Croup Treatment & Management

  • Author: Germaine L Defendi, MD, MS, FAAP; Chief Editor: Russell W Steele, MD  more...
Updated: Jun 17, 2015

Approach Considerations

Urgent care or emergency department treatment of croup depends on the degree of respiratory distress. In mild croup, a child may present with only a croupy cough and may require nothing more than parental reassurance, given alertness, baseline minimal respiratory distress, proper oxygenation, and stable fluid status. The caregivers may only need education regarding the course of the disease and supportive homecare guidelines.

However, any infant/child who presents with significant respiratory distress/complaints with stridor at rest must have a thorough clinical evaluation to ensure the patency of the airway and maintenance of effective oxygenation and ventilation. Keep young children as comfortable as possible, allowing him or her to remain in a parent's arms and avoiding unnecessary painful interventions that may cause agitation, respiratory distress, and lead to increased oxygen requirements. Persistent crying increases oxygen demands, and respiratory muscle fatigue can worsen the obstruction.

Concurrently, careful monitoring of the heart rate (for tachycardia), respiratory rate (for tachypnea), respiratory mechanics (for sternal wall retractions), and pulse oximetry (for hypoxia) are important. Assessment of the patient’s hydration status, given the risk of increased insensible losses from fever and tachypnea, along with a history of decreased oral intake, is also imperative.

Infants and children with severe respiratory distress or compromise may require 100% oxygenation with ventilation support, initially with a bag-valve-mask device. If the airway and breathing require further stabilization due to increasing respiratory fatigue and hence, worsening hypercarbia, (as evident by ABG) 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. Once airway stabilization is achieved, these patients are transferred for their ongoing care to a pediatric intensive care unit.

The current cornerstones of treatment in the urgent care clinics or emergency departments are corticosteroids and nebulized epinephrine; steroids have proven beneficial in severe, moderate, and even mild croup.[23] In the straightforward cases of croup, antibiotics are not prescribed, as the primary cause is viral. Lack of improvement or worsening of symptoms can be due to a secondary bacterial process, which would require the use of antimicrobials for treatment. Typically, these patients initially would have had moderate-to-severe croup scores, requiring inpatient care and observation.

Cool mist administration

Throughout the 19th and most of the 20th century, cool mist administration was the mainstay of treatment. Hospitals had "croup rooms" filled with cool 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.

However, despite its continued widespread use, little evidence supports the clinical efficacy of cool mist or humidification therapy. 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.[24] Mist tents, used in the hospital setting, can disperse fungus and molds if not properly cleaned.

More importantly, the tents separate the child from the parent by creating a “plastic barrier," causing anxiety and agitation, potentially worsening the child’s symptoms and hindering ongoing clinical assessment.[25, 26, 27] In the home, vaporizers (heated humidification) producing hot steam to moisten the air should not be used because of the risk of scalding or burns.[28]



Corticosteroids are beneficial due to their anti-inflammatory action, whereby laryngeal mucosal edema is decreased. They also decrease the need for salvage nebulized epinephrine. Corticosteroids may be warranted even in those children who present with mild symptoms. Treatment of croup with corticosteroids has not shown significant adverse effects; however despite the low risk, their use should be carefully evaluated for children with diabetes, an underlying immunocompromised state, or those recently exposed to or diagnosed with varicella or tuberculosis, due to the potential risk of exacerbating the systemic disease process.[29, 30, 31, 32, 33, 28]

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 the onset of illness. The long half-life of dexamethasone (36-54 h) often allows for a single injection or dose to cover the usual symptom duration. Studies have shown that dexamethasone dosed at 0.15 mg/kg is as effective as 0.3 mg/kg or 0.6 mg/kg (with a maximum daily dose of 10 mg) in relieving the symptoms of mild-to-moderate croup. Despite this knowledge, clinicians still tend to favor the dose of 0.6 mg/kg for initial treatment of croup. This dosage, in fact, is more effective for patients diagnosed with severe croup and remains the optimal amount for safety, benefit and cost-effectiveness.[34, 35]

Dexamethasone has shown the same efficacy if administered intravenously, intramuscularly, or orally.[36] The route of administration is patient-dependent as based on the patient’s age, ability to tolerate orals, an severity of presenting illness. The use of inhaled corticosteroids (budesonide) with systemic treatment does not provide additional benefit.[37]

Patients given a single oral dose of prednisolone (1 mg/kg) were found to have made more return visits than did those who received a single oral dose of dexamethasone (0.15 mg/kg).[38] This is due to the lesser potency to reduce inflammation and shortened half-life of prednisolone (18-36 h) when compared with dexamethasone (36-54 h).



