eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease

Croup: Treatment & Medication

Author: Antonio Muñiz, MD, Associate Professor of Emergency Medicine and Pediatrics, University of Texas Medical School at Houston; Medical Director of the Pediatric Emergency Department, Children's Memorial Hermann Hospital
Coauthor(s): Rona E Molodow, MD, Associate Clinical Professor, Department of Pediatrics, Olive View-University of California Los Angeles Medical Center; Germaine L Defendi, MD, MS, FAAP, Associate Clinical Professor of Pediatrics, Department of Pediatrics, Olive View-University of California Los Angeles Medical Center
Contributor Information and Disclosures

Updated: Nov 21, 2008

Treatment

Medical Care

Any infant who presents with respiratory distress must receive a thorough evaluation to ensure the patency of the airway and maintenance of effective oxygenation and ventilation. 

ED treatment of croup depends on the degree of distress. For example, a child who presents with only a croupy cough may require nothing more than parental reassurance, and the parents may only need education regarding the course of the disease. Any child who presents with respiratory complaints must have a thorough evaluation to ensure the patency of the airway and maintenance of effective oxygenation and ventilation. Infants with severe respiratory distress or compromise require 100% oxygenation with ventilation support initially with a bag-valve-mask device. If the airway and breathing require further maintenance, the patient should be intubated with an endotracheal tube. Intubation should be accomplished with an endotracheal tube that is 0.5-1 mm smaller than predicted.

  • The first rule of management is to keep the child as comfortable as possible, allowing the patient to remain in a parent's arms and avoiding unnecessary painful interventions that may cause agitation and increased oxygen requirements by the child. Persistent crying increases oxygen demands and respiratory muscle fatigue and worsens the obstruction.
  • Careful monitoring of the heart rate, respiratory rate, respiratory mechanics, and pulse oximetry are important to detect early hypoxia.
  • Throughout the 19th and most of the 20th century, cool mist administration was the mainstay of treatment. Hospitals had "croup rooms" filled with mist. Theoretically, mist moistens airway secretions, decreases their viscosity, and soothes the inflamed mucosa. Animal data show that microaerosol inhalation activates mechanoreceptors that produce a reflex slowing of respiratory flow rate and leads to improved airflow. Despite its continued widespread use, little evidence supports the clinical efficacy of cool mist. Randomized studies of children with moderate-to-severe croup revealed no difference in outcome between those who received cool mist and those who did not.2  In addition, the use of hot steam should be avoided because scalding has been reported. Also, mist tents can disperse fungus and molds if not properly cleaned and, more importantly, separates the child from the parent, which usually causes them to be agitated and worsens their symptoms.
  • The current cornerstones of treatment are glucocorticoids and nebulized epinephrine, although steroids have proven beneficial in severe, moderate, and even mild croup. 
  • Corticosteroids are beneficial because of their anti-inflammatory action, whereby laryngeal mucosal edema is decreased. They also decrease the need for salvage nebulized epinephrine. 
    • A single dose of dexamethasone has been shown to be effective in reducing the overall severity of croup if administered within the first 4-24 hours after onset of illness. The long half-life of dexamethasone (54 h) often allows for a single injection. Dexamethasone (0.15 mg/kg) is as effective as 0.3 mg/kg or 0.6 mg/kg in relieving symptoms of mild-to-moderate croup. It has the same efficacy if administered intravenously, intramuscularly, or orally.
    • A single oral dose of prednisolone (1 mg/kg) resulted in more return visits than a single oral dose of dexamethasone (0.15 mg/kg).3
    • Inhaled budesonide has also proven to be effective but is more expensive; in one study, oral dexamethasone resulted in better improvement than nebulized budesonide. 
    • Corticosteroids should not be administered to children with varicella or untreated tuberculosis.
  • Nebulized racemic (mixture of d -isomers and l -isomers) or L-epinephrine is typically reserved for patients in moderate-to-severe distress. It works by adrenergic stimulation, which causes constriction of the precapillary arterioles, thereby decreasing capillary hydrostatic pressure. This leads to fluid resorption from the interstitium and improvement in the laryngeal mucosal edema. Its beta-2-adrenergic activity leads to bronchial smooth muscle relaxation and bronchodilation. Although a child who is symptomatic enough to receive epinephrine may be discharged after at least 3 hours of observation, anyone receiving epinephrine should also be given corticosteroids.
  • Antibiotics are not indicated.
  • Heliox is a metabolically inert, nontoxic gas that is combined with oxygen. It has low viscosity and low specific gravity, which allows for greater laminar airflow through the respiratory tract. Helium decreases the force necessary to move the gas through the airways and decreases the mechanical work of respiratory muscles, which is clinically seen as less respiratory distress.4  Several trials of heliox have demonstrated no advantage over conventional modalities; however, other trials have shown it to be equally effective in moderate-to-severe croup when compared with racemic epinephrine.5,6,7  It has also been shown to improve symptoms in very severe croup that failed to improve with racemic epinephrine.

