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Croup:Approachtomanagement
Author
CharlesRWoods,MD,MS

SectionEditor
SheldonLKaplan,MD

DeputyEditor
CarrieArmsby,MD,MPH

Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:Dec2014.|Thistopiclastupdated:Dec14,2013.
INTRODUCTIONCroup(laryngotracheitis)isarespiratoryillnesscharacterizedbyinspiratorystridor,barking
cough,andhoarseness.Ittypicallyoccursinchildrensixmonthstothreeyearsofageandiscausedby
parainfluenzavirus.(See"Croup:Clinicalfeatures,evaluation,anddiagnosis".)
Thetreatmentofcrouphaschangedsignificantlysincethe1980s.Corticosteroidsandnebulizedepinephrinehave
becomethecornerstonesoftherapy.Substantialclinicalevidencesupportstheefficacyoftheseinterventions[1
5].TheimpactalsoisevidentinthedecreaseinannualhospitaladmissionsforcroupinchildrenintheUnited
Statesbetween1979and1982,and1994and1997(from2.8to2.1per1000forchildren<1yearandfrom1.8to
1.2per1000childrenforchildren1to4years)[6].
Theapproachtothemanagementofcroupwillbediscussedbelow.Theclinicalfeaturesandevaluationofcroup
andtheevidencesupportingtheuseofthepharmacologicandsupportiveinterventionsincludedbeloware
discussedseparately.(See"Croup:Clinicalfeatures,evaluation,anddiagnosis"and"Croup:Pharmacologicand
supportiveinterventions".)
OVERVIEWThetreatmentofcroupandthesettinginwhichthechildisinitiallyevaluateddependuponthe
severityofsymptomsandthepresenceofriskfactorsforrapidprogression.Thereisnodefinitivetreatmentforthe
virusesthatcausecroup.Pharmacologictherapyisdirectedtowarddecreasingairwayedema,andsupportivecare
isdirectedtowardtheprovisionofrespiratorysupportandthemaintenanceofhydration.(See"Croup:
Pharmacologicandsupportiveinterventions".)
Mostchildrenwithcroupwhoseekmedicalattentionhaveamild,selflimitedillnessandcanbesuccessfully
managedasoutpatients.Theclinicianmustbeabletoidentifychildrenwithmildsymptoms,whocanbesafely
managedathome,andthosewithmoderatetoseverecrouporrapidlyprogressingsymptoms,whorequirefull
evaluationandpossibletreatmentintheofficeoremergencydepartmentsetting.
SeverityassessmentTheseverityofcroupisoftendeterminedbytheclinicalscoringsystems.Althoughthere
areanumberofvalidatedcroupscoringsystems,theWestleycroupscore[1]hasbeenthemostextensively
studieditisdescribedbelow.Nomatterwhichsystemisusedtoassessseverity,thepresenceofchestwall
retractionsandstridoratrestarethetwomostcriticalclinicalfeatures[7].
WestleycroupscoreTheelementsoftheWestleycroupscoredescribekeyfeaturesofthephysical
examination[1].Eachelementisassignedascore,asillustratedbelow:

Levelofconsciousness:Normal,includingsleep=0disoriented=5
Cyanosis:None=0withagitation=4atrest=5
Stridor:None=0withagitation=1atrest=2
Airentry:Normal=0decreased=1markedlydecreased=2
Retractions:None=0mild=1moderate=2severe=3

Thetotalscorerangesfrom0to17.
MildcroupisdefinedbyaWestleycroupscoreof2.Typicallythesechildrenhaveabarkingcough,hoarse
cry,butnostridoratrest.Childrenwithmildcroupmayhavestridorwhenupsetorcrying(ie,agitated)and
eitherno,oronlymild,chestwall/subcostalretractions[8,9].

