Croup and Stridor In ChildrenAPPROACH

PEDIATRICS · 19 SECTIONS

⚲

543 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Fever In The Neonate And Young Infant Pediatric Fever By Age 0 To 28 Days Pediatric Fever By Age 29 To 60 Days Pediatric Fever By Age 2 To 24 Months Pediatric Respiratory Distress Croup And Stridor In Children Pediatric Dehydration Pediatric Abdominal Pain Febrile Seizure Rash In The Child Poor Feeding And Lethargy In The Infant Vomiting In The Child Diarrhea In The Child Pediatric Trauma Evaluation Brief Resolved Unexplained Event In The Infant And Apparent Life Threatening Event Concern Lethargy And Altered Mental Status In The Child

Environmental and Exposure4▾

01History/hx76

Presenting pattern

›Croup and stridor history anchors

›Barky cough

›Stridor

›Hoarse voice

›Viral prodrome

›Fever pattern

›Nighttime worsening

›Prior croup episodes

›Prior intubation

›Baseline airway anomalies

›Immunization status

›Hib vaccine status

›Sudden onset choking episode

›Possible foreign body exposure

›Drooling

›Dysphagia

›Muffled voice

›Neck pain

›Neck stiffness

›Toxic appearance timeline

›Recent airway instrumentation

›Recent ENT procedure

›Known allergy exposure

›Angioedema history

›History of asthma

›History of anaphylaxis

OPQRST

›Onset

›Time of onset

›Sudden onset

›Gradual onset

›Provocation and palliation

›Worse with agitation

›Worse when supine

›Better when upright

›Response to cool air

›Response to prior dexamethasone

›Response to prior nebulized epinephrine

›Quality

›Barky cough quality

›Inspiratory stridor quality

›Biphasic stridor quality

›Voice change quality

›Region and radiation

›Upper airway localization symptoms

›Chest symptoms suggesting lower airway

›Severity

›Stridor at rest

›Retractions severity

›Feeding difficulty severity

›Sleep disruption

›Ability to speak

›Timing

›Intermittent stridor

›Persistent stridor

›Progressive course

Associated symptoms

›Associated symptoms set

›Rhinorrhea

›Sore throat

›Cough

›Wheeze

›Increased work of breathing

›Apnea

›Cyanosis

›Vomiting

›Dehydration symptoms

›Rash

›Urticaria

›Facial swelling

›Chest pain

›Hemoptysis

Prior episodes and baseline

›Recurrent stridor framework

›Episodes before age 6 months

›Frequent episodes

›Poor response to standard therapy

›History of GERD symptoms

›History of noisy breathing at baseline

02Alarm Features/alarm30

Airway and breathing red flags

›Immediate danger features

›Stridor at rest with fatigue

›Silent chest

›Minimal air movement

›Cyanosis

›Apnea

›Altered level of consciousness

›Severe retractions

›Tripod position

›Drooling

›Unable to swallow secretions

›Muffled voice

›Rapid progression over minutes

›Suspected foreign body

›Suspected epiglottitis

›Suspected anaphylaxis

›Neck swelling

›Floor of mouth swelling

Vital sign danger thresholds

›High risk vitals patterns

›SpO2 below 92 percent on room air

›Severe tachypnea for age

›Marked tachycardia out of proportion to fever

›Hypotension

Escalation triggers

›Escalate immediately if

›Poor response to nebulized epinephrine within 10 to 20 minutes

›Recurrent stridor after initial improvement

›Need for repeated nebulized epinephrine

›Persistent stridor at rest after dexamethasone

›Concern for alternate diagnosis

›Any impending respiratory failure signs

03Medications/meds44

Current and recent exposures

›Medication and exposure inventory

›Recent dexamethasone

›Recent nebulized epinephrine

›Recent bronchodilator trial

›Recent antibiotics

›Recent sedation

