• This is a 20 month old male who presents to the
emergency department with a chief complaint of cough.
• Two days ago he developed rhinorrhea, fever, a hoarse
cry and a progressively worsening, harsh "barky,"
cough. Today he developed a "whistling" sound when
he breathes, so his parents brought him to the
• His past medical history is unremarkable. His 6 year old
brother also has cold symptoms.
• VS T 37.5, P 140, R 36, BP 90/64, oxygen saturation 96% in
room air. He is alert, with good eye contact, in mild respiratory
distress. He has a dry barking cough and a hoarse cry.
• He has some clear mucus rhinorrhea but no nasal flaring. His
pharynx is slightly injected, but there is no enlargement or
asymmetry.His heart is regular without murmurs.
• His lung exam shows good aeration and slight inspiratory
stridor at rest. He has very slight subcostal retractions. No
wheeze or rhonchi are noted. His abdomen is flat, soft, and
non-tender. His extremities are warm and pink with good
• He is treated with nebulized racemic epinephrine and
his cough subsided and his stridor resolved.
• A lateral neck X-ray revealed no prevertebral soft
tissue widening or evidence of epiglottitis. The
subglottic region is mildly narrowed.
• He is treated with oral dexamethasone. He is
discharged home after 3 hour of monitoring and his
parents were instructed to treat him with humidified mist
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 term croup has been used to describe a variety of
upper respiratory conditions in children including :
or spasmodic croup
refers to inflammation limited to the larynx and manifests
itself as hoarseness . It usually occurs in older children
refers to inflammation of the larynx and trachea .Although
lower airway signs are absent, the typical barking cough
will be present.
occurs when inflammation extends into the bronchi,
resulting in lower airway signs (eg, wheezing, crackles, air
trapping, increased tachypnea)
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
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.
Spasmodic croup is characterized by the sudden onset of
inspiratory stridor at night, short duration (several hours),
and sudden cessation
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 descriptive term, "frequently
recurrent croup". Because of some clinical overlap with
atopic diseases, it is sometimes referred to as "allergic
Croup is usually caused by viruses. Bacterial infection
may occur secondarily.
• Parainfluenza type 1
• Parainfluenza type 2
• Parainfluenza type 3
Other viral causes
Respiratory syncytial virus (RSV) and adenoviruses
Human coronavirus NL63 (HCoV-NL63)
Rhinoviruses, enteroviruses (especially Coxsackie types A9, B4,
and B5, and echovirus types 4, 11, and 21), and herpes simplex
Croup also may be caused by bacteria.
Mycoplasma pneumoniae has been associated with mild cases of croup.
secondary bacterial infection may occur in children with
laryngotracheitis, laryngotracheobronchitis, or
The most common secondary bacterial pathogens include
Staphylococcus aureus, Streptococcus pyogenes, and S.
• Like most respiratory infections, the initial site of
infection is thought to be the nasopharynx with
subsequent spread to the larynx and trachea.
• The respiratory epithelium becomes diffusely inflamed
and edematous, resulting in airway narrowing and
• Reduced mobility of the vocal cords results in a hoarse
voice or cry.
Croup affects about 15% of children
most commonly occurs in children 6 to 36 months of
It is more common in boys, with a male: female ratio
of about 1.4:1
Most cases occur in the fall or early winter
family history of croup is a risk factor for croup and
ED visits for croup are most freguent B/W 10:00 PM and
hospital admission for croup have declined steadily
since the late of 1970
• Croup generally starts with
several days of :
•Over the next 12 to 48 hours, a
progressively worsening "barky"
cough, hoarseness and inspiratory
stridor are noted, secondary to some
degree of upper airway obstruction
and laryngeal inflammation.
•The speed of progression and degree of
airway obstruction can vary widely.
The onset is often rapid and typically in the
early morning hours (e.g., 2:00 am).
Croup symptoms appear to subside during
the day (possibly because of positioning),
only to recur the following night.
Thus, a child with significant stridor presenting during
daylight, may be more seriously affected.
• the physical presentation of croup has
the child with croup typically does not appear
•Most children with mild symptoms have no more than
a"croupy" cough and hoarse cry and some may have
stridor only upon activity or agitation.
Children with more severe cases have:
inspiratory and expiratory stridor at rest.
visible suprasternal,intercostal,subcostal retractions.
Air entry may be poor.
lethergy and agitation
hypoxemia and increasing hypercarbia
respiratory arrest may occur suddenly during an episode
of severe coughing
tachypnea,tachycardia out of proportion to fever.
unable to maintain adequate oral intake.
