Discharge Parameters for Acute Laryngotracheobronchitis (Croup)
Patients with croup can be safely discharged when they demonstrate no stridor at rest, minimal respiratory distress, and stable symptoms following dexamethasone administration, with mandatory parental education on return precautions. 1
Clinical Stability Criteria Before Discharge
Patients must meet the following criteria to be considered safe for discharge:
- No stridor at rest - this is the most critical indicator that airway obstruction has resolved sufficiently for home management 1
- Minimal or no respiratory distress - absence of significant retractions, tachypnea, or accessory muscle use 1
- Significant clinical improvement after dexamethasone - typically assessed 2-4 hours post-administration to ensure sustained response 1
- Stable vital signs - normal respiratory rate for age and adequate oxygen saturation on room air 1
The key distinction here is that unlike asthma or reactive airway disease where peak flow measurements and 24-hour medication trials are required 2, croup discharge focuses primarily on clinical assessment of upper airway obstruction rather than objective measurements.
Observation Period Requirements
An adequate observation period after treatment is essential - discharging patients too early before confirming sustained improvement is a common pitfall that leads to increased return visits and poor outcomes 1. While specific timeframes aren't rigidly defined in the guidelines, clinical practice typically involves observing patients for 2-4 hours post-dexamethasone to ensure the effect is sustained and symptoms don't recur.
Mandatory Parental Education
Parents must receive clear, specific return precautions before discharge:
- Return immediately if stridor at rest returns or worsens - this indicates recurrent airway obstruction requiring urgent evaluation 1
- Watch for increased work of breathing - retractions, nasal flaring, or rapid breathing 1
- Monitor for inability to drink or excessive drooling - may indicate worsening obstruction 1
- Observe for altered mental status or extreme fatigue - signs of respiratory compromise 1
Failing to provide these clear return precautions is a critical error that can result in delayed recognition of deterioration 1.
Follow-Up Arrangements
Primary care follow-up within one week is mandatory to monitor recovery and ensure complete resolution of symptoms 1. This is particularly important given that croup can occasionally have a biphasic course.
Contraindications to Discharge (Admission Criteria)
The following situations warrant hospital admission rather than discharge:
- Persistent moderate to severe respiratory distress despite treatment - indicates inadequate response to therapy 1
- Stridor at rest that persists after dexamethasone - suggests significant ongoing airway obstruction 1
- Social concerns including parental inability to recognize worsening symptoms - compromises safety of home management 1
- Need for more than 2 doses of racemic epinephrine - patients requiring >2 doses had admission rates exceeding 80% 3
- Toxic appearance or high fever suggesting bacterial superinfection - may indicate pseudomembranous croup or epiglottitis 4
Special Considerations
The evidence from a large quality improvement study demonstrates that patients receiving ≤2 doses of racemic epinephrine can be safely discharged with admission rates as low as 1.7%, while those requiring >2 doses have fundamentally different risk profiles with admission rates >80% 3. This provides a clear algorithmic decision point.
Common pitfalls to avoid:
- Discharging before adequate observation period after dexamethasone 1
- Failing to assess parental competency in recognizing deterioration 1
- Not providing written return precautions 1
- Confusing viral croup with bacterial epiglottitis, which requires immediate airway management 5
Unlike the complex discharge requirements for asthma with peak flow meters, written action plans, and medication adjustments 2, croup discharge is more straightforward but requires careful clinical assessment and thorough parental education to ensure safe home management.