
a meta-analysis of the evidence from randomized trials. Pediatrics 1989;
83:683.
4. 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.
5. Klassen TP, Feldman ME, Watters LK, et al. Nebulized budesonide for children
with mild-to-moderate croup. N Engl J Med 1994; 331:285.
6. 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.
7. Russell KF, Liang Y, O'Gorman K, et al. Glucocorticoids for croup. Cochrane
Database Syst Rev 2011; :CD001955.
8. Tibballs J, Shann FA, Landau LI. Placebo-controlled trial of prednisolone in
children intubated for croup. Lancet 1992; 340:745.
9. 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.
10. Geelhoed GC, Macdonald WB. Oral and inhaled steroids in croup: a
randomized, placebo-controlled trial. Pediatr Pulmonol 1995; 20:355.
11. 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.
12. Geelhoed GC. Budesonide offers no advantage when added to oral
dexamethasone in the treatment of croup. Pediatr Emerg Care 2005; 21:359.
13. Griffin S, Ellis S, Fitzgerald-Barron A, et al. Nebulised steroid in the treatment of
croup: a systematic review of randomised controlled trials. Br J Gen Pract 2000;
50:135.
14. Johnson D. Croup. Clin Evid 2005; :310.
15. Vernacchio L, Mitchell AA. Oral dexamethasone for mild croup. N Engl J Med
2004; 351:2768.
16. Cherry JD. Croup (laryngitis, laryngotracheitis, spasmodic croup,
laryngotracheobronchitis, bacterial tracheitis, and
laryngotracheobronchopneumonitis) and epiglottitis (supraglottitis). In: Feigin
and Cherrys Textbook of Pediatric Infectious Diseases, 7th ed, Cherry JD,
Harrison GJ, Kaplan SL, et al (Eds), Elsevier Saunders, Philadelphia 2014.
p.241.
17. Johnson DW, Schuh S, Koren G, Jaffee DM. Outpatient treatment of croup with
nebulized dexamethasone. Arch Pediatr Adolesc Med 1996; 150:349.
18. Kaditis AG, Wald ER. Viral croup: current diagnosis and treatment. Pediatr
Infect Dis J 1998; 17:827.
19. Dowell SF, Bresee JS. Severe varicella associated with steroid use. Pediatrics
1993; 92:223.
20. Kiff KM, Mok Q, Dunne J, Tasker RC. Steroids for intubated croup masking
airway haemangioma. Arch Dis Child 1996; 74:66.
21. 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.
22. Geelhoed GC, Macdonald WB. Oral dexamethasone in the treatment of croup:
0.15 mg/kg versus 0.3 mg/kg versus 0.6 mg/kg. Pediatr Pulmonol 1995; 20:362.
23. Harper MB, Fleisher GR. Infectious Disease Emergencies. In: Textbook of
Pediatric Emergency Medicine, 6th, Fleisher GR, Ludwig SL (Eds), Lippincott
Willams & Wilkins, Philadelphia 2010. p.887.
24. Alberta Clinical Practice Guideline WorkingGroup. Guideline for the diagnosis
and management of croup. 2008.
www.topalbertadoctors.org/download/252/croup_guideline.pdf (Accessed on
October 31, 2013).
25. Paul RI. Oral dexamethasone for croup (commentary). AAP Grand Rounds
2004; 12:67.
26. Duggan DE, Yeh KC, Matalia N, et al. Bioavailability of oral dexamethasone.
Clin Pharmacol Ther 1975; 18:205.
27. Luria JW, Gonzalez-del-Rey JA, DiGiulio GA, et al. Effectiveness of oral or
nebulized dexamethasone for children with mild croup. Arch Pediatr Adolesc
Med 2001; 155:1340.
28. Cetinkaya F, Tfeki BS, Kutluk G. A comparison of nebulized budesonide, and
intramuscular, and oral dexamethasone for treatment of croup. Int J Pediatr
Otorhinolaryngol 2004; 68:453.
29. Garbutt JM, Conlon B, Sterkel R, et al. The comparative effectiveness of
prednisolone and dexamethasone for children with croup: a community-based
randomized trial. Clin Pediatr (Phila) 2013; 52:1014.
30. Sparrow A, Geelhoed G. Prednisolone versus dexamethasone in croup: a
randomised equivalence trial. Arch Dis Child 2006; 91:580.