›Recent opioids

›Recent antihistamines

›ACE inhibitor exposure in household

›Beta blocker exposure in household

ED therapies and dosing

›Croup medication core

›Dexamethasone

›0.6 mg per kg PO

›0.6 mg per kg IM

›0.6 mg per kg IV

›Maximum 10 mg

›Lower dose options local protocol dependent

›0.15 mg per kg

›0.3 mg per kg

›Nebulized epinephrine for moderate to severe

›Racemic epinephrine 2.25 percent

›0.05 mL per kg nebulized

›Maximum 0.5 mL

›L epinephrine 1 mg per mL

›0.5 mL per kg nebulized

›Maximum 5 mL

›Onset expected within 10 to 30 minutes

›Duration about 2 hours

›Rebound monitoring required

›Nebulized budesonide alternative or adjunct

›2 mg nebulized once

›Use when unable to take systemic steroid

›Oxygen

›Titrate to SpO2 at least 94 percent

›Blow by oxygen to minimize agitation

›Heliox adjunct for severe distress

›70 percent helium 30 percent oxygen if available

›Bridge while preparing definitive airway plan

Contraindications and do not do

›Safety cautions

›Avoid agitating procedures in suspected epiglottitis

›Avoid routine throat exam with tongue depressor in suspected epiglottitis

›Avoid sedatives unless airway plan and monitoring in place

›Avoid beta agonists as primary therapy for isolated stridor without wheeze

›Avoid antibiotics for uncomplicated viral croup

04Diet/diet11

Intake and hydration

›Hydration and intake status

›Oral intake tolerance

›Wet diapers count

›Vomiting limiting intake

›Signs of dehydration

Triggering exposures

›Dietary and inhalational exposures

›Honey ingestion in infants

›Caustic ingestion risk

›Smoke exposure

›Vaping exposure

›Allergen exposure

05Review of Systems/ros23

Respiratory

›Respiratory symptoms

›Stridor

›Wheeze

›Cough

›Shortness of breath

›Apnea

›Cyanosis

ENT

›Upper airway symptoms

›Sore throat

›Drooling

›Dysphonia

›Dysphagia

›Neck swelling

Infectious and systemic

›Systemic symptoms

›Fever

›Lethargy

›Poor feeding

›Rash

Allergy

›Allergy symptoms

›Urticaria

›Facial swelling

›Lip swelling

›Vomiting after exposure

06Collateral History and Family History/chafh9

Collateral source and reliability

›Source context

›Caregiver present

›EMS report

›Daycare report

›Witnessed choking history

Family history

›Relevant family conditions

›Atopy history

›Asthma history

›Hereditary angioedema history

07Risk Factors/rf17

Host and anatomic risks

›High risk patient features

›Age under 6 months

›Prematurity

›Known airway anomaly

›Subglottic stenosis history

›Neuromuscular weakness

›Immunocompromised state

›Incomplete immunizations

Exposure risks

›Environmental and infectious exposures

›Sick contacts

›Daycare attendance

›Secondhand smoke

›Recent travel

Procedure and device risks

›Iatrogenic risks

›Recent intubation

›Recent airway surgery

›Recent endoscopy

08Differential Diagnosis/ddx62

Life threatening

›Life threatening causes of stridor

›Epiglottitis (J05.1)

›Drooling

›Toxic appearance

›Tripod position

›Minimal cough

›Bacterial tracheitis

›Toxic appearance

›High fever

›Poor response to nebulized epinephrine

›Foreign body aspiration (T17)

›Sudden onset

›Witnessed choking

›Focal wheeze

›Unilateral decreased breath sounds

›Anaphylaxis (T78.2)

›Urticaria

›Angioedema

›Hypotension

›Retropharyngeal abscess

›Neck stiffness

›Limited neck extension

›Drooling

›Peritonsillar abscess

›Muffled voice

›Trismus

›Uvular deviation

›Airway burn or inhalation injury

›Soot

›Facial burns

›Hoarseness

Common

›Common causes

›Viral croup (acute laryngotracheitis) (J05.0)

