Croup: Emergency Management in Children

Document ID 00702 Version no. 2.0 Approval date 19/11/2014

Executive sponsor Executive Director Medical Services Effective date 19/11/2014
Author/custodian Director Paediatric Emergency Medicine, CHQ Review date 19/11/2016
Supercedes CHQ Procedure 00702
Applicable to CHQ medical & nursing staff
Authorisation Sue McKee, General Manager Operations

Purpose
This procedure provides clinical practice guidelines to guide clinicians involved in the emergency
management of children with acute croup.

Scope
This guideline relates to all staff involved in the care and management of children with acute croup.

Related documents
Procedures, Guidelines, Protocols
Flowchart: Emergency Management of Croup in Children
Parent Information: Acute Croup
Admission/Discharge Criteria for Children with Croup
Introduction
Croup (acute laryngotracheobronchitis) is a clinical syndrome characterised by barking cough, inspiratory
stridor and hoarseness of voice with or without respiratory distress.1,2 It is a common cause of upper airway
obstruction in young children, accounting for approximately 2.3% of emergency presentations in Australia
and New Zealand.3,4 Although croup is usually a mild and self-limited illness, significant upper airway
obstruction, respiratory distress and rarely death, can occur.4
Croup results from inflammation of the upper airway, including the larynx, trachea, and bronchi. Viral invasion
of the laryngeal mucosa leads to inflammation, hyperaemia, and oedema. This may then result in narrowing
of the subglottic region.5 Children then compensate for this narrowing by changing their work of breathing.
In children with severe croup, as the narrowing progresses their increased work of breathing becomes
counter-productive. Airflow through the upper airway becomes turbulent (producing stridor) and their
compliant chest wall begins to cave in during inspiration.6,7,8 This results in paradoxical breathing, and
consequently the child becomes fatigued. If untreated, these events may lead to hypoxia and hypercapnoea,
which may eventually result in respiratory failure and arrest.6-8
Typical viral croup develops over a few days with a concurrent coryzal illness. A number of viruses may
cause croup, the most common of which are Parainfluenza and RSV.1,2,4,9,10 The airway obstruction
symptoms of croup are classically worse at night and peak on the second or third night of the illness.
Symptoms usually resolve within 48 hours but occasionally persist for up to a week. 1,2,11,12 Croup mostly
affects children between 6 and 36 months, although it may occur in older children or infants as young as 3
months.10 It is rare beyond 6 years of age.5,13 Alternative causes of upper airway obstruction should be
considered and excluded in all children presenting with symptoms of upper airway obstruction but particularly
in those outside of this typical age range. Always consider foreign bodies in young children.
General consensus is that children with croup should be made as comfortable as possible, and clinicians
should take special care during assessment and treatment not to frighten or upset the child because agitation
may cause substantial worsening of symptoms.13

Assessment
Children with croup may present with a range of symptoms and varying levels of severity (mild, moderate,
severe and life-threatening). Accurate assessment of the severity of croup is important for initial
management. Croup severity scores have been used in hospital-based clinical research studies to assess
the suitability of patients for treatment in a standardised manner.14 However, they are of limited value in
clinical practice.14 It is also important to always consider differential diagnosis of an acute episode of stridor
(Table 1).

Table 1: Differential diagnosis of acute onset stridor and respiratory distress

Toxic appearance Non-toxic appearance
Bacterial tracheitis Spasmodic croup
Epiglottitis Angioneurotic oedema
Retropharyngeal abscess Laryngeal foreign body
Peritonsillar abscess (quinsy) Subglottic haemangioma
13
Note: Toxic appearance is defined as a child who looks unwell and has reduced interaction with their environment
15 16
Adapted from: Sydney West area health service and Royal Children’s Hospital, Melbourne

Guideline 00702 – Acute Croup: Emergency Management in Children

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Due to the lack of strong evidence for reliable croup severity scores CHQ consensus opinion is that the initial
assessment of a child presenting with croup should be based on the Nurse Practitioner Clinical Practice
Guideline for the Management of Croup developed by Sydney west area health service.15 When performing
the clinical assessment, the following clinical features should be considered to inform treatment (Table 2).

