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Practice Point

Acute management of croup in the
emergency department
Posted: May 24 2017
The Canadian Paediatric Society gives permission to print single copies of this document
from our website. For permission to reprint or reproduce multiple copies, please see our
copyright policy (http://www.cps.ca/en/policies-politiques/copyright).

Principal author(s)
Oliva Ortiz-Alvarez; Canadian Paediatric Society, Acute Care Committee
(https://www.cps.ca/en/documents/authors-auteurs/acute-care-committee)
Paediatr Child Health 22(3):166-169.

Abstract
Croup is one of the most common causes of upper airway obstruction in young children. It
is characterized by sudden onset of barky cough, hoarse voice, inspiratory stridor and
respiratory distress caused by upper airway inflammation secondary to a viral infection.
Published guidelines for the diagnosis and treatment of croup advise using steroids as the
mainstay treatment for all children who present to emergency department (ED) with croup
symptoms. Dexamethasone, given orally as a single dose at 0.6 mg/kg, is highly efficacious
in treating croup symptoms. Despite the evidence supporting the use of steroids as the
cornerstone of croup treatment, there is significant practice variation among physicians
treating croup in the ED. This practice point discusses evidence-based management of
typical croup in the ED.
Keywords: Corticosteroids, Croup, Dexamethasone, Epinephrine, Heliox

BACKGROUND AND EPIDEMIOLOGY
Most children with croup have mild and short-lived symptoms, with <1% of cases
experiencing severe symptoms [1][2]. However, croup accounts for significant rates of ED
visits and hospitalizations in Canada, with one population-based study in Alberta reporting
that 3.2% to 5.1% of all ED visits in children <2 years of age were related to croup [3].
Less than 6% of children presenting to ED with croup symptoms require hospitalization and
when they are admitted, it is usually for a short stay [3]. Endotracheal intubation is rare (at
0.4% to 1.4% of hospitalized cases) and death is exceptionally rare (at 0.5% of intubated
cases) [4]. There is considerable variation in clinical practice for croup. In small Canadian

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centres, children with croup are less likely to receive steroids than in larger centres, while
the use of antibiotics and beta-agonists (which are rarely indicated in the care of children
with croup) is more frequent than in larger centres [5][6].

ETIOLOGY AND PATHOPHYSIOLOGY
Croup is caused by viral infections of the respiratory tract and most commonly by
parainfluenza types 1 and 3 viruses. Other implicated viruses are influenza A and B,
adenovirus, respiratory syncytial virus and metapneumovirus [7]. These infections cause
generalized airway inflammation and edema of the upper airway mucosa. The subglottic
region becomes narrowed, causing upper airway obstruction and the symptoms typically
associated with croup.

CLINICAL PRESENTATION
Classical croup symptoms have a rapid onset and include barky cough, inspiratory stridor,
hoarseness and respiratory distress. Nonspecific symptoms of an upper respiratory illness
usually precede the typical croup symptoms, which often worsen at night. Typical croup
usually affects children between 6 months and 3 years of age. Symptoms are short-lived,
usually lasting 3 to 7 days. In 60% of patients, the barky cough disappears after 48 hours
[1]. In <5% of cases, symptoms may last longer than five nights and <5% of children
experience more than one episode. In Canada, croup season peaks over the fall and winter
[3][8][9].