›Barky cough

›Hoarseness

›Inspiratory stridor

›Viral URI with laryngitis

›Hoarseness predominant

›Minimal stridor

›Asthma with upper airway noise mimic

›Expiratory wheeze

›Response to bronchodilator

Less common

›Less common causes

›Laryngomalacia

›Chronic since infancy

›Worse supine

›Subglottic hemangioma

›Progressive stridor

›Poor response to croup therapy

›Vocal cord paralysis

›Weak cry

›Aspiration

›Diphtheria

›Pseudomembrane

›Unvaccinated

Mimics and pitfalls

›Mimics and pitfalls

›Bronchiolitis with transmitted upper airway sounds

›Diffuse crackles

›Wheeze

›Psychogenic stridor

›Normal oxygenation

›Variable symptoms with distraction

09Past Medical History/pmh17

Relevant conditions

›Key PMH for stridor

›Prior croup admissions

›Prior ICU admission

›Prior intubation history

›Known congenital airway disorder

›Chronic lung disease of prematurity

›Congenital heart disease

›GERD history

›Neuromuscular disease

Surgical and procedural history

›Airway related procedures

›Prior ENT surgery

›Prior endoscopy

›Recent dental procedure

Baseline status

›Baseline functional status

›Feeding baseline

›Sleep baseline

›Home oxygen use

10Physical Exam/exam39

General appearance

›Toxicity and work of breathing

›Level of consciousness

›Ability to console

›Hydration status

›Color

›Posture

Vitals interpretation

›Vitals patterns

›Fever severity

›Tachycardia severity

›Tachypnea severity

›SpO2 trend

Airway and ENT

›Upper airway focused exam

›Stridor at rest

›Stridor with agitation

›Voice quality

›Drooling

›Trismus

›Neck tenderness

›Neck range of motion

›Oropharynx inspection only if safe

Respiratory

›Lung and breathing exam

›Retractions location

›Nasal flaring

›Air entry

›Wheeze

›Crackles

›Prolonged expiratory phase

Cardiovascular

›Perfusion and hemodynamics

›Capillary refill

›Pulses

›Heart rate rhythm

Neurologic

›Neuro status

›Agitation

›Lethargy

›Tone

Skin

›Skin and allergy signs

›Urticaria

›Angioedema

›Rash

11Lab Studies/labs17

When labs help

›Lab strategy

›No routine labs for typical mild to moderate croup

›Labs if toxic appearance

›Labs if severe respiratory distress

Targeted labs for severe or alternate diagnosis

›Targeted labs

›Venous blood gas if impending failure

›Rising CO2 concern

›Worsening acidosis concern

›CBC if suspected bacterial tracheitis

›Leukocytosis support

›Not diagnostic alone

›Blood culture if septic appearance

›Before antibiotics if feasible

›Do not delay airway stabilization

›Respiratory viral testing local protocol dependent

›Cohorting utility

›Does not change acute management in most cases

12Imaging/img44

Scoring Systems

›Westley croup score use

›When to use

›Standardize severity description

›Track response over time

›When not to use

›Suspected epiglottitis

›Suspected foreign body

›Components

›Stridor

›Retractions

›Air entry

›Cyanosis

›Level of consciousness

›Interpretation

›Mild typical outpatient pathway

›Moderate consider nebulized epinephrine

›Severe high risk airway deterioration

MRI

›MRI role

›Not first line in acute stridor

›Consider for structural lesion workup after stabilization

›Requires sedation risk assessment

›CT indications after stabilization

›Suspected deep neck space infection

›Suspected abscess with airway symptoms

›Persistent stridor with atypical course

›Contrast allergy considerations

›Radiation risk considerations

Ultrasound

›Ultrasound role

›Neck soft tissue evaluation adjunct

›Lymph node and abscess screening adjunct

›Limited role for subglottic assessment

Plain radiography

›X ray indications

›Atypical presentation

›Poor response to standard therapy

›Suspected foreign body

›Suspected epiglottitis only if stable and escorted

›Suspected bacterial tracheitis

›Neck radiograph pearls

›Steeple sign supports croup but not required

›Thumb sign supports epiglottitis

›Normal film does not exclude dangerous causes

›Chest radiograph pearls

›Unilateral hyperinflation suggests foreign body

›Atelectasis is nonspecific

13Special Tests/spec13

Airway evaluation

›Airway tests and procedures

›Flexible nasolaryngoscopy

›ENT setting after stabilization

›Not for unstable child in ED without airway plan

›Direct laryngoscopy

›OR setting if suspected epiglottitis

›Coordinate anesthesia and ENT

›Bronchoscopy

›Suspected foreign body

›Persistent unexplained stridor

Bedside response tests

›Treatment response as diagnostic support

›Improvement after nebulized epinephrine supports croup physiology

›Lack of improvement raises alternate diagnosis concern

14ECG/ecg8

When ECG is relevant

›ECG considerations

›Severe tachycardia after epinephrine

›Known congenital heart disease

›Electrolyte abnormality concern

High risk patterns

›ECG red flags

›Supraventricular tachycardia

›Wide complex tachycardia

›Ischemic changes rare in children

15Assessment/ax20

Working diagnosis and severity

