This document provides clinical guidance for all staff involved in the care and management of a child presenting to an Emergency Department (ED) with symptoms suggestive of croup in Queensland.
This guideline has been developed by senior ED clinicians and Paediatricians across Queensland, with input from PICU and ENT staff, Queensland Children’s Hospital, Brisbane. It has been endorsed for use across Queensland by the Queensland Emergency Care of Children Working Group in partnership with the Queensland Emergency Department Strategic Advisory Panel and the Healthcare Improvement Unit, Clinical Excellence Queensland.
Croup (acute laryngotracheobronchitis) is a clinical syndrome characterised by barking cough, inspiratory stridor and hoarseness of voice, with or without respiratory distress.1, 2 Onset may be abrupt, and is more common at night. The illness is typically mild and self-limiting but can be severe and rarely, life-threatening. 1, 4, 5
Croup usually develops as part of a concurrent coryzal illness. Many viruses can cause croup, the most common of which are Parainfluenza and RSV, but also includes influenza and Covid-19. 2, 5, 6,10 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 Spasmodic croup can occur in the absence of acute viral illness, but assessment and treatment is identical. 2, 7
Croup results from inflammation of the upper airway, including the larynx and trachea. Inflammation of the laryngeal and tracheal mucosa leads to hyperaemia and oedema 8. As the subglottic region is surrounded by a firm cartilaginous ring, this swelling encroaches on the internal diameter of the airway, resulting in substantial narrowing. 2, 7 Airway narrowing leads to increased airflow resistance, turbulent airflow producing inspiratory stridor, and increased work of breathing.
Children with severe croup develop paradoxical breathing (asynchronous chest wall and abdominal movement). 2, 9, 10 This paradoxical breathing results in progressive fatigue and deterioration in ventilation. If untreated, respiratory failure with resulting hypoxia and hypercapnia may eventually progress to respiratory arrest. 2, 9, 10
Children with croup should be made as comfortable as possible. Take special care not to distress the child as this may exacerbate symptoms. Detailed examination, in particular examination of the throat, is not recommended as distress may exacerbate symptoms.11
Several conditions can result in acute onset stridor and respiratory distress.13 Consider alternative diagnoses, especially in children outside the typical age range (6 to 36 months). In young children, always consider foreign body inhalation.
| Toxic appearance | Non-toxic appearance |
|---|---|
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10, 14
Once confident in the diagnosis of croup, an accurate assessment of severity guides treatment.
| Mild | Moderate | Severe | Life-threatening |
|---|---|---|---|
| Occasional barking cough, no audible stridor at rest | Frequent barking cough, audible stridor at rest | Persistent stridor at rest (may also be expiratory) | Stridor at rest, although may be quieter |
| No or mild respiratory distress* at rest | Moderate respiratory distress | Severe respiratory distress | Exhausted, poor respiratory effort |
| Normal SpO2 #, no cyanosis | Normal SpO2 #, no cyanosis | SpO2 ≤93% or cyanosis | SpO2 ≤93% or cyanosis |
| Alert | Little or no agitation | Fatigue, agitation or distress | Lethargy or decreased level of consciousness |
*Signs of respiratory distress include accessory muscle use, abdominal breathing, intercostal recession, subcostal recession and tracheal tug. # Oxygen saturations using pulse oximetry, commonly referred to as “sats”
Adapted from Alberta Medical Association Guideline as referenced in Cherry13
Consider seeking senior emergency/paediatric advice as per local practice for a child with moderate to severe croup.
Seek senior emergency/paediatric advice as per local practice for a child with moderate to severe croup who is not responding to treatment.
Seek urgent senior assistance onsite (such as critical care, ENT, Anaesthetics) to manage airway for child with life-threatening croup. Contact paediatric critical care (onsite or via Retrieval Services Queensland (RSQ)).
Investigations (including blood tests, NPA, CXR) are usually not indicated and may unnecessarily distress the child and worsen symptoms. 10, 14 Lateral X-ray of the neck is not routinely required as rarely alters 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 the neck extension required may precipitate sudden severe obstruction. 14
Refer to the flowchart [PDF 741.23 KB] for a summary of the emergency management and medications for children presenting with symptoms of croup.
There is no definitive treatment for the viruses that cause croup. Therapy is aimed at decreasing airway oedema and providing supportive care (respiratory support and maintenance of hydration).