ModeratecroupisdefinedbyaWestleycroupscoreof3to7.Childrenwithmoderatecrouphavestridorat
rest,atleastmildretractions,andmayhaveothersymptomsorsignsofrespiratorydistress,butlittleorno
agitation[8,9].
SeverecroupisdefinedbyaWestleycroupscoreof8.Childrenwithseverecrouphavesignificantstridor
atrest,althoughstridormaydecreasewithworseningupperairwayobstructionanddecreasedairentry[8,9].
Retractionsaresevere(includingindrawingofthesternum)andthechildmayappearanxious,agitated,or
fatigued.Promptrecognitionandtreatmentofchildrenwithseverecroupareparamount.
RespiratoryfailureCroupoccasionallyresultsinsignificantupperairwayobstructionwithimpending
respiratoryfailure,heraldedbythefollowingsigns[8,10]:

Fatigueandlistlessness
Markedretractions(althoughretractionsmaydecreasewithincreasedobstructionanddecreasedairentry)
Decreasedorabsentbreathsounds
Depressedlevelofconsciousness
Tachycardiaoutofproportiontofever
Cyanosisorpallor

PHONETRIAGEThefirstcontactwiththehealthcaresystemregardingachildwithsymptomsofcroupmay
occurbyphone.Whenassessingpatientsbyphone,thehealthcareprovidermustdistinguishchildrenwhoneed
immediatemedicalattentionorfurtherevaluationfromthosewhocanbemanagedathome.Childrenwhoneed
furtherevaluationincludethosewhohave:

Stridoratrest
Anabnormalairway(eg,subglotticnarrowingfromcareintheneonatalintensivecareunit)
Previousepisodesofmoderatetoseverecroup
Medicalconditionsthatpredisposetorespiratoryfailure(eg,neuromusculardisorders)
Rapidprogressionofsymptoms(ie,symptomsofupperairwayobstructionafterlessthan12hoursofillness)
Inabilitytotolerateoralfluids
Parentalconcernthatcannotberelievedbyreassurance
Prolongedsymptoms(morethanthreetosevendays)oranatypicalcourse(perhapsindicatinganalternative
diagnosis)(see"Croup:Clinicalfeatures,evaluation,anddiagnosis",sectionon'Differentialdiagnosis')

Patientswhoareassessedbyphoneanddeterminedtohavemildsymptomsandnoneoftheaboveindicationsfor
furtherevaluationcanbemanagedathome.(See'Hometreatment'below.)
MILDCROUPChildrenwithmildsymptoms,definedbyaWestleycroupscoreof2,shouldbetreated
symptomaticallywithhumidity,feverreduction,andoralfluids.Manysuchchildrencanbemanagedbyphone,
providedthatnoneofthecriteriaforfurtherevaluationdescribedabovearepresent.
HometreatmentThecaregiversofchildrenwithmildcroupwhoaremanagedathomeshouldbeinstructedin
provisionofsupportivecareincludingmist,antipyretics,andencouragementoffluidintake.
Inacutesituationsandforshortperiodsoftime,caregiversmaytrysittingwiththechildinabathroomfilledwith
steamgeneratedbyrunninghotwaterfromtheshowertoimprovesymptoms.Thismayhelpreassureparentsthat
"something"isbeingdonetoreversethesymptoms,andanecdotalevidencesupportssomevalueofthis
measure.
Exposuretocoldnightairalsomaylessensymptomsofmildcroup,althoughthishasneverbeensystematically
studied.Ifparentsorcaregiverswishtousehumidifiersathome,onlythosethatproducemistatroom
temperatureshouldbeusedtoavoidtheriskofburnsfromsteamortheheatingelement.
Patientswhoaremanagedathomeshouldreceiveafollowupphonecallcaregiversshouldreceiveinstructions

regardingindicationstoseekmedicalattention,including[8]:

Difficultybreathing
Pallororcyanosis
Severecoughingspells
Droolingordifficultyswallowing
Fatigue
Worseningcourse
Fever(>38.5C)
Prolongedsymptoms(longerthansevendays)
Stridoratrest
Suprasternalretractions

