25/11/2015

Croup: Clinical features, evaluation, and diagnosis

OfficialreprintfromUpToDate
www.uptodate.com2015UpToDate

Croup:Clinicalfeatures,evaluation,anddiagnosis
Author
CharlesRWoods,MD,MS

SectionEditors
SheldonLKaplan,MD
GregoryRedding,MD

DeputyEditor
CarrieArmsby,MD,MPH

Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:Oct2015.|Thistopiclastupdated:Feb18,2015.
INTRODUCTIONCroupisarespiratoryillnesscharacterizedbyinspiratorystridor,cough,and
hoarseness.Thesesymptomsresultfrominflammationinthelarynxandsubglotticairway.Abarkingcough
isthehallmarkofcroupamonginfantsandyoungchildren,whereashoarsenesspredominatesinolder
childrenandadults.Althoughcroupusuallyisamildandselflimitedillness,significantupperairway
obstruction,respiratorydistress,and,rarely,death,canoccur.
Theclinicalfeatures,evaluation,anddiagnosisofcroupwillbediscussedhere.Themanagementofcroupis
discussedseparately.(See"Croup:Approachtomanagement"and"Croup:Pharmacologicandsupportive
interventions".)
DEFINITIONSThetermcrouphasbeenusedtodescribeavarietyofupperrespiratoryconditionsin
children,includinglaryngitis,laryngotracheitis,laryngotracheobronchitis,bacterialtracheitis,orspasmodic
croup[1].Thesetermsaredefinedbelow.Inthepast,thetermcroupalsohasbeenappliedtolaryngeal
diphtheria(diphtheriticormembranouscroup),whichisdiscussedseparately.(See"Epidemiologyand
pathophysiologyofdiphtheria"and"Clinicalmanifestations,diagnosisandtreatmentofdiphtheria".)
Throughoutthisreview,thetermcroupwillbeusedtorefertolaryngotracheitis.Laryngotracheobronchitis,
laryngotracheobronchopneumonitis,bacterialtracheitis,andspasmodiccrouparedesignatedspecificallyas
such.
Laryngitisreferstoinflammationlimitedtothelarynxandmanifestsitselfashoarseness[2].Itusually
occursinolderchildrenandadultsand,similartocroup,isfrequentlycausedbyaviralinfection.The
etiology,management,andevaluationofothercausesofhoarsenessarediscussedindetail
separately.(See"Hoarsenessinchildren:Etiologyandmanagement"and"Hoarsenessinchildren:
Evaluation".)
Laryngotracheitis(croup)referstoinflammationofthelarynxandtrachea[2].Althoughlowerairway
signsareabsent,thetypicalbarkingcoughwillbepresent.
Laryngotracheobronchitis(LTB)occurswheninflammationextendsintothebronchi,resultinginlower
airwaysigns(eg,wheezing,crackles,airtrapping,increasedtachypnea)andsometimesmoresevere
illnessthanlaryngotracheitisalone[2].Thistermcommonlyisusedinterchangeablywith
laryngotracheitis,andtheentitiesareoftenindistinctclinically.Furtherextensionofinflammationinto
thelowerairwaysresultsinlaryngotracheobronchopneumonitis,whichsometimescanbecomplicated
bybacterialsuperinfection.Bacterialsuperinfectioncanbemanifestaspneumonia,
bronchopneumonia,orbacterialtracheitis.
Bacterialtracheitis(alsocalledbacterialcroup)describesbacterialinfectionofthesubglottictrachea,
resultinginathick,purulentexudate,whichcausessymptomsofupperairwayobstruction(picture1).
Thebronchiandlungsaretypicallyinvolved,aswell(ie,bacterialtracheobronchitis).Bacterialtracheitis
mayoccurasacomplicationofviralrespiratoryinfections(usuallythosewhichmanifestthemselvesas
LTBorlaryngotracheobronchopneumonitis)orasaprimarybacterialinfection.(See"Bacterial
tracheitisinchildren:Clinicalfeaturesanddiagnosis".)
Spasmodiccroupischaracterizedbythesuddenonsetofinspiratorystridoratnight,shortduration

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(severalhours),andsuddencessation[2].Thisisofteninthesettingofamildupperrespiratory
infection,butwithoutfeverorinflammation.Astrikingfeatureofspasmodiccroupisitsrecurrentnature,
hencethealternatedescriptiveterm,"frequentlyrecurrentcroup".Becauseofsomeclinicaloverlap
withatopicdiseases,itissometimesreferredtoas"allergiccroup".
Weconsider"spasmodiccroup"tobedistinctfrom"atypicalcroup,"althoughthetermsaresometimes
usedinterchangeably.Atypicalcroupmaybedefinedasrecurrentepisodesofcrouplikesymptoms
occurringbeyondthetypicalagerangeofsixmonthstothreeyearsfor"viralcroup"orrecurrent
episodesthatdonotappeartobesimple"spasmodiccroup"[3].
ETIOLOGYCroupisusuallycausedbyviruses.Bacterialinfectionmayoccursecondarily,asdescribed
above.
Parainfluenzavirustype1isthemostcommoncauseofacutelaryngotracheitis,especiallythefalland
winterepidemics[46].Parainfluenzatype2sometimescausescroupoutbreaks,butusuallywithmilder
diseasethantype1.Parainfluenzatype3causessporadiccasesofcroupthatoftenaremoreseverethan
thoseduetotypes1and2.Inmulticentersurveillanceofchildren<5yearswhowerehospitalizedwith
febrileoracuterespiratoryillnesses,43percentofchildrenwithconfirmedparainfluenzainfectionwere
diagnosedwithcroup[7].Croupwasthemostcommondischargediagnosisforchildrenwithconfirmed
parainfluenza1(42percent)andparainfluenza2(48percent)infectionsbutwasonlydiagnosedin11
percentofchildrenwithconfirmedparainfluenza3infections.
Themicrobiology,pathogenesis,andepidemiologyofparainfluenzainfectionsarediscussedseparately.
(See"Parainfluenzavirusesinchildren".)
Anumberofothervirusesthattypicallycauselowerrespiratorytractdiseasealsocancauseupper
respiratorytractsymptoms,includingcroup,asdescribedbelow[6].
Respiratorysyncytialvirus(RSV)andadenovirusesarerelativelyfrequentcausesofcroup.The
laryngotrachealcomponentofdiseaseisusuallylesssignificantthanthatofthelowerairways.(See
"Respiratorysyncytialvirusinfection:Clinicalfeaturesanddiagnosis",sectionon'Clinical
manifestations'and"Epidemiologyandclinicalmanifestationsofadenovirusinfection",sectionon
'Clinicalpresentation'.)
HumancoronavirusNL63(HCoVNL63),firstidentifiedin2004,hasbeenimplicatedincroupandother
respiratoryillnesses[810].TheprevalenceofHCoVNL63variesgeographically.(See
"Coronaviruses",sectionon'Respiratory'.)
Measlesisanimportantcauseofcroupinareaswheremeaslesremainsprevalent.(See"Clinical
manifestationsanddiagnosisofmeasles".)
Influenzavirusisarelativelyuncommoncauseofcroup.However,childrenhospitalizedwithinfluenzal
crouptendtohavelongerhospitalizationandgreaterriskofreadmissionforrelapseoflaryngeal
symptomsthanthosewithparainfluenzalcroup.(See"Seasonalinfluenzainchildren:Clinicalfeatures
anddiagnosis".)
Rhinoviruses,enteroviruses(especiallyCoxsackietypesA9,B4,andB5,andechovirustypes4,11,
and21),andherpessimplexvirusareoccasionalcausesofsporadiccasesofcroupthatareusually
mild.(Seeappropriatetopicreviews).
MetapneumovirusescauseprimarilylowerrespiratorytractdiseasesimilartoRSV,butupper
respiratorytractsymptomshavebeendescribedinsomepatients[11].(See"Humanmetapneumovirus
infections".)
Croupalsomaybecausedbybacteria.Mycoplasmapneumoniaehasbeenassociatedwithmildcasesof
croup.Inaddition,secondarybacterialinfectionmayoccurinchildrenwithlaryngotracheitis,
laryngotracheobronchitis,orlaryngotracheobronchopneumonitis.Themostcommonsecondarybacterial