Table 2: Assessment of severity

Mild Moderate Severe Life Threatening
Occasional barking Frequent barking cough Persistent stridor at rest Audible stridor may
cough Audible stridor at rest (may be expiratory) be quieter
Mild or no Respiratory distress Severe respiratory Cyanosis
respiratory distress including increased work distress including Lethargy or
at rest of breathing (wob), increased effort, marked decreased level of
No audible stridor at increased respiratory rate decreased air entry, consciousness
rest and use of accessory hypotonia and pallor
No response to
No cyanosis muscles Fatigue or altered pharmacotherapy
No cyanosis mental state
Normal sao2
Normal sao2 Hypoxia (cyanosis or
sao2 ≤93%)
Little or no agitation
15 17
Adapted from: Sydney West Area Health Service and Cherry

Blood tests and a CXR are rarely indicated in the assessment of croup. Lateral x-ray of the neck is not
routinely required and seldom provides information that affects management.14 Although subglottic
narrowing, radio-opaque foreign bodies and supraglottic swelling may be apparent on radiographic imaging
of the airway, the risk of the procedure generally outweighs any benefits, as neck extension required for the
procedure may precipitate sudden severe obstruction.14

Management
The important steps in the management of croup include the appropriate use of systemic (or nebulised)
corticosteroids and nebulised adrenaline.18-23 These interventions have led to a demonstrated reduction in the
need for, and duration of, endotracheal intubation, length of stay, and representation rates to emergency
services.18,19,21,24-26 The use of nebulized medications must be considered in light of the amount of distress
this procedure causes a small child (risk vs benefit).
Given there is no definitive treatment for the viruses that cause croup, therapy should be directed toward
decreasing airway oedema and providing supportive care (respiratory support and maintenance of
hydration). Other important recommendations for the management of croup include:
avoid distressing procedures (e.g. examining throat) as anxiety may exacerbate croup
nurse the child sitting upright on carer's lap
blood tests, SaO2 monitoring and oxygen mask are rarely indicated
a routine NPA is not required for children with a typical clinical picture of croup
antibiotics are not indicated for typical croup.

Guideline 00702 – Acute Croup: Emergency Management in Children

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Corticosteroids
The precise mechanism by which corticosteroids exert their effect is not fully known. It is presumed to be on
the basis of vasoconstrictive actions in the upper airway followed by the systemic anti-inflammatory
properties. Corticosteroids take approximately 30 minutes after treatment to lessen respiratory distress45,
more quickly if given by nebulization.18,21
The method of delivery of corticosteroid has been compared in a number of trials with oral (liquid form), IV,
IM and inhaled (nebulised) routes all being shown to be superior to placebo. 1,2,20 Oral administration is
recommended, whenever possible, to reduce pain and distress to the child, and to lessen the risk of further
airway swelling and compromise.
Oral corticosteroids have the advantage of being inexpensive and therefore readily available and easy to
administer.2,20,27 Studies have demonstrated oral dexamethasone at doses between 0.15 to 0.6 mg/kg/dose
to be equivocal.1,2,20 It is therefore suggested that the smallest dose (0.15 mg/kg orally) be administered to
achieve the desired outcome. Higher doses (up to 0.6 mg/kg) are acceptable if repeat doses are required or
to ensure the desired oral dose is achieved in a distressed child who is resistant to taking oral medicine.
Prednisolone (at a dose of 1 mg/kg/dose) is a commonly used alternative to dexamethasone.28
Dexamethasone and prednisolone have been shown to provide equivalent initial clinical response, but
prednisolone use is associated with a higher representation rate.28,29 Current therapeutic guidelines therefore
suggest that, if prednisolone is used, a second dose be prescribed, to be taken on the evening following the
initial presentation.30 Note that oral dexamethasone may not be as readily available at community
pharmacies or all hospitals, while oral prednisolone is now available commercially and is manufactured in a
palatable liquid solution.30

