2008 Update

Guideline for the

'LDJQRVLVDQG0DQDJHPHQWRI Administered by the

Croup
Alberta Medical Association

This clinical practice guideline was developed by an Alberta History

Clinical Practice Guideline Working Group. This guideline will be
reviewed again as part of routine pracitce by the end of 2005.
DEFINITIONS
Croup is a childhood respiratory illness caused by a variety
of viruses and is usually contracted in the autumn and
ZLQWHUPRQWKV1 It is characterized by the abrupt onset of a
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i Croup symptoms may occur either with or without
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i Croup symptoms most commonly occur in the late
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• VHDOOLNHEDUN\FRXJK
VWULGRUQRLV\EUHDWKLQJRQLQVSLUDWLRQKRDUVHQHVVDQG • inspiratory stridor
UHVSLUDWRU\GLVWUHVV2 Children with croup can be broadly • hoarseness
FDWHJRUL]HGDVKDYLQJIRXUOHYHOVRIVHYHULW\ • QRWRPRGHUDWHO\KLJKIHYHU

i &URXSV\PSWRPVIUHTXHQWO\LPSURYHHQURXWHWR
Mild±RFFDVLRQDOEDUN\FRXJKQRDXGLEOHVWULGRUDWUHVW
PHGLFDOFDUHDQGÀXFWXDWHVLJQL¿FDQWO\GHSHQGLQJRQ
DQGQRWRPLOGVXSUDVWHUQDODQGRULQWHUFRVWDOLQGUDZLQJ
ZKHWKHUWKHFKLOGLVFDOPRUDJLWDWHG
UHWUDFWLRQVRIWKHVNLQRIWKHFKHVWZDOO
i &URXSV\PSWRPVXVXDOO\LPSURYHGXULQJWKHGD\DQG
Moderate±IUHTXHQWEDUN\FRXJKHDVLO\DXGLEOHVWULGRUDW
RIWHQUHFXUDJDLQWKHIROORZLQJQLJKW4
UHVWDQGVXSUDVWHUQDODQGVWHUQDOZDOOUHWUDFWLRQDWUHVWEXW
QRRUOLWWOHGLVWUHVVRUDJLWDWLRQ i 7KHPDMRULW\RIFKLOGUHQUHVROYHWKHLUFURXSV\PSWRPV
ZLWKLQKRXUVEXWDVPDOOSURSRUWLRQRIFKLOGUHQ
Severe±IUHTXHQWEDUN\FRXJKSURPLQHQWLQVSLUDWRU\DQG
KDYHV\PSWRPVWKDWSHUVLVWIRUXSWRRQHZHHN4
RFFDVLRQDOO\H[SLUDWRU\VWULGRUPDUNHGVWHUQDOZDOO
UHWUDFWLRQVDQGVLJQL¿FDQWGLVWUHVVDQGDJLWDWLRQ i )ROORZLQJWKHUHVROXWLRQRIFURXSV\PSWRPVFKLOGUHQ
XVXDOO\KDYHW\SLFDOµ857,¶OLNHV\PSWRPVDQGRF-
Impending respiratory failure±EDUN\FRXJKRIWHQQRW
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PRACTICE POINT
RECOMMENDATIONS VHH$OJRULWKP FEATURES SUGGESTING A DIFFERENT
Diagnosis
PRACTICE POINT
• Croup occurs most commonly in children between
PRQWKVDQG\HDUVRIDJHEXWFDQDOVRRFFXULQ
FKLOGUHQDV\RXQJDVPRQWKVDQGDVROGDVWR
\HDUVRIDJH1 It has been reported very rarely in
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DIAGNOSIS2,3
• +LJKIHYHUWR[LFDSSHDUDQFHDQGSRRUUHVSRQVHWR
HSLQHSKULQHVXJJHVWVbacterial tracheitis
• 6XGGHQRQVHWRIV\PSWRPVZLWKKLJKIHYHUDEVHQFH
RIEDUN\FRXJKG\VSKDJLDGURROLQJDQ[LRXVDS-
SHDUDQFHDQGVLWWLQJIRUZDUGLQ³VQLI¿QJSRVLWLRQ´
VXJJHVWVepiglottitis
• Other potential causes of stridor which are rare but
should be considered include foreign body lodged
in upper esophagus, retropharyngeal abscess,
and hereditary angioedema