›Viral croup (J05.0) assessment frame

›Severity by stridor

›None at rest

›Present at rest

›Severity by work of breathing

›Mild retractions

›Moderate retractions

›Severe retractions

›Air entry

›Normal

›Decreased

›Oxygenation

›Normal on room air

›Hypoxemia present

Complications and alternate diagnoses

›Alternate diagnosis screen

›Epiglottitis concern features present

›Foreign body concern features present

›Bacterial tracheitis concern features present

›Anaphylaxis concern features present

›Deep neck infection concern features present

16Plan/plan55

Approach to the critical patient first 5 minutes

›First 5 minutes workflow

›Minimize agitation

›Caregiver presence if calming

›Position of comfort

›Continuous pulse oximetry

›Cardiorespiratory monitor if moderate to severe

›Oxygen blow by if needed

›Nebulized epinephrine if stridor at rest

›Dexamethasone as early as possible

›IV access if severe distress

›Airway team activation triggers

›Fatigue

›Altered mental status

›Poor air entry

›Cyanosis

›Drooling with toxic appearance

Therapeutics by severity

›Mild

›Single dose dexamethasone

›Supportive care

›Moderate

›Dexamethasone

›Nebulized epinephrine

›Observation for recurrence

›Severe

›Dexamethasone

›Repeated nebulized epinephrine as needed

›Heliox if available

›Prepare advanced airway pathway

Reassessment loop

›Reassessment loop timing

›Recheck within 15 to 30 minutes after nebulized epinephrine

›Recheck within 30 to 60 minutes after dexamethasone if initial mild

›Repeat vitals each reassessment

›Repeat work of breathing assessment each reassessment

›Repeat stridor at rest assessment each reassessment

›Reassessment triggers for escalation

›Worsening retractions

›New hypoxemia

›Diminished air entry

›Exhaustion signs

Consultation plan

›Consult triggers

›ENT for suspected epiglottitis

›ENT for suspected foreign body airway

›PICU for severe or recurrent epinephrine need

›Anesthesia for high risk airway

Special populations and nuances

›Recurrent or atypical croup

›Consider anatomic lesion evaluation after stabilization

›Consider reflux contribution evaluation after stabilization

›Suspected epiglottitis pathway

›Keep child calm

›Avoid throat instrumentation

›Controlled airway in OR plan

›Suspected anaphylaxis pathway

›IM epinephrine 0.01 mg per kg of 1 mg per mL

›Maximum 0.5 mg per dose

›Repeat every 5 to 15 minutes if needed

17Disposition/dispo28

Level of care criteria

›ICU criteria

›Persistent severe distress after therapy

›Repeated nebulized epinephrine requirement

›Hypoxemia requiring high flow oxygen

›Hypercapnia concern

›Impending respiratory failure signs

›Inpatient admission criteria

›Persistent stridor at rest after observation

›Need for ongoing oxygen

›Dehydration requiring IV fluids

›Suspicion of bacterial tracheitis

›Unreliable follow up

›Observation pathway criteria

›Received nebulized epinephrine

›Monitor at least 2 to 3 hours after last dose

›Discharge only if no recurrence

Discharge criteria

›Safe discharge features

›No stridor at rest

›Minimal or no retractions

›Normal oxygenation on room air

›Adequate oral intake

›Caregivers understand return precautions

›Access to follow up

Transfer criteria

›Transfer triggers

›No pediatric airway capability locally

›Suspected epiglottitis

›Suspected foreign body requiring bronchoscopy

›Need for PICU not available

18Discharge Instructions/di21

Copy discharge instructions

›Diagnosis and expectations

›Croup causes swelling in the upper airway and can cause a barking cough and noisy breathing

›Symptoms often worsen at night and usually improve over a few days

›Medications given today

›Steroid dose given to reduce airway swelling

›If a breathing treatment was given it may wear off in a few hours

›Home care

›Keep your child calm and sitting upright

›Offer frequent fluids

›Use cool or humidified air if it helps

›Return to the emergency department now if

›Noisy breathing at rest

›Breathing is getting harder

›Skin looks blue or gray

›Pauses in breathing

›Drooling or trouble swallowing

›Very sleepy or hard to wake

›Signs of dehydration

›Follow up

›Primary care follow up within 1 to 2 days

›Earlier follow up if symptoms worsen

19References/r9

Guidelines and key sources

›Evidence based sources

›American Academy of Pediatrics clinical guidance on croup and upper airway obstruction local protocol dependent

›Canadian Paediatric Society practice point on croup year local protocol dependent

›Cochrane review on glucocorticoids for croup updated year local protocol dependent

›Cochrane review on nebulized epinephrine for croup updated year local protocol dependent

›Infectious Diseases Society guidance relevant to epiglottitis and deep neck infections local protocol dependent

›Source file

›Project instructions followed for formatting

›Point of care checklist structure

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.

