Croup (laryngotracheobronchitis)MANAGEMENT

RESPIRATORY PRESENTATIONS · 12 SECTIONS

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398 items

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01Approach to the Critical Patient/attcp42

Immediate risk stratification

›Severity and stabilization priorities

›Toxic appearance

›Altered mental status

›Exhaustion

›Poor air entry

›Airway and breathing red flags

›Stridor at rest

›Severe retractions

›Cyanosis

›Apnea

›High-risk contexts

›Age < 6 months

›Known airway anomaly

›Prior intubation for croup

Monitoring and environment

›Monitoring and setup

›Continuous pulse oximetry for moderate to severe disease

›SpO2 trend over spot checks

›Cardiorespiratory monitoring when nebulized epinephrine used

›Tachyarrhythmia risk

›Minimal agitation approach

›Parent present

›Avoid painful procedures until stabilized

Immediate actions and escalation

›Time-critical actions

›If impending respiratory failure, escalate to resuscitation bay

›Airway team activation

02History/hx38

Presenting pattern

›Symptom timeline and pattern

›Barky cough

›Nocturnal worsening

›Stridor

›At rest versus with agitation

›Voice change

›Hoarseness

›Fever

›Low-grade typical

›URI prodrome

›Rhinorrhea

›Sore throat

Severity cues and risk factors

›High-risk history features

›Poor oral intake or dehydration

›Reduced urine output

›Apnea episodes

›Color change

›Prior severe episodes

›Prior nebulized epinephrine

›Prior ICU admission

›Comorbidities

›Prematurity history

›Chronic lung disease

›Neuromuscular weakness

›Immunocompromise

03Physical Exam/exam32

Airway and work of breathing

›Respiratory assessment domains

›Stridor characterization

›Inspiratory

›Biphasic

›Retractions

›Suprasternal

›Intercostal

›Subcostal

›Air entry

›Symmetry

›Diminished breath sounds

›Respiratory rate relative to age

›Tachypnea threshold by age

General and HEENT findings

›Key examination findings

›Mental status

›Irritability

›Lethargy

›Hydration status

›Capillary refill

›Mucous membranes

›Oropharynx

›Tonsillar exudate absence typical

›Drooling presence atypical

›Fever degree

›High fever concern for bacterial process

04Differential Diagnosis/ddx39

Life-threatening and cannot-miss

›Emergent mimics

›Epiglottitis

›ICD-10 J05.1

›Drooling

›Tripod positioning

›Bacterial tracheitis

›ICD-10 J04.1

›Toxic appearance

›Poor response to epinephrine

›Foreign body aspiration

›ICD-10 T17.9

›Sudden onset

›Focal decreased air entry

›Anaphylaxis or angioedema

›ICD-10 T78.2

›Urticaria

›Hypotension

Common alternatives

›Non-emergent alternatives

›Asthma or viral wheeze

›ICD-10 J45.9

›Expiratory wheeze predominant

›Retropharyngeal abscess

›ICD-10 J39.0

›Neck stiffness

›Drooling

›Peritonsillar abscess

05Laboratory Tests/lt20

When labs help

›Lab testing indications and limits

›Routine labs usually unnecessary

›Clinical diagnosis predominates

›If toxic appearance, sepsis concern, or alternative diagnosis

›Targeted testing

Targeted labs for atypical or severe cases

›Targeted laboratory options

›Venous or capillary blood gas for impending failure

›Rising CO2

›Respiratory acidosis

›Serum glucose for altered mental status

›Hypoglycemia exclusion

›C-reactive protein or procalcitonin in suspected bacterial tracheitis

›Adjunctive only

›Blood cultures in suspected bacterial tracheitis or sepsis

›Pre-antibiotics when feasible

Pitfalls

›Lab-related pitfalls

›Delays from low-yield testing

›Increased agitation risk

›Normal labs do not exclude epiglottitis or foreign body

›Clinical priority

06Diagnostic Tests/dt36

Scoring Systems

›Westley croup score

›Components

›Level of consciousness

›Cyanosis

›Stridor

›Air entry

›Retractions

›Severity interpretation

›0-2 mild

›3-5 moderate

›6-11 severe

›12+ impending respiratory failure

›Clinical use

›Trend over time

›Response to therapy documentation

MRI

›MRI considerations

›Not routine for croup

›Time and sedation burden

›Rare indications

›Suspected deep neck space infection when CT contraindicated

›Safety constraints

›Sedation risk in upper airway obstruction

›CT considerations

›Not routine for typical croup

›Diagnosis primarily clinical

07Disposition/dispo29

Discharge criteria

›Safe discharge features

›No stridor at rest

›Minimal work of breathing

›Normal or improving hydration

›Tolerating oral intake

›Caregiver reliability

›Return precautions understood

›Observation completed after nebulized epinephrine

›No recurrence of stridor at rest

Admission criteria

›Inpatient level of care triggers

›Persistent stridor at rest after therapy

›Recurrent need for nebulized epinephrine

›Hypoxemia requiring oxygen

›Ongoing supplemental oxygen