The above recommendations are systematically developed statements to assist practitioner and patient decisions about appropriate
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Physical Examination • If laboratory tests are obtained they should be
Physicians should always be alert to the possibility of   ZHOOMXVWL¿HGDQGVKRXOGEHGHIHUUHGZKLOHWKH
RWKHUFDXVHVRIµFURXSOLNH¶V\PSWRPVDQGFRQVHTXHQWO\ patient is in respiratory distress
DFDUHIXOKLVWRU\DQGSK\VLFDOH[DPLVLPSRUWDQW.H\ • ,PDJLQJVWXGLHVDUHQRWUHTXLUHGLQSDWLHQWV
IHDWXUHVWRIRFXVRQLQFOXGH with a typical history that respond
  DSSURSULDWHO\WRWUHDWPHQWKRZHYHUODWHUDODQG
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i Voice is often hoarse   ZLWKFURXSOLNHV\PSWRPV

i 9DU\LQJGHJUHHVRIVWULGRUpredominantly inspiratory &RQHVKDSHGQDUURZLQJ³VWHHSOLQJ´LQVWHDGRIWKH

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i 9DU\LQJGHJUHHVRIUHWUDFWLRQVRIWKHFKHVWZDOO DUHDVXJJHVWVcroup7KH$3QHFNUDGLRJUDSKLVDOVR
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i $EVHQFHRIGURROLQJ GLVHDVHV
• $UDJJHGHGJHRUDPHPEUDQHVSDQQLQJWKH 
i Appears non-toxic  WUDFKHDVXJJHVWVbacterial tracheitis
• 7KLFNHQLQJRIHSLJORWWLVDQGDU\HSLJORWWLFIROGV
Other associated features that can be found on physical  VXJJHVWVepiglottitis
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retropharyngeal abcess
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PRACTICE POINT
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IF RADIOGRAPHS ARE OBTAINED
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health care personnel who are able to
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normal
Note this should not be routinely attempted in any child with
i Pulse oximetry is indicated in children with
respiratory distress
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PRACTICE POINT Pulse oximetry is not essential in patients with
 PLOGFURXS
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• &KDQJHLQPHQWDOVWDWXVVXFKDVIDWLJXHDQGOLVWOHVVQHVV i 9LUDOFXOWXUHVRUUDSLGDQWLJHQWHVWVGRQRWDLGLQ
• Pallor  WKHURXWLQHPDQDJHPHQWRISDWLHQWVHVSHFLDOO\
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• Decreased retractions
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Emergency Department Care

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Investigations RQHRIWKHSDUHQWVFDUHWDNHUV

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can be reliably made based on the clinical presentation

in combination with a careful history and physical
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Note that mist therapy has not been shown to have any meas- i Sedation is contraindicated26
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Indications for Admission
i Epinephrine is indicated in patients with severe res-
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• ,PSURYHPHQWRFFXUVZLWKLQPLQXWHVDQGEHJLQVWR
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• Treatment does not alter disease symptoms beyond
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epinephrine and institutional preference may
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Therefore these recommendations should be applied with
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more hours after treatment with corticosteroids
(If possible physicians should wait at least 4 hours
after treatment with dexamethasone before deciding
i 'H[DPHWKDVRQHLVLQGLFDWHGLQDOOFKLOGUHQGLDJQRVHG to admit a child to hospital
WRKDYHFURXSLQFOXGLQJWKRVHZLWKRQO\DEDUN\ • 6WHUQDOZDOOLQGUDZLQJ
FRXJKZLWKRXWDQ\RWKHUVLJQVRIUHVSLUDWRU\GLVWUHVV • Easily audible stridor at rest
• ,PSURYHPHQWEHJLQVZLWKLQWRKRXUVDIWHU
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• A potential exception is the rare child with a
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i Nebulized budesonide is not routinely indicated for
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may be mixed with epinephrine and administered
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Complications
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* Based on consensus opinion