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pathogensincludeStaphylococcusaureus,Streptococcuspyogenes,andS.pneumoniae[1].
EPIDEMIOLOGYCroupmostcommonlyoccursinchildren6to36monthsofage.Itisseeninyounger
infants(asyoungasthreemonths)andinpreschoolchildren,butitisrarebeyondagesixyears[1,12].Itis
morecommoninboys,withamale:femaleratioofabout1.4:1[1,1214].
Familyhistoryofcroupisariskfactorforcroupandrecurrentcroup.Inacasecontrolstudy,childrenwhose
parentshadahistoryofcroupwere3.2timesaslikelytohaveanepisodeofcroupand4.1timesaslikelyto
haverecurrentcroupaschildrenwithnoparentalhistoryofcroup[15].Parentalsmoking,awellrecognized
riskfactorforrespiratorytractinfectionsinchildren,doesnotappeartoincreasetheriskofcroup[15,16].
(See"Secondhandsmokeexposure:Effectsinchildren",sectionon'Respiratorysymptomsandillness'.)
Mostcasesofcroupoccurinthefallorearlywinter,withthemajorincidencepeakscoincidingwith
parainfluenzatype1activity(ofteninOctober)andminorpeaksoccurringduringperiodsofrespiratory
syncytialvirusorinfluenzavirusactivity.(See"Respiratorysyncytialvirusinfection:Clinicalfeaturesand
diagnosis",sectionon'Seasonality'and"Seasonalinfluenzainchildren:Clinicalfeaturesanddiagnosis",
sectionon'Influenzaactivity'.)
Emergencydepartment(ED)visitsforcrouparemostfrequentbetween10:00PMand4:00AM.However,
childrenseenforcroupbetweennoonand6:00PMaremorelikelytobeadmittedtothehospital[4,17].A
morningpeakbetween7:00AMand11:00AMinEDvisitsforcroupalsohasbeennoted[14].
Hospitaladmissionsforcrouphavedeclinedsteadilysincethelate1970s.Inananalysisofdatafromthe
NationalHospitalDischargeSurveysfrom1979through1997,theestimatednumberofannual
hospitalizationsforcroupdecreasedfrom48,900to33,500[5].Estimatesofannualhospitalizationratesfor
croupcausedbyparainfluenzavirustypes1to3from1994to1997were0.4to1.1per1000childrenfor
childrenyoungerthanoneyearand0.24to0.61per1000childrenforchildrenbetweenoneandfouryears.
Approximatelyonehalfofthesehospitalizationswereattributedtoparainfluenzatype1.
Inasixyear(1999to2005)populationbasedstudy,5.6percentofchildrenwithadiagnosisofcroupinthe
EDrequiredhospitaladmission.Amongthosedischargedhome,4.4percenthadarepeatEDvisitwithin48
hours[14].
PATHOGENESISThevirusesthatcausecrouptypicallyinfectthenasalandpharyngealmucosal
epitheliainitiallyandthenspreadlocallyalongtherespiratoryepitheliumtothelarynxandtrachea.
Theanatomichallmarkofcroupisnarrowingofthetracheainthesubglotticregion.Thisportionofthe
tracheaissurroundedbyafirmcartilaginousringsuchthatanyinflammationresultsinnarrowingofthe
airway.Inadditiontothis"fixed"obstruction,dynamicobstructionoftheextrathoracictracheabelowthe
cartilaginousringmayoccurwhenthechildstruggles,cries,orbecomesagitated.Thedynamicobstruction
occursasaresultofthecombinationofhighnegativepressureinthedistalextrathoracictracheaandthe
floppinessofthetrachealwallinchildren.
Laryngoscopicevaluationofpatientsduringacutelaryngotracheitisshowsrednessandswellingofthelateral
wallsofthetrachea.Inseverecases,thesubglotticairwaymaybereducedtoadiameterof1to2mm.In
additiontomucosaledemaandswelling,fibrinousexudatesand,occasionally,pseudomembranescanbuild
uponthetrachealsurfacesandcontributetoairwaynarrowing.Thevocalcordsandlaryngealtissuesalso
canbecomeswollen,andcordmobilitymaybeimpaired[2,1820].Autopsystudiesinchildrenwith
laryngotracheitisshowinfiltrationofhistiocytes,lymphocytes,plasmacells,andneutrophilsintoedematous
laminapropria,submucosa,andadventitiaofthelarynxandtrachea[2123].
Inspasmodiccroup,findingsondirectlaryngoscopydemonstratenoninflammatoryedema[18].This
suggeststhatthereisnodirectviralinvolvementofthetrachealepithelium.
Patientswithbacterialtracheitishaveabacterialsuperinfectionthatcausesthickpustodevelopwithinthe
lumenofthesubglottictrachea(picture1).Ulcerations,pseudomembranes,andmicroabscessesofthe
mucosalsurfaceoccur.Thesupraglottictissuesusuallyarenormal.(See"Bacterialtracheitisinchildren:

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Clinicalfeaturesanddiagnosis",sectionon'Pathogenesisandpathology'.)
HostfactorsOnlyasmallfractionofchildrenwithparainfluenzavirusinfectionsdevelopovertcroup.
Thissuggeststhathost(orgenetic)factorsplayaroleinthepathogenesis.Hostfactorsthatmaycontribute
tothedevelopmentofcroupincludefunctionaloranatomicsusceptibilitytoupperairwaynarrowing,
variationsinimmuneresponse,andpredispositiontoatopy[14].
Underlyinghostfactorsthatpredisposetoclinicallysignificantnarrowingoftheupperairwayinclude:
Anatomicnarrowingoftheairway,frometiologiessuchassubglotticstenosis,laryngealwebs,
tracheomalacia,laryngomalacia,laryngealclefts,orsubglottichemangiomas[3]
Hyperactiveairways,perhapsaggravatedbyatopyorgastroesophagealreflux,assuggestedinsome
childrenwithspasmodiccrouporrecurrentcroup[2426]
Acquiredairwaynarrowingfromrespiratorytractpapillomas(humanpapillomavirus),postintubation
scarring,orirritationfromaspirationsassociatedwithgastroesophagealreflux
Thepotentialroleoftheimmuneresponsewasdemonstratedinstudiesthatdemonstratedincreased
productionofparainfluenzavirusspecificIgEandincreasedlymphoproliferativeresponsetoparainfluenza
virusantigen,anddiminishedhistamineinducedsuppressionoflymphocytetransformationresponsesto
parainfluenzavirusinchildrenwithparainfluenzavirusandcroupcomparedwiththosewithparainfluenza
viruswithoutcroup[27,28].
CLINICALPRESENTATIONTheclinicalpresentationofcroupdependsuponthespecificcroup
syndromeandthedegreeofupperairwayobstruction.Althoughcroupusuallyisamildandselflimited
illness,specificfeaturesofthehistoryandphysicalexaminationidentifychildrenwhoareseriouslyillorat
riskforrapidprogressionofdisease.(See'Evaluation'below.)
LaryngotracheitisLaryngotracheitistypicallyoccursinchildrenthreemonthstothreeyearsofage[2].
Theonsetofsymptomsisusuallygradual,beginningwithnasalirritation,congestion,andcoryza.Symptoms
generallyprogressover12to48hourstoincludefever,hoarseness,barkingcough,andstridor.Respiratory
distressincreasesasupperairwayobstructionbecomesmoresevere.Rapidprogressionorsignsoflower
airwayinvolvementsuggestsamoreseriousillness.Coughusuallyresolveswithinthreedays[29]other
symptomsmaypersistforsevendayswithagradualreturntonormal[2].Deviationsfromthisexpected
courseshouldpromptconsiderationofdiagnosesotherthanlaryngotracheitis.(See'Differentialdiagnosis'
below.)
Thedegreeofupperairwayobstructionisevidentonphysicalexamination,asdescribedbelow.Inmild
cases,thechildishoarseandhasnasalcongestion.Thereisminimal,ifany,pharyngitis.Asairway
obstructionprogresses,stridordevelops,andtheremaybemildtachypneawithaprolongedinspiratory
phase.Thepresenceofstridorisakeyelementintheassessmentofseverity.Stridoratrestisasignof
significantupperairwayobstruction.Asupperairwayobstructionprogresses,thechildmaybecomerestless
oranxious.(See'Severityassessment'below.)
Whenairwayobstructionbecomessevere,suprasternal,subcostal,andintercostalretractionsmaybeseen.
Breathsoundscanbediminished.Agitation,whichgenerallyisaccompaniedbyincreasedinspiratoryeffort,
exacerbatesthesubglotticnarrowingbycreatingnegativepressureintheairway.Thiscanleadtofurther
respiratorydistressandagitation.
Hypoxiaandcyanosiscandevelop,ascanrespiratoryfatiguefromsustainedincreasedrespiratoryeffort.
Highrespiratoryratesalsotendtocorrelatewiththepresenceofhypoxia.Withoutintervention,thehypoxia
orfatiguecansometimesleadtodeath.
SpasmodiccroupSpasmodiccroupalsooccursinchildrenthreemonthstothreeyearsofage[2].In
contrasttolaryngotracheitis,spasmodiccroupalwaysoccursatnightthedurationofsymptomsisshort,
oftenwithsymptomssubsidingbythetimeofpresentationformedicalattentionandtheonsetandcessation

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ofsymptomsareabrupt.Feveristypicallyabsent,butmildupperrespiratorytractsymptoms(eg,coryza)
maybepresent.Episodescanrecurwithinthesamenightandfortwotofoursuccessiveevenings[30].A
strikingfeatureofspasmodiccroupisitsrecurrentnature,hencethealternatedescriptiveterm,"frequently
recurrentcroup".Theremaybeafamilialpredispositiontospasmodiccroup,anditmaybemorecommonin
childrenwithafamilyhistoryofallergies[24].
Earlyintheclinicalcourse,spasmodiccroupmaybedifficulttodistinguishfromlaryngotracheitis.Asthe
courseprogresses,theepisodicnatureofspasmodiccroupandrelativewellnessofthechildbetween
attacksdifferentiateitfromclassiccroup,inwhichthesymptomsarecontinuous.
Althoughtheinitialpresentationcanbedramatic,theclinicalcourseisusuallybenign.Symptomsarealmost
alwaysrelievedbycomfortingtheanxiouschildandadministeringhumidifiedair.Rarely,childrenmay
benefitfromtreatmentwithcorticosteroidsand/ornebulizedepinephrine[31].Othertherapiesgenerallyare
notindicated.(See"Croup:Approachtomanagement".)
BacterialtracheitisBacterialtracheitismaypresentasaprimaryorsecondaryinfection[32].Inprimary
infection,thereisacuteonsetofsymptomsofupperairwayobstructionwithfeverandtoxicappearance.In
secondaryinfection,thereismarkedworseningduringtheclinicalcourseofvirallaryngotracheitis,withhigh
fever,toxicappearance,andincreasingrespiratorydistresssecondarytotrachealobstructionfrompurulent
secretions.Inbothofthesepresentations,signsoflowerairwaydisease,suchascracklesandwheezes,
maybepresent.However,theupperairwayobstructionisthemoreclinicallysignificantmanifestation[2,33].
(See"Bacterialtracheitisinchildren:Clinicalfeaturesanddiagnosis",sectionon'Clinicalfeatures'.)
RecurrentcroupAchildwhohashadrecurrentepisodesofclassicviralcroupmayhaveanunderlying
conditionthatpredisposeshimorhertodevelopclinicallysignificantnarrowingoftheupperairway.
Recurrentepisodesofcrouplikesymptomsoccurringoutsidethetypicalagerangefor"viralcroup"(ie,six
monthstothreeyears)andrecurrentepisodesthatdonotappeartobesimple"spasmodiccroup"should
raisesuspicionforlargeairwaylesions,gastroesophagealrefluxoreosinophilicesophagitis,oratopic
conditions[3,3438].
Childrenwithrecurrentcroupmayrequireradiographicevaluationorbronchoscopy.(See'Hostfactors'
aboveand'Imaging'below.)
EVALUATION
OverviewTheevaluationofchildrenwithsuspectedcrouphasseveralobjectives,includingprompt
identificationofpatientswithsignificantupperairwayobstructionoratriskforrapidprogressionofupper
airwayobstruction.Inaddition,therearesomeconditionswithpresentationssimilartothatofcroupthat
requirespecificevaluationsand/orinterventionsthesetoomustbepromptlyidentified.(See'Differential
diagnosis'below.)
Duringtheevaluation,effortsshouldbemadetomakethechildascomfortableaspossible.Theincreased
inspiratoryeffortthataccompaniesanxietyandfearinyoungchildrencanexacerbatesubglotticnarrowing,
furtherdiminishingairexchangeandoxygenation.(See'Pathogenesis'above.)
RapidassessmentandinitialmanagementRapidassessmentofgeneralappearance(includingthe
presenceofstridoratrest),vitalsigns,pulseoximetry,airwaystability,andmentalstatusisnecessaryto
identifychildrenwithsevererespiratorydistressand/orimpendingrespiratoryfailure.(See"Croup:Approach
tomanagement",sectionon'Respiratorycare'.)
Endotrachealintubationisrequiredinlessthan1percentofchildrenwithcroupwhoareseeninthe
emergencydepartment.However,theneedforendotrachealintubationshouldbeanticipatedinchildrenwith
progressiverespiratoryfailuresothatitcanbeperformedinascontrolledasettingaspossible.Respiratory
failureisheraldedbythefollowingsigns[1,39,40]:
Fatigueandlistlessness
Markedretractions(althoughretractionsmaydecreasewithincreasedobstructionanddecreasedair