Caregiversalsoshouldbeprovidedwithsomeguidanceregardingwhenitissafeforthemtodrivethechildtothe
emergencydepartmentandwhentocallforemergencymedicalservices.Emergencymedicalservicesshould
providetransportationforchildrenwhoareseverelyagitated,cyanotic,strugglingtobreathe,orlethargic[8].
OutpatienttreatmentChildrenwhoareseenintheofficeoremergencydepartmentwithmildcroupmayrequire
littleornotherapy,ormayhaveimprovementwithhumidifiedair.(See"Croup:Pharmacologicandsupportive
interventions",sectionon'Misttherapy'.)Randomizedcontrolledtrialshavedemonstratedthattreatmentwitha
singledoseoforaldexamethasone(0.15to0.6mg/kg,maximumdose10mg)mayreducetheneedfor
reevaluation,shortenthecourse,improvedurationofthechild'ssleep,andreduceparentalstress[11,12].
Wesuggestthatchildrenwithmildcroupwhoareseenintheoutpatientsettingbetreatedwithasingledoseof
oraldexamethasone(0.6mg/kg).Treatmentofsuchchildreninthelatemorningorearlyafternoonhoursmay
preventworseningofsymptomsaseveningapproaches.However,anticipatoryguidanceaboutpotential
worseningandwhentoseekcareorreturnforfollowupalsoisreasonable.(See"Croup:Pharmacologicand
supportiveinterventions",sectionon'Dexamethasone'.)
Childrenwithmildcroupwhoaretoleratingfluidsandhavenotreceivednebulizedepinephrinecanbesenthome
afterspecificfollowup(whichmayoccurbyphone)hasbeenarrangedandthecaregiverhasreceivedinstructions
regardinghomecareandindicationstoseekmedicalattentionasdescribedabove.(See'Hometreatment'above.)
MODERATETOSEVERECROUPChildrenwithmoderatecroup(Westleycroupscore3to7,stridorand
retractionsatrestwithoutagitation)shouldbeevaluatedintheemergencydepartmentoroffice(providedtheoffice
isequippedtohandleacuteupperairwayobstruction).Childrenwithseverecroup(Westleycroupscore8,stridor
andretractionsatrestwithagitation,lethargy,orcyanosis,markedsternalwallindrawing)shouldbeevaluatedin
theemergencydepartment.Suchchildrenrequireaggressivetherapy,monitoring,andsupportivecare.
SupportivecareSupportivecareforchildrenwithmoderate/severecroupincludesadministrationofhumidified
airorhumidifiedoxygenasindicatedforhypoxemia(oxygensaturation<92percentinroomair)orrespiratory
distress.(See"Croup:Pharmacologicandsupportiveinterventions",sectionon'Oxygen'.)
Thechildwithseverecroupmustbeapproachedcautiously,asanyincreaseinanxietymayworsenairway
obstruction.Theparentorcaregivershouldbeinstructedtoholdandcomfortthechildandtoadministerhumidified
oxygen.Nebulizedepinephrineshouldbeaddedasquicklyaspossible,asdescribedbelow.Inthemeantime,
healthcareprovidersshouldcontinuouslyobservethechildandbepreparedtoprovidebagmaskventilationand
advancedairwaytechniquesiftheconditionworsens.(See"Emergentendotrachealintubationinchildren".)
MonitoringMonitoringshouldincludepulseoximetryandcloseobservationofrespiratorystatus,including
levelofconsciousness,stridor,cyanosis,airentry,andretractions.Trendsinventilationcanbemonitored
noninvasivelywithcapnographyifcapnographyisavailableandthechildwilltoleratethenasalprongs[13].
FluidsAdministrationofintravenousfluidsmaybenecessaryinsomechildren.Feverandtachypneamay

