Croup: Clinical features, evaluation, and diagnosis Author Charles R Woods, MD, MS Section Editors Sheldon L Kaplan, MD Gregory Redding, MD Deputy Editor Carrie Armsby, MD, MPH Disclosures: Charles R Woods, MD, MS Other Financial Interest: Cerexa [Epiglottitis (Data Safety Monitoring Board for pediatric trials of the antibiotic agent ceftaroline)]. Sheldon L Kaplan, MDGrant/Research/Clinical Trial Support: Pfizer [vaccine (PCV13)]; Forest Lab [antibiotic (Ceftaroline)]; Optimer [antibiotic (fidaxomicin)]. Consultant/Advisory Boards: Pfizer [vaccine (PCV13)]. Gregory Redding, MD Nothing to disclose. Carrie Armsby, MD, MPH Nothing to disclose. Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence. Conflict of interest policy All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Jul 2015. | This topic last updated: Feb 18, 2015. INTRODUCTION — Croup is a respiratory illness characterized by inspiratory stridor, cough, and hoarseness. These symptoms result from inflammation in the larynx and subglottic airway. A barking cough is the hallmark of croup among infants and young children, whereas hoarseness predominates in older children and adults. Although croup usually is a mild and self-limited illness, significant upper airway obstruction, respiratory distress, and, rarely, death, can occur. The clinical features, evaluation, and diagnosis of croup will be discussed here. The management of croup is discussed separately. (See "Croup: Approach to management" and "Croup: Pharmacologic and supportive interventions".) DEFINITIONS — The term croup has been used to describe a variety of upper respiratory conditions in children, including laryngitis, laryngotracheitis, laryngotracheobronchitis, bacterial tracheitis, or spasmodic croup [1]. These terms are defined below. In the past, the term croup also has been applied to laryngeal diphtheria (diphtheritic or membranous croup), which is discussed separately. (See "Epidemiology and pathophysiology of diphtheria" and "Clinical manifestations, diagnosis and treatment of diphtheria".) Throughout this review, the term croup will be used to refer to laryngotracheitis. Laryngotracheobronchitis, laryngotracheobronchopneumonitis, bacterial tracheitis, and spasmodic croup are designated specifically as such. ●Laryngitis refers to inflammation limited to the larynx and manifests itself as hoarseness [2]. It usually occurs in older children and adults and, similar to croup, is frequently caused by a viral infection. The etiology, management, and evaluation of other causes of hoarseness are discussed in detail separately. (See"Hoarseness in children: Etiology and management" and "Hoarseness in children: Evaluation".) ●Laryngotracheitis (croup) refers to inflammation of the larynx and trachea [2]. Although lower airway signs are absent, the typical barking cough will be present. ●Laryngotracheobronchitis (LTB) occurs when inflammation extends into the bronchi, resulting in lower airway signs (eg, wheezing, crackles, air trapping, increased tachypnea) and sometimes more severe illness than laryngotracheitis alone [2]. This term commonly is used interchangeably with laryngotracheitis, and the entities are often indistinct clinically. Further extension of inflammation into the lower airways results in laryngotracheobronchopneumonitis, which sometimes can be complicated by bacterial superinfection. Bacterial superinfection can be manifest as pneumonia, bronchopneumonia, or bacterial tracheitis. ●Bacterial tracheitis (also called bacterial croup) describes bacterial infection of the subglottic trachea, resulting in a thick, purulent exudate, which causes symptoms of upper airway obstruction (picture 1). The bronchi and lungs are typically involved, as well (ie, bacterial tracheobronchitis). Bacterial tracheitis may occur as a complication of viral respiratory infections (usually those which manifest themselves as LTB or laryngotracheobronchopneumonitis) or as a primary bacterial infection. (See "Bacterial tracheitis in children: Clinical features and diagnosis".) ●Spasmodic croup is characterized by the sudden onset of inspiratory stridor at night, short duration (several hours), and sudden cessation [2]. This is often in the setting of a mild upper respiratory infection, but without fever or inflammation. A striking feature of spasmodic croup is its recurrent nature, hence the alternate
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Croup: Clinical features, evaluation, and diagnosis Author Charles R Woods, MD, MS Section Editors Sheldon L Kaplan, MD Gregory Redding, MD Deputy Editor Carrie Armsby, MD, MPH Disclosures: Charles R Woods, MD, MS Other Financial Interest: Cerexa [Epiglottitis (Data Safety Monitoring Board for pediatric trials of the antibiotic
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level
review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all
authors and must conform to UpToDate standards of evidence.
Conflict of interest policy
All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Jul 2015. | This topic last updated: Feb 18, 2015.