31. Fifoot AA, Ting JY. Comparison between single-dose oral prednisolone and oral
dexamethasone in the treatment of croup: a randomized, double-blinded clinical
trial. Emerg Med Australas 2007; 19:51.
32. Connors K, Gavula D, Terndrup T. The use of corticosteroids in croup: a
survey. Pediatr Emerg Care 1994; 10:197.
33. Amir L, Hubermann H, Halevi A, et al. Oral betamethasone versus
intramuscular dexamethasone for the treatment of mild to moderate viral croup:
a prospective, randomized trial. Pediatr Emerg Care 2006; 22:541.
34. Cherry JD. State of the evidence for standard-of-care treatments for croup: are
we where we need to be? Pediatr Infect Dis J 2005; 24:S198.
35. Kristjnsson S, Berg-Kelly K, Wins 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.
36. 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.
37. Corkey CW, Barker GA, Edmonds JF, et al. Radiographic tracheal diameter
measurements in acute infectious croup: an objective scoring system. Crit Care
Med 1981; 9:587.
38. Kuusela AL, Vesikari T. A randomized double-blind, placebo-controlled trial of
dexamethasone and racemic epinephrine in the treatment of croup. Acta
Paediatr Scand 1988; 77:99.
39. Bjornson C, Russell K, Vandermeer B, et al. Nebulized epinephrine for croup in
children. Cochrane Database Syst Rev 2013; 10:CD006619.
40. 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.
41. Butte MJ, Nguyen BX, Hutchison TJ, et al. Pediatric myocardial infarction after
racemic epinephrine administration. Pediatrics 1999; 104:e9.
42. Duncan PG. Efficacy of helium--oxygen mixtures in the management of severe
viral and post-intubation croup. Can Anaesth Soc J 1979; 26:206.
43. Terregino CA, Nairn SJ, Chansky ME, Kass JE. The effect of heliox on croup: a
pilot study. Acad Emerg Med 1998; 5:1130.
44. Weber JE, Chudnofsky CR, Younger JG, et al. A randomized comparison of
helium-oxygen mixture (Heliox) and racemic epinephrine for the treatment of
moderate to severe croup. Pediatrics 2001; 107:E96.
45. Moraa I, Sturman N, McGuire T, van Driel ML. Heliox for croup in children.
Cochrane Database Syst Rev 2013; 12:CD006822.
46. Skolnik NS. Treatment of croup. A critical review. Am J Dis Child 1989;
143:1045.
47. Neto GM, Kentab O, Klassen TP, Osmond MH. A randomized controlled trial of
mist in the acute treatment of moderate croup. Acad Emerg Med 2002; 9:873.
48. Scolnik D, Coates AL, Stephens D, et al. Controlled delivery of high vs low
humidity vs mist therapy for croup in emergency departments: a randomized
controlled trial. JAMA 2006; 295:1274.
49. Dulfano MJ, Adler K, Wooten O. Physical properties of sputum. IV. Effects of
100 per cent humidity and water mist. Am Rev Respir Dis 1973; 107:130.
50. Parks CR. Mist therapy: rationale and practice. J Pediatr 1970; 76:305.
51. Henry R. Moist air in the treatment of laryngotracheitis. Arch Dis Child 1983;
58:577.
52. Sasaki CT, Suzuki M. The respiratory mechanism of aerosol inhalation in the
treatment of partial airway obstruction. Pediatrics 1977; 59:689.
53. Fanconi S, Burger R, Maurer H, et al. Transcutaneous carbon dioxide pressure
for monitoring patients with severe croup. J Pediatr 1990; 117:701.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found,
these are addressed by vetting through a multi-level review process, and through requirements
for references to be provided to support the content. Appropriately referenced content is
required of all authors and must conform to UpToDate standards of evidence.
All topics are updated as new evidence becomes available and our peer review
process is complete.
Literature review current through: Mar 2015. | This topic last updated: Dec
14, 2013.
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".)
