This document provides information on croup, a respiratory illness that typically affects children aged 6 months to 3 years. It discusses croup severity scoring using the Westley croup score. Mild croup is treated as an outpatient with dexamethasone, while moderate to severe croup receives dexamethasone and nebulized epinephrine in the emergency department along with supportive care. Hospitalized children may need repeated nebulized epinephrine and humidified oxygen, with most making a full recovery within a week.

1. CROUP
PREPARED BY Nkundimana jean paul

2. Croup
• INTRODUCTION — Croup (laryngotracheitis) is a respiratory illness
characterized by inspiratory stridor, barking cough, and hoarseness. It
typically occurs in children 6 months to 3 years of age and is chiefly
caused by parainfluenza virus

3. • Croup severity score — There are a number of validated croup
scoring systems. The Westley croup score has been the most
extensively studied].
• Severity is determined by the presence or absence of stridor at rest,
the degree of chest wall retractions, air entry, the presence or
absence of pallor or cyanosis, and the mental status.
• In a study that evaluated the individual components of the Westley
croup score, the degree of chest wall retractions and air entry were
the strongest predictors of need for hospitalization

4. • ●Mild croup (Westley croup score of ≤2) − Children with mild croup
have no stridor at rest (although stridor may be present when upset
or crying), a barking cough, hoarse cry, and either no, or only mild,
chest wall/subcostal retractions
• ●Moderate croup (Westley croup score of 3 to 7) − Children with
moderate croup have stridor at rest, have at least mild retractions,
and may have other symptoms or signs of respiratory distress, but
little or no agitation
• ●Severe croup (Westley croup score of ≥8) − Children with severe
croup have stridor at rest, although the loudness of the stridor may
decrease with worsening upper airway obstruction and decreased air
entry [3-5]. Retractions are severe (including indrawing of the
sternum), and the child may appear anxious, agitated, or pale and
fatigued. Prompt recognition and treatment of children with severe
croup are paramount.

5. • Impending respiratory failure (Westley croup score of ≥12) − Croup
occasionally results in severe upper airway obstruction with
impending respiratory failure, heralded by the following signs
• Fatigue and listlessness
• Marked retractions (although retractions may decrease with
increased obstruction and decreased air entry)
• Decreased or absent breath sounds
• Depressed level of consciousness
• Tachycardia out of proportion to fever
• Cyanosis or pallor

6. MILD CROUP
• Outpatient treatment — We suggest that children with mild croup
who are seen in the outpatient setting be treated with a single dose
of oral dexamethasone (0.15 to 0.6 mg/kg, maximum dose 16 mg).
Randomized controlled trials in children with mild croup have
demonstrated that treatment with a single dose of oral
dexamethasone reduces the need for reevaluation, shortens the
duration of symptoms, improves the child's sleep, and reduces
parental
• Treatment with nebulized epinephrine is not typically necessary for
management of mild croup.
• Children with mild croup who are tolerating fluids and have not
received nebulized epinephrine can be sent home after specific
follow-up (which may occur by phone) has been arranged and the
caregiver has received instructions regarding home care

7. MODERATE TO SEVERE CROUP
• nitial treatment — Initial treatment of moderate to severe croup
includes administration of dexamethasone and
nebulized epinephrine. Children with moderate to severe croup
should also receive supportive care including humidified air or
oxygen, antipyretics, and encouragement of fluid intake

8. • We recommend administration
of dexamethasone (0.6 mg/kg, maximum of 16 mg) in all children
with moderate to severe croup. Dexamethasone should be
administered by the least invasive route possible: oral if oral intake is
tolerated, intravenous (IV) if IV access has been established, or
intramuscular (IM) if oral intake is not tolerated and IV access has not
been established. The oral preparation of dexamethasone
(1 mg/mL) has an unpleasant taste. The IV preparation is more
concentrated (4 mg per mL) and can be given orally mixed with syrup
. A single dose of nebulized budesonide (2 mg [2 mL solution] via
nebulizer) is an alternative option, particularly for children who are
vomiting and who lack IV access

9. • In addition to dexamethasone, we recommend nebulized epinephrine in all
patients with moderate to severe croup:
• ●Racemic epinephrine 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.
• ●L-epinephrine (parenteral product) is administered as 0.5 mL/kg per dose
(maximum of 5 mL) using the 1 mg/mL strength (may also be referred to as
a 1:1000 dilution). It is given via nebulizer over 15 minutes.
• The benefits of nebulized epinephrine have been demonstrated in a meta-
analysis of eight trials that found improvement in croup score 30 minutes
posttreatment and shorter hospital stay; there was no difference in
effectiveness between racemic epinephrine and

10. epinephrine
• It is non-selective alph 1,2 beta 1,2 agonist . on alph
• is cause vasocontraction in trachea which reduce the blood
flow to the epithelium thus reduce secretion and edem
• On beta 2 it has an effect on bronchodilation

11. Supportive care —
• Supportive care for children hospitalized with moderate to severe croup includes:
• Fluids − Administration of intravenous fluids may be necessary in some children.
Fever and tachypnea may increase fluid requirements, and respiratory difficulty
may prevent the child from achieving adequate oral intake.
• Fever control − High fever can contribute to tachypnea and respiratory distress in
children with croup, and treatment with antipyretics can improve work of
breathing and insensible fluid losses.
• Comfort − Care must be taken to avoid provoking agitation or anxiety in children
with moderate to severe croup as this can worsen the degree of respiratory
distress and airway obstruction. Children with severe croup should be
approached cautiously, and unnecessary invasive interventions should be
avoided. The parent or caregiver should be instructed to hold and comfort the
child and to assist in care. The use of sedatives or anxiolytics to reduce agitation is
discouraged as this may cause respiratory depression.