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entry)
Decreasedorabsentbreathsounds
Depressedlevelofconsciousness
Tachycardiaoutofproportiontofever
Cyanosisorpallor

Atrachealtubethatis0.5to1mmsmallerthanwouldtypicallybeusedmayberequired.(See"Emergency
endotrachealintubationinchildren",sectionon'Endotrachealtube'.)
Inadditiontoestablishmentofanairway,childrenwhohavesevererespiratorydistressrequireimmediate
pharmacologictreatment,includingadministrationofnebulizedepinephrineandsystemicornebulized
corticosteroids.(See"Croup:Approachtomanagement",sectionon'Moderatetoseverecroup'.)
Oncecontroloftheairwayisestablishedandpharmacologictreatment,ifnecessary,isunderway,the
remainderoftheevaluationcanproceed.
HistoryThehistoryshouldincludeadescriptionoftheonset,duration,andprogressionofsymptoms.
Factorsthatareassociatedwithincreasedseverityofillnessinclude:
Suddenonsetofsymptoms
Rapidlyprogressingsymptoms(ie,symptomsofupperairwayobstructionafterfewerthan12hoursof
illness)
Previousepisodesofcroup
Underlyingabnormalityoftheupperairway
Medicalconditionsthatpredisposetorespiratoryfailure(eg,neuromusculardisorders)
Aspectsofthehistorythatarehelpfulindistinguishingcroupfromothercausesofacuteupperairway
obstructioninclude[1,41]:
FeverTheabsenceoffeverfromonsetofsymptomstothetimeofpresentationissuggestiveof
spasmodiccrouporanoninfectiousetiology(eg,foreignbodyaspirationoringestion,acute
angioneuroticedema).
HoarsenessandbarkingcoughHoarsenessandbarkingcough,characteristicfindingsincroup,are
typicallyabsentinchildrenwithacuteepiglottitis,foreignbodyaspiration,andangioneuroticedema.
DifficultyswallowingDifficultyswallowingmayoccurinacuteepiglottitisandforeignbodyaspiration.
Alargeingestedforeignbodymaylodgeintheupperesophagus,whereitdistortsandnarrowsthe
uppertrachea,thusmimickingthecroupsyndrome(includingbarkingcoughandinspiratorystridor).
DroolingDroolingmayoccurinchildrenwithperitonsillarorretropharyngealabscesses,
retropharyngealcellulitis,andepiglottitis.Inanobservationalstudy,droolingwaspresentin
approximately80percentofchildrenwithepiglottitis,butonly10percentofthosewithcroup[41].
ThroatpainComplaintsofdysphagiaandsorethroataremorecommoninchildrenwithepiglottitis
thancroup(approximately60to70percentversus<10percent)[41].
Thedifferentialdiagnosisofcroupisdiscussedingreaterdetailbelow.(See'Differentialdiagnosis'below.)
ExaminationTheobjectivesoftheexaminationofthechildwithcroupincludeassessmentofseverityof
upperairwayobstructionandexclusionofotherinfectiousandnoninfectiouscausesofacuteupperairway
obstruction,bothofwhicharenecessaryinmakingmanagementdecisions.
Theinitialexaminationoftencanbeaccomplishedbyobservingthechildinacomfortablepositionwiththe
caretaker.Everyeffortshouldbemadetomeasurethechild'sweightandvitalsigns.
Aspectsoftheexaminationthatarehelpfulinassessingthedegreeofupperairwayobstructionandseverity
ofillnessinclude:

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OverallappearanceIsthechildcomfortableandinteractive,anxiousandquiet,orobtunded?Isthere
stridoratrest?Stridoratrestisasignofsignificantupperairwayobstruction.Childrenwithsignificant
upperairwayobstructionmayprefertositupandleanforwardina"sniffing"position(neckismildly
flexed,andheadismildlyextended).Thispositiontendstoimprovethepatencyoftheupperairway.
QualityofthevoiceDoesthechildhaveahoarseordiminishedcry?Isthevoicemuffled?Amuffled
"hotpotato"voiceissuggestiveofepiglottitis,retropharyngealabscess,orperitonsillarabscess.
DegreeofrespiratorydistressSignsofrespiratorydistressincludetachypnea,hypoxemia,and
increasedworkofbreathing(intercostal,subcostal,orsuprasternalretractionsnasalflaringgrunting
useofaccessorymuscles)
TidalvolumeDoesthereappeartobegoodchestexpansionwithinspiration,indicatingadequateair
entry?
LungexaminationArethereabnormalrespiratorysoundsduringinspirationorexpiration?Inspiratory
stridorindicatesupperairwayobstruction,whereasexpiratorywheezingisasignoflowerairway
obstruction.Ifthereisstridor,isitpresentatrestoronlywithagitation?Asdiscussedabove,stridorat
restisasignofsignificantupperairwayobstruction.Stridorwillbemoreobviousonauscultation,since
theinspiratorynoiseistransmittedthroughthechest.Thepresenceofcrackles(rales)alsosuggests
lowerrespiratorytractinvolvement(eg,laryngotracheobronchitis,laryngotracheobronchopneumonitis,
orbacterialtracheitis).
AssessmentofhydrationstatusDecreasedoralintakeandincreasedinsensiblelossesfromfever
andtachypneamayresultindehydration.(See"Clinicalassessmentanddiagnosisofhypovolemia
(dehydration)inchildren".)
Theseaspectsoftheexaminationareoftenusedinclinicalscoringsystemstoevaluatetheseverityof
illnessand/orinmakingdecisionsregardingtheneedforhospitaladmission.(See'Severityassessment'
belowand"Croup:Approachtomanagement",sectionon'Observationanddisposition'.)
Componentsoftheexaminationthatareusefulindistinguishingcroupfromothercausesofacuteupper
airwayobstructioninclude[39,41]:
PreferredpostureChildrenwithepiglottitisusuallyprefertositupinthe"tripod"or"sniffingposition"
(picture2AB).
Examinationoftheoropharynxforthefollowingsigns:
Cherryred,swollenepiglottis,suggestiveofepiglottitis
Pharyngitis,typicallyminimalinlaryngotracheitis,maybemorepronouncedinepiglottitisor
laryngitis
Excessivesalivation,suggestiveofacuteepiglottitis,peritonsillarabscess,orretropharyngeal
abscess
Diphtheriticmembrane
Tonsillarasymmetryordeviationoftheuvulasuggestiveofperitonsillarabscess
Midlineorunilateralswellingoftheposteriorpharyngealwallsuggestiveofretropharyngeal
abscess
Concernshavebeenraisedaboutsafetyofexaminingthepharynxinchildrenwithupperairway
obstructionandpossibleepiglottitissincesucheffortshavebeenreportedtoprecipitate
cardiorespiratoryarrest.However,intwoseries,eachincludingmorethan200patientswith
epiglottitisorviralcroup,directexaminationoftheoropharynxwasnotassociatedwithsudden
clinicaldeterioration[32,42].