OVERVIEW 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 croup score The elements of the Westley croup score describe
key features of the physical examination [1]. Each element is assigned a score,
as illustrated below:
PHONE TRIAGE The first contact with the health-care system regarding a
child with symptoms of croup may occur by phone. When assessing patients by
phone, the health-care provider must distinguish children who need immediate
medical attention or further evaluation from those who can be managed at
home. Children who need further evaluation include those who have:
Stridor at rest
An abnormal airway (eg, subglottic narrowing from care in the neonatal
intensive care unit)
Previous episodes of moderate to severe croup
Medical conditions that predispose to respiratory failure (eg,
neuromuscular disorders)
Rapid progression of symptoms (ie, symptoms of upper airway
obstruction after less than 12 hours of illness)
Inability to tolerate oral fluids
Parental concern that cannot be relieved by reassurance
Prolonged symptoms (more than three to seven days) or an atypical
course (perhaps indicating an alternative diagnosis) (see "Croup: Clinical
features, evaluation, and diagnosis", section on 'Differential diagnosis')
Patients who are assessed by phone and determined to have mild symptoms
and none of the above indications for further evaluation can be managed at
home. (See 'Home treatment' below.)
Home treatment The caregivers of children with mild croup who are
managed at home should be instructed in provision of supportive care including
mist, antipyretics, and encouragement of fluid intake.
In acute situations and for short periods of time, caregivers may try sitting with
the child in a bathroom filled with steam generated by running hot water from
the shower to improve symptoms. This may help reassure parents that
"something" is being done to reverse the symptoms, and anecdotal evidence
supports some value of this measure.
Exposure to cold night air also may lessen symptoms of mild croup, although
this has never been systematically studied. If parents or caregivers wish to use
humidifiers at home, only those that produce mist at room temperature should
be used to avoid the risk of burns from steam or the heating element.
Patients who are managed at home should receive a follow-up phone call;
caregivers should receive instructions regarding indications to seek medical
attention, including [8]:
Difficulty breathing
Pallor or cyanosis
Severe coughing spells
Drooling or difficulty swallowing
Fatigue
Worsening course
Fever (>38.5C)
Prolonged symptoms (longer than seven days)
Stridor at rest
Suprasternal retractions
We suggest that children with mild croup who are seen in the outpatient setting
be treated with a single dose of oral dexamethasone (0.6 mg/kg). Treatment of
such children in the late morning or early afternoon hours may prevent
worsening of symptoms as evening approaches. However, anticipatory
guidance about potential worsening and when to seek care or return for follow-
up also is reasonable. (See "Croup: Pharmacologic and supportive
interventions", section on 'Dexamethasone'.)
Children with mild croup who are tolerating fluids and have not received
nebulized epinephrine can be sent home after specific follow-up (which may
occur by phone) has been arranged and the caregiver has received instructions
regarding home care and indications to seek medical attention as described
above. (See 'Home treatment' above.)
The child with severe croup must be approached cautiously, as any increase in
anxiety may worsen airway obstruction. The parent or caregiver should be
instructed to hold and comfort the child and to administer humidified oxygen.
Nebulized epinephrine should be added as quickly as possible, as described
below. In the meantime, health-care providers should continuously observe the
child and be prepared to provide bag mask ventilation and advanced airway
techniques if the condition worsens. (See "Emergent endotracheal intubation in
children".)
After three to four hours of observation, children who remain comfortable may
be discharged home if they meet the following criteria [24-27]:
No stridor at rest
Normal pulse oximetry
Good air exchange
Normal color
Normal level of consciousness
Demonstrated ability to tolerate fluids by mouth
Caregivers understand the indications for return to care and would be
able to return if necessary
Before discharge, follow-up with the primary care provider should be arranged
within the next 24 hours. Instructions regarding home treatment should be
provided. (See 'Home treatment' above.)
About 5 percent of children well enough for discharge from the emergency
department after receiving corticosteroids and
nebulized epinephrine treatments may be expected to return for care. Relapse
within 24 hours is unlikely in those who have minimal symptoms at the time of
discharge [30].
Hospitalization
Additional factors that influence the decision regarding admission include [8,31]:
Repeat doses of corticosteroids are not necessary on a routine basis and may
have adverse effects. Moderate to severe symptoms that persist for more than
a few days should prompt investigation for other causes of airway obstruction.
(See "Croup: Clinical features, evaluation, and diagnosis", section on
'Differential diagnosis'.)
Infection control Children who are admitted to the hospital with croup
should be managed with contact precautions (ie, gown and gloves for contact),
particularly if parainfluenza or respiratory syncytial virus is the suspected
etiology. If influenza is suspected, droplet isolation measures (ie, respiratory
mask within three feet) also should be followed. (See "General principles of
infection control".)
