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  • Also known as laryngotracheobronchitis
  • Typically affects ages 6 mo-3 yr (peak in 2nd year)
    • Most common in fall & winter
  • Etiology
    • Parainfluenza (50%), RSV, rhinovirus
    • Consider Diphtheria if not immunized
  • Spasmodic croup
    • Sudden onset of barking cough/stridor
    • No viral prodrome, unlike standard croup
    • Difficult to differentiate from croup
  • Must rule-out foreign body

Clinical Features

  • 1-2 day of URI followed by barking cough and stridor
  • Low-grade fever
  • NO drooling or dysphagia
  • Duration = 3-7d, most severe on days 3-4

Westley Croup Score[1][2]

Helps to stratify patients into mild moderate and severe and guide treatment

Parameter 0 Point 1 Point 2 Points 3 Points
Inspiratory stridor None When agitated On/off at rest Continuous at rest
Retractions None Mild Moderate Severe
Air Entry Normal Decreased Mod decreased Severely decreased
Cyanosis None When crying At rest
Alertness Alert Restless, anxious Depressed


  • <2 Very mild
  • 2-9 Mild to moderately severe
  • >9 Severe croup

Differential Diagnosis



  • Consider CXR if concerned about alternative diagnosis
    • Steeple sign on AP (not Sp, not Sn)
  • Consider nasal washings for RSV, parainfluenza, influenza serologies.


  • Often a clinical diagnosis


  • Cool mist
    • May provide symptomatic treatment for patients with ongoing stridor[3]
  • Steroids (first line treatment)
    • Dexamethasone 0.15-0.6mg/kg PO/IM (max 10mg)[4]
  • Epinephrine (nebulized)
    • Use in moderate to severe cases based on the croup scores. Use either Racemic or Standard Epinephrine[5]
    • Racemic Epi (2.25%): 0.05 mL per kg (maximal dose: 0.5 mL) of racemic epinephrine 2.25% [6]
    • Epinephrine (1:1,000): 0.5 mL per kg (maximal dose: 5 mL) via nebulizer,
  • Do NOT give albuterol (may worsen edema (vasodilation))

Intubation rarely needed but if so, use tube that is one half size smaller than normal for age/size of pt


  • Consider Discharge if:
    • 3hr since last epinephrine
    • Able to tolerate PO
    • Nontoxic appearance
  • Admit
    • Persistent respiratory symptoms/signs
    • ≥2 treatments with epinephrine

See Also

Bronchiolitis (RSV)

External Links


  1. Westley CR, et al. Nebulized racemic epinephrine by IPPB for the treatment of croup: a double-blind study. Am J Dis Child. 1978; 132(5):484-487.
  2. Klassen TP, et al. Croup. A current perspective. Pediatr Clin North Am. 1999; 46(6):1167–1178.
  3. Scolnik D, Coates AL, Stephens D, Da Silva Z, Lavine E, Schuh S. Controlled delivery of high vs low humidity vs mist therapy for croup in emergency departments. JAMA. 2006;295(11):1274–1280
  4. Geelhoed GC, Macdonald WB. Oral dexamethasone in the treatment of croup: 0.15 mg/kg versus 0.3 mg/kg versus 0.6 mg/kg. Pediatr Pulmonol. 1995;20(6):362–368.
  5. Adair JC, Ring WH, Jordan WS, Elwyn RA. Ten-year experience with IPPB in the treatment of acute laryngotracheobronchitis. Anesth Analg. 1971;50(4):649–55
  6. Westley CR, Cotton EK, Brooks JG. Nebulized racemic epinephrine by IPPB for the treatment of croup: a double-blind study. Am J Dis Child. 1978;132(5):484–487