INTRODUCTION — Croup is a respiratory illness characterized
by inspiratory stridor, cough, and hoarseness. These symptoms
result from inflammation in the larynx and subglottic airway. A
barking cough is the hallmark of croup among infants and young
children, whereas hoarseness predominates in older children
and adults. Although croup usually is a mild and self-limited
3. Cooper T, Kuruvilla G, Persad R, El-Hakim H. Atypical croup: association with airway lesions, atopy, and esophagitis. Otolaryngol Head Neck Surg 2012; 147:209.
4. Peltola V, Heikkinen T, Ruuskanen O. Clinical courses of croup caused by influenza and parainfluenza viruses. Pediatr Infect Dis J 2002; 21:76.
5. Counihan ME, Shay DK, Holman RC, et al. Human parainfluenza virus-associated hospitalizations among children less than five years of age in the United States. Pediatr Infect Dis J 2001; 20:646.
6. Rihkanen H, Rönkkö E, Nieminen T, et al. Respiratory viruses in laryngeal croup of young children. J Pediatr 2008; 152:661.
7. Weinberg GA, Hall CB, Iwane MK, et al. Parainfluenza virus infection of young children: estimates of the population-based burden of hospitalization. J Pediatr 2009; 154:694.
8. Kuypers J, Martin ET, Heugel J, et al. Clinical disease in children associated with newly described coronavirus subtypes. Pediatrics 2007; 119:e70.
9. Sung JY, Lee HJ, Eun BW, et al. Role of human coronavirus NL63 in hospitalized children with croup. Pediatr Infect Dis J 2010; 29:822.
10. van der Hoek L, Sure K, Ihorst G, et al. Croup is associated with the novel coronavirus NL63. PLoS Med 2005; 2:e240.
11. Døllner H, Risnes K, Radtke A, Nordbø SA. Outbreak of human metapneumovirus infection in norwegian children. Pediatr Infect Dis J 2004; 23:436.
12. Bjornson CL, Johnson DW. Croup. Lancet 2008; 371:329. 13. Segal AO, Crighton EJ, Moineddin R, et al. Croup
hospitalizations in Ontario: a 14-year time-series analysis. Pediatrics 2005; 116:51.
14. Rosychuk RJ, Klassen TP, Metes D, et al. Croup presentations to emergency departments in Alberta, Canada: a large population-based study. Pediatr Pulmonol 2010; 45:83.
15. Pruikkonen H, Dunder T, Renko M, et al. Risk factors for croup in children with recurrent respiratory infections: a case-control study. Paediatr Perinat Epidemiol 2009; 23:153.
16. Salzman MB, Filler HF, Schechter CB. Passive smoking and croup. Arch Otolaryngol Head Neck Surg 1987; 113:866.
17. Marx A, Török TJ, Holman RC, et al. Pediatric hospitalizations for croup (laryngotracheobronchitis): biennial increases associated with human parainfluenza virus 1 epidemics. J Infect Dis 1997; 176:1423.
18. DAVISON FW. Acute laryngeal obstruction in children. J Am Med Assoc 1959; 171:1301.
19. Davison FW. Acute obstructive laryngitis in children. Penn Med J 1950; 53:250.
20. Szpunar J, Glowacki J, Laskowski A, Miszke A. Fibrinous laryngotracheobronchitis in children. Arch Otolaryngol 1971; 93:173.
21. MORGAN EA, WISHART DE. Laryngotracheo-bronchitis (a statistical review of 549 cases). Can Med Assoc J 1947; 56:8.
22. Orton HB, Smith EL, Bell HO, et al. Acute laryngotracheobronchitis: analysis of sixty-two cases with report of autopsies in eight cases. Arch Otolaryngol 1941; 33:926.
23. Richards L. A further study of the pathology of acute laryngo-tracheobronchitis in children. Ann Otol Rhinol Laryngol 1938; 47:326.
25. Van Bever HP, Wieringa MH, Weyler JJ, et al. Croup and recurrent croup: their association with asthma and allergy. An epidemiological study on 5-8-year-old children. Eur J Pediatr 1999; 158:253.
27. Welliver RC, Sun M, Rinaldo D. Defective regulation of immune responses in croup due to parainfluenza virus. Pediatr Res 1985; 19:716.
28. Welliver RC, Wong DT, Middleton E Jr, et al. Role of parainfluenza virus-specific IgE in pathogenesis of croup and wheezing subsequent to infection. J Pediatr 1982; 101:889.
29. Thompson M, Vodicka TA, Blair PS, et al. Duration of symptoms of respiratory tract infections in children: systematic review. BMJ 2013; 347:f7027.
30. Cherry JD. The treatment of croup: continued controversy due to failure of recognition of historic, ecologic, etiologic and clinical perspectives. J Pediatr 1979; 94:352.
31. Kaditis AG, Wald ER. Viral croup: current diagnosis and treatment. Pediatr Infect Dis J 1998; 17:827.
32. Mauro RD, Poole SR, Lockhart CH. Differentiation of epiglottitis from laryngotracheitis in the child with stridor. Am J Dis Child 1988; 142:679.