No stridor at rest
Normal pulse oximetry
Good air exchange
Normal color
Normal level of consciousness
Demonstrated ability to tolerate fluids by mouth
FOLLOW-UP Any patient who was admitted to the hospital, received
nebulized epinephrine, or had a prolonged outpatient visit should have follow-
up scheduled with the primary care provider within 24 hours or as soon as can
be arranged. Although some children may continue to have mild to moderate
symptoms at the time of follow-up, there are no studies that support the routine
use of corticosteroid therapy beyond 24 hours.
Follow-up should continue until the child's symptoms have begun to resolve.
The child who does not improve as expected (over the course of approximately
seven days) may have an underlying airway abnormality or may be developing
a complication of croup. Further evaluation, particularly with a radiograph of the
soft tissues of the neck, or consultation with otolaryngology, may be warranted.
(See "Croup: Clinical features, evaluation, and diagnosis", section on
'Differential diagnosis'.)
Here are the patient education articles that are relevant to this topic. We
encourage you to print or e-mail these topics to your patients. (You can also
locate patient education articles on a variety of subjects by searching on
patient info and the keyword(s) of interest.)
Overview
Mild symptoms
Supportive care for the child with moderate or severe croup includes
administration of humidified air or oxygen as indicated by
hypoxemia and/or respiratory distress, provision of intravenous fluids, and
monitoring for worsening respiratory distress. (See 'Supportive
care' above and "Croup: Pharmacologic and supportive interventions",
section on 'Mist therapy'.)
We recommend that children with moderate to severe croup who have
moderate stridor at rest, moderate retractions, and/or more severe
symptoms be treated with nebulized epinephrine (Grade 1A) in addition
to dexamethasone. (See 'Pharmacotherapy' above and "Croup:
Pharmacologic and supportive interventions", section on 'Nebulized
epinephrine'.)
Racemic epinephrine is administered as 0.05 mL/kg per dose
(maximum of 0.5 mL) of a 2.25 percent solution diluted to 3 mL total
volume with normal saline. It is given via nebulizer over 15 minutes.
L-epinephrine is administered as 0.5 mL/kg per dose (maximum of
5 mL) of a 1:1000 dilution. It is given via nebulizer over 15 minutes.
Outcome
1. 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.
2. 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.
3. Kairys SW, Olmstead EM, O'Connor GT. Steroid treatment of laryngotracheitis:
a meta-analysis of the evidence from randomized trials. Pediatrics 1989;
83:683.
4. 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.
5. Klassen TP, Feldman ME, Watters LK, et al. Nebulized budesonide for children
with mild-to-moderate croup. N Engl J Med 1994; 331:285.
6. 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.
7. Bjornson CL, Johnson DW. Croup. Lancet 2008; 371:329.
8. 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).
9. Cherry JD. Clinical practice. Croup. N Engl J Med 2008; 358:384.
10. 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.
11. 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.
12. 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.
13. Bhende MS. End-tidal carbon dioxide monitoring in pediatrics - clinical
applications. J Postgrad Med 2001; 47:215.
14. 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.
15. 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.
16. Wagener JS, Landau LI, Olinsky A, Phelan PD. Management of children
hospitalized for laryngotracheobronchitis. Pediatr Pulmonol 1986; 2:159.
17. Tan AK, Manoukian JJ. Hospitalized croup (bacterial and viral): the role of rigid
endoscopy. J Otolaryngol 1992; 21:48.
18. Russell KF, Liang Y, O'Gorman K, et al. Glucocorticoids for croup. Cochrane
Database Syst Rev 2011; :CD001955.
19. Kristjnsson S, Berg-Kelly K, Wins 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.
20. 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.
21. 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.
22. Paul RI. Oral dexamethasone for croup (commentary). AAP Grand Rounds
2004; 12:67.
23. Duggan DE, Yeh KC, Matalia N, et al. Bioavailability of oral dexamethasone.
Clin Pharmacol Ther 1975; 18:205.
24. 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.
25. 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.
26. Kunkel NC, Baker MD. Use of racemic epinephrine, dexamethasone, and mist
in the outpatient management of croup. Pediatr Emerg Care 1996; 12:156.