Nebulised budesonide
Nebulised budesonide has an onset of action within 30 minutes. This is comparable to adrenaline and
slightly faster compared to orally or intramuscularly administered corticosteroids.1,2,20,31 Oral corticosteroids
however are the preferred option (unless the child repeatedly vomits the oral medication), due to the
availability and cost of the medication, equipment required, the time needed for administration and the
potential for the child to become distressed when nebulised preparations are used.1,2,20
The recommended dose of budesonide is 2 mg/dose (independent of age and weight) to be nebulised with
high flow oxygen.32 The child's eyes should be covered and their face washed afterwards to prevent facial
irritation.32

Nebulised adrenaline
Immediate treatment with nebulised adrenaline should be considered in any child with persisting inspiratory
stridor (at rest) and marked chest wall retractions (moderate to severe croup). Adrenaline is thought to
reduce bronchial and tracheal epithelial vascular permeability thereby decreasing airway oedema, resulting in
an increase in the airway radius and improved airflow.2,18 Nebulized adrenaline is associated with clinically
and statistically significant transient reduction of symptoms of croup 30 minutes post-treatment.44
The recommended dose for adrenaline is independent of age and weight (5 mL of undiluted 1:1000
adrenaline nebulised with oxygen).30 The child should be reassessed regularly following administration
(clinical observations every 15 minutes for the first hour) and the dose may be repeated if there is inadequate
response.30 If a child requires more than one dose of nebulised adrenaline the paediatric team and/or PICU
should be notified.30

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Adrenaline has a rapid onset of action with an improvement in croup symptom scores within 30 minutes. 18,33
The duration of effect is approximately 2 hours.1,2,34,44 Historically, children were admitted for 24 hours after
an initial dose of nebulised adrenaline. However, combined data from 5 prospective clinical trials in patients
treated with adrenaline and dexamethasone (or budesonide) and observed for 2-4 hours found that fewer
than 5% of children discharged home returned within 72 hours (with only 6/253 requiring admission).23,35-38
There were no reported adverse outcomes. This prospectively derived data, along with 2 retrospective cohort
studies, provides good evidence that children treated with nebulised adrenaline may be safely discharged
home, provided they have tolerated an effective dose of systemic steroids and their symptoms have not
recurred within 2 hours of the nebulised adrenaline dose.22,34,44 To allow a margin of safety it is therefore
recommended that children who require nebulised adrenaline should be observed for at least 3 hours after
the administration of both adrenaline and an effective, tolerated, dose of systemic steroid before discharge is
considered.

Other Treatments
Supplemental oxygen therapy may be required for children with severe viral croup who have significant
oxygen de-saturation (SaO2 < 93%). Oxygen may be administered without causing the child to be agitated
via a plastic hose with the opening held within a few centimetres of the nose and mouth (blow-by oxygen at
minimum 10 litres per minute flow rate).13
The use of steam inhalations has not been shown to be of significant benefit in acute croup treatment. 39 It is
also contraindicated as the use of steam inhalers has been associated with scalds and burns in young
children.40
A recent update to the Cochrane review of heliox treatment in croup in children pooled data from 3 RCT (total
91 patients) and showed a statistically significant difference in croup scores at 60 minutes in favour of heliox
but no significant difference after 120minutes. 42 Given the cost and complexity involved in this treatment until
further RCT evidence is available heliox is not routinely recommended in the treatment of croup. Individual
clinicians can consider its use in refractory cases of moderate or severe croup.

Disposition
See flowchart Appendix 2 – Admission/Discharge Criteria for Children with Acute Croup
Most children with appropriately diagnosed croup who are managed with corticosteroids, and adrenaline
where indicated, will eventually be discharged from the emergency department. Prior to discharge clinicians
should ensure that the child has adequately responded to treatment, can access further doses of any
prescribed medication and has parents who have been appropriately educated about the condition, have
access to transport or emergency services and feel comfortable with the diagnosis and what to do if
symptoms recur.
The decision to admit a child with acute croup is made after initial treatment and observation. The presence
of ongoing stridor at rest after treatment necessitates admission.
When a decision is made to transfer a child to a higher level facility (Level 6), referral must be made through
RSQ.43
Activation of the QLD emergency medical system coordination centre (QCC)
Further information on the preparation of a infant prior to transport can be obtained through RSQ Clinical
Guidelines paediatric section (pages 31-35).43 Statewide RSQ clinical guidelines—Paediatrics

Guideline 00702 – Acute Croup: Emergency Management in Children

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Consultation
Key stakeholders who reviewed this version:
Kerry Gordon – Nurse Practitioner, Paediatric Emergency Department, Mater Children’s Hospital
Therese Oates – CNC Royal Children’s Hospital, Brisbane
Dr Geoff Pearce – Paediatric Emergency Fellow, Mater Children’s Hospital
Dr Grant Stone – Director, Paediatric Emergency Department, Mater Children’s Hospital

Acknowledgements:
We would like to acknowledge the original members of the Greater Brisbane metropolitan area clinical
procedures working group who established this guideline.