DIFFERENTIAL DIAGNOSIS
Children who present with croup at <6 months of age or whose symptoms are recurrent,
prolonged or unusually severe require further assessment to rule out congenital or acquired
airway narrowing [1]. Prolonged duration of croup symptoms associated with fever may be
seen with secondary bacterial infection [1]. Less than 1% of children with croup have
severe or life-threatening symptoms [1][2], but there are several other life-threatening
conditions that may present with stridor. Toxic appearance, drooling and dysphagia are
important red flags suggestive of more serious conditions (Table 1).
Table 1.
Differential diagnosis
Condition
Characteristics
High fever, toxic appearance and poor response to
Bacterial tracheitis
nebulized epinephrine
Retropharyngeal,
High fever, neck pain, sore throat and dysphagia followed
parapharyngeal, peritonsillar
by torticollis, drooling, respiratory distress and stridor
abscesses
Absence of barky cough, sudden onset of high fever,
Epiglottitis
dysphagia, drooling, toxic appearance, anxious appearance
and sitting forward in the ‘sniffing’ position
Aspiration or ingestion of a
Croupy cough, choking episode, wheezing, hoarseness,
foreign body
biphasic stridor, dyspnea and decreased air entry
Acute allergic reaction
Rapid onset of dysphagia, wheezing, stridor and possible
(anaphylaxis or angioneurotic
cutaneous allergic signs, such as urticarial rash
edema)

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Adapted from Bjornson and Johnson [9]

TREATMENT
The severity of the child’s respiratory distress on presentation to the ED should guide
management (Table 2). Clinical scores used in research studies have not been shown to
improve clinical care [10][11]. Most clinicians characterize respiratory distress as mild,
moderate, severe or impending respiratory failure. Using this classification, an algorithm for
the outpatient management of croup in children was developed through expert consensus
[12]. Children presenting with severe distress or impending respiratory failure should be
referred to paediatric intensive care or to anaesthesia for advanced care when clinical
response to initial treatment is poor or not sustained.
Table 2.
Croup severity
Impending
Feature
Mild
Moderate Severe
respiratory failure
Often not prominent
Barky cough
Occasional Frequent
Frequent
due to fatigue
Prominent
Audible at rest, but
None or
Easily
inspiratory and
audible at
may be quiet or hard
Stridor
minimal at
occasionally
rest
rest
to hear
expiratory
In-drawing
Visible at
suprasternal and/or None to mild
Marked or severe
May not be marked
rest
intercostal
Distress, agitation
None to
Substantial lethargy Lethargy or decreased
or lethargy (CNS
None
limited
may be present
level of consciousness
hypoxia)
Dusky or cyanotic
Cyanosis
None
None
None
without supplemental
oxygen
CNS Central nervous system. Modified from Bjornson and Johnson [1].
Overall, the recommended treatment for croup involves the following measures (Figure 1).
General care
Children should be made comfortable and health care providers must take special care not
to frighten them during assessment and treatment. There is no evidence to support the
treatment of croup with the use of humidified air [13]. Mist tents separate children from
their caregivers, can disperse fungus and therefore are not recommended [13]. The use of
antipyretics is beneficial for reducing fever and discomfort.
Corticosteroids
The clinical benefit of corticosteroids in croup is well established [2][14]-[16] and should be
considered for treating all children presenting with croup and symptoms ranging from mild
to severe. Improvement generally begins within 2 to 3 hours after a single oral dose of
dexamethasone and persists for 24 to 48 hours [2][15][16]. One recent Cochrane review
analyzed results from 38 randomized controlled trials (n=4299) associating corticosteroids

