Emergency Department Evaluation
Children with croup are typically between the age of 6 months and 3 years, but croup can be seen until adulthood. The illness typically starts with upper respiratory tract symptoms such as rhinorrhea and low-grade fever. Inspiratory stridor, hoarseness, and the classic barky “seal-like” cough appear abruptly within 12 to 48 hours of illness, most often in the overnight hours, for unknown reasons. Most symptoms tend to improve during the daytime period. The symptoms typically resolve progressively within 2 to 5 days.30
The ED evaluation should focus on eliminating other life-threatening causes of stridor. Confirm the absence of drooling, nontoxic appearance or dysphagia, no neck pain or limitations of movements, and no history of choking on food or small object. Ask questions regarding immunization status. Review past medical history for previous episodes of croup, airway hyperreactivity, previous endotracheal intubation, or subglottic manipulations, as these can lead to subglottic stenosis and precipitate upper airway obstruction.
Vitals signs (heart rate, respiratory rate, temperature, oxygen saturation) should be obtained on all children with suspected croup; however, symptoms may worsen if the child is anxious or agitated. Observation is a key tool. The urgency and aggressiveness of interventions are driven by the appearance, breathing, and circulation status of the child. Moderate tachypnea and tachycardia may be seen as well as varying degrees of respiratory distress. Stridor may be audible at rest or on auscultation and may be inspiratory, expiratory, or biphasic depending on the severity of symptoms.
Scoring systems have been developed to attempt to grade the severity of viral croup. Although useful in clinical research, there is no consensus as to whether they improve clinical practice. The most widely used score is the Westley Croup score. Developed in 1978 by Westley et al,31 its validity and reliability has been well established.32 It consists of a maximum of 17 points, depending on the presence or absence of 5 clinical characteristics: (1) level of consciousness, (2) cyanosis, (3) stridor, (4) air entry, and (5) retractions. (See Table 2.)
The Alberta Clinical Practice Guideline Working Group categorizes croup according to its clinical signs into 4 categories that are more useful in a clinical setting.6 These categories include: (1) mild, (2) moderate, (3) severe, and (4) impending respiratory failure. (See Table 3.) According to these categories, over 85% of children presenting to EDs have mild croup, and < 1% fall into the severe croup category.33