Medication

Corticosteroids

Although a subject of controversy throughout the 1980s and 1990s, corticosteroids have since become a routine part of ED management of croup. Corticosteroids have shown to decrease hospitalization rates by 86%. Steroids are thought to decrease airway edema via their anti-inflammatory effect. In mild disease, corticosteroids have been proven to reduce the number of children returning to the ED for further treatment. In moderate-to-severe disease, they improve croup scores within 12-24 hours and decrease hospitalization rates. Most trials have used dexamethasone at 0.6 mg/kg (intramuscular or oral), but oral doses as low as 0.15 mg/kg are effective. Oral and intramuscular routes appear equally beneficial. Prednisolone (1 mg/kg) has been proven effective but may be associated with a greater return of children to the ED. 

Inhaled corticosteroids also have demonstrated efficacy, with most trials using budesonide. However, according to most authors, the relative ease, speed, and cost of administration make systemic corticosteroids preferable to nebulized formulations.


Dexamethasone (Decadron)

Several studies have shown improvement in clinical symptoms and croup score in patients who were hospitalized or treated in the ED. Dexamethasone exerts beneficial effect via anti-inflammatory action in which laryngeal mucosal edema is decreased. Onset of action occurs within 6 h for PO and IM. Long pharmacodynamic effect of 36-56 h. No studies have evaluated the effect of multiple doses.

Adult

Pediatric

0.15-0.6 mg/kg PO/IM as a single dose; not to exceed 10 mg/dose

Coadministration with barbiturates, phenytoin, or rifampin can decrease effectiveness

Documented hypersensitivity; systemic fungal infections; varicella exposure; tuberculosis

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Prolonged use has been associated with adrenal insufficiency, psychosis, immunosuppression, peptic ulcer disease, CHF, anaphylaxis, osteoporosis, pseudotumor cerebri, pancreatitis, nausea, vomiting, dyspepsia, edema, headache, dizziness, mood swings, insomnia, anxiety, hypokalemia, hypertension, hyperglycemia, cushingoid features, menstrual irregularities, ecchymosis, acne, skin atrophy, and impaired wound healing
One case report of a child developing candidal tracheitis after receiving both steroids and antibiotics while hospitalized for croup


Prednisone (Deltasone) or prednisolone (Prelone)

Several studies have shown improvement in clinical symptoms and croup score in patients who were hospitalized or treated in the ED. Corticosteroids exert beneficial effect via anti-inflammatory action in which laryngeal mucosal edema is decreased. In calculating an appropriate prednisone dose, dexamethasone is 6.67 times more potent and has a long half-life of 36-56 h vs a median half-life of 18-36 h for prednisone.