Recommended management includes:
Recommended for all children with croup. 21
Oral corticosteroids take approximately 30 minutes to lessen respiratory distress, 22 and if not tolerated, can be more reliably given via a nebuliser. 16 While not fully understood, corticosteroids are thought to reduce airway oedema through an anti-inflammatory effect. 20
Oral administration is recommended whenever possible. Advantages of oral over other methods include:
| Dexamethasone (Oral/IM/IV) | Mild-moderate croup: 0.15-0.3mg/kg 20, 23, maximum 12mg 23
Severe or life-threatening: 0.6mg/kg (oral/IV/IM), maximum 12mg.
Preferred corticosteroid as associated with lower representation rate, shorter course, less vomiting and fewer school days missed. 20, 24-27 Oral suspension is not widely available. Dexamethasone 0.5mg and 4mg tablets are available but they are not easily dispersed in water to give in a partial dose. Doses that can be rounded to full tablet size can however be crushed and dispersed in water 28. Dexamethasone injection can be given orally and is tasteless. If IV stock is in shortage, please give liquid suspension. |
| Prednisolone (Oral) | Day 1: 1mg/kg/day Day 2: 1mg/kg/day in the evening |
Consider for a child who repeatedly vomits the oral medication.
| Dose | 2 mg nebulised with oxygen. |
| Side effects | Facial irritation – cover child’s eyes while administering, wash face afterwards. |
Consider as first-line treatment in any child with persisting inspiratory stridor (at rest) and marked chest wall retractions. Adrenaline generally improves symptoms rapidly, and ‘buys time’ for corticosteroids to take effect.
Adrenaline is thought to work by reducing bronchial and tracheal epithelial vascular permeability thereby decreasing airway oedema, increasing the airway radius and improving airflow. 8, 29, 30 Symptoms usually improve significantly within minutes, and the duration of effect is up to two hours. 2, 3, 29, 30
| Dose |
5 mL of undiluted 1:1000 Adrenaline nebulised with oxygen as a single dose.
Dose may be repeated in 10 minutes if there is inadequate response. 37 |
| Monitoring | Clinical observations every 15 minutes for the first hour. |
A period of observation is required after nebulised adrenaline, to ensure recurrence of symptoms does not occur. Multiple studies have demonstrated low rates of recurrence of symptoms requiring intervention outside of a 2-3 hour period post adrenaline administration. 3, 31-34 Based on this evidence and allowing a margin of safety, discharge may be considered three hours after nebulised adrenaline providing the child has tolerated an effective dose of corticosteroids and symptoms (stridor and/or respiratory distress) have not persisted or recurred. If a repeat dose of adrenaline is required, the three hours must be taken from the time of the second dose. In practice, the decision to discharge will also depend on non-clinical factors including the time of day and the family’s proximity to hospital.
Seek urgent paediatric critical care advice (onsite or via RSQ) for a child who fails to respond to two doses of nebulised Adrenaline.
Oxygen desaturation may herald an impending complete upper airway obstruction.
Administer high flow oxygen at 15 L/min via non-rebreather mask to children with life-threatening croup while getting expert help for an anticipated difficult airway.
Consider supplemental oxygen for children with severe croup and SpO2 less than 93% providing it can be administered without distressing the child. This can be done using plastic tubing with the opening held within a few centimetres of the nose and mouth (blow-by oxygen) at minimum of 10 L/min flow rate.
Clinicians can contact the services below to escalate the care of a paediatric patient as per local practices. Transfer is recommended if the child requires a higher level of care.
| Includes children with the following (as a guide): | ||
|---|---|---|
| ||
| Less than 1 year | 1-4 years | 5-11 years |
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| Reason for contact | Who to contact |
|---|---|
| For immediate onsite assistance including airway management (anticipate difficult airway) | The most senior resources available onsite at the time as per local practices. Options may include:
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| Paediatric critical care advice and assistance | Onsite or via Retrieval Services Queensland (RSQ). If no onsite paediatric critical care service contact RSQ on 1300 799 127:
RSQ (access via QH intranet) Notify early of child potentially requiring transfer. Consider early involvement of local paediatric/critical care service. In the event of retrieval, inform your local paediatric service. |
| May include the following children: |
|---|
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| Reason for contact | Who to contact |
|---|---|
| Advice (including management, disposition or follow-up) | Follow local practices. Options:
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| Referral | First point of call is the onsite/local paediatric service |
| Do I need a critical transfer? |
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| Request a non-critical inter-hospital transfer |
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| Non-critical transfer forms |
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Most children with croup will be safely discharged from the ED.
Discharge is recommended for children who meet the following criteria:
Admission is recommended for children with persistent or recurrent symptoms(stridor and/or respiratory distress) despite treatment at three hours.
Consider admission to a SSU for children who are responding to treatment but require a period of observation prior to meeting the criteria for discharge.
Consider admission to an inpatient service for children who are failing to improve (persistent/recurring or worsening symptoms) after 12 hours of care.