Croup and Stridor In ChildrenAPPROACH

PEDIATRICS · 19 SECTIONS

⚲

543 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx76

Presenting pattern

›Croup and stridor history anchors

›Barky cough

›Stridor

›Hoarse voice

›Viral prodrome

›Fever pattern

›Nighttime worsening

›Prior croup episodes

›Prior intubation

›Baseline airway anomalies

›Immunization status

›Hib vaccine status

›Sudden onset choking episode

›Possible foreign body exposure

›Drooling

›Dysphagia

›Muffled voice

›Neck pain

›Neck stiffness

›Toxic appearance timeline

›Recent airway instrumentation

›Recent ENT procedure

›Known allergy exposure

›Angioedema history

›History of asthma

›History of anaphylaxis

OPQRST

›Onset

›Time of onset

›Sudden onset

›Gradual onset

›Provocation and palliation

›Worse with agitation

›Worse when supine

›Better when upright

›Response to cool air

›Response to prior dexamethasone

›Response to prior nebulized epinephrine

›Quality

›Barky cough quality

›Inspiratory stridor quality

›Biphasic stridor quality

›Voice change quality

›Region and radiation

›Upper airway localization symptoms

›Chest symptoms suggesting lower airway

›Severity

›Stridor at rest

›Retractions severity

›Feeding difficulty severity

›Sleep disruption

›Ability to speak

›Timing

›Intermittent stridor

›Persistent stridor

›Progressive course

Associated symptoms

›Associated symptoms set

›Rhinorrhea

›Sore throat

›Cough

›Wheeze

›Increased work of breathing

›Apnea

›Cyanosis

›Vomiting

›Dehydration symptoms

›Rash

›Urticaria

›Facial swelling

›Chest pain

›Hemoptysis

Prior episodes and baseline

›Recurrent stridor framework

›Episodes before age 6 months

›Frequent episodes

›Poor response to standard therapy

›History of GERD symptoms

›History of noisy breathing at baseline

02Alarm Features/alarm30

Airway and breathing red flags

›Immediate danger features

›Stridor at rest with fatigue

›Silent chest

›Minimal air movement

›Cyanosis

›Apnea

›Altered level of consciousness

›Severe retractions

›Tripod position

›Drooling

›Unable to swallow secretions

›Muffled voice

›Rapid progression over minutes

›Suspected foreign body

›Suspected epiglottitis

›Suspected anaphylaxis

›Neck swelling

›Floor of mouth swelling

Vital sign danger thresholds

›High risk vitals patterns

›SpO2 below 92 percent on room air

›Severe tachypnea for age

›Marked tachycardia out of proportion to fever

›Hypotension

Escalation triggers

›Escalate immediately if

›Poor response to nebulized epinephrine within 10 to 20 minutes

›Recurrent stridor after initial improvement

›Need for repeated nebulized epinephrine

›Persistent stridor at rest after dexamethasone

›Concern for alternate diagnosis

›Any impending respiratory failure signs

03Medications/meds44

Current and recent exposures

›Medication and exposure inventory

›Recent dexamethasone

›Recent nebulized epinephrine

›Recent bronchodilator trial

›Recent antibiotics

›Recent sedation

›Recent opioids

›Recent antihistamines

›ACE inhibitor exposure in household

›Beta blocker exposure in household

ED therapies and dosing

›Croup medication core

›Dexamethasone

›0.6 mg per kg PO

›0.6 mg per kg IM

›0.6 mg per kg IV

›Maximum 10 mg

›Lower dose options local protocol dependent