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Examinationofthecervicallymphnodes,whichcanbeenlargedinpatientswithretropharyngealor
peritonsillarabscesses.
Otherphysicalfindingsmaybepresent,dependingontheparticularincitingvirus.Asanexample,rash,
conjunctivitis,exudativepharyngitis,andadenopathyaresuggestiveofadenovirusinfection.
Otitismedia(acuteorwitheffusion)maybepresentasaprimaryviralorsecondarybacterialprocess.
Thedifferentialdiagnosisofcroupisdiscussedingreaterdetailbelow.(See'Differentialdiagnosis'below.)
SeverityassessmentTheseverityofcroupisoftendeterminedbytheclinicalscoringsystems.
Althoughthereareanumberofvalidatedcroupscoringsystems,theWestleycroupscore[43]hasbeenthe
mostextensivelystudieditisdescribedbelow.Nomatterwhichsystemisusedtoassessseverity,the
presenceofchestwallretractionsandstridoratrestarethetwocriticalclinicalfeatures.
TheelementsoftheWestleycroupscoredescribekeyfeaturesofthephysicalexamination[43].Each
elementisassignedascore,asillustratedbelow:

Levelofconsciousness:Normal,includingsleep=0disoriented=5
Cyanosis:None=0withagitation=4atrest=5
Stridor:None=0withagitation=1atrest=2
Airentry:Normal=0decreased=1markedlydecreased=2
Retractions:None=0mild=1moderate=2severe=3

MildcroupisdefinedbyaWestleycroupscoreof2.Typically,thesechildrenhaveabarkingcoughand
hoarsecry,butnostridoratrest.Childrenwithmildcroupmayhavestridorwhenupsetorcrying(ie,
agitated)andeitherno,oronlymild,chestwall/subcostalretractions[1,39].
ModeratecroupisdefinedbyaWestleycroupscoreof3to7.Childrenwithmoderatecrouphavestridorat
rest,atleastmildretractions,andmayhaveothersymptomsorsignsofrespiratorydistress,butlittleorno
agitation[1,39].
SeverecroupisdefinedbyaWestleycroupscoreof8.Childrenwithseverecrouphavesignificantstridor
atrest,althoughstridormaydecreasewithworseningupperairwayobstructionanddecreasedairentry
[1,39].Retractionsaresevere(includingindrawingofthesternum)andthechildmayappearanxious,
agitated,orfatigued.Promptrecognitionandtreatmentofchildrenwithseverecroupareparamount.
Imaging
IndicationsRadiographicconfirmationofacutelaryngotracheitisisnotrequiredinthevastmajorityof
childrenwithcroup.Radiographicevaluationofthechestand/oruppertracheaisindicatedifthediagnosisis
inquestion,thecourseisatypical,aninhaledorswallowedforeignbodyissuspected(althoughthemajority
arenotradioopaque),croupisrecurrent,and/orthereisafailuretorespondasexpectedtotherapeutic
interventions.(See'Differentialdiagnosis'belowand"Croup:Approachtomanagement".)
FindingsInchildrenwithcroup,aposterioranteriorchestradiographdemonstratessubglottic
narrowing,commonlycalledthe"steeplesign"(image1).Thelateralviewmaydemonstrateoverdistentionof
thehypopharynxduringinspiration[44]andsubglottichaziness(image2).Theepiglottisshouldhavea
normalappearance.
Incontrast,thelateralradiographinvirtuallyallchildrenwithepiglottitisdemonstratesswellingofthe
epiglottis,sometimescalledthe"thumbsign"(image3).(See"Epiglottitis(supraglottitis):Clinicalfeatures
anddiagnosis",sectionon'Radiographicfeatures'.)
Thelateralradiographinchildrenwithbacterialtracheitismaydemonstrateonlynonspecificedemaor
intraluminalmembranesandirregularitiesofthetrachealwall(image4)[45].
LaboratorystudiesLaboratorystudies,whicharerarelyindicatedinchildrenwithcroup,areoflimited

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diagnosticutilitybutmayhelpguidemanagementinmoreseverecases.
BloodtestsThewhitebloodcell(WBC)countcanbelow,normal,orelevatedWBCcounts>10,000
cells/microLarecommon.Neutrophilorlymphocytepredominancemaybepresentonthedifferential
[46,47].Thepresenceofalargenumberofbandformneutrophilsissuggestiveofprimaryorsecondary
bacterialinfection.Croupisnotassociatedwithanyspecificalterationsinserumchemistries.
MicrobiologyConfirmationofetiologicdiagnosisisnotnecessaryformostchildrenwithcroup,since
croupisaselflimitedillnessthatusuallyrequiresonlysymptomatictherapy.Whenanetiologicdiagnosisis
necessary,viralcultureand/orrapiddiagnosticteststhatdetectviralantigensareperformedonsecretions
fromthenasopharynxorthroat.(See'Etiologicdiagnosis'below.)
DIAGNOSIS
ClinicaldiagnosisThediagnosisofcroupisclinical,basedonthepresenceofabarkingcoughand
stridor,especiallyduringatypicalcommunityepidemicofoneofthecausativeviruses.(See'Etiology'
above.)
Neitherradiographsnorlaboratorytestsarenecessarytomakethediagnosis.However,radiographsmay
behelpfulinexcludingothercausesifthediagnosisisinquestion.(See'Differentialdiagnosis'below.)
EtiologicdiagnosisAlthoughnottypicallyrequiredinmostcasesofcroup,identificationofaspecific
viraletiologymaybenecessarytomakedecisionsregardingisolationforpatientsrequiringhospitalizationor
forpublichealth/epidemiologicmonitoringpurposes.Testingforinfluenzaisindicatediftheresultswill
influencedecisionsregardingtreatment,prophylaxisofcontacts,orperformanceofotherdiagnostictests
laboratoryconfirmationshouldnotdelaytheinitiationofantiviraltherapyforinfluenzawhenclinicaland
seasonalconsiderationsarecompatiblewithinfluenzaasthepotentialetiologyofcroup.(See"Seasonal
influenzainchildren:Clinicalfeaturesanddiagnosis",sectionon'Laboratorydiagnosis'and"Seasonal
influenzainchildren:Preventionandtreatmentwithantiviraldrugs",sectionon'Timingoftreatment'.)
Diagnosisofaspecificviraletiologycanbemadebyviralcultureofsecretionsfromthenasopharynxor
throat.Rapidteststhatdetectviralantigensinthesesecretionsarecommerciallyavailableformany
respiratoryviruses.Thediagnosisofspecificviralinfectionsisdiscussedindetailinindividualtopicreviews:
Parainfluenza(see"Parainfluenzavirusesinchildren",sectionon'Diagnosis')
Influenza(see"Seasonalinfluenzainchildren:Clinicalfeaturesanddiagnosis",sectionon'Diagnosis')
Respiratorysyncytialvirus(see"Respiratorysyncytialvirusinfection:Clinicalfeaturesanddiagnosis",
sectionon'Laboratorydiagnosis')
Adenovirus(see"Diagnosis,treatment,andpreventionofadenovirusinfection",sectionon'Diagnostic
testsofchoicefordifferentadenovirussyndromes')
Measles(see"Clinicalmanifestationsanddiagnosisofmeasles",sectionon'Diagnosis')
Enteroviruses(see"Clinicalmanifestationsanddiagnosisofenterovirusandparechovirusinfections",
sectionon'Laboratorydiagnosis')
Metapneumovirus(see"Humanmetapneumovirusinfections",sectionon'Diagnosis')
Coronavirus(see"Coronaviruses",sectionon'Diagnosis')
Inaddition,multiplextests,whichassessthepresenceofmultipleagentsatthesametime,andPCRbased
testsarebecomingmorewidelyavailable[48].
DIFFERENTIALDIAGNOSISThedifferentialdiagnosisofcroupincludesothercausesofstridorand/or
respiratorydistress.Theprimaryconsiderationsarethosewithacuteonset,particularlythosethatmay
rapidlyprogresstocompleteupperairwayobstruction,andthosethatrequirespecifictherapy.Underlying
anatomicanomaliesoftheupperairwayalsomustbeconsidered,sincetheymaycontributetomoresevere

