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Consensus Guidelines for Management of Croup: Northern California Pediatric Hospital Medicine Consortium

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Northern California Pediatric Hospital Medicine Consortium

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Table of Contents


Executive summary


  • Standardize the care of pediatric patients with viral croup in acute care, ER, and inpatient settings

  • Decrease utilization of non-evidence-based evaluation and treatment modalities for croup


  • Consider alternative diagnoses in patients with atypical or severe clinical presentation, or those with poor response to standard treatments

  • Do not routinely order laboratory testing (including viral testing)

  • Do not routinely order x-rays

  • Use the consensus croup algorithm (appendix 1) for classifying severity and managing accordingly

  • Administer Dexamethasone to all patients with a diagnosis of croup, regardless of symptom severity

  • Do not routinely give repeat doses of steroid

  • Discharge patients meeting the following criteria:

    • No or minimal stridor at rest

    • No or minimal work of breathing

    • Able to talk and feed without difficulty

    • >2 hours from last racemic epinephrine treatment

    • No supplemental oxygen requirement


This guideline was developed through local consensus based on published evidence and expert opinion as part of the UCSF Northern California Pediatric Hospital Medicine Consortium.

Metrics Plan

  • Percentage of patients with discharge diagnosis of croup that receive Dexamethasone

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Clinical Consensus Guidelines for Management of Croup: Northern California Pediatric Hospital Medicine Consortium


Criteria for Use of Guideline

  • Inclusion:

    • Previously healthy children

    • Common age: 6 months – 6 years

    • History & clinical exam consistent with primary diagnosis of croup

  • Exclusion:

    • Toxic appearance

    • Symptoms suggestive of alternative diagnosis (see below)

    • Known upper airway abnormality or chronic lung disease

    • Recent airway instrumentation

    • History of chronic / recurrent aspiration

    • Neurologic impairment (hypotonia or neuromuscular disorder)

    • Immunocompromise


  • Croup (laryngotracheobronchitis) is a viral illness, most common in late fall to early winter, leading to inflammation of the upper airway

    • Most common pathogen: parainfluenza virus

    • Others: RSV, influenza A and B, Mycoplasma pneumonia, other respiratory viruses

  • Symptoms:

    • Sudden onset of barky cough

    • Inspiratory stridor

    • Hoarse voice

    • +/- Antecedent URI symptoms

    • +/- Fever

    • +/- Respiratory distress

  • Natural History:

    • Symptoms worse at night

    • Typical resolution after 3 days

    • Commonly followed by URI symptoms


Alternative Diagnoses

  • Differential Diagnosis:

    • Bacterial tracheitis

    • Epiglottitis

    • Foreign body aspiration

    • Allergic reaction

    • Trauma

    • Paratonsillar or retropharyngeal abscess

    • Diphtheria

    • Infectious mononucleosis

    • Spasmodic croup

    • Laryngeal nerve compression

    • Subglottic stenosis

    • Subglottic hemangioma

    • Tumor

  • Consider alternative diagnoses IF:

    • Age < 6 months or > 6 years

    • Duration of stridor > 4 days or cough > 10 days

    • History of non-elective intubation in past 6 months

    • History of prolonged intubation

    • History of recurrent croup

      • 2nd episode within 30 days

      • > 3 episodes within last 12 months

    • Toxic appearance

    • Drooling, difficulty swallowing, severe anxiety

    • Asymmetry of respiratory exam

    • Cutaneous hemangiomas present

    • Hypoxia / cyanosis

    • Poor response to treatment

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Severity Assessment

  • Quantitative measurement of severity using a scale such as the Westley Croup Score is impractical for routine use in acute care / inpatient settings

  • Qualitative clinical severity assessment is recommended:

    • NOTE: use clinical gestalt to determine severity classification; patients may have one or more sign or symptom within a selected severity category

    • Mild

      • Barky cough, hoarse voice

      • No stridor at rest

      • Mild coarse stridor only during agitation / activity

      • No or mild work of breathing

    • Moderate

      • Stridor at rest

      • Tachypnea

      • Moderate work of breathing

      • Anxiety / agitation / restlessness

      • Difficulty talking or feeding

    • Severe

      • Stridor at rest

      • Severe work of breathing or respiratory fatigue

      • Self-positioning (example: tripoding, neck extension)