›0.15 mg per kg

›0.3 mg per kg

›Nebulized epinephrine for moderate to severe

›Racemic epinephrine 2.25 percent

›0.05 mL per kg nebulized

›Maximum 0.5 mL

›L epinephrine 1 mg per mL

›0.5 mL per kg nebulized

›Maximum 5 mL

›Onset expected within 10 to 30 minutes

›Duration about 2 hours

›Rebound monitoring required

›Nebulized budesonide alternative or adjunct

›2 mg nebulized once

›Use when unable to take systemic steroid

›Oxygen

›Titrate to SpO2 at least 94 percent

›Blow by oxygen to minimize agitation

›Heliox adjunct for severe distress

›70 percent helium 30 percent oxygen if available

›Bridge while preparing definitive airway plan

Contraindications and do not do

›Safety cautions

›Avoid agitating procedures in suspected epiglottitis

›Avoid routine throat exam with tongue depressor in suspected epiglottitis

›Avoid sedatives unless airway plan and monitoring in place

›Avoid beta agonists as primary therapy for isolated stridor without wheeze

›Avoid antibiotics for uncomplicated viral croup

04Diet/diet11

Intake and hydration

›Hydration and intake status

›Oral intake tolerance

›Wet diapers count

›Vomiting limiting intake

›Signs of dehydration

Triggering exposures

›Dietary and inhalational exposures

›Honey ingestion in infants

›Caustic ingestion risk

›Smoke exposure

›Vaping exposure

›Allergen exposure

05Review of Systems/ros23

Respiratory

›Respiratory symptoms

›Stridor

›Wheeze

›Cough

›Shortness of breath

›Apnea

›Cyanosis

ENT

›Upper airway symptoms

›Sore throat

›Drooling

›Dysphonia

›Dysphagia

›Neck swelling

Infectious and systemic

›Systemic symptoms

›Fever

›Lethargy

›Poor feeding

›Rash

Allergy

›Allergy symptoms

›Urticaria

›Facial swelling

›Lip swelling

›Vomiting after exposure

06Collateral History and Family History/chafh9

Collateral source and reliability

›Source context

›Caregiver present

›EMS report

›Daycare report

›Witnessed choking history

Family history

›Relevant family conditions

›Atopy history

›Asthma history

›Hereditary angioedema history

07Risk Factors/rf17

Host and anatomic risks

›High risk patient features

›Age under 6 months

›Prematurity

›Known airway anomaly

›Subglottic stenosis history

›Neuromuscular weakness

›Immunocompromised state

›Incomplete immunizations

Exposure risks

›Environmental and infectious exposures

›Sick contacts

›Daycare attendance

›Secondhand smoke

›Recent travel

Procedure and device risks

›Iatrogenic risks

›Recent intubation

›Recent airway surgery

›Recent endoscopy

08Differential Diagnosis/ddx62

Life threatening

›Life threatening causes of stridor

›Epiglottitis (J05.1)

›Drooling

›Toxic appearance

›Tripod position

›Minimal cough

›Bacterial tracheitis

›Toxic appearance

›High fever

›Poor response to nebulized epinephrine

›Foreign body aspiration (T17)

›Sudden onset

›Witnessed choking

›Focal wheeze

›Unilateral decreased breath sounds

›Anaphylaxis (T78.2)

›Urticaria

›Angioedema

›Hypotension

›Retropharyngeal abscess

›Neck stiffness

›Limited neck extension

›Drooling

›Peritonsillar abscess

›Muffled voice

›Trismus

›Uvular deviation

›Airway burn or inhalation injury

›Soot

›Facial burns

›Hoarseness

Common

›Common causes

›Viral croup (acute laryngotracheitis) (J05.0)