12. Respiratory care
• Respiratory support for children hospitalized with croup may include the following:
• Nebulized epinephrine − Repeated doses of nebulized epinephrine may be warranted for
children with moderate to severe distress.
• Supplemental oxygen − Oxygen should be administered to children who are hypoxemic
(oxygen saturation of <92 percent in room air). Supplemental oxygen should be
humidified to decrease drying effects on the airways, since drying may impede the
physiologic removal of airway secretions via mucociliary and cough mechanisms
• Mist − Humidified air is frequently used in the treatment of croup, although a meta-
analysis of three trials evaluating the use of humidified air in croup found only marginal
improvement in croup scores [26]. Mist therapy may provide a sense of comfort and
reassurance to both the child and family; however, if the child is instead agitated by the
mist, it should be discontinued
• Heliox − Heliox is a mixture of helium (70 to 80 percent) and oxygen (20 to 30 percent).
Heliox may decrease the work of breathing in children with croup by reducing turbulent
airflow.
• Intubation − The need for intubation should be anticipated in children with progressive
respiratory failure so that the procedure can be performed in a controlled setting if
possible. Intubation can be challenging due to the narrowed subglottic airway and should
be performed with the assistance of a skilled provider

13. • Repeated corticosteroid dosing — Repeat doses of corticosteroids
are not necessary on a routine basis and may have adverse effects.
Moderate to severe symptoms that persist for more than a few days
should prompt investigation for other causes of airway obstruction.
• Infection control — Children who are admitted to the hospital with
croup should be managed with contact precautions (ie, gown and
gloves for contact), particularly if parainfluenza or respiratory
syncytial virus is the suspected etiology. If influenza is suspected,
droplet isolation measures (ie, respiratory mask within three feet)
also should be followed

14. Discharge criteria
• — Children who require hospital admission may be discharged when
they meet the following criteria:
• No stridor at rest
• Normal pulse oximetry in room air
• Good air exchange
• Normal color
• Normal level of consciousness
• Demonstrated ability to tolerate fluids by mouth

15. • PROGNOSIS — Symptoms of croup resolve in most children within
three days but may persist for up to one week.Approximately 8 to 15
percent of children with croup require hospital admission], and
among those, <3 percent require intubation .Mortality is rare,
occurring in <1 percent of intubated children .
• Complications — Complications of croup are uncommon. Children
with moderate to severe croup are at risk for hypoxemia (oxygen
saturation <92 percent in room air) and respiratory failure. Other
complications include pulmonary edema, pneumothorax, and
pneumomediastinum .These complications can be anticipated and
managed by aggressive monitoring and intervention in the medical
setting. Out-of-hospital cardiac arrest and death also have been
reported

16. • S UMMARY AND RECOMMENDATIONS
• ●Children with croup should be seen in the office or emergency
department if they have stridor at rest, an underlying airway abnormality,
previous episodes of moderate to severe croup, underlying conditions that
may predispose to respiratory failure, rapid progression of symptoms,
inability to tolerate fluids, prolonged symptoms, or an atypical course.
(See 'Telephone triage' above.)
• ●Children with mild symptoms (ie, no stridor at rest and no respiratory
distress) can be managed at home. Families should be instructed in
provision of supportive care and indications to seek medical attention.
(See 'Home treatment' above.)
• ●We suggest that children with mild croup who are seen in the outpatient
setting be treated with a single dose of dexamethasone (algorithm 1)
(Grade 2A). In this setting, the appropriate dose of dexamethasone is 0.15
to 0.6 mg/kg (maximum 16 mg) given orally. (See 'Outpatient
treatment' above and "Croup: Pharmacologic and supportive
interventions", section on 'Dexamethasone'.)

17. • ●Children with moderate croup (ie, stridor at rest with mild to moderate retractions)
should be evaluated in the office or emergency department, and those with severe croup
(stridor at rest with marked retractions and significant distress or agitation) should be
evaluated in the emergency department (table 1) (calculator 1). Children with severe
croup must be approached cautiously, as any increase in anxiety may worsen airway
obstruction. (See 'Moderate to severe croup'above.)
• ●We recommend that children with moderate to severe croup be treated with a single
dose of dexamethasone (Grade 1A). Dexamethasone is given at a dose of
0.6 mg/kg (maximum of 16 mg) by the least invasive route (algorithm 1). (See 'Initial
treatment' above and "Croup: Pharmacologic and supportive interventions", section on
'Glucocorticoids'.)
• ●We recommend that children with moderate to severe croup be treated with
nebulized epinephrine (Grade 1A) in addition to dexamethasone (algorithm 1).
(See 'Initial treatment' above and "Croup: Pharmacologic and supportive interventions",
section on 'Nebulized epinephrine'.)

18. • Racemic epinephrine 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.
• L-epinephrine 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.
• Nebulized epinephrine can be repeated every 15 to 20 minutes. The
administration of three or more 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)

19. • 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 routinely 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'.)
• ●Most children with croup recover uneventfully. 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. (See 'Follow-
up' above and 'Prognosis' above.)

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