27. 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.
28. 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.
29. Fitzgerald D, Mellis C, Johnson M, et al. Nebulized budesonide is as effective
as nebulized adrenaline in moderately severe croup. Pediatrics 1996; 97:722.
30. Brown JC. The management of croup. Br Med Bull 2002; 61:189.
31. Kaditis AG, Wald ER. Viral croup: current diagnosis and treatment. Pediatr
Infect Dis J 1998; 17:827.
32. Thompson M, Vodicka TA, Blair PS, et al. Duration of symptoms of respiratory
tract infections in children: systematic review. BMJ 2013; 347:f7027.
33. Cherry JD. Croup (laryngitis, laryngotracheitis, spasmodic croup,
laryngotracheobronchitis, bacterial tracheitis, and
laryngotracheobronchopneumonitis) and epiglottitis (supraglottitis). In: Feigin
and Cherrys Textbook of Pediatric Infectious Diseases, 7th ed, Cherry JD,
Harrison GJ, Kaplan SL, et al (Eds), Elsevier Saunders, Philadelphia 2014.
p.241.
34. Johnson D. Croup. Clin Evid 2005; :310.
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Literature review current through: Mar 2015. | This topic last updated: Feb
18, 2015.
The clinical features, evaluation, and diagnosis of croup will be discussed here.
The management of croup is discussed separately. (See "Croup: Approach to
management" and "Croup: Pharmacologic and supportive interventions".)
DEFINITIONS The term croup has been used to describe a variety of upper
respiratory conditions in children, including laryngitis, laryngotracheitis,
laryngotracheobronchitis, bacterial tracheitis, or spasmodic croup [1]. These
terms are defined below. In the past, the term croup also has been applied to
laryngeal diphtheria (diphtheritic or membranous croup), which is discussed
separately. (See "Epidemiology and pathophysiology of diphtheria" and "Clinical
manifestations, diagnosis and treatment of diphtheria".)
Throughout this review, the term croup will be used to refer to laryngotracheitis.
Laryngotracheobronchitis, laryngotracheobronchopneumonitis, bacterial
tracheitis, and spasmodic croup are designated specifically as such.
A number of other viruses that typically cause lower respiratory tract disease
also can cause upper respiratory tract symptoms, including croup, as described
below [6].
Family history of croup is a risk factor for croup and recurrent croup. In a case-
control study, children whose parents had a history of croup were 3.2 times as
likely to have an episode of croup and 4.1 times as likely to have recurrent
croup as children with no parental history of croup [15]. Parental smoking, a
well-recognized risk factor for respiratory tract infections in children, does not
appear to increase the risk of croup [15,16]. (See"Secondhand smoke
exposure: Effects in children", section on 'Respiratory symptoms and illness'.)
Most cases of croup occur in the fall or early winter, with the major incidence
peaks coinciding with parainfluenza type 1 activity (often in October) and minor
peaks occurring during periods of respiratory syncytial virus or influenza virus
activity. (See "Respiratory syncytial virus infection: Clinical features and
diagnosis", section on 'Seasonality' and "Seasonal influenza in children: Clinical
features and diagnosis", section on 'Influenza activity'.)
Emergency department (ED) visits for croup are most frequent between 10:00
PM and 4:00 AM. However, children seen for croup between noon and 6:00 PM
are more likely to be admitted to the hospital [4,17]. A morning peak between
7:00 AM and 11:00 AM in ED visits for croup also has been noted [14].
Hospital admissions for croup have declined steadily since the late 1970s. In an
analysis of data from the National Hospital Discharge Surveys from 1979
through 1997, the estimated number of annual hospitalizations for croup
decreased from 48,900 to 33,500 [5]. Estimates of annual hospitalization rates
for croup caused by parainfluenza virus types 1 to 3 from 1994 to 1997 were
0.4 to 1.1 per 1000 children for children younger than one year and 0.24 to 0.61
per 1000 children for children between one and four years. Approximately one-
half of these hospitalizations were attributed to parainfluenza type 1.
PATHOGENESIS The viruses that cause croup typically infect the nasal and
pharyngeal mucosal epithelia initially and then spread locally along the
respiratory epithelium to the larynx and trachea.