›Barky cough

›Hoarseness

›Inspiratory stridor

›Viral URI with laryngitis

›Hoarseness predominant

›Minimal stridor

›Asthma with upper airway noise mimic

›Expiratory wheeze

›Response to bronchodilator

Less common

›Less common causes

›Laryngomalacia

›Chronic since infancy

›Worse supine

›Subglottic hemangioma

›Progressive stridor

›Poor response to croup therapy

›Vocal cord paralysis

›Weak cry

›Aspiration

›Diphtheria

›Pseudomembrane

›Unvaccinated

Mimics and pitfalls

›Mimics and pitfalls

›Bronchiolitis with transmitted upper airway sounds

›Diffuse crackles

›Wheeze

›Psychogenic stridor

›Normal oxygenation

›Variable symptoms with distraction

09Past Medical History/pmh17

Relevant conditions

›Key PMH for stridor

›Prior croup admissions

›Prior ICU admission

›Prior intubation history

›Known congenital airway disorder

›Chronic lung disease of prematurity

›Congenital heart disease

›GERD history

›Neuromuscular disease

Surgical and procedural history

›Airway related procedures

›Prior ENT surgery

›Prior endoscopy

›Recent dental procedure

Baseline status

›Baseline functional status

›Feeding baseline

›Sleep baseline

›Home oxygen use

10Physical Exam/exam39

General appearance

›Toxicity and work of breathing

›Level of consciousness

›Ability to console

›Hydration status

›Color

›Posture

Vitals interpretation

›Vitals patterns

›Fever severity

›Tachycardia severity

›Tachypnea severity

›SpO2 trend

Airway and ENT

›Upper airway focused exam

›Stridor at rest

›Stridor with agitation

›Voice quality

›Drooling

›Trismus

›Neck tenderness

›Neck range of motion

›Oropharynx inspection only if safe

Respiratory

›Lung and breathing exam

›Retractions location

›Nasal flaring

›Air entry

›Wheeze

›Crackles

›Prolonged expiratory phase

Cardiovascular

›Perfusion and hemodynamics

›Capillary refill

›Pulses

›Heart rate rhythm

Neurologic

›Neuro status

›Agitation

›Lethargy

›Tone

Skin

›Skin and allergy signs

›Urticaria

›Angioedema

›Rash

11Lab Studies/labs17

When labs help

›Lab strategy

›No routine labs for typical mild to moderate croup

›Labs if toxic appearance

›Labs if severe respiratory distress

Targeted labs for severe or alternate diagnosis

›Targeted labs

›Venous blood gas if impending failure

›Rising CO2 concern

›Worsening acidosis concern

›CBC if suspected bacterial tracheitis

›Leukocytosis support

›Not diagnostic alone

›Blood culture if septic appearance

›Before antibiotics if feasible

›Do not delay airway stabilization

›Respiratory viral testing local protocol dependent

›Cohorting utility

›Does not change acute management in most cases

12Imaging/img44

Scoring Systems

›Westley croup score use

›When to use

›Standardize severity description

›Track response over time

›When not to use

›Suspected epiglottitis

›Suspected foreign body

›Components

›Stridor

›Retractions

›Air entry

›Cyanosis

›Level of consciousness

›Interpretation

›Mild typical outpatient pathway

›Moderate consider nebulized epinephrine

›Severe high risk airway deterioration

MRI

›MRI role

›Not first line in acute stridor

›Consider for structural lesion workup after stabilization

›Requires sedation risk assessment

›CT indications after stabilization

›Suspected deep neck space infection

›Suspected abscess with airway symptoms

›Persistent stridor with atypical course

›Contrast allergy considerations

›Radiation risk considerations

Ultrasound

›Ultrasound role

›Neck soft tissue evaluation adjunct

›Lymph node and abscess screening adjunct

›Limited role for subglottic assessment

Plain radiography

›X ray indications

›Atypical presentation

›Poor response to standard therapy

›Suspected foreign body

›Suspected epiglottitis only if stable and escorted

›Suspected bacterial tracheitis

›Neck radiograph pearls

›Steeple sign supports croup but not required

›Thumb sign supports epiglottitis

›Normal film does not exclude dangerous causes

›Chest radiograph pearls

›Unilateral hyperinflation suggests foreign body

›Atelectasis is nonspecific

13Special Tests/spec13

Airway evaluation

›Airway tests and procedures

›Flexible nasolaryngoscopy

›ENT setting after stabilization

›Not for unstable child in ED without airway plan

›Direct laryngoscopy

›OR setting if suspected epiglottitis

›Coordinate anesthesia and ENT

›Bronchoscopy

›Suspected foreign body

›Persistent unexplained stridor

Bedside response tests

›Treatment response as diagnostic support

›Improvement after nebulized epinephrine supports croup physiology

›Lack of improvement raises alternate diagnosis concern

14ECG/ecg8

When ECG is relevant

›ECG considerations

›Severe tachycardia after epinephrine

›Known congenital heart disease

›Electrolyte abnormality concern

High risk patterns

›ECG red flags

›Supraventricular tachycardia

›Wide complex tachycardia

›Ischemic changes rare in children

15Assessment/ax20

Working diagnosis and severity