      • Decreased LOC

      • Inability to talk or feed

    • Impending Respiratory Failure

      • Stridor may be present or decreased

      • Severe work of breathing

      • Bradypnea or poor respiratory effort

      • Cyanosis / hypoxemia despite supplemental oxygen

      • Hypercarbia

      • Listless / decreased LOC

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Lab Testing & Imaging

  • Labs: Routine lab testing (including respiratory viral testing) NOT recommended

    • Consider arterial blood gas if suspected / impending respiratory failure

  • Imaging: Routine imaging (CXR or lateral neck x-ray) NOT recommended

    • Consider imaging if atypical presentation or suspected alternative diagnosis

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Acute Management Algorithm

Admission & Discharge Criteria

  • ER Discharge criteria

    • Croup symptoms mild or improved from presentation

      • No or minimal stridor at rest

      • No or minimal work of breathing

    • Able to talk and feed without difficulty

    • >2 hours since last racemic epinephrine treatment


    • Received dexamethasone

  • Admission criteria

    • Pediatric Ward

      • Persistent moderate symptoms after Dexamethasone & racemic epinephrine

      • Continued stridor at rest despite therapy

      • Inadequate hydration

      • Moderate work of breathing

      • Need for supplemental oxygen

      • Atypical presentation / concern for alternative diagnosis

    • PICU / Transfer to higher level of care

      • Persistent severe croup symptoms despite therapy

      • Escalating stridor at rest despite therapy

      • Need for intubation in ER

      • Impending respiratory failure

        • Bradypnea or poor respiratory effort

        • Severe work of breathing

        • Stridor may be present or decreased

        • Cyanosis / hypoxemia despite supplemental oxygen

        • Hypercarbia

        • Listlessness / decreased LOC

  • Hospital discharge criteria

    • Croup symptoms mild or improved

      • No or minimal stridor at rest

      • No or minimal work of breathing

      • Able to talk and feed without difficulty

    • Able to maintain adequate hydration

    • >2 hours since last racemic epinephrine treatment

    • >12 hours since supplemental oxygen requirement

    • Consider postponing discharge until after an event-free/symptom-free NIGHT, unless respiratory exam is completely normal

  • Follow-up

    • Consider phone or in person follow-up with PMD in 1-2 days depending on reliability of patient/family and access to care

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  • Medications:

    • See APPENDIX 2 for medication dosing

    • Steroids

      • NOTE: no conclusive studies recommend one drug, dose, or route over another. Oral route may be preferred due to non-invasiveness causing less stress for the child. However, IM, IV, or neb routes may be useful in children who cannot tolerate oral medications.

      • Dexamethasone: single PO dose

        • Administer for all patients with croup (regardless of severity)

        • Alternative routes: IV, IM

        • No evidence supports repeated doses of dexamethasone

        • NOTE: For severe or atypical cases, repeat steroid doses may be considered; consultation with pediatric subspecialists (PICU, ENT) is recommended

      • Budesonide: single nebulized dose

        • Evidence demonstrates equal efficacy to Dexamethasone but more expensive medication

        • Consider as alternative to Dexamethasone in children with emesis, severe respiratory distress, or parental refusal of systemic steroid

      • Prednisone / Prednisolone are NOT recommended

    • Nebulized Epinephrine: racemic or L-epinephrine doses PRN

      • Nebulized L-epinephrine may be used as an alternative to racemic epinephrine in settings where racemic epinephrine is unavailable (e.g. EMS vehicles)

      • The clinical effect of nebulized epinephrine is apparent at 30 minutes post-treatment and the clinical benefit of racemic epinephrine has dissipated at 120 minutes (NOTE: L-epinephrine may have longer half-life)

      • There is no evidence to suggest that croup symptoms, on average, worsen after the treatment effect of nebulized epinephrine dissipates