increasefluidrequirements,andrespiratorydifficultymaypreventthechildfromachievingadequateoralintake.
(See"Maintenancefluidtherapyinchildren".)
IntubationEndotrachealintubationisrequiredinlessthan1percentofthosewhoareseeninthe
emergencydepartmentand2to6percentofthosewhoarehospitalized[1417].Theneedforintubationshouldbe
anticipatedinchildrenwithprogressiverespiratoryfailuresothattheprocedurecanbeperformedinascontrolleda
settingaspossible.Atrachealtubethatis0.5to1mmsmallerthanwouldtypicallybeusedmayberequired.(See
'Respiratoryfailure'aboveand"Emergentendotrachealintubationinchildren",sectionon'Endotrachealtube'.)
PharmacotherapyThebenefitsofcorticosteroidsandnebulizedepinephrineformoderatetoseverecrouphave
beendemonstratedinmetaanalysisandrandomizedcontrolledtrials,respectively[1,1820].Specific
pharmacologicinterventiondependsupontheseverityofsymptoms:
Forchildrenwithmoderatestridoratrestandmoderateretractionsormoreseveresymptoms,we
recommendadministrationofdexamethasone(0.6mg/kg,maximumof10mg)bytheleastinvasiveroute
possible:oraliforalintakeistolerated,intravenousifIVaccesshasbeenestablished,IMiforalintakeisnot
toleratedandIVaccesshasnotbeenestablished.Theoralpreparationofdexamethasone(1mgpermL)has
afoultaste.Theintravenouspreparationismoreconcentrated(4mgpermL)andcanbegivenorallymixed
withsyrup[8,2123].Asingledoseofnebulizedbudesonide(asdescribedbelow)isanotheroption,
particularlyforchildrenwhoarevomiting.(See"Croup:Pharmacologicandsupportiveinterventions",section
on'Glucocorticoids'.)
Forchildrenwithmoderatestridoratrestandmoderateretractions,ormoreseveresymptoms,we
recommendnebulizedepinephrineinadditiontodexamethasone:
Racemicepinephrineisadministeredas0.05mL/kgperdose(maximumof0.5mL)ofa2.25percent
solutiondilutedto3mLtotalvolumewithnormalsaline.Itisgivenvianebulizerover15minutes.
Lepinephrineisadministeredas0.5mL/kgperdose(maximumof5mL)ofa1:1000dilution.Itisgiven
vianebulizerover15minutes.
Nebulizedepinephrinecanberepeatedevery15to20minutes.Theadministrationofthreeormoredoseswithina
twotothreehourtimeperiodshouldpromptinitiationofclosecardiacmonitoringifthisisnotalreadyunderway.
(See"Croup:Pharmacologicandsupportiveinterventions",sectionon'Nebulizedepinephrine'.)
Childrenwhoreceivenebulizedepinephrineshouldalsoreceivedexamethasonebytheleastinvasiveroutethat
canbeaccomplished,asdescribedabove.(See"Croup:Pharmacologicandsupportiveinterventions",sectionon
'Glucocorticoids'.)
Althoughitisnotroutinelyindicatedinthetreatmentofcroup,asingledoseofnebulizedbudesonide(2mg[2mL
solution]vianebulizer)mayprovideanalternativetoIMorIVdexamethasoneforchildrenwithvomitingorsevere
respiratorydistress[8].Inchildrenwithsevererespiratorydistress,budesonidemaybemixedwithepinephrine
andadministeredsimultaneously[8].(See"Croup:Pharmacologicandsupportiveinterventions",sectionon
'Budesonide'.)
ObservationChildrenwithmoderate/severecroupshouldbeobservedafterpharmacologicintervention.During
theobservationperiod,childrenshouldbeencouragedtodrink.
Childrenwhohavereceivednebulizedepinephrineanddexamethasonewithgoodresponseshouldbe
observedforatleastthreetofourhours[2427].Croupsymptomsusuallyimprovewithin30minutesof
administrationofnebulizedepinephrine[28,29]butmayreturntobaselineastheeffectsofepinephrinewear
off(usuallybytwohours).
Childrenwhoreceiveddexamethasoneandremainsymptomaticshouldbeobservedforatleastfourhours
beforedecidingwhethertheyrequirehospitaladmission(astheeffectofdexamethasonemaynotbe
apparentforseveralhours)[8].

DischargetohomeManychildrenwithmoderate/severecrouphavesymptomaticimprovementaftertreatment
withnebulizedepinephrineand/orcorticosteroids.
Afterthreetofourhoursofobservation,childrenwhoremaincomfortablemaybedischargedhomeiftheymeetthe
followingcriteria[2427]:

Nostridoratrest
Normalpulseoximetry
Goodairexchange
Normalcolor
Normallevelofconsciousness
Demonstratedabilitytotoleratefluidsbymouth
Caregiversunderstandtheindicationsforreturntocareandwouldbeabletoreturnifnecessary

