Croup (Laryngotracheobronchitis)

Key considerations: Epiglottitis, Bacterial tracheitis, Retropharyngeal abscess

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history: Barky cough, worse at night; Preceding URI symptoms (1-2 days of coryza); Age (peak 6 months to 3 years); Previous episodes of croup; Vaccination history (Hib); Worsening despite home steam treatment; exam: Assess severity: Westley Croup Score; Stridor: inspiratory (mild-moderate), biphasic (severe); Work of breathing: retractions, nasal flaring; Level of consciousness; Air entry; Oral exam — do NOT force if epiglottitis suspected; labs: No routine labs needed; CBC, blood culture if bacterial tracheitis suspected; imaging: AP neck X-ray: steeple sign (subglottic narrowing) — clinical diagnosis preferred; Lateral neck X-ray if epiglottitis suspected (thumbprint sign); bedside: Continuous SpO2; Keep child calm and in caregiver's arms

immediate: Dexamethasone 0.6mg/kg PO/IM x1 (max 16mg); Nebulized racemic epinephrine 0.5mL of 2.25% in 3mL NS for moderate-severe croup; general: Keep child calm — crying worsens obstruction; Blow-by O2 if needed (avoid mask if distressing child); Mist/cool mist therapy NOT supported by evidence but widely used; specific: diagnosis: Mild croup (no stridor at rest); steps: Dexamethasone 0.6mg/kg PO x1; Can discharge after 30-60 min observation; Cool mist humidifier at home, fluid intake; Return if stridor at rest or worsening distress; diagnosis: Moderate croup (stridor at rest); steps: Dexamethasone 0.6mg/kg PO/IM x1; Racemic epinephrine 0.5mL in 3mL NS nebulized; Observe minimum 2-4 hours post racemic epi for rebound; May discharge if improved and no rebound stridor; diagnosis: Severe croup; steps: Racemic epinephrine nebulized — may repeat q15-20min; Dexamethasone 0.6mg/kg IM if unable to take PO; Prepare for advanced airway (use ETT 0.5-1 size smaller); Heliox 70:30 as bridge if severe obstruction and waiting for response

admit: Persistent stridor at rest after treatment; Required >2 doses of racemic epinephrine; SpO2 <92% on room air; Young age (<6 months) with moderate symptoms; High concern for bacterial tracheitis or epiglottitis; discharge: Mild croup after dexamethasone and 30-60 min observation; Moderate croup resolved after racemic epi with 2-4 hour observation and no rebound; No stridor at rest, comfortable on room air; consults: ENT/Anesthesia if unable to manage airway; PICU for severe or refractory croup

Dexamethasone 0.6mg/kg PO single dose works for ALL severities of croup — the key medication
Racemic epinephrine effect lasts 1-2 hours — observe for rebound (return of stridor) for 2-4 hours before discharge
If you intubate croup, use an ETT 0.5-1.0 size SMALLER than age-predicted due to subglottic swelling
Mist therapy is NOT supported by evidence — but dexamethasone is. Focus on steroids.

Cochrane Review on Croup Treatment, Pediatric Emergency Medicine (Fleisher & Ludwig). Last reviewed: 2024-11-01