  • Supportive Care & monitoring

    • Oxygen

      • Initiate supplemental oxygen for saturations <90% in room air

      • NOTE: hypoxia in croup is uncommon; consider alternative diagnoses in patients with significant hypoxia

    • Continuous pulse oximetry NOT routinely recommended

      • Consider continuous monitoring for unstable patients or those receiving numerous repeated doses of racemic epinephrine

    • Cool mist in ER / hospital settings NOT supported by evidence

      • There is no supporting evidence for added benefit of cool mist over other evidence-based therapies in hospital setting

      • Cool mist therapy / moist night air is still recommended + has potential benefit in home setting; recommend to families at ER/hospital discharge

    • Antipyretics PRN

    • Avoid painful procedures and maintain calm atmosphere (example: child in parent’s arms for exam and therapies) since agitation may worsen clinical status

  • Therapies NOT Recommended:

    • Antibiotics

    • Decongestant or antitussive medications

    • Heliox

  • Subspecialty consultation (ENT, anesthesia, pulmonology, ID, surgery, etc) indications:

    • Severe / impending respiratory failure

    • Intubation / need to secure critical airway

    • Atypical or complicated presentation (rule-out alternative diagnoses)

    • Recurrent croup

  • Critical airway stabilization

    • Intubation:

      • Personnel:

        • Recognize clinical deterioration quickly and activate expert providers with greatest airway skills immediately when respiratory failure + potential need for intubation is identified (consider anesthesia or PICU if available)

        • Most experienced provider should intubate

      • Equipment:

        • Cuffed ET tube (if available): cuff deflated; use high volume, low pressure cuff if available

        • ETT size: 4 + ¼ x age, minus 0.5 for cuffed tube; 0.5 size lower ETT also available for back-up

      • Sedation:

        • Use RSI (or protocol most familiar to providers) for intubation

        • NOTE: If aspiration is a likely alternative diagnosis, use caution when considering intubation. Paralysis is relatively contraindicated as it is important to maintain spontaneous respirations so potential partial obstruction doesn’t become complete

      • Supportive resources:

        • For non-invasive PPV, choose a flow-dependent bag over self-inflating bag for option of delivering CPAP (providing PEEP) while awaiting intubation

        • Consider placing salem sump/NG tube to decompress stomach from non-invasive PPV, once patient is appropriately sedated

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  • Beigelman A, Chipps BE, Bacharier LB. Update on the utility of corticosteroids in acute pediatric respiratory disorders. Allergy Asthma Proc, 2015;36:332-338.

  • Bjornson C, et al. 2011. Nebulized epinephrine for croup in children. Cochrane Database of Systematic Reviews, 2, 006619.

  • Cetinkaya F, Tufekci BS, Kutluk G. A comparison of nebulized budesonide, and intramuscular, and oral dexamethasone for treatment of croup. . Int J Pediatr Otorhinolaryngol, 2004;68(4) : 453-456.

  • 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;339:498-503.

  • Mandal A, Kabra SK, Lodha R. Upper Airway Obstruction in Children. Indian J Pediatr, 2015;82 8 :737-744.

  • Petrocheilou A, Tanou K, Kalampouka E, et al. Viral Croup: Diagnosis and a Treatment Algorithm. Pediatr Pulmonol, 2014;49:421-429.

  • Russel KF, et al. 2011. Glucocorticoids for croup. Cochrane Database of Systematic Reviews, 1, 001955.

  • Taketomo CK, Hodding JH, Kraus DM. Pediatric & Neonatal Dosage Handbook: A Universal Resource for Clinicians Treating Pediatric and Neonatal Patients, 21st ed. Hudson, OH: Lexi-Comp, 2014.

  • Zoorob, R, Sidani M, Murray J. Croup: An Overview. Am Fam Physician, 2011;83(9):1067-1073.

Published U.S. Children’s Hospital Croup Guidelines / Pathways:

APPENDIX 1: Croup Algorithm

APPENDIX 2: Medications for Croup

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Northern California Pediatric Hospital Medicine Consortium. Originated 1/2016. Updated: 06/2016, 10/2017.

Approved by UCSF P&T: 1.10.18

Approved by UCSF QIEC: 12.19.17