Definition of terms

Term Definition
Children 0-14 years of age

CHS Children’s Health Services

CPAP Continuous positive airway pressure
CRP C-reactive protein
CXR Chest x-ray
FBC Full blood count
HR Heart rate
INH Inhaler
IV Intravenous
MDI Metered dose inhaler
NaCl Sodium chloride
NBM Nil by mouth
NEB Nebuliser
NIV Non invasive ventilation
PICU Paediatric Intensive Care Unit
PO Orally
RR Respiratory rate
RSQ Retrieval Services Queensland
SaO2 Oxygen saturations
U&E's Urea and electrolytes (serum electrolyte analysis)
VBG Venous blood gas

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References and suggested reading
1. Fitzgerald DA., Mellis C.M. Management of acute upper airways obstruction in children. Modern Medicine of
Australia. 1995; 38: 80-88.
2. Klassen TP. Croup: A current perspective in emergency medicine. Pediatric Clinics of North America. 1999; 46 (6):
1167-1178.
3. Acworth J., Babl F., Borland M., et al. Patterns of presentations to the Australian and New Zealand paediatric
emergency research network. Emergency Medicine Australasia. 2009; 21 (1): 59-66.
4. Segal AO., Crighton EJ., Moineddin R., et al. Croup hospitalizations in Ontario: A 14-year time-series analysis.
Pediatrics. 2005; 116 (1): 51-55.
5. Cherry JD., Feigin RD. Textbook of paediatric infectious diseases. 3rd ed. Philadelphia (USA): WB Saunders
Company; 2006.
6. Johnson D. Clinical evidence: Croup [internet]. Clinical Evidence website; 2009 [cited 2011 May 10]. Available from:
http://clinicalevidence.bmj.com/ceweb/conditions/chd/0321/0321-get.pdf
7. Davis G. An examination of the physiological consequences of chest wall distortion in infants with croup. Calgary
(CA): University of Calgary; 1985.
8. Davis G., Cooper D., Mitchell I. The measurement of thoraco-abdominal asynchrony in infants with severe
laryngotracheobronchitis. Chest. 1993; 103 (6): 1842–1848.
9. Peltola V., Heikkinen T., Ruuskanen O. Clinical courses of croup caused by influenza and parainfluenza viruses.
Pediatric Infectious Diseases Journal. 2002; 21(1): 76-78.
10. Denny FW., Murphy TF., Clyde WA., et al. Croup: an 11-year study in a pediatric practice. Pediatrics. 1983; 71 (6);
871-876.
11. Skolnik NS. Treatment of Croup: a critical review. American Journal of Diseases of Children. 1989; 143 (9): 1045-
1049.
12. Johnson DW., Williamson J. Croup: duration of symptoms and impact on family functioning. Pediatric Research.
2001; 49: 83A.
13. Bjornson CL., Johnson DW. Croup. The Lancet. 2008; 371 (9609): 329-339.
14. Fitzgerald DA., Kilham HA. Croup: Assessment and evidence-based management. Medical Journal of Australia.
2003; 179 (7): 372 - 377.
15. Sydney West Area Health Service. Nurse Practitioner Clinical Practice Guideline for the Management of Croup
[internet]. NSW Health website; 2004 [cited 2011 May 11]. Available from:
http://www.health.nsw.gov.au/resources/nursing/practitioner/pdf/ab_croup_np_guidelines.pdf
16. Royal Children’s Hospital, Melbourne. Croup (Laryngotracheobronchitis) [internet]. Royal Children’s Hospital,
Melbourne website; 2009 [cited 2011 May 11]. Available from:
http://www.rch.org.au/clinicalguide/cpg.cfm?doc_id=5141
17. Cherry JD. Croup. The New England Journal of Medicine. 2008; 358 (4): 384-91.
18. Fitzgerald DA., Mellis CM., Johnson M., et al. Nebulised budesonide as effective as nebulised adrenaline in
moderately severe croup. Pediatrics. 1996; 97 (5): 722-725.
19. Tibbals J., Shann FA., Landau LI. Placebo-controlled trial of prednisolone in children intubated for croup. Lancet.
1992; 340 (8822): 745-748.
20. 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. Pediatric Pulmonology. 1995; 20 (6): 362-368.
21. Klassen TP., Craig WR., Moher D., et al. Nebulized budesonide and oral dexamethasone for treatment of croup.
Journal of the American Medical Association. 1998; 279 (20): 1629-1632.
22. Kelley PB., Simon JE. Racemic epinephrine use in croup and disposition. American Journal of Emergency
Medicine. 1992; 10 (3): 181-183.
23. Prendergast M., Jones JS., Hartman D. Racemic adrenaline in the treatment of laryngotracheitis: Can we identify
children for outpatient therapy. American Journal of Emergency Medicine. 1994; 12 (6): 613-616.
24. Jaffe D. The treatment of croup with glucosteroids. New England Journal of Medicine. 1998; 339 (8): 553-555.
25. Cruz MN., Stewart G., Rosenberg N. Use of dexamethasone in the outpatient management of acute
laryngotracheitis. Pediatrics. 1995; 96 (2 Pt 1): 220-223.
26. Super DM., Cartelli NA., Brooks JG., et al. A prospective randomised doubleblind study to evaluate the effect of
dexamethasone in acute laryngotracheitis. Journal of Pediatrics. 1989; 115 (2): 323-329.