Beforedischarge,followupwiththeprimarycareprovidershouldbearrangedwithinthenext24hours.
Instructionsregardinghometreatmentshouldbeprovided.(See'Hometreatment'above.)
About5percentofchildrenwellenoughfordischargefromtheemergencydepartmentafterreceiving
corticosteroidsandnebulizedepinephrinetreatmentsmaybeexpectedtoreturnforcare.Relapsewithin24hours
isunlikelyinthosewhohaveminimalsymptomsatthetimeofdischarge[30].
Hospitalization
IndicationsChildrenwithmoderate/severecroupwhoseconditionworsensorfailstoimproveasexpected
aftertreatmentwithnebulizedepinephrineandcorticosteroidsshouldbeadmittedtothehospitalforrepeated
dosesofnebulizedepinephrine,observation,andsupportivecare.Poorresponsetonebulizedepinephrinein
conjunctionwithhighfeverandtoxicappearanceshouldpromptconsiderationofbacterialtracheitis(picture1)[8].
(See"Croup:Clinicalfeatures,evaluation,anddiagnosis",sectionon'Bacterialtracheitis'and"Bacterialtracheitis
inchildren:Clinicalfeaturesanddiagnosis",sectionon'Clinicalfeatures'.)
Additionalfactorsthatinfluencethedecisionregardingadmissioninclude[8,31]:
Needforsupplementaloxygen
Moderateretractionsandtachypnea,indicatingincreasedworkofbreathing,whichmayleadtorespiratory
fatigueandfailure
Degreeofresponsetoinitialtherapies
"Toxicity"orclinicalpicturesuggestingserioussecondarybacterialinfection
Poororalintakeanddegreeofdehydration
Youngage,particularlyyoungerthansixmonths
Abilityofthefamilytocomprehendtheinstructionsregardingrecognitionoffeaturesthatindicatetheneedto
returnforcare
Abilityofthefamilytoreturnforcare(eg,distancefromhometocaresite,weather/travelconditions)
RecurrentvisitstotheEDwithin24hours
InterventionsChildrenwhoareadmittedtothehospitalshouldcontinuetobemonitoredforheartrateand
oxygensaturationandtoreceivehumidifiedoxygenasnecessary.Capnography,ifitisavailable,isauseful
techniqueformonitoringventilationifthechildwilltoleratenasalprongs.Ifthechildisunabletotolerateoral
intake,maintenanceintravenousfluidsshouldbeadministered.
Pharmacologicinterventionsforhospitalizedpatientsmayincludenebulizedepinephrineforpersistingsevere
respiratorydistress.Nebulizedepinephrinecanberepeatedevery15to20minutes,asdescribedabove.(See
'Pharmacotherapy'above.)
However,childrenwhorequirerepeateddosesofepinephrine(eg,threeormoredoseswithintwotothreehours,or

ongoingadministrationmorefrequentlythaneveryonetotwohours)shouldbeadmitted/transferredtoanintensive
careunitorothersettingwhereappropriatelyclosemonitoringcanbeaccomplished.
Repeatdosesofcorticosteroidsarenotnecessaryonaroutinebasisandmayhaveadverseeffects.Moderateto
severesymptomsthatpersistformorethanafewdaysshouldpromptinvestigationforothercausesofairway
obstruction.(See"Croup:Clinicalfeatures,evaluation,anddiagnosis",sectionon'Differentialdiagnosis'.)
InfectioncontrolChildrenwhoareadmittedtothehospitalwithcroupshouldbemanagedwithcontact
precautions(ie,gownandglovesforcontact),particularlyifparainfluenzaorrespiratorysyncytialvirusisthe
suspectedetiology.Ifinfluenzaissuspected,dropletisolationmeasures(ie,respiratorymaskwithinthreefeet)
alsoshouldbefollowed.(See"Generalprinciplesofinfectioncontrol".)
DischargecriteriaChildrenwhorequirehospitaladmissionmaybedischargedwhentheymeetthe
followingcriteria:

Nostridoratrest
Normalpulseoximetry
Goodairexchange
Normalcolor
Normallevelofconsciousness
Demonstratedabilitytotoleratefluidsbymouth