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disease.(See'Hostfactors'above.)
Importantconsiderationsinclude[1,12]:
Acuteepiglottitis
Peritonsillarandretropharyngealabscesses
Foreignbodyaspirationoringestion
Allergicreaction
Acuteangioneuroticedema
Upperairwayinjury
Congenitalanomaliesoftheupperairway
Laryngealdiphtheria(see"Clinicalmanifestations,diagnosisandtreatmentofdiphtheria")
AcuteepiglottitisEpiglottitis,whichisrareintheeraofvaccinationagainstHaemophilusinfluenzaetype
b,isdistinguishedfromcroupbytheabsenceofbarkingcoughandthepresenceofanxietythatisoutof
proportiontothedegreeofrespiratorydistress.Onsetofsymptomsisrapid,andbecauseoftheassociated
bacteremia,thechildishighlyfebrile,pale,toxic,andillappearing.Becauseoftheswollenepiglottis,the
childwillhavedifficultyswallowingandisoftendrooling.Thechildrenusuallyprefertositupandseldom
haveobservedcough[41].Epiglottitisoccursinfrequently,andthereisnopredominantetiologicpathogen.
(See"Epiglottitis(supraglottitis):Clinicalfeaturesanddiagnosis".)
PeritonsillarorretropharyngealabscessesChildrenwithdeepneckspaceabscesses,cellulitisofthe
cervicalprevertebraltissues,orotherpainfulinfectionsoftheoropharynxmaypresentwithdroolingand
neckextensionandvaryingdegreesoftoxicity.Barkingcoughisusuallyabsent.(See"Peritonsillarcellulitis
andabscess",sectionon'Presentation'and"Retropharyngealinfectionsinchildren",sectionon
'Presentation'.)
ForeignbodyInforeignbodyaspiration,thereoftenisahistoryofthesuddenonsetofchokingand
symptomsofupperairwayobstructioninapreviouslyhealthychild.Ifaninhaledforeignbodylodgesinthe
larynx,itwillproducehoarsenessandstridor.Ifalargeforeignbodyisswallowed,itmaylodgeintheupper
esophagus,resultingindistortionoftheadjacentsoftextrathoracictrachea,producingabarkingcoughand
inspiratorystridor.(See"Airwayforeignbodiesinchildren"and"Foreignbodiesoftheesophagusand
gastrointestinaltractinchildren".)
AllergicreactionoracuteangioneuroticedemaAllergicreactionoracuteangioneuroticedemahas
rapidonsetwithoutantecedentcoldsymptomsorfever.Theprimarymanifestationsareswellingofthelips
andtongue,urticarialrash,dysphagiawithouthoarseness,andsometimesinspiratorystridor[1,12].There
maybeahistoryofallergyorapreviousattack.(See"Anoverviewofangioedema:Clinicalfeatures,
diagnosis,andmanagement",sectionon'Clinicalfeatures'.)
UpperairwayinjuryInjurytotheairwayfromsmokeorthermalorchemicalburnsshouldbeevidentfrom
thehistory.Thechildtypicallydoesnothavefeveroraviralprodrome.
AnomaliesoftheupperairwayHoarsenessandstridorcausedbyanomaliesoftheupperairway(eg,
laryngealwebs,laryngomalacia,vocalcordparalysis,congenitalsubglotticstenosis,andsubglottic
hemangioma)andlaryngealpapillomashaveamorechroniccoursewithabsenceoffeverandsymptomsof
upperrespiratorytractillness,unlessthepresentationisduetoexacerbationofairwaynarrowingfromthe
impactofaconcomitantviralinfection.(See"Assessmentofstridorinchildren"and"Hoarsenessinchildren:
Etiologyandmanagement"and"Congenitalanomaliesofthelarynx".)
OtherpotentialmimickersofcroupOtherpotentialmimickersofcroupincludebronchogeniccyst(which
cancauseairwaycompression)andearlyGuillainBarrsyndrome(involvementofthelaryngealnervemay

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causevocalcordparalysis)[49,50].(See"Congenitalanomaliesoftheintrathoracicairwaysand
tracheoesophagealfistula",sectionon'Bronchogeniccyst'and"Epidemiology,clinicalfeatures,and
diagnosisofGuillainBarrsyndromeinchildren",sectionon'Clinicalfeatures'and"Hoarsenessinchildren:
Etiologyandmanagement",sectionon'Vocalfoldparalysis'.)
INFORMATIONFORPATIENTSUpToDateofferstwotypesofpatienteducationmaterials,"TheBasics"
and"BeyondtheBasics."TheBasicspatienteducationpiecesarewritteninplainlanguage,atthe5thto6th
gradereadinglevel,andtheyanswerthefourorfivekeyquestionsapatientmighthaveaboutagiven
condition.Thesearticlesarebestforpatientswhowantageneraloverviewandwhoprefershort,easyto
readmaterials.BeyondtheBasicspatienteducationpiecesarelonger,moresophisticated,andmore
detailed.Thesearticlesarewrittenatthe10thto12thgradereadinglevelandarebestforpatientswhowant
indepthinformationandarecomfortablewithsomemedicaljargon.
Herearethepatienteducationarticlesthatarerelevanttothistopic.Weencourageyoutoprintoremail
thesetopicstoyourpatients.(Youcanalsolocatepatienteducationarticlesonavarietyofsubjectsby
searchingon"patientinfo"andthekeyword(s)ofinterest.)
Basicstopic(see"Patientinformation:Croup(TheBasics)")
BeyondtheBasicstopic(see"Patientinformation:Croupininfantsandchildren(BeyondtheBasics)")
SUMMARYANDRECOMMENDATIONS
Thetermcrouphasbeenusedtodescribeavarietyofupperrespiratoryconditionsinchildren,
includinglaryngitis,laryngotracheitis,laryngotracheobronchitis,bacterialtracheitis,orspasmodiccroup.
(See'Definitions'above.)
Croupisusuallycausedbyviruses.Bacterialinfectionmayoccursecondarily.Parainfluenzavirustype
1isthemostcommoncauseofcroupothercausesincluderespiratorysyncytialvirusandinfluenza
virus.(See'Etiology'above.)
Croupmostcommonlyoccursinchildren6to36monthsofage.Mostcasesoccurinthefallorearly
winter.(See'Epidemiology'above.)
Hostfactorsthatmaycontributetothedevelopmentofcroupincludefunctionaloranatomic
susceptibilitytoupperairwaynarrowing.(See'Pathogenesis'above.)
Theclinicalpresentationofcroupdependsuponthespecificcroupsyndromeandthedegreeofupper
airwayobstruction.(See'Clinicalpresentation'above.)
Theonsetofsymptomsinlaryngotracheitisisgradual,beginningwithnasalirritation,congestion,and
coryza.Fever,hoarseness,barkingcough,andstridorusuallydevelopduringthenext12to48hours.
Rapidprogressionorsignsoflowerairwayinvolvementsuggestamoreseriousillness.(See
'Laryngotracheitis'above.)
Theonsetofsymptomsinspasmodiccroupissuddenandalwaysoccursatnight.Feveristypically
absent,butmildupperrespiratorytractsymptomsmaybepresent.(See'Spasmodiccroup'above.)
Bacterialtracheitis(picture1andimage4)maypresentacutelyorasmarkedworseningduringthe
courseofanantecedentviralupperrespiratoryinfection.Clinicalmanifestationsofbacterialtracheitis
includefever,toxicappearance,andsevererespiratorydistress.(See'Bacterialtracheitis'aboveand
"Bacterialtracheitisinchildren:Clinicalfeaturesanddiagnosis".)
Theobjectivesoftheevaluationofthechildwithcroupincludeassessmentofseverityandexclusionof
othercausesofupperairwayobstruction.(See'Overview'above.)
Rapidassessmentofgeneralappearance,vitalsigns,pulseoximetry,airwaystability,andmental
statusarenecessarytoidentifychildrenwithsevererespiratorydistressand/orimpendingrespiratory
failure.(See'Rapidassessmentandinitialmanagement'above.)