›Viral croup (J05.0) assessment frame

›Severity by stridor

›None at rest

›Present at rest

›Severity by work of breathing

›Mild retractions

›Moderate retractions

›Severe retractions

›Air entry

›Normal

›Decreased

›Oxygenation

›Normal on room air

›Hypoxemia present

Complications and alternate diagnoses

›Alternate diagnosis screen

›Epiglottitis concern features present

›Foreign body concern features present

›Bacterial tracheitis concern features present

›Anaphylaxis concern features present

›Deep neck infection concern features present

16Plan/plan55

Approach to the critical patient first 5 minutes

›First 5 minutes workflow

›Minimize agitation

›Caregiver presence if calming

›Position of comfort

›Continuous pulse oximetry

›Cardiorespiratory monitor if moderate to severe

›Oxygen blow by if needed

›Nebulized epinephrine if stridor at rest

›Dexamethasone as early as possible

›IV access if severe distress

›Airway team activation triggers

›Fatigue

›Altered mental status

›Poor air entry

›Cyanosis

›Drooling with toxic appearance

Therapeutics by severity

›Mild

›Single dose dexamethasone

›Supportive care

›Moderate

›Dexamethasone

›Nebulized epinephrine

›Observation for recurrence

›Severe

›Dexamethasone

›Repeated nebulized epinephrine as needed

›Heliox if available

›Prepare advanced airway pathway

Reassessment loop

›Reassessment loop timing

›Recheck within 15 to 30 minutes after nebulized epinephrine

›Recheck within 30 to 60 minutes after dexamethasone if initial mild

›Repeat vitals each reassessment

›Repeat work of breathing assessment each reassessment

›Repeat stridor at rest assessment each reassessment

›Reassessment triggers for escalation

›Worsening retractions

›New hypoxemia

›Diminished air entry

›Exhaustion signs

Consultation plan

›Consult triggers

›ENT for suspected epiglottitis

›ENT for suspected foreign body airway

›PICU for severe or recurrent epinephrine need

›Anesthesia for high risk airway

Special populations and nuances

›Recurrent or atypical croup

›Consider anatomic lesion evaluation after stabilization

›Consider reflux contribution evaluation after stabilization

›Suspected epiglottitis pathway

›Keep child calm

›Avoid throat instrumentation

›Controlled airway in OR plan

›Suspected anaphylaxis pathway

›IM epinephrine 0.01 mg per kg of 1 mg per mL

›Maximum 0.5 mg per dose

›Repeat every 5 to 15 minutes if needed

17Disposition/dispo28

Level of care criteria

›ICU criteria

›Persistent severe distress after therapy

›Repeated nebulized epinephrine requirement

›Hypoxemia requiring high flow oxygen

›Hypercapnia concern

›Impending respiratory failure signs

›Inpatient admission criteria

›Persistent stridor at rest after observation

›Need for ongoing oxygen

›Dehydration requiring IV fluids

›Suspicion of bacterial tracheitis

›Unreliable follow up

›Observation pathway criteria

›Received nebulized epinephrine

›Monitor at least 2 to 3 hours after last dose

›Discharge only if no recurrence

Discharge criteria

›Safe discharge features

›No stridor at rest

›Minimal or no retractions

›Normal oxygenation on room air

›Adequate oral intake

›Caregivers understand return precautions

›Access to follow up

Transfer criteria

›Transfer triggers

›No pediatric airway capability locally

›Suspected epiglottitis

›Suspected foreign body requiring bronchoscopy

›Need for PICU not available

18Discharge Instructions/di21

Copy discharge instructions

›Diagnosis and expectations

›Croup causes swelling in the upper airway and can cause a barking cough and noisy breathing

›Symptoms often worsen at night and usually improve over a few days

›Medications given today

›Steroid dose given to reduce airway swelling

›If a breathing treatment was given it may wear off in a few hours

›Home care

›Keep your child calm and sitting upright

›Offer frequent fluids

›Use cool or humidified air if it helps

›Return to the emergency department now if

›Noisy breathing at rest

›Breathing is getting harder

›Skin looks blue or gray

›Pauses in breathing

›Drooling or trouble swallowing

›Very sleepy or hard to wake

›Signs of dehydration

›Follow up

›Primary care follow up within 1 to 2 days

›Earlier follow up if symptoms worsen

19References/r9

Guidelines and key sources

›Evidence based sources

›American Academy of Pediatrics clinical guidance on croup and upper airway obstruction local protocol dependent

›Canadian Paediatric Society practice point on croup year local protocol dependent

›Cochrane review on glucocorticoids for croup updated year local protocol dependent

›Cochrane review on nebulized epinephrine for croup updated year local protocol dependent

›Infectious Diseases Society guidance relevant to epiglottitis and deep neck infections local protocol dependent

›Source file

›Project instructions followed for formatting

›Point of care checklist structure

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.