When should a child with acute laryngotracheobronchitis (croup) be admitted?

From the Guidelines

A child with acute laryngotracheobronchitis (croup) should be admitted to the hospital when they show signs of moderate to severe respiratory distress, including stridor at rest, significant retractions, decreased air entry, hypoxemia (oxygen saturation <92%), or altered mental status, as evidenced by a recent study published in Pediatrics in 2022 1. When determining the need for admission, it is crucial to consider the severity of symptoms and the potential for rapid progression to airway obstruction. The study found that the implementation of a clinical guideline and orderset reduced hospital admissions for croup by 57% (95% CI: 24 to 89) without significant changes in balancing measures, including inpatient airway interventions or length of stay (LOS) 1. Key indicators for admission include:

• Stridor at rest
• Significant retractions
• Decreased air entry
• Hypoxemia (oxygen saturation <92%)
• Altered mental status
• Failure to respond to outpatient treatments such as dexamethasone and nebulized epinephrine
• Recurrent episodes within 24-48 hours
• Dehydration or inability to maintain oral intake
• Very young infants (less than 6 months)
• Social factors such as limited access to healthcare, parental inability to monitor the child, or living far from medical facilities. The decision to admit a child with croup should be based on a thorough assessment of their clinical condition and the potential risks and benefits of hospitalization, as supported by the most recent and highest quality evidence available 1.

From the Research

Admission Criteria for Croup

The decision to admit a child with acute laryngotracheobronchitis (croup) depends on several factors, including the severity of symptoms and the presence of certain clinical findings.

• Admission is indicated in children with:
  • Stridor at rest 2
  • Evidence of exhaustion 2
  • Toxicity 2
  • Respiratory distress 2
  • Hypoxemia, which may require supplemental oxygen in a mist tent 3
• Children with moderate to severe croup may benefit from hospitalization, especially if they require close monitoring and treatment with racemic epinephrine and steroids 3, 4, 2
• The presence of certain clinical findings, such as a barking cough, inspiratory stridor, and hoarseness, can help guide the decision to admit a child with croup 3, 5, 4
• It is essential to differentiate croup from other conditions, such as epiglottitis and retropharyngeal abscess, which may require more urgent and aggressive treatment 3, 5, 2

Treatment and Management

The treatment of croup typically involves the use of humidified air, racemic epinephrine, and adrenal corticosteroids.

• Maintaining at least 50% relative humidity in the child's room is recommended 3
• Racemic epinephrine administered by nebulizer can quickly reverse airway obstruction in children with croup, but the patient needs to be monitored for rebound airway obstruction for at least 2 hours after administration 3
• Dexamethasone is the mainstay of treatment for severe croup, and its correct dosage is essential to decrease the obstructive symptoms of croup 3, 4