Adult

Pediatric

Not established; one randomized controlled trial demonstrated decreased duration of intubation in children receiving prednisolone 1 mg/kg PO q12h until 24 h after extubation; not to exceed 60 mg/24 h

Coadministration with barbiturates, phenytoin, or rifampin can decrease effectiveness; coadministration with estrogens can decrease clearance; concurrent use with digoxin may cause digitalis toxicity secondary to hypokalemia

Documented hypersensitivity; systemic fungal infections; tuberculosis; varicella or exposure to varicella; peptic ulcer disease; hepatic dysfunction

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Prolonged use has been associated with adrenal insufficiency, psychosis, immunosuppression, peptic ulcer disease, CHF, anaphylaxis, osteoporosis, pseudotumor cerebri, pancreatitis, nausea, vomiting, dyspepsia, edema, headache, dizziness, mood swings, insomnia, anxiety, hypokalemia, hypertension, hyperglycemia, cushingoid features, menstrual irregularities, ecchymosis, acne, skin atrophy, and impaired wound healing


Budesonide (Pulmicort Respules)

Clinical studies have documented improvement in symptoms and decrease in hospital admissions with nebulized budesonide in children with croup. Corticosteroids exert beneficial effect via anti-inflammatory action in which laryngeal mucosal edema is decreased.

Adult

Pediatric

2 mL (0.5 mg) of solution inhaled via nebulizer

Documented hypersensitivity; active bacterial or fungal infection

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Prolonged use may increase the systemic absorption of corticosteroids; hypothalamic-pituitary axis suppression; hyperglycemia; glycosuria

Nebulized vasoconstrictors

Epinephrine stimulates alpha-receptors and beta2-receptors. It constricts the precapillary arterioles, thus decreasing airway edema. Because of the potential adverse effects of tachycardia and hypertension, it is reserved for children with moderate-to-severe disease. The effects of epinephrine are transient, and most trials show alleviation of symptoms for no longer than 2 h. In the 1980s and early 1990s, a rebound phenomenon was thought to occur, necessitating admission of all children who received the drug. However, in recent years, patient discharge after 3-4 hours of observation has become acceptable as long as they have no stridor at rest, normal air entry, normal color, normal consciousness, and have received a dose of steroids.


Epinephrine, racemic (microNefrin) 2.25%

Mixture of dextro and levo isomers. Causes adrenergic stimulation, which constricts precapillary arterioles, thus decreasing capillary hydrostatic pressure. This leads to fluid resorption from the interstitium and improvement in the laryngeal mucosal edema, although its beta2 activity leads to bronchial smooth muscle relaxation.

Adult

Pediatric

Administer 2.25% solution for nebulization (dose according to weight listed below) mixed with 3 mL saline:
<20 kg: 0.25 mL
20-40 kg: 0.5 mL
>40 kg: 0.75 mL
May repeat q20-30min

Inhaled anesthetics may enhance cardiac irritability; nonselective beta-blockers leave alpha effects unopposed, increasing risk of hypertension and tachycardia

Documented hypersensitivity; angle-closure glaucoma; obstruction of ventricular outflow, as in tetralogy of Fallot

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Adverse effects include tachycardia (discontinue if heart rate >200 bpm), dysrhythmias, palpitations, hypertension, tremor, agitation, nausea, vomiting, headache; randomized controlled trials in children with croup reported no adverse effects, particularly tachycardia; one case report of a previously healthy 11-year-old child who developed ventricular tachycardia after receiving 3 doses in 60 min and was later found to have experienced a small MI


Epinephrine (Adrenalin)

Levo isomer. Stimulates alpha-, beta1-, and beta2-adrenergic receptors, which results in bronchodilatation, increased peripheral vascular resistance, hypertension, increased chronotropic cardiac activity, and positive inotropic effects. Causes alpha-adrenergic receptor–mediated vasoconstriction of edematous tissues, thus reversing upper airway edema.