Nebulized racemic epinephrine is a 1:1 mixture of dextro (D) isomers and levo (L) isomers of epinephrine with the L form (L-epinephrine) as the active component. Its use is typically reserved for patients in the hospital setting with moderate-to-severe respiratory distress. Epinephrine 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.[23] Epinephrine’s beta2-adrenergic activity leads to bronchial smooth muscle relaxation and bronchodilation. Its effectiveness is immediate with evidence of therapeutic benefit within the first 30 minutes and then, lasts from 90-120 minutes (1.5-2 h).

Patients who receive nebulized racemic epinephrine in the emergency department should be observed for at least 3 hours post last treatment because of concerns for a return of bronchospasm, worsening respiratory distress, and/or persistent tachycardia. Patients can be discharged home only if they demonstrate healthy color, good air entry, baseline consciousness, and no stridor at rest and have received a dose of corticosteroids.



Heliox is a gas containing a mixture of helium and oxygen (with not less than 20% oxygen). Delivery to the patient is via nasal cannula, face mask, or hood. It has low viscosity and low specific gravity, which allows for greater laminar airflow through the respiratory tract. Helium decreases the force necessary and facilitates the movement of oxygen through the airways and decreases the mechanical work of respiratory muscles. This clinical response reduces respiratory distress.[39, 40]

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.[41, 42, 43] Heliox has also been shown to improve symptoms in very severe croup that failed to improve with racemic epinephrine. Currently, the evidence is not sufficient to establish the beneficial effect of heliox in pediatric croup management.[44]

Contributor Information and Disclosures

Germaine L Defendi, MD, MS, FAAP Associate Clinical Professor, Department of Pediatrics, Olive View-UCLA Medical Center

Germaine L Defendi, MD, MS, FAAP is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.


Antonio Muñiz, MD 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, Southern Medical Association

Disclosure: Nothing to disclose.

Rona E Molodow, MD, JD Clinical Professor, Department of Pediatrics, Olive View-UCLA Medical Center

Rona E Molodow, MD, JD is a member of the following medical societies: American Academy of Pediatrics, American Professional Society on the Abuse of Children

Disclosure: Nothing to disclose.

Chief Editor

Russell W Steele, MD Clinical Professor, Tulane University School of Medicine; Staff Physician, Ochsner Clinic Foundation

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, Southern Medical Association

Disclosure: Nothing to disclose.


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.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

  1. Benson BE, Baredes S, Schwartz RA. Stridor. Medscape Reference by WebMD. January 26, 2010. [Full Text].

  2. American Academy of Pediatrics. Parainfluenza Viral Infections. Pickering LK, ed. Red Book: 2003 Report of the Committee on Infectious Diseases. 26th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2003. 479-81.

  3. Sung JY, Lee HJ, Eun BW, et al. Role of human coronavirus NL63 in hospitalized children with croup. Pediatr Infect Dis J. 2010 Sep. 29(9):822-6. [Medline].

  4. 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. 2004 Jan 29. 350(5):443-50. [Medline]. [Full Text].

  5. Worrall G. Croup. Can Fam Physician. 2008 Apr. 54(4):573-4. [Medline].

  6. Bjornson C, Russell KF, Vandermeer B, et al. Nebulized epinephrine for croup in children. Cochrane Database Syst Rev. 2011 Feb 16. CD006619. [Medline].

  7. Segal AO, Crighton EJ, Moineddin R, Mamdani M, Upshur RE. Croup hospitalizations in Ontario: a 14-year time-series analysis. Pediatrics. 2005 Jul. 116(1):51-5. [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. 1998 Sep. 27(3):458-62. [Medline].

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

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

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

  12. Sobol SE, Zapata S. Epiglottitis and croup. Otolaryngol Clin North Am. 2008 Jun. 41(3):551-66, ix. [Medline].

  13. Hoa M, Kingsley EL, Coticchia JM. Correlating the clinical course of recurrent croup with endoscopic findings: a retrospective observational study. Ann Otol Rhinol Laryngol. 2008 Jun. 117(6):464-9. [Medline].