33. Kasian GF, Bingham WT, Steinberg J, et al. Bacterial tracheitis in children. CMAJ 1989; 140:46.
34. Duval M, Tarasidis G, Grimmer JF, et al. Role of operative airway evaluation in children with recurrent croup: a retrospective cohort study. Clin Otolaryngol 2015; 40:227.
35. Delany DR, Johnston DR. Role of direct laryngoscopy and bronchoscopy in recurrent croup. Otolaryngol Head Neck Surg 2015; 152:159.
36. Rankin I, Wang SM, Waters A, et al. The management of recurrent croup in children. J Laryngol Otol 2013; 127:494.
37. Jabbour N, Parker NP, Finkelstein M, et al. Incidence of operative endoscopy findings in recurrent croup. Otolaryngol Head Neck Surg 2011; 144:596.
38. Chun R, Preciado DA, Zalzal GH, Shah RK. Utility of bronchoscopy for recurrent croup. Ann Otol Rhinol Laryngol 2009; 118:495.
39. Alberta Clinical Practice Guidelines Guideline Working Group. Guidelines for the diagnosis and management of croup http://www.topalbertadoctors.org.sci-hub.org/informed_practice/cpgs/croup.html (Accessed on February 22, 2011).
40. Fleisher G. Infectious disease emergencies. In: Textbook of Pediatric Emergency Medicine, 5th ed, Fleisher GR, Ludwig S, Henretig FM (Eds), Lippincott, Williams & Wilkins, Philadelphia 2006. p.783.
41. Tibballs J, Watson T. Symptoms and signs differentiating croup and epiglottitis. J Paediatr Child Health 2011; 47:77.
42. Diaz JH, Lockhart CH. Early diagnosis and airway management of acute epiglottitis in children. South Med J 1982; 75:399.
43. Westley CR, Cotton EK, Brooks JG. Nebulized racemic epinephrine by IPPB for the treatment of croup: a double-blind study. Am J Dis Child 1978; 132:484.
44. Mills JL, Spackman TJ, Borns P, et al. The usefulness of lateral neck roentgenograms in laryngotracheobronchitis. Am J Dis Child 1979; 133:1140.
45. Bernstein T, Brilli R, Jacobs B. Is bacterial tracheitis changing? A 14-month experience in a pediatric intensive care unit. Clin Infect Dis 1998; 27:458.
46. Cherry JD. Newer respiratory viruses: their role in respiratory illnesses of children. In: Advances in Pediatrics, Vol 20, Schulman I (Ed), Mosby Year Book, Chicago 1973. p.225.
47. Denny FW, Clyde WA Jr. Acute lower respiratory tract infections in nonhospitalized children. J Pediatr 1986; 108:635.
48. Henrickson KJ, Hoover S, Kehl KS, Hua W. National disease burden of respiratory viruses detected in children by polymerase chain reaction. Pediatr Infect Dis J 2004; 23:S11.
49. Lin CY, Chi H, Shih SL, et al. A 4-year-old boy presenting with recurrent croup. Eur J Pediatr 2010; 169:249.
50. Hsia SH, Lin JJ, Wu CT, et al. Guillain-Barré syndrome presenting as mimicking croup. Am J Emerg Med 2010; 28:749.e1.
Croup: Approach to management Author Charles R Woods, MD, MS Section Editors Sheldon L Kaplan, MD Anna H Messner, MD Deputy Editor Carrie Armsby, MD, MPH Disclosures: Charles R Woods, MD, MS Other Financial Interest: Cerexa [Epiglottitis (Data Safety Monitoring Board for pediatric trials of the antibiotic agent ceftaroline)]. Sheldon L Kaplan, MDGrant/Research/Clinical Trial Support: Pfizer [vaccine (PCV13)]; Forest Lab [antibiotic (Ceftaroline)]; Optimer [antibiotic (fidaxomicin)]. Consultant/Advisory Boards: Pfizer [vaccine (PCV13)]. Anna H Messner, MD Nothing to disclose. Carrie Armsby, MD, MPH Nothing to disclose.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence.
Conflict of interest policy
All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Jul 2015. | This topic last updated: Apr 17, 2015.
INTRODUCTION — Croup (laryngotracheitis) is a
respiratory illness characterized by inspiratory stridor,
barking cough, and hoarseness. It typically occurs in
children six months to three years of age and is chiefly
caused by parainfluenza virus. (See "Croup: Clinical
features, evaluation, and diagnosis".)
Most children with croup who seek medical attention
have a mild, self-limited illness and can be successfully
managed as outpatients. The clinician must be able to
identify children with mild symptoms, who can be safely
managed at home, and those with moderate to severe
croup or rapidly progressing symptoms, who require full
evaluation and possible treatment in the office or
emergency department setting. (See 'Severity
assessment' below and 'Outpatient treatment' below.)