Adult

Pediatric

5 mL (5 mg) of 1:1000 solution diluted in 2 mL saline administered via nebulization; may repeat q20-30min

Increases toxicity of beta- and alpha-blocking agents and that of halogenated inhalational anesthetics

Documented hypersensitivity; cardiac arrhythmias; angle-closure glaucoma; during labor (may delay second stage of labor)

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in cardiovascular disease, tachycardia (especially with HR >200 bpm), diabetes mellitus, hyperthyroidism, and cerebrovascular insufficiency

More on Croup

Overview: Croup
Differential Diagnoses & Workup: Croup
Treatment & Medication: Croup
Follow-up: Croup
Multimedia: Croup
References
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References

  1. Alberta Medical Association. Guideline for the diagnosis and management of croup. Alberta Clinical Practice Guidelines 2005 Update. Available at www.albertadoctors.org/bcm/ama/ama-website.nsf.

  2. [Best Evidence] Scolnik D, Coates AL, Stephens D, et al. Controlled delivery of high vs low humidity vs mist therapy for croup in emergency departments: a randomized controlled trial. JAMA. Mar 15 2006;295(11):1274-80. [Medline].

  3. Amir L, Hubermann H, Halevi A, Mor M, Mimouni M, Waisman Y. Oral betamethasone versus intramuscular dexamethasone for the treatment of mild to moderate viral croup: a prospective, randomized trial. Pediatr Emerg Care. Aug 2006;22(8):541-4. [Medline].

  4. McGee DL, Wald DA, Hinchliffe S. Helium-oxygen therapy in the emergency department. J Emerg Med. May-Jun 1997;15(3):291-6. [Medline].

  5. Beckmann KR, Brueggemann WM Jr. Heliox treatment of severe croup. Am J Emerg Med. Oct 2000;18(6):735-6. [Medline].

  6. Terregino CA, Nairn SJ, Chansky ME, Kass JE. The effect of heliox on croup: a pilot study. Acad Emerg Med. Nov 1998;5(11):1130-3. [Medline].

  7. Weber JE, Chudnofsky CR, Younger JG, et al. A randomized comparison of helium-oxygen mixture (Heliox) and racemic epinephrine for the treatment of moderate to severe croup. Pediatrics. Jun 2001;107(6):E96. [Medline].

  8. Bernstein T, Brilli R, Jacobs B. Is bacterial tracheitis changing? A 14-month experience in a pediatric intensive care unit. Clin Infect Dis. Sep 1998;27(3):458-62. [Medline].

  9. Donnelly BW, McMillan JA, Weiner LB. Bacterial tracheitis: report of eight new cases and review. Rev Infect Dis. Sep-Oct 1990;12(5):729-35. [Medline].

  10. Edwards KM, Dundon MC, Altemeier WA. Bacterial tracheitis as a complication of viral croup. Pediatr Infect Dis. Sep-Oct 1983;2(5):390-1. [Medline].

  11. Jones R, Santos JI, Overall JC. Bacterial tracheitis. JAMA. Aug 24-31 1979;242(8):721-6. [Medline].

  12. Ausejo M, Saenz A, Pham B, Kellner JD, et al. The effectiveness of glucocorticoids in treating croup: meta-analysis. BMJ. Sep 4 1999;319(7210):595-600. [Medline].

  13. Bjornson CL, Johnson DW. Croup. Lancet. Jan 26 2008;371(9609):329-39. [Medline].

  14. Bjornson CL, Klassen TP, Williamson J, et al. A randomized trial of a single dose of oral dexamethasone for mild croup. N Engl J Med. Sep 23 2004;351(13):1306-13. [Medline].

  15. Cetinkaya F, Tufekci BS, Kutluk G. A comparison of nebulized budesonide, and intramuscular, and oral dexamethasone for treatment of croup. Int J Pediatr Otorhinolaryngol. Apr 2004;68(4):453-6. [Medline].

  16. Chapman RS, Henderson FW, Clyde WA Jr, Collier AM, Denny FW. The epidemiology of tracheobronchitis in pediatric practice. Am J Epidemiol. Dec 1981;114(6):786-97. [Medline].