FOLLOWUPAnypatientwhowasadmittedtothehospital,receivednebulizedepinephrine,orhadaprolonged
outpatientvisitshouldhavefollowupscheduledwiththeprimarycareproviderwithin24hoursorassoonascan
bearranged.Althoughsomechildrenmaycontinuetohavemildtomoderatesymptomsatthetimeoffollowup,
therearenostudiesthatsupporttheroutineuseofcorticosteroidtherapybeyond24hours.
Followupshouldcontinueuntilthechild'ssymptomshavebeguntoresolve.Thechildwhodoesnotimproveas
expected(overthecourseofapproximatelysevendays)mayhaveanunderlyingairwayabnormalityormaybe
developingacomplicationofcroup.Furtherevaluation,particularlywitharadiographofthesofttissuesofthe
neck,orconsultationwithotolaryngology,maybewarranted.(See"Croup:Clinicalfeatures,evaluation,and
diagnosis",sectionon'Differentialdiagnosis'.)
PROGNOSISSymptomsofcroupresolveinmostchildrenwithinthreedaysbutmaypersistforuptoone
week[32,33].Lessthan5percentofchildrenwithcrouprequirehospitaladmission[34],andamongthose,1to6
percentrequireintubation[1417,35].Mortalityisrare,occurringin<0.5percentofintubatedchildren[36].
ComplicationsComplicationsofcroupareuncommon.Childrenwithmoderatetoseverecroupareatriskfor
hypoxemia(oxygensaturation<92percentinroomair)andrespiratoryfailure.Othercomplicationsinclude
pulmonaryedema,pneumothorax,andpneumomediastinum[37].Thesecomplicationscanbeanticipatedand
managedbyaggressivemonitoringandinterventioninthemedicalsetting.Outofhospitalcardiacarrestanddeath
alsohavebeenreported[38].
Secondarybacterialinfectionsmayarisefromcroup.Bacterialtracheitis,bronchopneumonia,andpneumonia
occurinasmallnumberofpatients[10,15,33,39].Inmostinstances,thechildhasbeenrelativelystableor
beginningtoimproveafterseveraldaysofillnessbutthensuddenlyworsens,withhigherorrecurrentfever,
increased(andpotentiallyproductive)cough,and/orrespiratorydistress.(See"Bacterialtracheitisinchildren:
Clinicalfeaturesanddiagnosis",sectionon'Clinicalfeatures'and"Communityacquiredpneumoniainchildren:
Clinicalfeaturesanddiagnosis",sectionon'Clinicalpresentation'.)
INFORMATIONFORPATIENTSUpToDateofferstwotypesofpatienteducationmaterials,TheBasicsand
BeyondtheBasics.TheBasicspatienteducationpiecesarewritteninplainlanguage,atthe5thto6thgrade
readinglevel,andtheyanswerthefourorfivekeyquestionsapatientmighthaveaboutagivencondition.These
articlesarebestforpatientswhowantageneraloverviewandwhoprefershort,easytoreadmaterials.Beyond

theBasicspatienteducationpiecesarelonger,moresophisticated,andmoredetailed.Thesearticlesarewritten
atthe10thto12thgradereadinglevelandarebestforpatientswhowantindepthinformationandarecomfortable
withsomemedicaljargon.
Herearethepatienteducationarticlesthatarerelevanttothistopic.Weencourageyoutoprintoremailthese
topicstoyourpatients.(Youcanalsolocatepatienteducationarticlesonavarietyofsubjectsbysearchingon
patientinfoandthekeyword(s)ofinterest.)
Basicstopics(see"Patientinformation:Croup(TheBasics)")
BeyondtheBasicstopics(see"Patientinformation:Croupininfantsandchildren(BeyondtheBasics)")
SUMMARYANDRECOMMENDATIONS
Overview
Childrenwithcroupwhoshouldbeseenintheofficeoremergencydepartmentincludethosewhohave
stridoratrest,anabnormalairway,previousepisodesofmoderatetoseverecroup,underlyingconditionsthat
maypredisposetorespiratoryfailure,rapidprogressionofsymptoms,inabilitytotoleratefluids,prolonged
symptoms,oranatypicalcourse.(See'Phonetriage'above.)
Mildsymptoms
Childrenwithmildsymptomscanbemanagedathome.Familiesshouldbeinstructedinprovisionof
supportivecareandindicationstoseekmedicalattention.(See'Hometreatment'above.)
Wesuggestthatasingledoseoforaldexamethasone(0.6mg/kg)beusedwhenelectingtotreatchildren
withmildcroupwhoareseenintheoutpatientsetting(Grade2A).(See'Outpatienttreatment'aboveand
"Croup:Pharmacologicandsupportiveinterventions",sectionon'Dexamethasone'.)
Childrenwithmoderatecroupshouldbeevaluatedintheofficeoremergencydepartment,andthosewith
severecroupshouldbeevaluatedintheemergencydepartment.Childrenwithseverecroupmustbe
approachedcautiously,asanyincreaseinanxietymayworsenairwayobstruction.(See'Moderatetosevere
croup'above.)
Moderatetoseveresymptoms