›Dehydration requiring IV fluids

›Inability to maintain oral intake

›High-risk comorbidity

›Airway anomaly

›Immunocompromise

ICU and transfer criteria

›Critical care triggers

›Impending respiratory failure

›Fatigue

›Hypercapnia concern

›Need for repeated nebulized epinephrine at short intervals

›Persistent severe symptoms

08Treatment/t71

Supportive care

›Supportive measures

›Calm environment

›Parent presence

›Oxygen when needed

›Blow-by oxygen

›Nasal cannula if tolerated

›Oral hydration when mild

›Small frequent fluids

›Antipyretics for comfort

›Acetaminophen weight-based per local formulary

›Ibuprofen weight-based per local formulary

Corticosteroids

›Systemic corticosteroids for all severities

›Dexamethasone PO or IM 0.6 mg/kg once

›Maximum 10 mg

›Onset within several hours

›Reduced return visits and admission risk

›Dexamethasone lower-dose options

›0.15 mg/kg once

›0.3 mg/kg once

›Budesonide nebulized alternative when oral not possible

›2 mg nebulized once

›Similar efficacy to dexamethasone in many studies

›Evidence level framing

›High-quality evidence supports corticosteroids improving symptoms and reducing admissions

›ACEP Level A style evidence equivalent support for steroid use in croup pathways

09Special Populations/sp26

Pregnancy

›Pregnancy considerations

›Rare adult croup presentation

›Alternative diagnosis prioritization

›Medication safety

›Dexamethasone acceptable when clinically indicated

›Nebulized epinephrine with maternal monitoring

›Fetal considerations

›Maternal hypoxemia avoidance

›Obstetric consultation if severe illness

Geriatric

›Older adult considerations

›Croup uncommon

›Broader differential emphasis

›Cardiac risk with epinephrine

›Ischemia and arrhythmia monitoring

›Medication interactions

›Beta-blocker use and epinephrine response variability

Pediatrics

›Pediatric-specific considerations

›Peak age 6 months to 3 years

›Highest hospitalization risk in younger children

›Weight-based dosing accuracy

›kg-based dosing confirmation

›Small airway physiology

›Rapid deterioration potential

›Admission threshold lower in infants

›Age < 6 months

10Background/b28

Epidemiology

›Epidemiology overview

›Common pediatric cause of acute upper airway obstruction

›Seasonal peaks fall and early winter

›Typical age range

›6 months to 6 years

›Viral causes

›Parainfluenza most common

›Influenza and RSV possible

Pathophysiology

›Mechanism of disease

›Laryngeal and tracheal mucosal inflammation

›Subglottic edema

›Airflow limitation dynamics

›Increased resistance with small radius reduction

›Stridor mechanism

›Turbulent inspiratory airflow across narrowed subglottis

Therapeutic Considerations

›Rationale for core therapies

›Corticosteroids

›Reduced mucosal edema

›Reduced symptom duration

›Nebulized epinephrine

›Alpha-adrenergic vasoconstriction reduces edema

›Rapid but transient benefit

›Observation requirement after epinephrine

›Effect wanes within hours

›Rebound symptoms possible

11Patient Discharge Instructions/pdi22

copy discharge instructions

›Discharge instructions for croup

›Diagnosis explanation

›Viral swelling of the upper airway

›Barky cough and noisy breathing can worsen at night

›Home care

›Keep child calm

›Encourage fluids

›Antipyretics for fever or discomfort per label instructions

›Expected course

›Often improves over 2-3 days

›Cough may last up to 1 week

›Return to ED immediately

›Stridor at rest

›Increased work of breathing

›Blue lips or face

›Drooling or trouble swallowing

›Very sleepy or hard to wake

›Poor drinking or signs of dehydration

›Symptoms worsening after initial improvement

›Follow-up

›Primary care follow-up within 1-2 days if not improving

›Earlier follow-up for infants or recurrent episodes

12References/r15

Clinical guidelines and evidence

›Core references

›American Academy of Pediatrics clinical resources on croup and upper airway obstruction

›Steroid therapy supported across severities

›Canadian Paediatric Society practice point on acute management of croup

›Dexamethasone as first-line therapy

›Cochrane reviews on glucocorticoids for croup

›Reduced symptom scores and admissions

›Cochrane reviews on nebulized epinephrine for croup

›Short-term improvement in moderate to severe disease

›Emergency medicine clinical pathways for croup severity-based management

›Observation after nebulized epinephrine 2-3 hours

›Evidence level notation mapping

›ACEP Level A strong evidence

›ACEP Level B moderate evidence

›ACEP Level C consensus or limited evidence

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Reviewed by SymptomDx Medical Team · Last reviewed August 18, 2026

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