  17. Cherry JD. Clinical practice. Croup. N Engl J Med. Jan 24 2008;358(4):384-91. [Medline].

  18. Chub-Uppakarn S, Sangsupawanich P. A randomized comparison of dexamethasone 0.15 mg/kg versus 0.6 mg/kg for the treatment of moderate to severe croup. Int J Pediatr Otorhinolaryngol. Mar 2007;71(3):473-7. [Medline].

  19. Colletti JE. Myth: Cool mist is an effective therapy in the management of croup. CJEM. Sep 2004;6(5):357-8. [Medline].

  20. Counihan ME, Shay DK, Holman RC, et al. Human parainfluenza virus-associated hospitalizations among children less than five years of age in the United States. Pediatr Infect Dis J. Jul 2001;20(7):646-53. [Medline].

  21. Cressman WR, Myer CM 3rd. Diagnosis and management of croup and epiglottitis. Pediatr Clin North Am. Apr 1994;41(2):265-76. [Medline].

  22. Cruz MN, Stewart G, Rosenberg N. Use of dexamethasone in the outpatient management of acute laryngotracheitis. Pediatrics. Aug 1995;96(2 Pt 1):220-3. [Medline].

  23. Denny FW, Murphy TF, Clyde WA Jr, Collier AM, Henderson FW. Croup: an 11-year study in a pediatric practice. Pediatrics. Jun 1983;71(6):871-6. [Medline].

  24. Donaldson D, Poleski D, Knipple E, et al. Intramuscular versus oral dexamethasone for the treatment of moderate-to-severe croup: a randomized, double-blind trial. Acad Emerg Med. Jan 2003;10(1):16-21. [Medline].

  25. Fifoot AA, Ting JY. Comparison between single-dose oral prednisolone and oral dexamethasone in the treatment of croup: a randomized, double-blinded clinical trial. Emerg Med Australas. Feb 2007;19(1):51-8. [Medline].

  26. Gardner HG, Powell KR, Roden VJ, Cherry JD. The evaluation of racemic epinephrine in the treatment of infectious croup. Pediatrics. Jul 1973;52(1):52-5. [Medline].

  27. Geelhoed GC. Sixteen years of croup in a Western Australian teaching hospital: effects of routine steroid treatment. Ann Emerg Med. Dec 1996;28(6):621-6. [Medline].

  28. Geelhoed GC, Macdonald WB. Oral and inhaled steroids in croup: a randomized, placebo-controlled trial. Pediatr Pulmonol. Dec 1995;20(6):355-61. [Medline].

  29. 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. Dec 1995;20(6):362-8. [Medline].

  30. Geelhoed GC, Turner J, Macdonald WB. Efficacy of a small single dose of oral dexamethasone for outpatient croup: a double blind placebo controlled clinical trial. BMJ. Jul 20 1996;313(7050):140-2. [Medline]. [Full Text].

  31. Godden CW, Campbell MJ, Hussey M, Cogswell JJ. Double blind placebo controlled trial of nebulised budesonide for croup. Arch Dis Child. Feb 1997;76(2):155-8. [Medline]. [Full Text].

  32. Greally P, Cheng K, Tanner MS, Field DJ. Children with croup presenting with scalds. BMJ. Jul 14 1990;301(6743):113. [Medline].

  33. Griffin S, Ellis S, Fitzgerald-Barron A, et al. Nebulised steroid in the treatment of croup: a systematic review of randomised controlled trials. Br J Gen Pract. Feb 2000;50(451):135-41. [Medline].

  34. Henry R. Moist air in the treatment of laryngotracheitis. Arch Dis Child. 1983;58:577.

  35. Humidified air inhalation for treating croup [database online]. Cochrane Database of Systematic Reviews; 2006.

  36. Husby S, Agertoft L, Mortensen S, Pedersen S. Treatment of croup with nebulised steroid (budesonide): a double blind, placebo controlled study. Arch Dis Child. Mar 1993;68(3):352-5. [Medline].

  37. Hvizdos KM, Jarvis B. Budesonide inhalation suspension: a review of its use in infants, children and adults with inflammatory respiratory disorders. Drugs. Nov 2000;60(5):1141-78. [Medline].

