CroupMANAGEMENT

RESPIRATORY PRESENTATIONS · 12 SECTIONS

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430 items

☷ Legend

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Cardiovascular Presentations66▾

Respiratory Presentations47▾

Acute bronchitis Acute Respiratory Distress Syndrome (ARDS)Acute respiratory failure Apparent Life-Threatening Event (ALTE-BRUE)Aspiration pneumonia Asthma exacerbation Bacterial Tracheitis Bronchiolitis Bronchiolitis (RSV)Chylothorax Community-acquired pneumonia COPD exacerbation COVID-19 pneumonia Croup Croup (laryngotracheobronchitis)Cystic Fibrosis Exacerbation Empyema Epiglottitis Epiglottitis (Pediatric)Fat Embolism Syndrome Foreign Body Aspiration Foreign Body Aspiration (Pediatric)Healthcare-Associated Pneumonia Hemothorax Hospital-acquired pneumonia Legionnaires' Disease Lung Abscess Pertussis Pleural effusion Pleurisy Pneumocystis jirovecii Pneumonia Pneumocystis Pneumonia Pneumomediastinum Pneumothorax (Simple)Pneumothorax (traumatic)Psittacosis Pulmonary Alveolar Proteinosis Pulmonary contusion Pulmonary Edema (Non-cardiogenic)Sarcoidosis Exacerbation Smoke Inhalation Injury Spontaneous pneumothorax Status Asthmaticus Sudden Infant Death Syndrome (SIDS)Tension Pneumothorax Tracheal Stenosis Viral Pneumonia