  14. Johnson D. Croup. Clin Evid (Online). 2009 Mar 10. 2009:[Medline]. [Full Text].

  15. [Guideline] Alberta Medical Association. Guideline for the diagnosis and management of croup. Alberta Clinical Practice Guidelines 2005 Update. [Full Text].

  16. Guidelines for the diagnosis and management of croup. 2008 update. Alberta Medical Association. 2011.

  17. Chun R, Preciado DA, Zalzal GH, Shah RK. Utility of bronchoscopy for recurrent croup. Ann Otol Rhinol Laryngol. 2009 Jul. 118(7):495-9. [Medline].

  18. Delany DR, Johnston DR. Role of direct laryngoscopy and bronchoscopy in recurrent croup. Otolaryngol Head Neck Surg. 2015 Jan. 152 (1):159-64. [Medline].

  19. Wald EL. Croup: common syndromes and therapy. Pediatr Ann. 2010 Jan. 39(1):15-21. [Medline].

  20. Swingler GH, Zwarenstein M. Chest radiograph in acute respiratory infections. Cochrane Database Syst Rev. 2008. (1):CD001268. [Medline].

  21. Huang CC, Shih SL. Images in clinical medicine. Steeple sign of croup. N Engl J Med. 2012 Jul 5. 367(1):66. [Medline].

  22. Kirks DR. The respiratory system. Practical Pediatric Imaging: Diagnostic Radiology of Infants and Children. 3rd ed. Philadelphia, Pa: Lippincott-Raven; 1998. 651-53.

  23. Bjornson C, Russell KF, Vandermeer B, Durec T, Klassen TP, Johnson DW. Nebulized epinephrine for croup in children. Cochrane Database Syst Rev. 2011 Feb 16. CD006619. [Medline].

  24. 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: a randomized controlled trial. JAMA. 2006 Mar 15. 295(11):1274-80. [Medline].

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

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

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

  28. Zoorob R, Sidani M, Murray J. Croup: an overview. Am Fam Physician. 2011 May 1. 83(9):1067-73. [Medline].

  29. 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. 2004 Sep 23. 351(13):1306-13. [Medline].

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

  31. 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. 2007 Mar. 71(3):473-7. [Medline].

  32. 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. 2007 Feb. 19(1):51-8. [Medline].

  33. Russell K, Wiebe N, Saenz A, et al. Glucocorticoids for croup. Cochrane Database Syst Rev. 2004. CD001955. [Medline].

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

  35. Russell KF, Liang Y, O'Gorman K, Johnson DW, Klassen TP. Glucocorticoids for croup. Cochrane Database Syst Rev. 2011. (1):CD001955. [Medline].

  36. 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. 2006 Aug. 22(8):541-4. [Medline].

  37. Geelhoed GC. Budesonide offers no advantage when added to oral dexamethasone in the treatment of croup. Pediatr Emerg Care. 2005 Jun. 21(6):359-62. [Medline].

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

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

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

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

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

  43. 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. 2001 Jun. 107(6):E96. [Medline].

  44. Vorwerk C, Coats T. Heliox for croup in children. Cochrane Database Syst Rev. 2010 Feb 17. CD006822. [Medline].

  45. Dobrovoljac M, Geelhoed GC. 27 years of croup: an update highlighting the effectiveness of 0.15 mg/kg of dexamethasone. Emerg Med Australas. 2009 Aug. 21(4):309-14. [Medline].

  46. Cruz CI, Patel D. Impacted Button-Battery Masquerading as Croup. J Emerg Med. 2013 Jan 30. [Medline].

  47. Elbuluk O, Shiba T, Shapiro NL. Laryngomalacia presenting as recurrent croup in an infant. Case Rep Otolaryngol. 2013. 2013:649203. [Medline]. [Full Text].

  48. Ibrahimov M, Yollu U, Akil F, Aydin F, Yener M. Laryngeal foreign body mimicking croup. J Craniofac Surg. 2013 Jan. 24(1):e7-8. [Medline].

Child with croup. Note the steeple or pencil sign of the proximal trachea evident on this anteroposterior film. Courtesy of Dr. Kelly Marshall, CHOA at Scottish Rite.
Steeple sign on radiograph.
Medscape Consult
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.