  38. Jacobs S, Shortland G, Warner J, et al. Validation of a croup score and its use in triaging children with croup. Anaesthesia. Oct 1994;49(10):903-6. [Medline].

  39. Jamshidi PB, Kemp JS, Peter JR, et al. The effect of humidified air in mild to moderate croup: evaluation using croup scores and respiratory inductance plethysmography (rip). Acad Emerg Med. May 2001;8(5):417. [Medline].

  40. Johnson D, Williamson J. Croup: duration of symptoms and impact on family functioning. Pediatr Research. 2001;49.

  41. Johnson DW, Jacobson S, Edney PC, et al. A comparison of nebulized budesonide, intramuscular dexamethasone, and placebo for moderately severe croup. N Engl J Med. Aug 20 1998;339(8):498-503. [Medline].

  42. Johnson DW, Schuh S, Koren G, Jaffee DM. Outpatient treatment of croup with nebulized dexamethasone. Arch Pediatr Adolesc Med. Apr 1996;150(4):349-55. [Medline].

  43. Kaditis AG, Wald ER. Viral croup: current diagnosis and treatment. Pediatr Infect Dis J. Sep 1998;17(9):827-34. [Medline].

  44. Kairys SW, Olmstead EM, O'Connor GT. Steroid treatment of laryngotracheitis: a meta-analysis of the evidence from randomized trials. Pediatrics. May 1989;83(5):683-93. [Medline].

  45. Kelley PB, Simon JE. Racemic epinephrine use in croup and disposition. Am J Emerg Med. May 1992;10(3):181-3. [Medline].

  46. King L. Pediatrics, croup or laryngotracheobronchitis. eMedicine from WebMD [serial online]. October 1, 2007;Available at www.emedicine.com/EMERG/topic370.htm.

  47. Klassen TP, Craig WR, Moher D, et al. Nebulized budesonide and oral dexamethasone for treatment of croup: a randomized controlled trial. JAMA. May 27 1998;279(20):1629-32. [Medline].

  48. Klassen TP, Feldman ME, Watters LK, et al. Nebulized budesonide for children with mild-to-moderate croup. New Engl J Med. 1994;331:285-289. [Medline].

  49. Klassen TP, Watters LK, Feldman ME, et al. The efficacy of nebulized budesonide in dexamethasone-treated outpatients with croup. Pediatrics. Apr 1996;97(4):463-6. [Medline].

  50. Kunkel NC, Baker MD. Use of racemic epinephrine, dexamethasone, and mist in the outpatient management of croup. Pediatr Emerg Care. Jun 1996;12(3):156-9. [Medline].

  51. Kunzelmann K, Konig J, Sun J, et al. Acute effects of parainfluenza virus on epithelial electrolyte transport. J Biol Chem. Nov 19 2004;279(47):48760-6. [Medline].

  52. Kuusela AL, Vesikari T. A randomized double-blind, placebo controlled trial of dexamethasone and racemic epinephrine in the treatment of croup. Acta Paediatr Scand. 1988;77:99-104. [Medline].

  53. Ledwith CA, Shea LM, Mauro RD. Safety and efficacy of nebulized racemic epinephrine in conjunction with oral dexamethasone and mist in the outpatient treatment of croup. Ann Emerg Med. 1995;25:331-337. [Medline].

  54. Luria JW, Gonzalez-del-Rey JA, DiGiulio GA, et al. Effectiveness of oral or nebulized dexamethasone for children with mild croup. Arch Pediatr Adolesc Med. Dec 2001;155(12):1340-5. [Medline].

  55. Malhotra A, Krilov LR. Viral croup. Pediatr Rev. Jan 2001;22(1):5-12. [Medline].

  56. Marx A, Torok TJ, Holman RC, et al. Pediatric hospitalizations for croup (laryngotracheobronchitis): biennial increases associated with human parainfluenza virus 1 epidemics. J Infect Dis. Dec 1997;176(6):1423-7. [Medline].