There is no definitive treatment for the viruses that cause
croup. Pharmacologic therapy is directed toward
decreasing airway edema, and supportive care is
directed toward the provision of respiratory support and
the maintenance of hydration. Corticosteroids and
nebulized epinephrine are the cornerstones of therapy;
their use is supported by substantial clinical evidence.
(See 'Initial treatment' below and "Croup: Pharmacologic
and supportive interventions".)
The approach to the management of croup will be
discussed below. The clinical features and evaluation of
croup, and the evidence supporting the use of the
pharmacologic and supportive interventions included
below are discussed separately. (See "Croup: Clinical
features, evaluation, and diagnosis" and "Croup:
Pharmacologic and supportive interventions".)
SEVERITY ASSESSMENT — This initial step in the
management of a child with croup is assessing severity
of illness. The first contact with the healthcare system
may occur by phone and the healthcare provider must be
able to distinguish children with more severe symptoms
who need immediate medical attention from those who
can be managed at home. (See 'Telephone
triage' below.)
When the child is seen in the office or emergency
department, croup severity is assessed by examining the
child and using a clinical scoring system. (See 'Croup
severity score' below.)
Telephone triage — When assessing patients by phone,
the healthcare provider must distinguish children who
need immediate medical attention or further evaluation
from those who can be managed at home. Children who
need further evaluation include those who have:
●Stridor at rest
●Rapid progression of symptoms (ie, symptoms of
upper airway obstruction after less than 12 hours of
illness)
●Inability to tolerate oral fluids
●Underlying known airway abnormality (eg,
subglottic stenosis, subglottic hemangioma,
previous intubation)
●Previous episodes of moderate to severe croup
●Medical conditions that predispose to respiratory
doses within a two- to three-hour time period should
prompt initiation of close cardiac monitoring if this is
not already underway.
●Children with moderate to severe croup should be
observed for three to four hours after intervention.
Those who improve may be discharged home.
Children with persistent or worsening symptoms
during the observation period should be admitted to
the hospital. (See 'Discharge to home' above
and 'Indications for hospital admission' above.)
●Management of children hospitalized for croup
includes:
•Supportive care with provision of intravenous
fluids and fever reduction. (See 'Supportive
care' above.)
•Respiratory care with repeated doses of
nebulized epinephrine, as indicated by
respiratory distress, and administration of
humidified air or oxygen, as indicated by
hypoxemia. (See 'Respiratory care' above.)
•Monitoring for worsening respiratory distress.
(See 'Monitoring' above.)
We suggest not using repeated doses of
corticosteroids (Grade 2C). (See 'Repeated
corticosteroid dosing' above and "Croup:
Pharmacologic and supportive interventions",
section on 'Repeated dosing'.)
●Children who have moderate to severe symptoms
that persist for more than a few days, or recurring
episodes of croup not associated with other
manifestations of a viral illness (no
fever and/or rhinorrhea) should undergo
investigation for other causes of upper airway
obstruction. (See 'Atypical course' above
and 'Recurrent symptoms' above and "Croup:
Clinical features, evaluation, and diagnosis", section
on 'Differential diagnosis'.)
●Children who received nebulized epinephrine, had
a prolonged outpatient visit, or were admitted to the
hospital should have follow-up scheduled with the
primary care provider within 24 hours of discharge
or as soon as follow-up can be arranged. Most
children with croup recover uneventfully.
(See 'Follow-up' above and 'Prognosis'above.)
Use of UpToDate is subject to the Subscription and License Agreement.
REFERENCES
1. Westley CR, Cotton EK, Brooks JG. Nebulized racemic epinephrine by IPPB for the treatment of croup: a double-blind study. Am J Dis Child 1978; 132:484.
2. Alberta Clinical Practice Guidelines Guideline Working Group. Guidelines for the diagnosis and management of croup. www.topalbertadoctors.org/download/252/croup_guideline.pdf (Accessed on March 13, 2015).
3. Cherry JD. Clinical practice. Croup. N Engl J Med 2008; 358:384.
4. Clarke M, Allaire J. An evidence-based approach to the evaluation and treatment of croup in children. Pediatric Emergency Medicine Practice 2012; 9:1.
5. Fleisher G. Infectious disease emergencies. In: Textbook of Pediatric Emergency Medicine, 5th ed, Fleisher GR, Ludwig S, Henretig FM (Eds), Lippincott, Williams & Wilkins, Philadelphia 2006. p.783.
6. Geelhoed GC, Turner J, Macdonald WB. Efficacy of a small single dose of oral dexamethasone for outpatient croup: a double blind placebo controlled clinical trial. BMJ 1996; 313:140.
7. Bjornson CL, Klassen TP, Williamson J, et al. A randomized trial of a single dose of oral dexamethasone for mild croup. N Engl J Med 2004; 351:1306.