Neurological Presentations77▾

Gastrointestinal Presentations63▾

Genitourinary and Reproductive Presentations44▾

Infectious Disease Presentations146▾

Trauma Presentations88▾

Toxicologic Presentations67▾

Psychiatric Presentations25▾

Musculoskeletal and Rheumatologic Presentations89▾

Dermatology Presentations21▾

Environmental and Exposure Presentations26▾

Hematologic and Oncologic Presentations30▾

Pediatric-Specific Presentations13▾

Endocrine and Metabolic Presentations42▾

ENT and Maxillofacial Presentations21▾

Ophthalmologic Presentations15▾

Obstetric Presentations17▾

Systemic and Miscellaneous Presentations15▾

01Approach to the Critical Patient/attcp46

Immediate airway risk stratification

›Airway threat triage

›Toxic appearance

›Drooling

›Muffled voice

›Impending respiratory failure

›Altered mental status

›Exhaustion with decreased work of breathing

›Severe upper airway obstruction

›Stridor at rest

›Marked suprasternal retractions

›Hypoxemia

›SpO2 persistently low on room air

›Cyanosis

First minutes management

›Stabilization priorities

›Minimal agitation strategy

›Caregiver presence

›Avoid painful procedures until treatment effect

›Position of comfort

›Upright posture

›Avoid supine restraint

›Oxygen

›Blow by oxygen for distress

›Escalation to mask only if tolerated

›Nebulized epinephrine for severe symptoms

›Clinical response expected within minutes

›Rebound monitoring requirement after initial improvement

Escalation triggers and team activation

›Immediate escalation

›Stridor at rest with poor air entry

›Resuscitation bay

›Airway capable clinician at bedside

›Recurrent severe symptoms after epinephrine

›Repeat nebulized epinephrine

›Admit for ongoing therapy

›Suspected alternate diagnosis

›Epiglottitis

›Bacterial tracheitis

Airway intervention framework

›Intubation decision pathway

›Indications

›Worsening fatigue or altered mental status

›Inadequate ventilation despite therapy

›Technique principles

›Most experienced airway operator

›Smaller endotracheal tube than age prediction

›Post intubation considerations

›ICU level monitoring

›Ongoing steroid therapy

02History/hx50

Presentation pattern and course

›Core syndrome elements

›Barking cough

›Often worse at night

›Recurrent episodes possible

›Inspiratory stridor

›Exertional early

›At rest with progression

›Hoarseness

›Voice change

›Cry change in infants

›Timeline

›Viral prodrome

›Coryza

›Low grade fever

›Abrupt nocturnal onset pattern

›Spasmodic croup phenotype

›Minimal fever phenotype

Severity and risk factors

›Severity modifiers

›Stridor at rest

›Persistent

›Intermittent

›Work of breathing

›Retractions

›Nasal flaring

›Feeding and hydration

›Poor intake

›Decreased urine output

›High risk features

›Age under 6 months

›Smaller airway reserve

›Lower threshold for admission

›Prior airway disease

›Subglottic stenosis

›Prior intubation history

›Immunocompromise

›Risk for bacterial tracheitis

›Atypical pathogens

Exposure and alternate diagnosis clues

›Alternate diagnosis screen

›Drooling

›Epiglottitis concern

›Retropharyngeal abscess concern

›Sudden onset after choking

›Airway foreign body

›Aspiration event

›High fever with toxic appearance

›Bacterial tracheitis

›Pneumonia

›Known allergen exposure

›Angioedema

›Anaphylaxis

03Physical Exam/exam39

Global assessment and vitals

›Respiratory status snapshot

›Stridor

›None

›With agitation only

›At rest

›Work of breathing

›Suprasternal retractions

›Intercostal retractions

›Air entry

›Normal

›Decreased

›Mental status

›Alert

›Agitated

›Lethargic

›Vital sign interpretation

›Fever

›Low grade consistent with viral croup

›High fever suggesting bacterial tracheitis or pneumonia

›Tachycardia

›Distress marker

›Epinephrine effect after treatment

Upper airway focused exam

›Upper airway findings

›Barking cough

›Typical quality

›Absent in alternate diagnoses

›Voice

›Hoarseness

›Muffled voice as red flag

›Oropharynx

›Avoid provocative exam in severe obstruction

›Visible swelling or abscess clues if safely observed

PITFALLS

›Common pitfalls

›Quiet child with minimal movement

›Fatigue and impending failure

›False reassurance from reduced stridor

›Normal oxygen saturation

›Upper airway obstruction may maintain SpO2 until late

›Clinical work of breathing remains primary severity signal

04Differential Diagnosis/ddx33

Life threatening mimics

›High risk alternatives

›Epiglottitis

›Drooling

›Tripod posture

›Bacterial tracheitis

›High fever

›Toxic appearance

›Airway foreign body

›Sudden onset

›Asymmetric breath sounds

›Anaphylaxis or angioedema

›Urticaria

›Facial or lip swelling

Other causes of stridor

›Broader differential

›Retropharyngeal abscess

›Neck stiffness

›Drooling

›Peritonsillar abscess