Westley croup score
Normal, including sleep = 0
None = 0
None = 0
Normal = 0
None = 0
Total score 0-
Depressed = 5
with agitation = 4 at rest = 5
with agitation = 1 at rest = 2
decreased = 1 markedly decreased = 2
mild = 1 moderate = 2 sevre=3
Is defined by a Westley croup score of <3
consists of occasional barking cough, no stridor at
rest, and mild or absent suprasternal or subcostal
Is defined by a Westley croup score of 3 to 6.
includes frequent cough, audible stridor at rest, and
visible retractions, but little distress or agitation.
Is defined by a Westley croup score of ≥8.
consists of frequent cough, prominent inspiratory (and,
occasionally, expiratory) stridor, conspicuous
retractions, decreased air entry on auscultation, and
significant distress and agitation. Lethargy, cyanosis,
and decreasing retractions are harbingers of
impending respiratory failure.
Laboratory studies add little to the diagnosis of croup if
bacterial infection is not suspected.
White blood cell counts may be elevated above 10,000
with a predominance of polymorphonuclear cells.
White blood cell counts greater than 20,000 may suggest
Chest radiographs may show subglottic narrowing (in 50%
of children with croup), but this can also be seen in normal
Lateral neck radiographs are often obtained, not as much to
confirm the diagnosis of croup, but to rule out other causes
of stridor such as soft tissue densities in the trachea, a
retropharyngeal abscess and epiglottitis.
Croup: Anteroposterior radiograph with
The lateral view :demonstrate overdistention of the
hypopharynx during inspiration and subglottic
Foreign body aspiration or
Upper airway injury
of the upper airway
Epiglottitis vs Croup
Feature Epiglottitis Croup
Organism H. influenzae parainfluenza virus
Age 2-6 years 6m-3y
Onset rapid gradual
Site supraglottic subglottic
Temperature high fever low grade fever
Dysphagia severe absent (mild)
Dyspnoea +++ variable
Drooling present not present
Epiglottitis vs Croup (cont.)
Feature Epiglottitis Croup
Stridor inspiratory or expiratory mainly inspiratory
Lymph nodes +++ +
Cough not common barking cough
Voice muffled hoarse
Posture sitting forward lying down
Behaviour quiet; terrified struggling
Appereance toxic not toxic
X-ray thumb sign steeple sign
Keep child calm
Cool mist or night air
Steam(vaporizer of from
Encouragement of fluid
treatment: Humidified air
Single dose of oral
MODERATE TO SEVERE CROUP
Humidified air or humidified oxygen
Corticosteroids provide benefit for children with viral croup
by reducing the severity and shortening the course of the
Dexamethasone is the most commonly used, with the dose
being 0.6 mg/kg (maximum 10 mg) by mouth or
Clinical improvement from corticosteroids is usually not
apparent until 6 hours after treatment.
More recent studies have shown high dose nebulized
budesonide to be as effective as dexamethasone, with
more rapid onset of effect.
is thought to stimulate alpha-adrenergic receptors with
subsequent constriction of arterioles and decreased laryngeal
Nebulized epinephrine may have marked effect to decrease
inspiratory stridor and the work of breathing.
The effects of this medication last less than two hours and
children need to be monitored serially for the return of
Is administered as 0.05 mL/kg per dose (maximum of 0.5
mL)of a 2.25 percent solution diluted to 3 mL total volume
with normal saline.
It is given via nebulizer over 15 minutes.
is administered as 0.5 mL/kg per dose (maximum of 5 mL) of
a 1:1000 dilution. It is given via nebulizer over 15 minutes.
Racemic epinephrine and L-epinephrine appear to be equally
As n:tibiotics should be used only to treat specific bacterial
complications of croup.
Antitussives and decongestants :
Antitussives and decongestants are of unproven benefit in
the management of croup.
Hospitalization if :
• Progressive stridor
• Stridor at rest
• Respiratory distress
• Depressed mental status
No stridor at rest
Normal pulse oximetry
Good air exchange
Normal level of consciousness
Demonstrated ability to tolerate fluids by
Viral croup is usually a self-limited disease
The prognosis for croup is excellent, and recovery is
almost always complete.
Symptoms usually improve within tree days, but may
last for up to seven days
Less than 5 percent of children with croup require
hospital admission, and among those, 1 to 6 percent
rMeoqrutairleit yin itsu braarteio, no ccurring in <0.5 percent of intubated
1. Which of the following viruses are most
commonly associated with viral croup?
b. Human papilloma virus
c. Varicella virus
d. Parainfluenza viruses
2. Which of the following is/are true?
a. There is good evidence from randomized controlled
trials that mist therapy is effective for the treatment of
b. Antibiotics are indicated in the treatment of croup.
c. Dexamethasone has been shown to be effective in
the treatment of croup.
3. Which of the following is/are true?
a. Croup affects more girls than boys.
b. Croup shows no seasonal prevalence.
c. Most cases occur in teenagers.
d. It is a common respiratory infection in children.
Once a child with croup has been given corticosteroid
treatment and racemic epinephrine, they may safely be
discharged home after 20-30 minutes of monitoring?