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27. Ausejo M., Sanez A., Pham B., et al. The effectiveness of glucosteroids in treating croup: meta-analysis. British
Medical Journal. 1999; 319 (7210): 595-600.
28. Sparrow A., Geelhoed G. Prednisolone vs. dexamethasone in croup: A randomised equivalence trial. Archives of
Disease in Childhood. 2006; 91 (7): 580-583.
29. Fifoot AA., Ting JY. Comparison between single-dose oral prednisolone and oral dexamethasone in the treatment of
croup: a randomized, double-blinded clinical trial. Emergency Medicine Australasia. 2007; 19 (1): 51-58.
30. Therapeutic Guidelines Ltd. Croup [internet]. Therapeutic Guidelines website; 2009 [cited 2011 May 12]. Available
from: http://online.tg.org.au.cknservices.dotosec.com/ip/tgc/rsg/3807.htm
31. Husby S., Agertoft L., Mortensen S., et al. Treatment of croup with nebulized steroid (budesonide): a double-blind
placebo controlled study. Archives of Disease in Childhood. 1993; 68 (3): 352-355.
32. Waiisman Y., Klein BL., Boenning DA., et al. Prospective randomised double-blind study compairing L-epinephrine
aerosols in the treatment of laryngotracheitis (croup). Pediatrics. 1992; 89 92): 302-306.
33. Corneli H., Bolte R. Outpatient use of racemix epinephrine in croup. American Family Physician. 1992; 46 (3): 683–
684.
34. Johnson D., Jacobson S., Edney P., et al. A comparison of nebulized budesonide, intramuscular dexamethasone,
and placebo for moderately severe croup. New England Journal of Medicine. 1998; 339 (8): 498:503.
35. Rizos J., DiGravio B., Sehl M., et al. The disposition of children with croup treated with racemic epinephrine and
dexamethasone in the emergency department. The Journal of Emergency Medicine. 1998; 16 (4): 535–539.
36. Ledwith C., Shea L., Mauro R. Safety and efficacy of nebulized racemic epinephrine in conjunction with oral
dexamethasone and mist in the outpatient treatment of croup. Annals of Emergency Medicine. 1995; 25 (3): 331-
337.
37. Kunkel N., Baker M. Use of racemic epinephrine, dexamethasone and mist in the outpatient management of croup.
Pediatric Emergency Care. 1996; 12 (3): 156-159.
38. Moore M., Little P. Humidified air inhalation for treating croup. Cochrane Database of Systematic Reviews. 2006;
Issue 3, Art. No.: CD002870.
39. Greally P., Cheng K., Tanner M., et al. Children with croup presenting with scalds. British Medical Journal. 1990;
301 (6743): 113.
40. Weber JE., Chudnofsky CR., Younger JG., et al. A randomised comparison of helium-oxygen mixture (heliox) and
racemix epinephrine for the treatment of moderate to severe croup. Pediatrics. 2001; 107(6): e96.
41. Moraa I, Sturman N, McGuire T, van Driel ML. Heliox for croup in children. Cochrane Database for Systematic
Reviews. 2013 Dec 7; 12, Art. No.: CD006822.
42. Statewide Clinical Coordination and Retrieval Services. Clinical guidelines: Section two [intranet]. Brisbane (AU):
Queensland Government (Queensland Health); 2008 [cited July 25]. Available from:
http://qheps.health.qld.gov.au/rts/docs/clin_guide_pt2.pdf
43. Bjornson C, Russell K, Vandermeer B, Klassen TP, Johnson DW. Nebulized epinephrine for croup in children.
Cochrane Database of Systematic Reviews 2013, Issue 10. Art. No.: CD006619.
44. Dobrovoljac M, Geelhoed GC. How fast does oral dexamethasone work in mild to moderately severe croup? A
randomized double-blinded clinical trial. Emergency Medicine Australasia 2012;24(1):79–85.