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with clinical improvement as measured by Westley croup scores at 6, 12 and 24 hours [14].
Dexamethasone was the corticosteroid tested in most (31/38) of these clinical trials. Two
studies compared oral dexamethasone with oral prednisolone. In one study,
dexamethasone was found to be superior, and in the other, both therapies were equally
effective [14].
Administering corticosteroids by the oral or intramuscular route is as efficacious or superior
to the nebulized form of medication [1][14]. Adding inhaled budesonide to oral
dexamethasone was not found to provide extra benefit in children admitted with croup
[17]. From a practical perspective, oral dexamethasone is less associated with vomiting
[14]. The oral route is preferred. When the child with croup has persistent vomiting or
significant respiratory distress, administering corticosteroids by the intramuscular route
may be indicated [1]. The dexamethasone dose used in most clinical trials is 0.6
mg/kg/dose [14]. It is unclear from studies using doses of 0.15 mg/kg to 0.3 mg/kg
whether these smaller doses are equally effective [18]. One meta-analysis of six studies
suggested that a higher dose could be more beneficial in children with severe disease [15].
Overall, children treated with corticosteroids have fewer return visits or admissions to the
hospital. Fully one-half of children with mild croup treated with corticosteroids are unlikely
to need further medical care for ongoing symptoms. Their sleep is improved and their
parents report less stress [2]. In children with moderate to severe croup treated with
corticosteroids, there was a reported average reduction of 12 hours in length of stay in the
ED or hospital. There was a 10% reduction in the need for treatment with nebulized
epinephrine and a 50% reduction in both the number of return visits and in hospitalization
rates [14]. There have been no adverse events associated with a single dose of
corticosteroids for treatment of croup.
Epinephrine
Nebulized epinephrine is recommended for moderate to severe croup. Reports of
administering epinephrine in children with severe croup have demonstrated a lower number
of cases requiring intubation or tracheotomy [19]. When compared with a placebo,
nebulized epinephrine improved signs of respiratory distress within 10 to 30 minutes of
initiating treatment. Clinical effect is sustained for at least 1 hour, but disappears after 2
hours [19]. The first prospective trial assessing safe discharge after treating paediatric
outpatients with a combination of dexamethasone and nebulized epinephrine, and including
observation for 2 to 4 hours, supported the safety of this measure [20]. There were no
adverse outcomes. These results, along with data from two retrospective cohort studies,
clearly support the safe discharge of children, providing that symptoms of croup do not
recur 2 to 4 hours after treatment [1][21][22].
Traditionally, racemic epinephrine has been used to treat children with croup. Racemic
epinephrine is not readily available in Canada. However, one randomized controlled trial
demonstrated that nebulized 1:1000 L-epinephrine is safe and equally effective. Equivalent
doses of either 0.5 mL racemic epinephrine or 5 mL of 1:1000 L-epinephrine are equally
effective. These standard doses can be used in all patients irrespective of their age and
weight [23].

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Heliox
A heliox or helium-oxygen mixture can reduce respiratory distress in children with severe
croup. A possible mechanism of action is that the lower density of helium gas decreases
airflow turbulence in a narrowed airway. Heliox is occasionally used in severe cases to
avoid intubation. Heliox has not been shown to improve croup symptoms when compared
with standard treatments and therefore is not routinely recommended [24].
Other therapies
The use of antibiotics and short-acting beta-2-agonist bronchodilators in children with
typical croup are rarely indicated because of the low incidence of bacterial infection
(<1:1000 cases of croup) as well as for physiological reasons. An otorhinolaryngology
(ORL) consultation for airway evaluation is indicated when croup symptoms are persistently
severe despite treatment. Outpatient referral to ORL is recommended for children with
multiple croup episodes and for those who present outside the usual age group for typical
croup (Figure 1).

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Algorithm for the outpatient management of crop in children, by level of severity.

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Acknowledgements
This practice point has been reviewed by the Community Paediatrics and Infectious
Diseases and Immunization Committees of the Canadian Paediatric Society, as well as by
the CPS Paediatric Emergency Section Executive.
CANADIAN PAEDIATRIC SOCIETY ACUTE CARE COMMITTEE
Members: Carolyn Beck MD, Laurel Chauvin-Kimoff MD (Chair), Isabelle Chevalier MD
(Board Representative), Catherine Farrell MD (past member), Jeremy Friedman MD (past
member), Kristina Krmpotic MD, Kyle McKenzie MD, Oliva Ortiz-Alvarez MD, Evelyne D.
Trottier MD
Liaisons: Dominic Allain MD, CPS Paediatric Emergency Section; Niraj Mistry MD, CPS
Hospital Paediatrics Section
Principal author: Oliva Ortiz-Alvarez MD

