From the Guidelines
Croup typically presents with a barking cough, hoarseness, inspiratory stridor, and respiratory distress in children aged 6 months to 3 years. Physical examination often reveals a child with a seal-like barking cough, inspiratory stridor that worsens with agitation, and varying degrees of respiratory distress including suprasternal and intercostal retractions. Fever may be present but is usually low-grade. The diagnosis is primarily clinical, with radiographic findings showing the classic "steeple sign" on anteroposterior neck X-rays, representing subglottic narrowing, as noted in studies such as 1. Pulse oximetry may show normal oxygen saturation in mild cases but hypoxemia in severe cases. Auscultation of the lungs typically reveals good air entry with transmitted upper airway sounds. The severity of croup can be assessed using the Westley Croup Score, which evaluates stridor, retractions, air entry, cyanosis, and level of consciousness. These findings reflect the viral-induced inflammation and edema of the upper airway, particularly in the subglottic region, which creates the characteristic narrowing responsible for the symptoms.
Some key points to consider in the diagnosis and management of croup include:
- The importance of early initiation of systemic steroids, as recommended in the clinical guideline and orderset for croup 1
- The use of a clinical guideline and orderset to reduce hospital admissions for croup, which has been shown to be effective in studies such as 1
- The need to avoid imaging unless necessary, and to consider further workup if a patient fails to respond to treatment, in order to rule out other conditions such as bacterial tracheitis or foreign body aspiration 1
- The use of the Westley Croup Score to assess the severity of croup, which can help guide treatment decisions and predict outcomes 1
Overall, the diagnosis and management of croup require a careful and evidence-based approach, taking into account the latest research and guidelines, such as those noted in 1.
From the Research
Typical Findings of Croup
The typical findings of croup, also known as acute laryngotracheobronchitis, include:
- Respiratory distress due to upper airway inflammation and swelling of the subglottic mucosa in children 2, 3, 4, 5
- Symptoms such as cough, hoarseness, and difficulty breathing 2, 3, 4, 5
- Most cases are mild and transient, resolving with supportive care 2, 3, 4, 5
- Moderate to severe cases may require treatment with corticosteroids and nebulised epinephrine (adrenaline) 2, 3, 4, 5
Croup Score
Croup score is a tool used to measure the severity of croup, with higher scores indicating more severe symptoms:
- The Westley croup score and Taussig croup score are two commonly used scoring systems 3, 4
- Croup scores can be used to assess the effectiveness of treatments, such as heliox inhalation 2, 3, 4
Treatment with Heliox
Heliox, a mixture of helium and oxygen, has been studied as a potential treatment for croup:
- Some studies suggest that heliox may be beneficial in the short term for children with moderate to severe croup treated with dexamethasone 2, 3, 4
- However, the evidence is limited, and adequately powered RCTs are needed to further assess the role of heliox in the treatment of children with moderate to severe croup 2, 3, 4, 5
- One study found that heliox resulted in similar improvements in croup scores compared to racemic epinephrine in patients with moderate to severe croup 6