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Thehistoryshouldincludeadescriptionoftheonset,durationandprogressionofsymptoms,and
ascertainwhetherthereareanyunderlyingconditionsthatpredisposetoamoreseverecourse.(See
'History'above.)
Aspectsoftheexaminationthatareusefulinassessingtheseverityofupperairwayobstructioninclude
overallappearance(includingthepresenceofstridoratrestoronlywithagitation),qualityofvoice,
workofbreathing,tidalvolumeandairentry,andthepresenceofwheezing.(See'Examination'
above.)
Thediagnosisofcroupisclinical,baseduponthepresenceofabarkingcoughandstridor.Neither
radiographsnorlaboratorytestsarenecessarytomakethediagnosis.However,radiographsmaybe
helpfulinexcludingothercausesifthediagnosisisinquestion.(See'Diagnosis'above.)
Thedifferentialdiagnosisofcroupincludesothercausesofstridorand/orrespiratorydistress.The
primaryconsiderationsarethosewithacuteonset,particularlythosethatmayrapidlyprogressto
completeupperairwayobstruction,andthosethatrequirespecifictherapy.Importantconsiderations
includeacuteepiglottitis,peritonsillarandretropharyngealabscesses,foreignbodyaspiration,acute
angioneuroticedema,upperairwayinjury,andcongenitalanomaliesoftheupperairway.(See
'Differentialdiagnosis'above.)
UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.
REFERENCES
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tracheitis,andlaryngotracheobronchopneumonitis)andepiglottitis(supraglottitis).In:Feiginand
CherrysTextbookofPediatricInfectiousDiseases,7thed,CherryJD,HarrisonGJ,KaplanSL,etal
(Eds),ElsevierSaunders,Philadelphia2014.p.241.
3. CooperT,KuruvillaG,PersadR,ElHakimH.Atypicalcroup:associationwithairwaylesions,atopy,
andesophagitis.OtolaryngolHeadNeckSurg2012147:209.
4. PeltolaV,HeikkinenT,RuuskanenO.Clinicalcoursesofcroupcausedbyinfluenzaandparainfluenza
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5. CounihanME,ShayDK,HolmanRC,etal.Humanparainfluenzavirusassociatedhospitalizations
amongchildrenlessthanfiveyearsofageintheUnitedStates.PediatrInfectDisJ200120:646.
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Pediatr2008152:661.
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thepopulationbasedburdenofhospitalization.JPediatr2009154:694.
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Med20052:e240.
11. DllnerH,RisnesK,RadtkeA,NordbSA.Outbreakofhumanmetapneumovirusinfectionin
norwegianchildren.PediatrInfectDisJ200423:436.
12. BjornsonCL,JohnsonDW.Croup.Lancet2008371:329.
13. SegalAO,CrightonEJ,MoineddinR,etal.CrouphospitalizationsinOntario:a14yeartimeseries
analysis.Pediatrics2005116:51.
14. RosychukRJ,KlassenTP,MetesD,etal.CrouppresentationstoemergencydepartmentsinAlberta,
Canada:alargepopulationbasedstudy.PediatrPulmonol201045:83.
15. PruikkonenH,DunderT,RenkoM,etal.Riskfactorsforcroupinchildrenwithrecurrentrespiratory