The potential role of the immune response was demonstrated in studies that
demonstrated increased production of parainfluenza virus-specific IgE and
increased lymphoproliferative response to parainfluenza virus antigen, and
diminished histamine-induced suppression of lymphocyte transformation
responses to parainfluenza virus in children with parainfluenza virus and croup
compared with those with parainfluenza virus without croup [27,28].
Hypoxia and cyanosis can develop, as can respiratory fatigue from sustained
increased respiratory effort. High respiratory rates also tend to correlate with the
presence of hypoxia. Without intervention, the hypoxia or fatigue can
sometimes lead to death.
Early in the clinical course, spasmodic croup may be difficult to distinguish from
laryngotracheitis. As the course progresses, the episodic nature of spasmodic
croup and relative wellness of the child between attacks differentiate it from
classic croup, in which the symptoms are continuous.
Although the initial presentation can be dramatic, the clinical course is usually
benign. Symptoms are almost always relieved by comforting the anxious child
and administering humidified air. Rarely, children may benefit from treatment
with corticosteroids and/or nebulized epinephrine [31]. Other therapies
generally are not indicated. (See "Croup: Approach to management".)
Recurrent croup A child who has had recurrent episodes of classic viral
croup may have an underlying condition that predisposes him or her to develop
clinically significant narrowing of the upper airway. Recurrent episodes of croup-
like symptoms occurring outside the typical age range for viral croup (ie, six
months to three years) and recurrent episodes that do not appear to be simple
spasmodic croup should raise suspicion for large airway lesions,
gastroesophageal reflux or eosinophilic esophagitis, or atopic conditions [3,34-
38].
EVALUATION
During the evaluation, efforts should be made to make the child as comfortable
as possible. The increased inspiratory effort that accompanies anxiety and fear
in young children can exacerbate subglottic narrowing, further diminishing air
exchange and oxygenation. (See 'Pathogenesis' above.)
A tracheal tube that is 0.5 to 1 mm smaller than would typically be used may be
required. (See "Emergent endotracheal intubation in children", section on
'Endotracheal tube'.)
History The history should include a description of the onset, duration, and
progression of symptoms. Factors that are associated with increased severity of
illness include:
Aspects of the examination that are helpful in assessing the degree of upper
airway obstruction and severity of illness include:
Overall appearance Is the child comfortable and interactive, anxious
and quiet, or obtunded? Is there stridor at rest? Stridor at rest is a sign of
significant upper airway obstruction. Children with significant upper airway
obstruction may prefer to sit up and lean forward in a "sniffing" position
(neck is mildly flexed, and head is mildly extended). This position tends to
improve the patency of the upper airway.
Quality of the voice Does the child have a hoarse or diminished cry? Is
the voice muffled? A muffled "hot potato" voice is suggestive of epiglottitis,
retropharyngeal abscess, or peritonsillar abscess.
Degree of respiratory distress Signs of respiratory distress include
tachypnea, hypoxemia, and increased work of breathing (intercostal,
subcostal, or suprasternal retractions; nasal flaring; grunting; use of
accessory muscles)
Tidal volume Does there appear to be good chest expansion with
inspiration, indicating adequate air entry?
Lung examination Are there abnormal respiratory sounds during
inspiration or expiration? Inspiratory stridor indicates upper airway
obstruction, whereas expiratory wheezing is a sign of lower airway
obstruction. If there is stridor, is it present at rest or only with agitation? As
discussed above, stridor at rest is a sign of significant upper airway
obstruction. Stridor will be more obvious on auscultation, since the
inspiratory noise is transmitted through the chest. The presence of
crackles (rales) also suggests lower respiratory tract involvement (eg,
laryngotracheobronchitis, laryngotracheobronchopneumonitis, or bacterial
tracheitis).
Assessment of hydration status Decreased oral intake and increased
insensible losses from fever and tachypnea may result in dehydration.
(See "Clinical assessment and diagnosis of hypovolemia (dehydration) in
children".)
These aspects of the examination are often used in clinical scoring systems to
evaluate the severity of illnessand/or in making decisions regarding the need for
hospital admission. (See 'Severity assessment' below and"Croup: Approach to
management".)
Components of the examination that are useful in distinguishing croup from
other causes of acute upper airway obstruction include [39,41]:
The elements of the Westley croup score describe key features of the physical
examination [43]. Each element is assigned a score, as illustrated below:
Imaging
The lateral radiograph in children with bacterial tracheitis may demonstrate only
nonspecific edema or intraluminal membranes and irregularities of the tracheal
wall (image 4) [45].