›Hot potato voice

›Uvula deviation

›Viral wheeze or asthma

›Expiratory wheeze predominance

›Response to bronchodilator

›Congenital airway lesions

›Laryngomalacia

›Subglottic hemangioma

Coding aligned diagnoses

›Coding anchors

›ICD 10 J05.0 acute obstructive laryngitis croup

›Viral croup phenotype

›Spasmodic croup phenotype

›SNOMED CT obstructive laryngitis croup

›Acute laryngotracheitis

›Laryngotracheobronchitis phenotype

05Laboratory Tests/lt24

Limited role in typical croup

›Testing strategy

›No routine labs in typical mild to moderate croup

›Diagnosis primarily clinical

›Labs increase agitation risk

›Targeted labs for atypical or toxic presentation

›Bacterial tracheitis concern

›Sepsis concern

Blood tests when indicated

›Blood tests for alternate diagnoses

›Complete blood count for toxic appearance

›Leukocytosis with left shift supporting bacterial process

›Normal count does not exclude serious infection

›C reactive protein for inflammatory signal

›Elevated values nonspecific

›Use only with clinical context

›Blood culture for septic phenotype

›Pre antibiotics if feasible

›Do not delay airway stabilization

Point of care tests

›Bedside testing

›Capillary or venous blood gas for impending failure

›Rising CO2 as late sign

›Normal gas early does not reassure

›Glucose for altered mental status

›Hypoglycemia correction

›Consider ingestion if unexplained

06Diagnostic Tests/dt42

Scoring Systems

›Westley croup score

›Stridor component

›None

›With agitation

›At rest

›Retractions component

›None

›Mild

›Moderate

›Severe

›Air entry component

›Normal

›Decreased

›Markedly decreased

›Cyanosis component

›None

›With agitation

›At rest

›Level of consciousness component

›Normal

›Disoriented

MRI

›MRI role

›Not indicated for routine croup

›Time and sedation burden

›No management change in typical cases

›Consideration only for atypical recurrent stridor

›Vascular ring evaluation pathway

›Airway mass evaluation pathway

›CT role

›Not indicated for routine croup

›Radiation burden

›Need for immobility may worsen obstruction

›Consideration for deep neck infection concern

›Retropharyngeal abscess phenotype

›Persistent high fever with neck stiffness

Ultrasound

›Ultrasound applications

›Limited bedside role

›Upper airway sonographic signs in research settings

›Operator dependent and not standard of care

›Lung ultrasound if lower respiratory process suspected

›Pneumonia pattern

›Bronchiolitis pattern

07Disposition/dispo20

Observation and admission criteria

›Level of care decision

›Discharge eligibility

›No stridor at rest after treatment effect

›Minimal work of breathing

›Observation need

›Nebulized epinephrine given

›Recurrence risk during medication offset

›Admission indications

›Persistent stridor at rest after steroids

›Repeated epinephrine requirement

›ICU indications

›Impending respiratory failure

›Need for advanced airway

Post epinephrine monitoring

›Monitoring window principles

›Clinical observation after epinephrine

›Recurrence can occur as effect wanes

›Longer observation for severe baseline symptoms

›Reassessment focus

›Stridor at rest

›Work of breathing

08Treatment/t85

Non pharmacologic measures

›Supportive care bundle

›Calm environment

›Reduce crying triggers

›Single examiner when possible

›Hydration

›Oral fluids for mild cases

›IV fluids if poor intake and significant distress

›Oxygen

›Blow by oxygen for hypoxemia

›Escalation only as tolerated

Corticosteroids

›Dexamethasone

›Indications

›Any severity of croup

›Spasmodic croup with significant symptoms

›Dosing

›0.15 mg per kg PO single dose

›Maximum 10 mg

›Lower dose supported by trials for many patients

›0.6 mg per kg PO single dose

›Maximum 10 mg

›Common ED standard for simplicity

›Alternate routes

›IM dexamethasone for vomiting or refusal

›Same mg per kg dosing options

›Pain may increase agitation

›IV dexamethasone for established IV access

›Same mg per kg dosing options

›Reserve for severe cases

›Nebulized budesonide

›Indications

›Unable to take oral or IM steroids

›Severe symptoms as adjunct

›Dosing

›2 mg nebulized once

›Clinical effect within hours

›Consider combined with dexamethasone when feasible

Nebulized epinephrine

›Nebulized epinephrine strategy

›Indications

›Stridor at rest

›Moderate to severe work of breathing

›Racemic epinephrine 2.25 percent

›Dose 0.05 mL per kg nebulized

›Maximum 0.5 mL

›Dilute to total 3 mL with normal saline

›Repeat dosing

›Re dose for recurrent severe symptoms

›Escalate disposition after repeated need

›L epinephrine 1 mg per mL

›Dose 0.5 mL per kg nebulized

›Maximum 5 mL

›Equivalent clinical effect to racemic formulations

›Repeat dosing

›Re dose for recurrent severe symptoms

›Continuous monitoring for severe cases