8. Klassen TP, Craig WR, Moher D, et al. Nebulized budesonide and oral dexamethasone for treatment of croup: a randomized controlled trial. JAMA 1998; 279:1629.
9. Paul RI. Oral dexamethasone for croup (commentary). AAP Grand Rounds 2004; 12:67.
10. Duggan DE, Yeh KC, Matalia N, et al. Bioavailability of oral dexamethasone. Clin Pharmacol Ther 1975; 18:205.
11. Johnson DW, Jacobson S, Edney PC, et al. A comparison of nebulized budesonide, intramuscular dexamethasone, and placebo for moderately severe croup. N Engl J Med 1998; 339:498.
12. Russell KF, Liang Y, O'Gorman K, et al. Glucocorticoids for croup. Cochrane Database Syst Rev 2011; :CD001955.
13. Bjornson C, Russell K, Vandermeer B, et al. Nebulized epinephrine for croup in children. Cochrane Database Syst Rev 2013; 10:CD006619.
14. Prendergast M, Jones JS, Hartman D. Racemic epinephrine in the treatment of laryngotracheitis: can we identify children for outpatient therapy? Am J Emerg Med 1994; 12:613.
15. Ledwith CA, Shea LM, Mauro RD. Safety and efficacy of nebulized racemic epinephrine in conjunction with oral
dexamethasone and mist in the outpatient treatment of croup. Ann Emerg Med 1995; 25:331.
16. Kunkel NC, Baker MD. Use of racemic epinephrine, dexamethasone, and mist in the outpatient management of croup. Pediatr Emerg Care 1996; 12:156.
17. Rizos JD, DiGravio BE, Sehl MJ, Tallon JM. The disposition of children with croup treated with racemic epinephrine and dexamethasone in the emergency department. J Emerg Med 1998; 16:535.
18. Waisman Y, Klein BL, Boenning DA, et al. Prospective randomized double-blind study comparing L-epinephrine and racemic epinephrine aerosols in the treatment of laryngotracheitis (croup). Pediatrics 1992; 89:302.
19. Fitzgerald D, Mellis C, Johnson M, et al. Nebulized budesonide is as effective as nebulized adrenaline in moderately severe croup. Pediatrics 1996; 97:722.
20. Rosychuk RJ, Klassen TP, Metes D, et al. Croup presentations to emergency departments in Alberta, Canada: a large population-based study. Pediatr Pulmonol 2010; 45:83.
21. Brown JC. The management of croup. Br Med Bull 2002; 61:189.
22. Petrocheilou A, Tanou K, Kalampouka E, et al. Viral croup: diagnosis and a treatment algorithm. Pediatr Pulmonol 2014; 49:421.
23. Dobrovoljac M, Geelhoed GC. 27 years of croup: an update highlighting the effectiveness of 0.15 mg/kg of dexamethasone. Emerg Med Australas 2009; 21:309.
24. Narayanan S, Funkhouser E. Inpatient hospitalizations for croup. Hosp Pediatr 2014; 4:88.
25. Moore M, Little P. Humidified air inhalation for treating croup. Cochrane Database Syst Rev 2006; :CD002870.
26. Moraa I, Sturman N, McGuire T, van Driel ML. Heliox for croup in children. Cochrane Database Syst Rev 2013; 12:CD006822.
27. Thompson M, Vodicka TA, Blair PS, et al. Duration of symptoms of respiratory tract infections in children: systematic review. BMJ 2013; 347:f7027.
28. Cherry JD. Croup (laryngitis, laryngotracheitis, spasmodic croup, laryngotracheobronchitis, bacterial tracheitis, and laryngotracheobronchopneumonitis) and epiglottitis
(supraglottitis). In: Feigin and Cherry’s Textbook of Pediatric Infectious Diseases, 7th ed, Cherry JD, Harrison GJ, Kaplan SL, et al (Eds), Elsevier Saunders, Philadelphia 2014. p.241.
29. Johnson D. Croup. Clin Evid 2005; :310. 30. McEniery J, Gillis J, Kilham H, Benjamin B. Review of
intubation in severe laryngotracheobronchitis. Pediatrics 1991; 87:847.
31. Travis KW, Todres ID, Shannon DC. Pulmonary edema associated with croup and epiglottitis. Pediatrics 1977; 59:695.
32. Fisher JD. Out-of-hospital cardiopulmonary arrest in children with croup. Pediatr Emerg Care 2004; 20:35.
33. Sofer S, Dagan R, Tal A. The need for intubation in serious upper respiratory tract infection in pediatric patients (a retrospective study). Infection 1991; 19:131.
34. Rosekrans JA. Viral croup: current diagnosis and treatment. Mayo Clin Proc 1998; 73:1102.
35. Cooper T, Kuruvilla G, Persad R, El-Hakim H. Atypical croup: association with airway lesions, atopy, and esophagitis. Otolaryngol Head Neck Surg 2012; 147:209.