Blood tests The white blood cell (WBC) count can be low, normal, or
elevated; WBC counts >10,000cells/microL are common. Neutrophil or
lymphocyte predominance may be present on the differential [46,47]. The
presence of a large number of band-form neutrophils is suggestive of primary or
secondary bacterial infection. Croup is not associated with any specific
alterations in serum chemistries.
DIAGNOSIS
In addition, multiplex tests, which assess the presence of multiple agents at the
same time, and PCR-based tests are becoming more widely available [48].
Acute epiglottitis
Peritonsillar and retropharyngeal abscesses
Foreign body aspiration or ingestion
Allergic reaction
Acute angioneurotic edema
Upper airway injury
Congenital anomalies of the upper airway
Laryngeal diphtheria (see "Clinical manifestations, diagnosis and
treatment of diphtheria")
Upper airway injury Injury to the airway from smoke or thermal or chemical
burns should be evident from the history. The child typically does not have fever
or a viral prodrome.
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The term croup has been used to describe a variety of upper respiratory
conditions in children, including laryngitis, laryngotracheitis,
laryngotracheobronchitis, bacterial tracheitis, or spasmodic croup.
(See'Definitions' above.)
Croup is usually caused by viruses. Bacterial infection may occur
secondarily. Parainfluenza virus type 1 is the most common cause of
croup; other causes include respiratory syncytial virus and influenza virus.
(See 'Etiology' above.)
Croup most commonly occurs in children 6 to 36 months of age. Most
cases occur in the fall or early winter. (See 'Epidemiology' above.)
Host factors that may contribute to the development of croup include
functional or anatomic susceptibility to upper airway narrowing.
(See 'Pathogenesis' above.)
The clinical presentation of croup depends upon the specific croup
syndrome and the degree of upper airway obstruction. (See 'Clinical
presentation' above.)
The onset of symptoms in laryngotracheitis is gradual, beginning with
nasal irritation, congestion, and coryza. Fever, hoarseness, barking
cough, and stridor usually develop during the next 12 to 48 hours. Rapid
progression or signs of lower airway involvement suggest a more serious
illness. (See'Laryngotracheitis' above.)
The onset of symptoms in spasmodic croup is sudden and always
occurs at night. Fever is typically absent, but mild upper respiratory tract
symptoms may be present. (See 'Spasmodic croup' above.)
Bacterial tracheitis (picture 1 and image 4) may present acutely or as
marked worsening during the course of an antecedent viral upper
respiratory infection. Clinical manifestations of bacterial tracheitis include
fever, toxic appearance, and severe respiratory distress. (See 'Bacterial
tracheitis' above and"Bacterial tracheitis in children: Clinical features and
diagnosis".)
The objectives of the evaluation of the child with croup include
assessment of severity and exclusion of other causes of upper airway
obstruction. (See 'Overview' above.)
Rapid assessment of general appearance, vital signs, pulse oximetry,
airway stability, and mental status are necessary to identify children with
severe respiratory distress and/or impending respiratory failure.
(See 'Rapid assessment and initial management' above.)
The history should include a description of the onset, duration and
progression of symptoms, and ascertain whether there are any underlying
conditions that predispose to a more severe course. (See'History' above.)
Aspects of the examination that are useful in assessing the severity of
upper airway obstruction include overall appearance (including the
presence of stridor at rest or only with agitation), quality of voice, work of
breathing, tidal volume and air entry, and the presence of wheezing.
(See 'Examination' above.)
The diagnosis of croup is clinical, based upon the presence of a barking
cough and stridor. Neither radiographs nor laboratory tests are necessary
to make the diagnosis. However, radiographs may be helpful in excluding
other causes if the diagnosis is in question. (See 'Diagnosis' above.)
The differential diagnosis of croup includes other causes of
stridor and/or respiratory distress. The primary considerations are those
with acute onset, particularly those that may rapidly progress to complete
upper airway obstruction, and those that require specific therapy.
Important considerations include acute epiglottitis, peritonsillar and
retropharyngeal abscesses, foreign body aspiration, acute angioneurotic
edema, upper airway injury, and congenital anomalies of the upper
airway. (See'Differential diagnosis' above.)
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