  57. McDonogh AJ. The use of steroids and nebulised adrenaline in the treatment of viral croup over a seven year period at a district hospital. Anaesth Intensive Care. Apr 1994;22(2):175-8. [Medline].

  58. Moore M, Little P. Humidified air inhalation for treating croup: a systematic review and meta-analysis. Fam Pract. Aug 2007;24(4):295-301. [Medline].

  59. Nelson DS, McClellan L. Helium-oxygen mixtures as adjunctive support for refractory viral croup. Ohio State Med J. Oct 1982;78(10):729-30. [Medline].

  60. Neto GM, Kentab O, Klassen TP, Osmond MH. A randomized controlled trial of mist in the acute treatment of moderate croup. Acad Emerg Med. Sep 2002;9(9):873-9. [Medline].

  61. Peltola V, Heikkinen T, Ruuskanen O. Clinical courses of croup caused by influenza and parainfluenza viruses. Pediatr Infect Dis J. Jan 2002;21(1):76-8. [Medline].

  62. Prendergast M, Jones JS, Hartman D. Racemic epinephrine in the treatment of laryngotracheitis: can we identify children for outpatient therapy?. Am J Emerg Med. Nov 1994;12(6):613-6. [Medline].

  63. Remington S, Meakin G. Nebulized adrenaline 1:1000 in the treatment of croup. Anaesthesia. 1986;41:923-927. [Medline].

  64. Rittichier KK, Ledwith CA. Outpatient treatment of moderate croup with dexamethasone: intramuscular versus oral dosing. Pediatrics. Dec 2000;106(6):1344-8. [Medline]. [Full Text].

  65. Rizos JD, DiGravio BE, Sehl MJ, Tallon JM. The disposition of children with croup treated with racemic epinephrine and dexamethasone in the emergency department. J Emerg Med. Jul-Aug 1998;16(4):535-9. [Medline].

  66. Rotta AT, Wiryawan B. Respiratory emergencies in children. Respir Care. Mar 2003;48(3):248-58; discussion 258-60. [Medline].

  67. Russell K, Wiebe N, Saenz A, et al. Glucocorticoids for croup. Cochrane Database Syst Rev. 2004;(1):CD001955. [Medline].

  68. Salour M. The steeple sign. Radiology. Aug 2000;216(2):428-9. [Medline].

  69. Segal AO, Crighton EJ, Moineddin R, Mamdani M, Upshur RE. Croup hospitalizations in Ontario: a 14-year time-series analysis. Pediatrics. Jul 2005;116(1):51-5. [Medline].

  70. Skolnik NS. Treatment of croup-a critical review. Am J Dis Child. 1989;143:1045-1049. [Medline].

  71. [Best Evidence] Sparrow A, Geelhoed G. Prednisolone versus dexamethasone in croup: a randomised equivalence trial. Arch Dis Child. Jul 2006;91(7):580-3. [Medline]. [Full Text].

  72. Stankiewicz JA, Bowes AF. Croup and epiglottitis: a radiologic study. Laryngoscope. 1985;95:1159-1161. [Medline].

  73. Super DM, Cartelli NA, Brooks LJ, Lembo RM, Kumar ML. A prospective randomized double-blind study to evaluate the effect of dexamethasone in acute laryngotracheitis. J Pediatr. Aug 1989;115(2):323-9. [Medline].

  74. Taussig LM, Castro O, Beaudry PH, Fox WW, Bureau M. Treatment of laryngotracheobronchitis (croup). Use of intermittent positive-pressure breathing and racemic epinephrine. Am J Dis Child. Jul 1975;129(7):790-3. [Medline].

  75. Tibballs J, Shann FA, Landau LI. Placebo-controlled trial of prednisolone in children intubated for croup. Lancet. 1992;340:745-748. [Medline].

  76. Tunnessen WW Jr, Feinstein AR. The steroid-croup controversy: an analytic review of methodologic problems. J Pediatr. Apr 1980;96(4):751-6. [Medline].

