What is the recommended scoring system for assessing the severity of croup?

Recommended Scoring System for Assessing Croup Severity

The Westley Croup Score is the recommended scoring system for assessing the severity of croup, as it provides objective measurements that correlate with clinical outcomes and treatment needs. 1, 2

Westley Croup Score Components

The Westley Croup Score evaluates five key parameters:

Parameter	0 points	1 point	2 points	3 points	4 points	5 points
Stridor	None	When agitated	At rest	-	-	-
Retractions	None	Mild	Moderate	Severe	-	-
Air entry	Normal	Decreased	Markedly decreased	-	-	-
Cyanosis	None	-	-	With agitation	At rest	-
Level of consciousness	Normal	-	-	-	-	Altered

Severity Classification Based on Score

• Mild croup: Score 0-2

  • Barking cough
  • No audible stridor at rest
  • Minimal or no respiratory distress

• Moderate croup: Score 3-5

  • Barking cough
  • Audible stridor at rest
  • Mild to moderate retractions
  • No agitation

• Severe croup: Score 6-11

  • Barking cough
  • Prominent inspiratory and possibly expiratory stridor
  • Significant retractions
  • Decreased air entry
  • Agitation or lethargy

• Impending respiratory failure: Score ≥12

  • Cyanosis
  • Altered level of consciousness
  • Severe respiratory distress

Clinical Utility and Decision Points

The Westley Score has been validated for predicting clinical outcomes and guiding management decisions:

• Patients with an initial score <2 can typically be safely discharged home 2
• Patients with scores ≥5 are more likely to require extended observation in the emergency department 2
• Patients with scores ≥6 generally require hospital admission 2

Practical Application

1. Assessment frequency: Score patients upon initial presentation and after treatments
2. Treatment response: Monitor changes in score to evaluate effectiveness of interventions
3. Disposition decisions: Use score thresholds to guide admission decisions

Important Clinical Considerations

• Retraction severity and air entry are the most clinically significant components of the score for predicting outcomes 2
• The score shows strong correlation with length of hospital stay (r = 0.617, P < 0.001) 2
• Pulsus paradoxus correlates significantly with Westley Croup Score and may serve as an additional objective measure of severity 3

Limitations and Pitfalls

• Cyanosis and altered consciousness are rarely observed even in severe croup 2
• The score should be used in conjunction with clinical judgment, not as the sole determinant of management
• Scores may not fully capture rapid deterioration in some cases, so continuous monitoring remains essential

Treatment Considerations Based on Severity

• All severity levels: Dexamethasone 0.15-0.60 mg/kg orally as a single dose 1
• Moderate to severe (scores ≥3): Consider nebulized epinephrine (0.5 ml/kg of 1:1000 solution) 1
• Hospital admission should be considered after 3 total doses of nebulized epinephrine 4

The Westley Croup Score provides an objective, validated framework for assessing croup severity and guiding clinical decision-making, making it the preferred scoring system in clinical practice.