References
Bjornson CL, Johnson DW. Croup in children. CMAJ 2013;185(15):1317–23.
Bjornson CL, Klassen TP, Williamson J, et al.; Pediatric Emergency Research Canada
Network. A randomized trial of a single dose of oral dexamethasone for mild croup. N Engl
J Med 2004;351(13):1306–13.
Rosychuk RJ, Klassen TP, Metes D, Voaklander DC, Senthilselvan A, Rowe BH. Croup
presentations to emergency departments in Alberta, Canada: A large population-based
study. Pediatr Pulmonol 2010;45(1):83–91.
McEniery J, Gillis J, Kilham H, Benjamin B. Review of intubation in severe
laryngotracheobronchitis. Pediatrics 1991;87(6):847–53.
Hampers LC, Faries SG. Practice variation in the emergency management of croup.
Pediatrics 2002;109(3):505–8.
Johnson DW, Craig W, Brant R , Mitton C, Svenson L, Klassen TP. A cluster randomized
controlled trial comparing three methods of disseminating practice guidelines for children
with croup [ISRCTN73394937]. Implement Sci 2006;(1):10.
Rihkanen H, Rönkkö E, Nieminen T, et al. Respiratory viruses in laryngeal croup of young
children. J Pediatr 2008;152(5):661–5.
Rosychuk RJ, Klassen TP, Voaklander DC, Senthilselvan A, Rowe BH. Seasonality patterns
in croup presentations to emergency departments in Alberta, Canada: A time series
analysis. Pediatr Emerg Care 2011;27(4):256–60.
Bjornson CL, Johnson DW. Croup in the paediatric emergency department. Paediatr Child
Health 2007;12(6):473–7.
Fitzgerald DA. The assessment and management of croup. Paediatr Respir Rev 2006;7
(1):73–81.
Chan A, Langley J, Leblanc J. Interobserver variability of croup scoring in clinical practice.
Paediatr Child Health 2001;6(6):347–51.
Toward Optimized Practice. Diagnosis and Management of Croup. Clinical Practice
Guideline, January 2008. www.topalbertadoctors.org/download/252/croup_guideline.pdf
(Accessed September 27, 2016).

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Moore M, Little P. Humidified air inhalation for treating croup. Cochrane Database Syst Rev
2006;(3):CD002870.
Russell KF, Liang Y, O’Gorman K, Johnson DW, Klassen TP. Glucocorticoids for croup.
Cochrane Database Syst Rev 2011;(1):CD001955.
Kairys SW, Olmstead EM, O’Connor GT. Steroid treatment of laryngotracheitis: A metaanalysis of the evidence from randomized trials. Pediatrics 1989;83(5):683–93.
Ausejo M, Saenz A, Pham B, et al. The effectiveness of glucocorticoids in treating croup:
Meta-analysis. BMJ 1999;319(7210):595–600.
Geelhoed GC. Budesonide offers no advantage when added to oral dexamethasone in the
treatment of croup. Pediatr Emerg Care 2005;21(6):359–62.
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(6):362–8.
Bjornson C, Russell KF, Vandermeer B, Durec T, Klassen TP, Johnson DW. 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(6):613–6.
Kelley PB, Simon JE. Racemic epinephrine use in croup and disposition. Am J Emerg Med
1992;10(3):181–3.
Corneli HM, Bolte RG. Outpatient use of racemic epinephrine in croup. Am Fam Physician
1992;46(3):683–4.
Zhang L, Sanguebsche LS. The safety of nebulization with 3 to 5 ml of adrenaline (1:1000)
in children: An evidence based review. J Pediatr (Rio J) 2005;81(3):193–7.
Moraa I, Sturman N, McGuire T, van Driel ML. Heliox for croup in children. Cochrane
Database Syst Rev 2013;(12):CD006822.
Disclaimer: The recommendations in this position statement do not indicate an exclusive
course of treatment or procedure to be followed. Variations, taking into account individual
circumstances, may be appropriate. Internet addresses are current at time of publication.
Last updated: Nov 10 2017
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