›Monitoring and adverse effects

›Tachycardia expected

›Usually transient

›Reassess perfusion and distress rather than heart rate alone

›Rebound symptom monitoring requirement

›Observation period after dose

›Discharge only when stable off effect

Advanced therapies and rescue

›Heliox

›Indications

›Severe obstruction with poor response to standard therapy

›Bridge while preparing for airway management

›Operational constraints

›Requires specialized setup

›Less effective with high oxygen requirement

›Intubation pathway

›Preparation

›Difficult airway setup

›Surgical airway readiness

›Tube selection

›One size smaller than predicted

›Cuffed tube acceptable with careful pressure monitoring

›Post intubation care

›ICU admission

›Etiology evaluation for atypical disease

Evidence tags and guideline alignment

›Evidence summary

›Corticosteroids reduce symptom severity and return visits

›Supported by multiple randomized trials and systematic reviews

›Broad guideline endorsement in pediatric emergency care

›Nebulized epinephrine provides rapid temporary symptom relief

›Benefit within minutes

›Requires observation due to waning effect

09Special Populations/sp24

Pregnancy

›Pregnancy considerations

›Adult croup rarity

›Alternate diagnosis priority

›Airway anatomy and edema may increase difficulty

›Medication safety

›Dexamethasone generally acceptable when maternal benefit outweighs risk

›Epinephrine nebulization minimal systemic exposure but monitor maternal vitals

Geriatric

›Geriatric considerations

›Adult stridor alternate diagnoses

›Tumor

›Vocal cord dysfunction

›Comorbidity impact

›COPD or heart failure may complicate evaluation

›Lower threshold for imaging for alternate pathology

Pediatrics

›Pediatric specific approach

›Peak age group

›6 months to 3 years typical

›More severe course possible under 6 months

›Weight based dosing safety

›Dexamethasone mg per kg calculation

›Epinephrine nebulized dose caps

›Recurrent croup pathway

›Consider airway anomaly evaluation

›Consider reflux or allergic triggers

10Background/b30

Epidemiology

›Epidemiology essentials

›Typical age distribution

›Most common 6 months to 3 years

›Uncommon over 6 years

›Seasonal pattern

›Fall peak common

›Winter circulation also common

›Viral etiologies

›Parainfluenza viruses most common

›RSV and influenza possible

Pathophysiology

›Pathophysiology core

›Subglottic mucosal edema

›Narrowest pediatric airway region

›Increased resistance with small radius reduction

›Dynamic obstruction component

›Worsens with agitation and increased airflow demand

›Improves with reduced work and calming

›Clinical signs linkage

›Barking cough from laryngeal inflammation

›Inspiratory stridor from upper airway narrowing

Therapeutic Considerations

›Treatment rationale

›Corticosteroids

›Reduce airway edema

›Improve symptoms and reduce healthcare utilization

›Nebulized epinephrine

›Alpha adrenergic vasoconstriction

›Rapid onset with short duration

›Humidified air

›Limited evidence for meaningful benefit

›Use only if calming and tolerated

11Patient Discharge Instructions/pdi23

Copy discharge instructions

›Home care and expectations

›Typical course

›Symptoms often worse at night

›Gradual improvement over several days

›Comfort measures

›Keep child calm and upright

›Encourage small frequent fluids

›Return to ED now

›Stridor at rest

›Persistent noisy breathing when calm

›Worsening after initial improvement

›Increased work of breathing

›Marked chest retractions

›Fast breathing with fatigue

›Color or alertness concern

›Blue lips or face

›Unusual sleepiness or confusion

›Drooling or inability to swallow

›Suspected epiglottitis or deep neck infection

›Do not force throat exam at home

›Dehydration concern

›Minimal urine output

›Refusal of fluids

12References/r14

Clinical guidelines and evidence sources

›Pediatric croup guidelines and statements

›Canadian Paediatric Society position statement acute management of croup in the emergency department

›Steroid for all severities recommendation

›Nebulized epinephrine for moderate to severe symptoms recommendation

›American Academy of Pediatrics and pediatric emergency medicine summaries for croup

›Dexamethasone single dose standard of care

›Observation after epinephrine due to short duration

›Evidence based reviews

›Cochrane systematic reviews on glucocorticoids for croup

›Symptom score improvement

›Reduced hospitalization and return visits

›Randomized trials comparing dexamethasone doses

›Low dose 0.15 mg per kg efficacy in many cohorts

›Common maximum dose 10 mg practice pattern

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Reviewed by SymptomDx Medical Team · Last reviewed June 16, 2026

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