i Bacterial tracheitis can cause a precipitous deteriora- BACKGROUND
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Epidemiology
i Cardiopulmonary arrest can occur in patients who are
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i Pneumonia is a rare complication of croup33
Criteria for Discharge from ED
i The presence of mild symptoms either on initial evalu-
ation or after a period of observation 
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of upper airway obstruction in children and has an annual
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enza and is most prevalent in the late fall to early winter
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Croup occurs most commonly in children between 6
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\RXQJDVPRQWKVDQGDVROGDV\HDUV1 It has been
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Differential Diagnosis
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distress but is not severely agitated or cyanotic
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Follow-up
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low-up4
i Follow up with a primary care provider or an ED
physician should occur in patients who have had pro-
of upper airway obstruction characterized by stridor and
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bacterial tracheitis includes intravenous antibiotics and
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* Based on consensus opinion

 TABLE 1
PHARMACOTHERAPY
Drug Category Dose and Duration
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ƒ Epinephrine ƒ Racemic epineprhine
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diluted in 3mL of NS or
sterile water via nebulizer
ƒ L Epinephrine
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nebulizer
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severe respiratory distress
Corticosteroids ƒ PJNJ32,0RQFH
ƒ Dexamethasone ƒ 0D\UHSHDWGRVHLQWR
24 hours
Comments
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ƒThe duration of effect of epinephrine does
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ƒOral dexamethasone is well-absorbed and
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rapidly as with intramuscular administration
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intramuscular administration yield
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treatment
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dose
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 DSSURSULDWHVROXWLRQ and is substantially more expensive
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severe respiratory distress; budesonide
and epinephrine can be administered
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abscess can present with stridor (most children with these
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op respiratory failure; failure typically occurs over several
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acute onsetRIVWULGRULQFOXGHWUDXPDGLSWKHULDKHUHGLWDU\ ODU\QJRWUDFKHREURQFKLWLV/7%DQGVSDVPRGLFFURXS
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Acute LTB is described as an illness in which children
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Pathogenesis and Pathophysiology
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is described as an illness in which symptoms occur
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ALGORITHM: CROUP IN THE OUT-PATIENT SETTING
Based on severity at time of initial assessment

MILD MODERATE SEVERE

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APPENDIX 1:
INSTRUCTIONS FOR PARENTS OF A CHILD WITH CROUP

What is Croup?

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What can I do to make my child more comfortable?

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Never give your child more than 5 doses of acetaminophen or more than 4 doses of ibuprofen in a 24 hour
period.
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• Most importantly - if your child is upset - comfort him/her, and speak calmly and in quiet tones. This will
help more than anything to reduce breathing problems.

How can I monitor my child to be sure they are okay?

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The croup guideline for physicians and this patient hand-out were developed by a Clinical Practice Guideline
working group which promotes appropriate, effective and quality medical care in Alberta. July 2003. Reviewed
2007
This information is also available on the Alberta Medical Association web site:
www.albertadoctors.org
Should I call 911?

Ƈ Call if:
• Your child’s face is bluish-grey in color for more than a few seconds; or
• Your child becomes unusually sleepy or ‘glassy-eyed’ while making croupy sounds; or
• Your child is really stressed, is struggling to breathe, and you can not calm them within a few minutes.
Ƈ Remember that ambulance paramedics can start treatment for your child immediately, so that, if your child
has very severe symptoms, it is safer to call ‘911’ than to drive to the nearest hospital in your car.

Should I seek medical care right away?

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What medical treatment improves croup?

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WKDQWZRKRXUV7KLVLVXVXDOO\XVHGRQO\LQFKLOGUHQZLWKPRUHVHYHUHV\PSWRPV

Is it safe for my child to come home (or should they stay in the hospital)?

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Can I prevent my child from getting croup?

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