Evaluation
Severity of Airway Obstruction
Westley Croup Score
The Westley Croup Score is the most commonly used scoring system for assessing the severity of croup. Scoring is based on the patient's symptoms from which a total score is obtained to categorize the severity.
| Symptom | Status | Score |
| Consciousness | Normal, including sleep | 0 |
| Disoriented | 5 | |
| Cyanosis | None | 0 |
| With agitation | 4 | |
| At rest | 5 | |
| Stridor | None | 0 |
| With agitation | 1 | |
| At rest | 2 | |
| Air entry | Nomal | 0 |
| Decreased | 1 | |
| Markedly decreased | 2 | |
| Chest wall retractions | None | 0 |
| Mild | 1 | |
| Moderate | 2 | |
| Severe | 3 |
| Total Score | Severity |
| ≤2 | Mild |
| 3-7 | Moderate |
| 8-11 | Severe |
| ≥12 | Impending respiratory failure |
Mild Croup
- Occasional barking cough
- Patient is comfortable, no cyanosis
- Intermittent stridor may or may not be observed
- Chest wall retractions minimal or none at all
Moderate Croup
- Frequent barking cough
- Stridor persistent even at rest
- Chest wall retractions at rest are observed, and tracheal tug and nasal flaring present
- Tachycardia, labored breathing, or increased respiratory rate
- Irritable, little or no distress
- Symptoms may progress to severe airway obstruction; careful observation is warranted
Severe Croup
- Frequent barking cough
- Patient appears tired, easily irritated, lethargic, exhausted, restless, and agitated
- Persistent tachycardia
- Prominent stridor even at rest (inspiratory with or without expiratory stridor)
- Marked chest wall retractions, tracheal tug and nasal flaring present, markedly increased or decreased respiratory rate
Impending Respiratory Failure
- Barking cough (may not be prominent)
- Audible stridor at rest
- Chest wall retractions
- Irrational behavior, decreased level of consciousness
- Hypotonia
- Pallor, cyanosis without supplemental O₂
Pharmacological therapy
Supportive Therapy
Antipyretics may be given.
Epinephrine (Nebulized)
Croup_Management 1Nebulized epinephrine is recommended in all patients with moderate or severe croup. This reduces symptoms within minutes but exerts no effect beyond 1 hour. A combination with oral Dexamethasone is indicated for moderate to severe croup.
Corticosteroid (Nebulized)
Example drug: Budesonide
Nebulized corticosteroids may be given to children with moderate or severe croup who are intolerant to Dexamethasone. Administration may cause more agitation to the child. This is not routinely given to a child due to its cost, length of administration, and anxiety that it causes. This is indicated only in patients with persistent vomiting and with severe respiratory distress. Budesonide may be mixed with Epinephrine and administered simultaneously.
Corticosteroid (Systemic)
Example drugs: Dexamethasone, Prednisolone
Systemic corticosteroids should be given to children diagnosed with croup regardless of severity. This improves symptoms and reduces the risk of hospital admission. This is well-absorbed and relatively safe. Multiple doses do not provide additional benefit over a single dose. This should not be given to a child with known immune deficiency or recent varicella exposure.
Dexamethasone
Dexamethasone is recommended as a first-line corticosteroid therapy for moderate or severe croup due to its long half-life and route options. This is given orally, intravenously, or intramuscularly; use the least invasive route available. This may reduce return visits, hospital admission, and readmission rates.
Nonpharmacological
Patient/Parent/Guardian Education
Actions that minimize anxiety are appropriate until the airway is secure. The child should be held and comforted. Avoid anxiety-provoking maneuvers (eg blood extraction, IV-line placement, placing the child in a supine position, or direct inspection of the oral cavity) until the airway is secure. Encourage fluid intake and recommend exposure to cold outdoor air that may help alleviate symptoms.
If the patient is treated as an outpatient, advise them to seek medical attention if any of the following are observed: Stridor at rest, dyspnea, pallor or cyanosis, severe coughing spells, drooling or dysphagia, fatigue, worsening course, persistent or high fever, prolonged symptoms (>7 days), and suprasternal retractions.
Helium-Oxygen (Heliox) Inhalation
Further studies are needed to prove the use of heliox in patients with croup. This may be useful in reducing resistance of airflow and turbulence, thereby decreasing the work during respiration.
Oxygen (O2) Therapy
Provide supplemental O₂ (100% 15 L/min via non-rebreather mask) if necessary, especially in hypoxemic patients with O₂ saturation of <92%.
Croup_Management 2