36. Duval M, Tarasidis G, Grimmer JF, et al. Role of operative airway evaluation in children with recurrent croup: a retrospective cohort study. Clin Otolaryngol 2015; 40:227.
37. Delany DR, Johnston DR. Role of direct laryngoscopy and bronchoscopy in recurrent croup. Otolaryngol Head Neck Surg 2015; 152:159.
38. Rankin I, Wang SM, Waters A, et al. The management of recurrent croup in children. J Laryngol Otol 2013; 127:494.
39. Jabbour N, Parker NP, Finkelstein M, et al. Incidence of operative endoscopy findings in recurrent croup. Otolaryngol Head Neck Surg 2011; 144:596.
40. Chun R, Preciado DA, Zalzal GH, Shah RK. Utility of bronchoscopy for recurrent croup. Ann Otol Rhinol Laryngol 2009; 118:495.
Croup: Pharmacologic and supportive interventions Author Charles R Woods, MD, MS Section Editor Sheldon L Kaplan, MD Deputy Editor Carrie Armsby, MD, MPH Disclosures: Charles R Woods, MD, MS Other Financial Interest: Cerexa [Epiglottitis (Data Safety Monitoring Board for pediatric trials of the antibiotic agent ceftaroline)]. Sheldon L Kaplan, MDGrant/Research/Clinical Trial Support: Pfizer [vaccine (PCV13)]; Forest Lab [antibiotic (Ceftaroline)]; Optimer [antibiotic (fidaxomicin)]. Consultant/Advisory Boards: Pfizer [vaccine (PCV13)]. Carrie Armsby, MD, MPH Nothing to disclose.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence.
Conflict of interest policy
All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Jul 2015. | This topic last updated: Jan 30, 2014.
INTRODUCTION — Croup (laryngotracheitis) is a
respiratory illness characterized by inspiratory stridor,
barking cough, and hoarseness. It typically occurs in
children six months to three years of age and is caused
by parainfluenza virus. (See "Croup: Clinical features,
evaluation, and diagnosis".)
The treatment of croup has changed significantly since
the 1980s. Glucocorticoids and
nebulized epinephrine have become the cornerstones of
therapy. Substantial clinical evidence supports the
efficacy of these interventions [1-5]. The impact also is
evident in the decrease in annual hospital admissions for
croup in children in the United States between 1979 to
1982 and 1994 to 1997 (from 2.8 to 2.1 per 1000 for
children <1 year and from 1.8 to 1.2 per 1000 children
for children 1 to 4 years) [6].
Treatment of croup may involve a variety of
pharmacologic and nonpharmacologic interventions. It
may occur entirely at home, or in the office, emergency
department (ED), or hospital setting. Supportive and
pharmacologic interventions will be discussed below.
The clinical features and evaluation of croup and the
approach to management are discussed separately.
(See "Croup: Clinical features, evaluation, and
diagnosis" and "Croup: Approach to management".)
GLUCOCORTICOIDS — Glucocorticoids provide long-
lasting and effective treatment of mild, moderate, and
severe croup [3,7-9]. The antiinflammatory actions of
glucocorticoids are thought to decrease edema in the
laryngeal mucosa of children with croup. Improvement is
usually evident within six hours of administration but
seldom is dramatic [7,10].
Treatment with glucocorticoids at various doses and by
various routes has been shown to improve croup scores
and to decrease unscheduled medical visits, length of
stay in the emergency department or hospital, and the
use of epinephrine [7]. Among the available
glucocorticoids, dexamethasone has been used most
frequently, is the least expensive, has the longest
duration of action, and is the easiest to administer.
●Humidified air is frequently used as a supportive
treatment for croup; however, there have been no
studies supporting its efficacy in reducing
symptoms. (See 'Mist therapy' above.)
●Humidified oxygen should be administered to
children who are hypoxemic and/or in moderate to
severe respiratory distress. (See 'Oxygen' above.)
●Heliox has not definitively been shown to be more
effective than humidified oxygen or
racemic epinephrine in reducing croup scores.
(See 'Heliox' above.)
●Antibiotics should be used only to treat specific
bacterial complications of croup.
(See 'Antibiotics' above and "Croup: Approach to
management", section on 'Complications'.)
●Antitussives and decongestants are of unproven
benefit in the management of croup. Sedatives
may decrease the work of breathing and improve
agitation without actually improving ventilation or
addressing the underlying cause of agitation
(hypoxemia). (See 'Other therapies' above.)
Use of UpToDate is subject to the Subscription and License Agreement.
REFERENCES
1. Westley CR, Cotton EK, Brooks JG. Nebulized racemic epinephrine by IPPB for the treatment of croup: a double-blind study. Am J Dis Child 1978; 132:484.