  77. Vorwerk C, Coats TJ. Use of helium-oxygen mixtures in the treatment of croup: a systematic review. Emerg Med J. Sep 2008;25(9):547-50. [Medline].

  78. Waisman Y, Klein BL, Boenning DA, et al. Prospective randomized double-blind study comparing L-epinephrine and racemic epinephrine aerosols in the treatment of laryngotracheitis (croup). Pediatrics. Feb 1992;89(2):302-6. [Medline].

  79. Westley CR, Cotton EK, Brooks JG. Nebulized racemic epinephrine by IPPB for the treatment of croup: a double-blind study. Am J Dis Child. May 1978;132(5):484-7. [Medline].

  80. Williams JV, Harris PA, Tollefson SJ, et al. Human metapneumovirus and lower respiratory tract disease in otherwise healthy infants and children. N Engl J Med. Jan 29 2004;350(5):443-50. [Medline].

  81. Wong VK, Mason WH. Branhamella catarrhalis as a cause of bacterial tracheitis. Pediatr Infect Dis J. Oct 1987;6(10):945-6. [Medline].

  82. Yates RW, Doull IJ. A risk-benefit assessment of corticosteroids in the management of croup. Drug Saf. Jan 1997;16(1):48-55. [Medline].

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Further Reading

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Keywords

croup, barking cough, laryngotracheitis, stridor, laryngotracheobronchitis, spasmodic croup, influenza A, inspiratory stridor, parainfluenza virus 1, parainfluenza virus II, parainfluenza virus III, steeple sign, upper respiratory infection, Westley score, Westley scale, hypoxemia, laryngismus stridulus, cyanosis, adenovirus, respiratory syncytial virus, measles, coxsackievirus, rhinovirus, echovirus, reovirus, metapneumovirus, respiratory distress, influenza,

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Contributor Information and Disclosures

Author

Antonio Muñiz, MD, Associate Professor of Emergency Medicine and Pediatrics, University of Texas Medical School at Houston; Medical Director of the Pediatric Emergency Department, Children's Memorial Hermann Hospital
Antonio Muñiz, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Pediatrics, American College of Emergency Physicians, American Heart Association, American Medical Association, Society for Academic Emergency Medicine, and Southern Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Rona E Molodow, MD, Associate Clinical Professor, Department of Pediatrics, Olive View-University of California Los Angeles Medical Center
Rona E Molodow, MD is a member of the following medical societies: American Academy of Pediatrics and American Professional Society on the Abuse of Children
Disclosure: Nothing to disclose.

Germaine L Defendi, MD, MS, FAAP, Associate Clinical Professor of Pediatrics, Department of Pediatrics, Olive View-University of California Los Angeles Medical Center
Germaine L Defendi, MD, MS, FAAP is a member of the following medical societies: Ambulatory Pediatric Association and American Academy of Pediatrics
Disclosure: Nothing to disclose.

Medical Editor

David Jaimovich, MD, Chief Medical Officer, Joint Commission International and Joint Commission Resources
David Jaimovich, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation

Managing Editor

Joseph Domachowske, MD, Professor of Pediatrics, Microbiology and Immunology, Department of Pediatrics, Division of Infectious Diseases, State University of New York-Upstate Medical University
Joseph Domachowske, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Society for Microbiology, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and Phi Beta Kappa
Disclosure: Nothing to disclose.

CME Editor

Robert W Tolan Jr, MD, Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine
Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility
Disclosure: GlaxoSmithKline Honoraria Speaking and teaching; MedImmune Honoraria Consulting; MedImmune Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; Novartis Honoraria Speaking and teaching; sanofi pasteur Grant/research funds Unrestricted research grant; sanofi pasteur  Consulting; sanofi pasteur Honoraria Speaking and teaching; Tap Honoraria Speaking and teaching

Chief Editor

Russell W Steele, MD, Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine
Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association
Disclosure: None None None

 
 
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