Key Components of a Physical Exam for Croup
The physical examination for croup should focus on assessing respiratory distress, stridor, and signs of hypoxemia, with particular attention to retraction and air entry which are the most clinically significant predictors of outcomes.
Initial Assessment
Vital Signs
- Respiratory rate: Tachypnea indicates increased work of breathing
- Heart rate: Abnormal heart rate correlates with need for further intervention 1
- Temperature: Fever may indicate severity and need for further intervention 1
- Oxygen saturation: To assess for hypoxemia
Respiratory Assessment
Stridor assessment:
- At rest vs. only with agitation
- Inspiratory, expiratory, or biphasic
- Presence of stridor correlates with need for further intervention 1
Work of breathing:
- Retractions (suprasternal, intercostal, subcostal)
- Nasal flaring
- Use of accessory muscles
- Retraction severity is a major factor in predicting clinical outcomes 2
Air entry:
- Assess quality and equality of breath sounds
- Decreased air entry is a major predictor of clinical outcomes 2
- Note any wheezing or prolonged expiration
Level of Consciousness
- Assess alertness and responsiveness
- Note: While altered consciousness is included in the Westley Croup Score, it is not clinically significant even in severe croup 2
Upper Airway Examination
- Inspect oropharynx (avoid agitating the child)
- Note any drooling or inability to swallow (may suggest epiglottitis rather than croup)
- Assess voice quality and cry (hoarseness suggests laryngeal involvement)
Severity Assessment
Westley Croup Score Components
The Westley Croup Score can help objectively assess severity:
- Stridor: None (0), With agitation (1), At rest (2)
- Retractions: None (0), Mild (1), Moderate (2), Severe (3)
- Air entry: Normal (0), Decreased (1), Markedly decreased (2)
- Cyanosis: None (0), With agitation (4), At rest (5)
- Level of consciousness: Normal (0), Altered (5)
Severity interpretation based on score 2:
- Mild (WS 1-2): Can likely be safely treated at home
- Moderate (WS 3-5): Likely requires observation in ED
- Severe (WS ≥6): Likely requires hospital admission
Objective Measurements
- Pulsus paradoxus: An elevated pulsus paradoxus (>6 mm Hg) correlates with croup severity and can be used as an objective measure 3
Differential Diagnosis Assessment
Look for signs that might suggest alternative diagnoses:
- Toxic appearance (bacterial tracheitis)
- Drooling and inability to handle secretions (epiglottitis)
- Asymmetric findings (foreign body)
- Wheezing without barking cough (asthma, bronchiolitis)
Response to Treatment
- Reassessment after treatment with racemic epinephrine and steroids is crucial
- Monitor for at least 2 hours after the second dose of racemic epinephrine 4
- Improvement in stridor, retractions, and air entry suggests good response
Discharge Considerations
Patients may be suitable for discharge if they show:
- Normal heart rate
- No fever
- Absence of stridor
- No chronic medical conditions
- Age >6 months (younger patients may require more caution) 1
Common Pitfalls to Avoid
- Focusing only on stridor while ignoring other signs of respiratory distress
- Performing unnecessary radiographs (only needed if alternative diagnoses are suspected) 5
- Failing to reassess after treatment (observation for at least 2 hours after second dose of racemic epinephrine is recommended) 4
- Missing signs of impending respiratory failure requiring immediate intervention
- Confusing croup with other causes of upper airway obstruction like epiglottitis or bacterial tracheitis
By systematically evaluating these key components, clinicians can accurately assess croup severity and make appropriate management decisions to reduce morbidity and mortality.