Croup

Observe the child while seated with a caregiver and obtain the history without provoking distress. Assess stridor at rest, retractions, air entry, mental status, color, fatigue, and ability to handle secretions. Repeated examinations are necessary because upper-airway obstruction may progress rapidly. ScienceDirectScienceDirectThe assessment and management of croup

Pulse oximetry is useful as an adjunct but cannot exclude severe croup: oxygen saturation can remain near normal despite severe upper-airway obstruction, while lower saturations in otherwise mild-to-moderate presentations may reflect associated lower-airway disease. ScienceDirectScienceDirectThe assessment and management of croup

Treat a child with decreased air entry, cyanosis, altered consciousness, marked exhaustion, or progressive respiratory distress as impending respiratory failure. A Westley score greater than 12 suggests likely respiratory failure, although the score is used primarily in research rather than as a replacement for bedside assessment. PubMedPubMedCHILDHOOD RESPIRATORY DISORDERS - Nursing Health Promotion - NCBI Bookshelf

A barking or brassy cough with hoarseness and inspiratory stridor supports viral croup. The most consequential alternate diagnoses are epiglottitis, bacterial tracheitis, deep-neck infection, anaphylaxis or airway edema, and airway foreign body. ScienceDirect+2ScienceDirectStridor - an overview | ScienceDirect TopicsPubMedCroup in Children (Acute Laryngotracheobronchitis)PubMedA cluster randomized controlled trial comparing three methods of disseminating practice guidelines for children with croup [ISRCTN73394937]

High fever, rapid clinical progression, toxic appearance, drooling, and absent brassy cough are characteristic warning features for bacterial epiglottitis or tracheitis rather than uncomplicated viral croup. Avoid treating this pattern as routine croup simply because stridor is present. PubMedPubMedCroup in Children (Acute Laryngotracheobronchitis)

Failure to improve after nebulized epinephrine and corticosteroids should raise concern for bacterial tracheitis. It may complicate croup; lateral neck radiography may show tracheal mucosal-wall or air-column irregularity, described as a candle-dripping appearance, while chest radiography may identify concomitant pneumonia. PubMedPubMedBacterial Tracheitis - StatPearls - NCBI Bookshelf

Croup is primarily a clinical diagnosis. Nasopharyngeal viral cultures or aspirates can establish viral etiology but are generally confined to research settings and do not direct acute treatment. PubMedPubMedCroup - StatPearls - NCBI Bookshelf - NIH

Obtain anteroposterior and lateral neck radiographs only when the diagnosis is uncertain and airway stability permits. A steeple sign or symmetric subglottic narrowing can support croup; a lateral thumb sign supports epiglottitis. Neither image should delay management of a child with suspected critical upper-airway obstruction. ScienceDirect+1ScienceDirectCroup - an overview | ScienceDirect TopicsScienceDirectStridor - an overview | ScienceDirect Topics

Chest radiography has limited diagnostic value for bacterial tracheitis but may show concurrent pneumonia, reported in approximately 50% of cases; concomitant pneumonia is associated with greater severity and a higher likelihood of endotracheal intubation. Computed tomography is typically not used for initial bacterial-tracheitis diagnosis. PubMedPubMedBacterial Tracheitis - StatPearls - NCBI Bookshelf

Administer dexamethasone to children with croup requiring medical treatment. In a randomized trial of mild croup, a single oral dose accelerated symptom resolution, reduced lost sleep, and reduced parental stress. NEJMNEJMA Randomized Trial of a Single Dose of Oral ... High-quality trial evidence supports one outpatient dexamethasone dose, although inpatient repeat-dose strategies lack comparable trial evidence. WileyWileyDexamethasone regime and clinical outcomes in children ...

For severe croup when the oral route is not feasible or when parenteral administration is needed, dexamethasone 0.6 mg/kg can be given parenterally; one study used a maximum of 8 mg. WileyWileyViral croup: Diagnosis and a treatment algorithm Dexamethasone doses of 0.15 to 0.6 mg/kg have been used in croup studies and standard treatment descriptions. Wiley+1WileyOral dexamethasone in the treatment of croup: 0.15 mg/kg ...ScienceDirectEfficacy of low-dose nebulized epinephrine as treatment for croup: A randomized, placebo-controlled, double-blind trial - ScienceDirect

Nebulized budesonide is an alternative corticosteroid approach, but oral dexamethasone produced outcomes as good as nebulized budesonide alone or combined budesonide-dexamethasone in outpatients with mild-to-moderate croup. Dexamethasone is easier to administer, less expensive, and more widely available; do not add budesonide routinely to dexamethasone for a small score-only advantage. JAMAJAMANebulized Budesonide and Oral Dexamethasone for Treatment of Croup : A Randomized Controlled Trial

Use nebulized epinephrine for moderate-to-severe croup when rapid temporary reduction in airway obstruction is needed. In a randomized trial, both 0.1 mg/kg and 0.5 mg/kg of nebulized 1:1000 L-epinephrine improved croup scores by 30 minutes, and the lower dose was not inferior for score reduction; conventional dosing described in the study was 0.5 mg/kg to a maximum of 5 mg. ScienceDirectScienceDirectEfficacy of low-dose nebulized epinephrine as treatment for croup: A randomized, placebo-controlled, double-blind trial - ScienceDirect Pair epinephrine with dexamethasone rather than relying on temporary symptom relief alone. The Lancet+1The LancetCroupWileyThe Child with Breathing Difficulties

After nebulized epinephrine, repeat assessment of stridor at rest, retractions, air entry, oxygenation, color, and mental status. Epinephrine is effective for temporary relief, so clinical improvement shortly after treatment does not eliminate the need to observe for recurrent obstruction or an alternative diagnosis. The Lancet+2The LancetCroupScienceDirectThe assessment and management of croupScienceDirectEfficacy of low-dose nebulized epinephrine as treatment for croup: A randomized, placebo-controlled, double-blind trial - ScienceDirect

Escalate care for persistent or worsening stridor at rest, increasing retractions, diminished air entry, cyanosis, fatigue, altered consciousness, inability to tolerate oral intake because of respiratory distress, or a toxic febrile presentation. In these situations, prioritize airway management and reconsider bacterial tracheitis, epiglottitis, deep-neck infection, or foreign body. PubMed+2PubMedCroup in Children (Acute Laryngotracheobronchitis)PubMedBacterial Tracheitis - StatPearls - NCBI BookshelfPubMedCHILDHOOD RESPIRATORY DISORDERS - Nursing Health Promotion - NCBI Bookshelf

Children with recurrent croup merit evaluation for structural or acquired airway disease. Otolaryngology involvement is appropriate within a multidisciplinary assessment; children younger than 1 or 3 years with recurrent croup and a history of intubation have been identified as a group for consideration of triple endoscopy. PubMedPubMedCroup - StatPearls - NCBI Bookshelf - NIH