Supportivecareforthechildwithmoderateorseverecroupincludesadministrationofhumidifiedairor
oxygenasindicatedbyhypoxemiaand/orrespiratorydistress,provisionofintravenousfluids,andmonitoring
forworseningrespiratorydistress.(See'Supportivecare'aboveand"Croup:Pharmacologicandsupportive
interventions",sectionon'Misttherapy'.)
Werecommendthatchildrenwithmoderatetoseverecroupwhohavemoderatestridoratrest,moderate
retractions,and/ormoreseveresymptomsbetreatedwithnebulizedepinephrine(Grade1A)inadditionto
dexamethasone.(See'Pharmacotherapy'aboveand"Croup:Pharmacologicandsupportiveinterventions",
sectionon'Nebulizedepinephrine'.)
Racemicepinephrineisadministeredas0.05mL/kgperdose(maximumof0.5mL)ofa2.25percent
solutiondilutedto3mLtotalvolumewithnormalsaline.Itisgivenvianebulizerover15minutes.
Lepinephrineisadministeredas0.5mL/kgperdose(maximumof5mL)ofa1:1000dilution.Itisgiven
vianebulizerover15minutes.
Nebulizedepinephrinecanberepeatedevery15to20minutes.Theadministrationofthreeormoredoseswithina
twotothreehourtimeperiodshouldpromptinitiationofclosecardiacmonitoringifthisisnotalreadyunderway.
Werecommendthatchildrenwithmoderatetoseverecroupbetreatedwithdexamethasone(0.6mg/kg,
maximumof10mg),bytheleastinvasiveroute(Grade1A).(See'Pharmacotherapy'aboveand"Croup:

Pharmacologicandsupportiveinterventions",sectionon'Glucocorticoids'.)
Childrenwithmoderatetoseverecroupshouldbeobservedforthreetofourhoursafterintervention.Those
whoimprovemaybedischargedhome.(See'Dischargetohome'above.)
Childrenwithmoderatetoseverecroupwhoseconditionworsensorfailstoimproveasexpectedafter
treatmentwithnebulizedepinephrineandcorticosteroidsshouldbeadmittedtothehospital.(See
'Hospitalization'above.)
Wesuggestnotusingrepeateddosesofcorticosteroids.(Grade2C).(See'Hospitalization'aboveand
"Croup:Pharmacologicandsupportiveinterventions",sectionon'Repeateddosing'.)
Othercausesofupperairwayobstructionshouldbeinvestigatedinchildrenwhohavemoderatetosevere
symptomsthatpersistformorethanafewdays.(See"Croup:Clinicalfeatures,evaluation,anddiagnosis",
sectionon'Differentialdiagnosis'.)
Childrenwhoreceivednebulizedepinephrine,hadaprolongedoutpatientvisit,orwereadmittedtothe
hospitalshouldhavefollowupscheduledwiththeprimarycareproviderwithin24hoursofdischargeoras
soonasfollowupcanbearranged.(See'Followup'above.)
Outcome

SciHub

Mostchildrenwithcrouprecoveruneventfully.(See'Prognosis'above.)
UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.
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Topic6004Version9.0

GRAPHICS
Bacterialtracheitis:Endoscopy

Notetheadherentmucopurulentmembraneswithinthetrachea.
CourtesyofGlennCIsaacson,MD,FAAP,FACS.
Graphic55364Version2.0

Disclosures
Disclosures:CharlesRWoods,MD,MSOtherFinancialInterest:Cerexa[Epiglottitis(DataSafety
MonitoringBoardforpediatrictrialsoftheantibioticagentceftaroline)].SheldonLKaplan,MD
Grant/Research/ClinicalTrialSupport:Pfizer[Pneumococcalsurveillancestudies(PCV13)]Cubist[S.
aureusskinandsofttissueinfections(daptomycinpediatricstudies)]Optimer[fidaxomicinpediatric
studies]Cerexa[ceftarolinepediatricstudies].Consultant/AdvisoryBoards:Pfizer[Pneumococcal
surveillancestudies(PCV13)].CarrieArmsby,MD,MPHEmployeeofUpToDate,Inc.
Contributordisclosuresarereviewedforconflictsofinterestbytheeditorialgroup.Whenfound,theseare
addressedbyvettingthroughamultilevelreviewprocess,andthroughrequirementsforreferencestobe
providedtosupportthecontent.Appropriatelyreferencedcontentisrequiredofallauthorsandmust
conformtoUpToDatestandardsofevidence.
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