2. Fogel JM, Berg IJ, Gerber MA, Sherter CB. Racemic epinephrine in the treatment of croup: nebulization alone versus nebulization with intermittent positive pressure breathing. J Pediatr 1982; 101:1028.
3. Kairys SW, Olmstead EM, O'Connor GT. Steroid treatment of laryngotracheitis: a meta-analysis of the evidence from randomized trials. Pediatrics 1989; 83:683.
4. Johnson DW, Jacobson S, Edney PC, et al. A comparison of nebulized budesonide, intramuscular dexamethasone, and placebo for moderately severe croup. N Engl J Med 1998; 339:498.
5. Klassen TP, Feldman ME, Watters LK, et al. Nebulized budesonide for children with mild-to-moderate croup. N Engl J Med 1994; 331:285.
6. Counihan ME, Shay DK, Holman RC, et al. Human parainfluenza virus-associated hospitalizations among children less than five years of age in the United States. Pediatr Infect Dis J 2001; 20:646.
7. Russell KF, Liang Y, O'Gorman K, et al. Glucocorticoids for croup. Cochrane Database Syst Rev 2011; :CD001955.
8. Tibballs J, Shann FA, Landau LI. Placebo-controlled trial of prednisolone in children intubated for croup. Lancet 1992; 340:745.
9. Bjornson CL, Klassen TP, Williamson J, et al. A randomized trial of a single dose of oral dexamethasone for mild croup. N Engl J Med 2004; 351:1306.
10. Geelhoed GC, Macdonald WB. Oral and inhaled steroids in croup: a randomized, placebo-controlled trial. Pediatr Pulmonol 1995; 20:355.
11. Klassen TP, Craig WR, Moher D, et al. Nebulized budesonide and oral dexamethasone for treatment of croup: a randomized controlled trial. JAMA 1998; 279:1629.
12. Geelhoed GC. Budesonide offers no advantage when added to oral dexamethasone in the treatment of croup. Pediatr Emerg Care 2005; 21:359.
13. Griffin S, Ellis S, Fitzgerald-Barron A, et al. Nebulised steroid in the treatment of croup: a systematic review of randomised controlled trials. Br J Gen Pract 2000; 50:135.
14. Johnson D. Croup. Clin Evid 2005; :310. 15. Vernacchio L, Mitchell AA. Oral dexamethasone for mild
croup. N Engl J Med 2004; 351:2768. 16. Cherry JD. Croup (laryngitis, laryngotracheitis,
spasmodic croup, laryngotracheobronchitis, bacterial tracheitis, and laryngotracheobronchopneumonitis) and epiglottitis (supraglottitis). In: Feigin and Cherry’s Textbook of Pediatric Infectious Diseases, 7th ed, Cherry JD, Harrison GJ, Kaplan SL, et al (Eds), Elsevier Saunders, Philadelphia 2014. p.241.
17. Johnson DW, Schuh S, Koren G, Jaffee DM. Outpatient treatment of croup with nebulized dexamethasone. Arch Pediatr Adolesc Med 1996; 150:349.
18. Kaditis AG, Wald ER. Viral croup: current diagnosis and treatment. Pediatr Infect Dis J 1998; 17:827.
19. Dowell SF, Bresee JS. Severe varicella associated with steroid use. Pediatrics 1993; 92:223.
20. Kiff KM, Mok Q, Dunne J, Tasker RC. Steroids for intubated croup masking airway haemangioma. Arch Dis Child 1996; 74:66.
21. Geelhoed GC, Turner J, Macdonald WB. Efficacy of a small single dose of oral dexamethasone for outpatient croup: a double blind placebo controlled clinical trial. BMJ 1996; 313:140.
22. Geelhoed GC, Macdonald WB. Oral dexamethasone in the treatment of croup: 0.15 mg/kg versus 0.3 mg/kg versus 0.6 mg/kg. Pediatr Pulmonol 1995; 20:362.
23. Harper MB, Fleisher GR. Infectious Disease Emergencies. In: Textbook of Pediatric Emergency Medicine, 6th, Fleisher GR, Ludwig SL (Eds), Lippincott Willams & Wilkins, Philadelphia 2010. p.887.
24. Alberta Clinical Practice Guideline WorkingGroup. Guideline for the diagnosis and management of croup. 2008. www.topalbertadoctors.org/download/252/croup_guideline.pdf (Accessed on October 31, 2013).
25. Paul RI. Oral dexamethasone for croup (commentary). AAP Grand Rounds 2004; 12:67.
26. Duggan DE, Yeh KC, Matalia N, et al. Bioavailability of oral dexamethasone. Clin Pharmacol Ther 1975; 18:205.
27. Luria JW, Gonzalez-del-Rey JA, DiGiulio GA, et al. Effectiveness of oral or nebulized dexamethasone for children with mild croup. Arch Pediatr Adolesc Med 2001; 155:1340.