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infections:acasecontrolstudy.PaediatrPerinatEpidemiol200923:153.
16. SalzmanMB,FillerHF,SchechterCB.Passivesmokingandcroup.ArchOtolaryngolHeadNeckSurg
1987113:866.
17. MarxA,TrkTJ,HolmanRC,etal.Pediatrichospitalizationsforcroup(laryngotracheobronchitis):
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176:1423.
18. DAVISONFW.Acutelaryngealobstructioninchildren.JAmMedAssoc1959171:1301.
19. DavisonFW.Acuteobstructivelaryngitisinchildren.PennMedJ195053:250.
20. SzpunarJ,GlowackiJ,LaskowskiA,MiszkeA.Fibrinouslaryngotracheobronchitisinchildren.Arch
Otolaryngol197193:173.
21. MORGANEA,WISHARTDE.Laryngotracheobronchitis(astatisticalreviewof549cases).CanMed
AssocJ194756:8.
22. OrtonHB,SmithEL,BellHO,etal.Acutelaryngotracheobronchitis:analysisofsixtytwocaseswith
reportofautopsiesineightcases.ArchOtolaryngol194133:926.
23. RichardsL.Afurtherstudyofthepathologyofacutelaryngotracheobronchitisinchildren.AnnOtol
RhinolLaryngol193847:326.
24. HideDW,GuyerBM.Recurrentcroup.ArchDisChild198560:585.
25. VanBeverHP,WieringaMH,WeylerJJ,etal.Croupandrecurrentcroup:theirassociationwith
asthmaandallergy.Anepidemiologicalstudyon58yearoldchildren.EurJPediatr1999158:253.
26. GilgerMA.Pediatricotolaryngologicmanifestationsofgastroesophagealrefluxdisease.Curr
GastroenterolRep20035:247.
27. WelliverRC,SunM,RinaldoD.Defectiveregulationofimmuneresponsesincroupdueto
parainfluenzavirus.PediatrRes198519:716.
28. WelliverRC,WongDT,MiddletonEJr,etal.RoleofparainfluenzavirusspecificIgEinpathogenesis
ofcroupandwheezingsubsequenttoinfection.JPediatr1982101:889.
29. ThompsonM,VodickaTA,BlairPS,etal.Durationofsymptomsofrespiratorytractinfectionsin
children:systematicreview.BMJ2013347:f7027.
30. CherryJD.Thetreatmentofcroup:continuedcontroversyduetofailureofrecognitionofhistoric,
ecologic,etiologicandclinicalperspectives.JPediatr197994:352.
31. KaditisAG,WaldER.Viralcroup:currentdiagnosisandtreatment.PediatrInfectDisJ199817:827.
32. MauroRD,PooleSR,LockhartCH.Differentiationofepiglottitisfromlaryngotracheitisinthechildwith
stridor.AmJDisChild1988142:679.
33. KasianGF,BinghamWT,SteinbergJ,etal.Bacterialtracheitisinchildren.CMAJ1989140:46.
34. DuvalM,TarasidisG,GrimmerJF,etal.Roleofoperativeairwayevaluationinchildrenwithrecurrent
croup:aretrospectivecohortstudy.ClinOtolaryngol201540:227.
35. DelanyDR,JohnstonDR.Roleofdirectlaryngoscopyandbronchoscopyinrecurrentcroup.
OtolaryngolHeadNeckSurg2015152:159.
36. RankinI,WangSM,WatersA,etal.Themanagementofrecurrentcroupinchildren.JLaryngolOtol
2013127:494.
37. JabbourN,ParkerNP,FinkelsteinM,etal.Incidenceofoperativeendoscopyfindingsinrecurrent
croup.OtolaryngolHeadNeckSurg2011144:596.
38. ChunR,PreciadoDA,ZalzalGH,ShahRK.Utilityofbronchoscopyforrecurrentcroup.AnnOtol
RhinolLaryngol2009118:495.
39. AlbertaClinicalPracticeGuidelinesGuidelineWorkingGroup.Guidelinesforthediagnosisand
managementofcrouphttp://www.topalbertadoctors.org/informed_practice/cpgs/croup.html(Accessed
onFebruary22,2011).
40. FleisherG.Infectiousdiseaseemergencies.In:TextbookofPediatricEmergencyMedicine,5thed,
FleisherGR,LudwigS,HenretigFM(Eds),Lippincott,Williams&Wilkins,Philadelphia2006.p.783.
41. TibballsJ,WatsonT.Symptomsandsignsdifferentiatingcroupandepiglottitis.JPaediatrChildHealth
201147:77.
42. DiazJH,LockhartCH.Earlydiagnosisandairwaymanagementofacuteepiglottitisinchildren.South
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43. WestleyCR,CottonEK,BrooksJG.NebulizedracemicepinephrinebyIPPBforthetreatmentof
croup:adoubleblindstudy.AmJDisChild1978132:484.
44. MillsJL,SpackmanTJ,BornsP,etal.Theusefulnessoflateralneckroentgenogramsin
laryngotracheobronchitis.AmJDisChild1979133:1140.
45. BernsteinT,BrilliR,JacobsB.Isbacterialtracheitischanging?A14monthexperienceinapediatric
intensivecareunit.ClinInfectDis199827:458.
46. CherryJD.Newerrespiratoryviruses:theirroleinrespiratoryillnessesofchildren.In:Advancesin
Pediatrics,Vol20,SchulmanI(Ed),MosbyYearBook,Chicago1973.p.225.
47. DennyFW,ClydeWAJr.Acutelowerrespiratorytractinfectionsinnonhospitalizedchildren.JPediatr
1986108:635.
48. HenricksonKJ,HooverS,KehlKS,HuaW.Nationaldiseaseburdenofrespiratoryvirusesdetectedin
childrenbypolymerasechainreaction.PediatrInfectDisJ200423:S11.
49. LinCY,ChiH,ShihSL,etal.A4yearoldboypresentingwithrecurrentcroup.EurJPediatr2010
169:249.
50. HsiaSH,LinJJ,WuCT,etal.GuillainBarrsyndromepresentingasmimickingcroup.AmJEmerg
Med201028:749.e1.
Topic6002Version20.0

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GRAPHICS
Bacterialtracheitis:Endoscopy

Notetheadherentmucopurulentmembraneswithinthetrachea.
CourtesyofGlennCIsaacson,MD,FAAP,FACS.
Graphic55364Version3.0

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Epiglottitis:Tripodposture

Thischild's"tripod"positioning(trunkleaningforward,neck
hyperextended,chinthrustforward)isindicativeofepiglottitis.Notethe
child'stoxicappearance.
Reproducedwithpermissionfrom:MDouglasBaker,MD.
Graphic79826Version2.0

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Childwithclassicpresentationofacuteepiglottitis

ThisfouryearoldgirlhasepiglottitiscausedbyHaemophilusinfluenzae
typeb.
(A)Shepreferstositandappearsanxious.
(B)Thechildassumesthecharacteristicsniffingpositiontomaximizethe
patencyofherairway.
Reproducedwithpermissionfrom:FleisherGR,LudwigW,BaskinMN.Atlasof
PediatricEmergencyMedicine.Philadelphia:LippincottWilliams&Wilkins,
2004.Copyright2004LippincottWilliams&Wilkins.
Graphic76538Version4.0

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Croup:Anteroposteriorradiographwith"steeple
sign"

Theanteroposterior(AP)viewdemonstratestaperingoftheupper
trachea,knownasthe"steeplesign"ofcroup.Notethatthefindingcan
besimulatedbydifferingphasesofrespirationeveninnormalchildren.
CourtesyoftheDepartmentofDiagnosticImaging,TexasChildren's
Hospital.
Graphic52418Version2.0

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Croup: Clinical features, evaluation, and diagnosis

Lateralneckradiographofachildwithcroup

Lateralneckradiographshowingsubglotticnarrowing(arrow)and
distendedhypopharynx(arrowheads)consistentwithacute
laryngotracheitis.
CourtesyofJoeBlack,DiagnosticImaging,TexasChildren'sHospital.
Graphic64727Version4.0

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Croup: Clinical features, evaluation, and diagnosis

Epiglottitis:Lateralradiograph

Lateralneckradiographdemonstratingswollenepiglottis(arrow)and
aryepiglotticfoldsinachildwithepiglottitisduetoHaemophilus
influenzaetypeb.Theswollenepiglottisisoftencalleda"thumbsign."
CourtesyofEvelynYAnthony,MD,WakeForestUniversitySchoolof
Medicine.
Graphic67878Version6.0

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Croup: Clinical features, evaluation, and diagnosis

Bacterialtracheitis:Lateralneckradiograph

Lateralneckradiographshowingintraluminalmembranesandtracheal
wallirregularityconsistentwithbacterialtracheitis.
CourtesyofR.PaulGuillerman,MD,DepartmentofRadiology,BaylorCollege
ofMedicine.
Graphic80331Version4.0

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Disclosures
Disclosures:CharlesRWoods,MD,MSOtherFinancialInterest:Cerexa[Epiglottitis(DataSafetyMonitoringBoardforpediatric
trialsoftheantibioticagentceftaroline)].SheldonLKaplan,MDGrant/Research/ClinicalTrialSupport:Pfizer[vaccine(PCV13)]
ForestLab[antibiotic(Ceftaroline)]Optimer[antibiotic(fidaxomicin)].Consultant/AdvisoryBoards:Pfizer[vaccine(PCV13)].
GregoryRedding,MDNothingtodisclose.CarrieArmsby,MD,MPHNothingtodisclose.
Contributordisclosuresarereviewedforconflictsofinterestbytheeditorialgroup.Whenfound,theseareaddressedbyvetting
throughamultilevelreviewprocess,andthroughrequirementsforreferencestobeprovidedtosupportthecontent.Appropriately
referencedcontentisrequiredofallauthorsandmustconformtoUpToDatestandardsofevidence.
Conflictofinterestpolicy

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