Croup - Symptoms, diagnosis and treatment | BMJ Best Practice

Last reviewed: February 2020

Last updated: November 2019

Summary

Common cause of acute respiratory distress in children.

Acute onset of seal-like barky cough, in moderate to severe cases accompanied by stridor and sternal/intercostal indrawing.

Careful history and physical exam sufficient for confirming clinical diagnosis and ruling out potentially serious differentials.

Orally administered corticosteroids are the mainstay for all levels of severity, combined with nebulized epinephrine in moderate to severe croup to provide temporary relief of the symptoms of upper-airway obstruction.

Definition

Croup, also known as laryngotracheobronchitis, is a common respiratory disease of childhood, characterized by the sudden onset of a seal-like barky cough, often accompanied by stridor, voice hoarseness, and respiratory distress. The symptoms are a result of upper-airway obstruction due to generalized inflammation of the airways, as a result of viral infection (typically parainfluenza virus types 1 or 3).

History and exam

Key diagnostic factors

symptoms increasing with agitation
distinctive seal-like barky cough
age 6 months to 6 years

More key diagnostic factors

Other diagnostic factors

male sex
peak season late autumn (North America)
prodromal symptoms
abrupt onset of symptoms
symptoms worse at night
hoarse voice
respiratory distress (sternal/intercostal indrawing, stridor)
persistent agitation
lethargy
asynchronous chest wall and abdominal movement
fatigue
signs of hypoxia (pallor or cyanosis)
signs of hypercapnia (decreased level of consciousness secondary to rising PaCO₂)

Other diagnostic factors

Risk factors

age 6 months to 6 years
male sex
prior intubation

More risk factors

Diagnostic investigations

1st investigations to order

clinical exam

More 1st investigations to order

Investigations to consider

x-ray anteroposterior and lateral neck

More investigations to consider

Treatment algorithm

ACUTE

mild (no stridor at rest)

moderate (stridor at rest; no agitation or lethargy)

severe (stridor at rest with agitation or lethargy)

Contributors

AuthorsVIEW ALL

Candice Bjornson, MSc, MD, FRCPC

Associate Professor

University of Calgary

Calgary

Canada

Disclosures

CB declares that she has no competing interests. CB is the author of several references in this topic.

David Johnson, MD

Professor

Department of Pediatrics and Physiology and Pharmacology

University of Calgary

Calgary

Canada

Disclosures

DJ declares that he has no competing interests. DJ is the author of several references in this topic.

Peer reviewersVIEW ALL

Jeffrey Chapman, MD

Staff

Department of Pulmonary and Critical Care Medicine

Cleveland Clinic

Cleveland

OH

Disclosures

JC declares that he has no competing interests.

Ken Farion, MD

Assistant Professor

Pediatrics and Emergency Medicine

University of Ottawa

Ottawa

Canada

Disclosures

KF declares that he has no competing interests.

Doreen Matsui, MD, FRCPC

Associate Professor

Departments of Paediatrics and Medicine

Children's Hospital of Western Ontario

London

Ontario

Canada

Disclosures

DM declares that she has no competing interests.

Jeremy Hull, MBBS

Consultant Paediatrician

Children's Hospital and West Wing

John Radcliffe Hospital

Oxford

UK

Disclosures

JH declares that he has no competing interests.

Steve Cunningham, MBBS, PhD

Consultant Respiratory Paediatrician

Department of Respiratory & Sleep Medicine

Royal Hospital for Sick Children

Edinburgh

UK

Disclosures

SC declares that he has no competing interests.

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