28. Cetinkaya F, Tüfekçi BS, Kutluk G. A comparison of nebulized budesonide, and intramuscular, and oral dexamethasone for treatment of croup. Int J Pediatr Otorhinolaryngol 2004; 68:453.
29. Garbutt JM, Conlon B, Sterkel R, et al. The comparative effectiveness of prednisolone and dexamethasone for children with croup: a community-based randomized trial. Clin Pediatr (Phila) 2013; 52:1014.
30. Sparrow A, Geelhoed G. Prednisolone versus dexamethasone in croup: a randomised equivalence trial. Arch Dis Child 2006; 91:580.
31. Fifoot AA, Ting JY. Comparison between single-dose oral prednisolone and oral dexamethasone in the treatment of croup: a randomized, double-blinded clinical trial. Emerg Med Australas 2007; 19:51.
32. Connors K, Gavula D, Terndrup T. The use of corticosteroids in croup: a survey. Pediatr Emerg Care 1994; 10:197.
33. Amir L, Hubermann H, Halevi A, et al. Oral betamethasone versus intramuscular dexamethasone for the treatment of mild to moderate viral croup: a prospective, randomized trial. Pediatr Emerg Care 2006; 22:541.
34. Cherry JD. State of the evidence for standard-of-care treatments for croup: are we where we need to be? Pediatr Infect Dis J 2005; 24:S198.
35. Kristjánsson S, Berg-Kelly K, Winsö E. Inhalation of racemic adrenaline in the treatment of mild and moderately severe croup. Clinical symptom score and oxygen saturation measurements for evaluation of treatment effects. Acta Paediatr 1994; 83:1156.
36. Taussig LM, Castro O, Beaudry PH, et al. Treatment of laryngotracheobronchitis (croup). Use of intermittent positive-pressure breathing and racemic epinephrine. Am J Dis Child 1975; 129:790.
37. Corkey CW, Barker GA, Edmonds JF, et al. Radiographic tracheal diameter measurements in acute infectious croup: an objective scoring system. Crit Care Med 1981; 9:587.
38. Kuusela AL, Vesikari T. A randomized double-blind, placebo-controlled trial of dexamethasone and racemic epinephrine in the treatment of croup. Acta Paediatr Scand 1988; 77:99.
39. Bjornson C, Russell K, Vandermeer B, et al. Nebulized epinephrine for croup in children. Cochrane Database Syst Rev 2013; 10:CD006619.
40. Waisman Y, Klein BL, Boenning DA, et al. Prospective randomized double-blind study comparing L-epinephrine and racemic epinephrine aerosols in the treatment of laryngotracheitis (croup). Pediatrics 1992; 89:302.
41. Butte MJ, Nguyen BX, Hutchison TJ, et al. Pediatric myocardial infarction after racemic epinephrine administration. Pediatrics 1999; 104:e9.
42. Duncan PG. Efficacy of helium--oxygen mixtures in the management of severe viral and post-intubation croup. Can Anaesth Soc J 1979; 26:206.
43. Terregino CA, Nairn SJ, Chansky ME, Kass JE. The effect of heliox on croup: a pilot study. Acad Emerg Med 1998; 5:1130.
44. Weber JE, Chudnofsky CR, Younger JG, et al. A randomized comparison of helium-oxygen mixture (Heliox) and racemic epinephrine for the treatment of moderate to severe croup. Pediatrics 2001; 107:E96.
45. Moraa I, Sturman N, McGuire T, van Driel ML. Heliox for croup in children. Cochrane Database Syst Rev 2013; 12:CD006822.
46. Skolnik NS. Treatment of croup. A critical review. Am J Dis Child 1989; 143:1045.
47. Neto GM, Kentab O, Klassen TP, Osmond MH. A randomized controlled trial of mist in the acute treatment of moderate croup. Acad Emerg Med 2002; 9:873.
48. Scolnik D, Coates AL, Stephens D, et al. Controlled delivery of high vs low humidity vs mist therapy for croup in emergency departments: a randomized controlled trial. JAMA 2006; 295:1274.
49. Dulfano MJ, Adler K, Wooten O. Physical properties of sputum. IV. Effects of 100 per cent humidity and water mist. Am Rev Respir Dis 1973; 107:130.
50. Parks CR. Mist therapy: rationale and practice. J Pediatr 1970; 76:305.
51. Henry R. Moist air in the treatment of laryngotracheitis. Arch Dis Child 1983; 58:577.
52. Sasaki CT, Suzuki M. The respiratory mechanism of aerosol inhalation in the treatment of partial airway obstruction. Pediatrics 1977; 59:689.
53. Fanconi S, Burger R, Maurer H, et al. Transcutaneous carbon dioxide pressure for monitoring patients with severe croup. J Pediatr 1990; 117:701.