Guideline revision and approval history

Version Modified by Amendments authorised by Approved by
No.
1.1 Greater Brisbane metropolitan Greater Brisbane metropolitan area Chief Executive Officer,
area clinical procedures working clinical procedures editorial group Children’s Health Services
group
2.0 Geoff Pearce, Paediatric Jason Acworth, Director Paediatric General Manager Operations,
Emergency Physician Emergency Medicine, CHQ CHQ

Keywords Children, croup, emergency management, guideline

Accreditation references EQuIP National Standards: 1, 12

Guideline 00702 – Acute Croup: Emergency Management in Children

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Appendix 1 Admission/Discharge Criteria for Children with Croup
High risk factors in acute croup
Risk factors for acute croup in children include:
· age <6 months
· underlying structural upper airway condition, e.g.
tracheomalacia, subglottic stenosis
· history of previous severe croup
· unplanned representation to the emergency service within
24 hours following a diagnosis of croup at first
presentation.
Criteria for discharge from the emergency service
Criteria for discharging a child with croup from the
emergency service includes:
· responded effectively to treatment – no respiratory
distress or stridor at rest
· differential diagnoses considered and acute croup
remains primary diagnosis
· 3 hours post nebulised adrenaline with no recurrence of
symptoms
· parent information sheet given and discussed.
When discharging a child with croup, their social
circumstances should be considered and appropriately
addressed after the initial assessment and observation
period:
· time of day
· parents/carers comprehension and compliance
· access to transport should return be required
· distance to local hospital.
Guideline 00702 – Acute Croup: Emergency Management in Children
Criteria for admission to children’s inpatient service
Criteria for admission to the children’s inpatient service for
a child with croup includes:
· age < 6 months
· history of severe obstruction
· history of previous severe croup or known structural
airway anomaly (e.g. subglottic stenosis)
· trisomy 21
· persistence of symptoms (e.g. respiratory distress or
stridor at rest) after treatment and 4 hours observation
· inadequate fluid intake
· representation to the emergency service within 24 hours
following a diagnosis of croup at first presentation
· uncertain diagnosis.
Criteria for admission to Level 6 emergency
or PICU service
Consultation with the paediatric specialty team in the
current facility and/or discussion with a Level 6 children’s
health service via Retrieval Services Queensland (RSQ) is
required when:
· presents with symptoms and/or signs of life threatening
acute croup or airway obstruction
· persistent stridor and respiratory distress despite 2
doses of nebulised adrenaline
· requirement for respiratory support (intubation and
ventilation) as indicated by failure to maintain
saturations despite supplemental oxygen or severe
respiratory distress
· signs of progressive fatigue.
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