Emergent Management of Croup (Laryngotracheobronchitis)



Laryngotracheobronchitis (ie, croup) is a viral infection of the upper respiratory tract that causes varying degrees of airway obstruction but that,[1] with aggressive emergent management, only infrequently requires hospital admission.[2]  Although the disease is most often self-limited, it occasionally is severe and can in rare cases be fatal. A barking cough, stridor, and fever are characteristic symptoms; laryngotracheobronchitis is the most common cause of stridor in children.[3, 4, 5] (See the image below.)

View Image

Child with croup. Note the steeple or pencil sign of the proximal trachea evident on this anteroposterior film. Courtesy of Dr. Kelly Marshall, CHOA a....


Emergency Care

Prehospital care

Avoid actions that may agitate the child with laryngotracheobronchitis and lead to worsened respiratory distress. Transport the child in a parent's lap and give oxygen as tolerated, usually via a blow-by technique.

Emergency department care

Goals of emergency department (ED) care are to reduce respiratory distress, monitor for worsening condition, and consider or evaluate for other etiologies of stridor. Evidence-based guidelines have been established for the management of laryngotracheobronchitis.[6]

Make the child as comfortable as possible, and avoid agitating the patient with unnecessary procedures and examinations. Humidified air or mist therapy may be used, but both have unproven efficacy.[7] Provide oxygen (humidified) to all hypoxic patients.

L -epinephrine (1:1000) is as effective as racemic epinephrine. Nebulized epinephrine has proven to significantly reduce symptoms of laryngotracheobronchitis within 30 minutes of administration. (Epinephrine therapy does not indicate the need for admission.)[8, 9]

Rebound stridor after epinephrine therapy has been described in patients with laryngotracheobronchitis, but it appears to be less of a problem if corticosteroid therapy is initiated early in the ED course.

Dexamethasone has been shown to reduce symptoms in patients with moderate to severe laryngotracheobronchitis (0.6 mg/kg IM, not to exceed 10 mg).[10] The intravenous formulation of dexamethasone may be administered orally as it is readily bioavailable from the GI tract.[11] Some authorities recommend a repeat dose of dexamethasone in 6 hours.[12, 13]  Prednisolone (2 mg/kg/dose/day for a total of 3 days) may be an alternative if dexamethasone is not available.[14]

Nebulized budesonide (2 mg) has been shown in several studies to be equivalent to oral dexamethasone. Inhaled dexamethasone is also used, when budesonide is unavailable.[15]

Always consider other causes of stridor, such as foreign bodies, bacterial tracheitis, and epiglottitis. Be sure to observe patients for an adequate period before ED discharge and to document satisfactory pulse oximetry.

Consultation with an otorhinolaryngologist and anesthesia prior to rapid sequence induction (RSI) may be necessary if the patient is exhibiting rapid deterioration that might suggest an alternative diagnosis.


Lonnie King, MD, Consulting Staff, Department of Emergency Medicine, Children's Healthcare of Atlanta at Scottish Rite

Disclosure: Nothing to disclose.

Specialty Editors

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.

Wayne Wolfram, MD, MPH, Professor, Department of Emergency Medicine, Mercy St Vincent Medical Center; Chairman, Pediatric Institutional Review Board, Mercy St Vincent Medical Center, Toledo, Ohio

Disclosure: Nothing to disclose.

Chief Editor

Kirsten A Bechtel, MD, Associate Professor of Pediatrics, Section of Pediatric Emergency Medicine, Yale University School of Medicine; Co-Director, Injury Free Coalition for Kids, Yale-New Haven Children's Hospital

Disclosure: Nothing to disclose.

Additional Contributors

Jerry R Balentine, DO, FACEP, FACOEP, Vice President, Medical Affairs and Global Health, New York Institute of Technology; Professor of Emergency Medicine, New York Institute of Technology College of Osteopathic Medicine

Disclosure: Nothing to disclose.


  1. Johnson DW. Croup. Clin Evid (Online). 2009 Mar 10. 2009:[View Abstract]
  2. Narayanan S, Funkhouser E. Inpatient hospitalizations for croup. Hosp Pediatr. 2014 Mar. 4 (2):88-92. [View Abstract]
  3. Miller EK, Gebretsadik T, Carroll KN, Dupont WD, Mohamed YA, Morin LL, et al. Viral Etiologies of Infant Bronchiolitis, Croup, and Upper Respiratory Illness during Four Consecutive Years. Pediatr Infect Dis J. 2013 May 20. [View Abstract]
  4. Atkinson PR, Boyle AA, Lennon RS. Weather factors associated with paediatric croup presentations to an Australian emergency department. Emerg Med J. 2013 Apr 4. [View Abstract]
  5. Rankin I, Wang SM, Waters A, Clement WA, Kubba H. The management of recurrent croup in children. J Laryngol Otol. 2013 May. 127(5):494-500. [View Abstract]
  6. [Guideline] Mazza D, Wilkinson F, Turner T, Harris C. Evidence based guideline for the management of croup. Aust Fam Physician. 2008 Jun. 37(6 Spec No):14-20. [View Abstract]
  7. Petrocheilou A, Tanou K, Kalampouka E, Malakasioti G, Giannios C, Kaditis AG. Viral croup: diagnosis and a treatment algorithm. Pediatr Pulmonol. 2014 May. 49 (5):421-9. [View Abstract]
  8. 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. 2:CD006619. [View Abstract]
  9. Bagwell T, Hollingsworth A, Thompson T, Abramo T, Huckabee M, Chang D, et al. Management of Croup in the Emergency Department: The Role of Multidose Nebulized Epinephrine. Pediatr Emerg Care. 2017 Sep 25. [View Abstract]
  10. Gates A, Gates M, Vandermeer B, Johnson C, Hartling L, Johnson DW, et al. Glucocorticoids for croup in children. Cochrane Database Syst Rev. 2018 Aug 22. 8:CD001955. [View Abstract]
  11. Chou JW, Decarie D, Dumont RJ, et al. Stability of dexamethasone in extemporaneously prepared oral suspensions. J Can Pharm Hosp. 2001. 54:97-103.
  12. 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. [View Abstract]
  13. Beigelman A, Chipps BE, Bacharier LB. Update on the utility of corticosteroids in acute pediatric respiratory disorders. Allergy Asthma Proc. 2015 Sep. 36 (5):332-8. [View Abstract]
  14. Garbutt JM, Conlon B, Sterkel R, Baty J, Schechtman KB, Mandrell K, et al. The comparative effectiveness of prednisolone and dexamethasone for children with croup: a community-based randomized trial. Clin Pediatr (Phila). 2013 Nov. 52 (11):1014-21. [View Abstract]
  15. Fitzgerald D, Mellis C, Johnson M, Allen H, Cooper P, Van Asperen P. Nebulized budesonide is as effective as nebulized adrenaline in moderately severe croup. Pediatrics. 1996 May. 97 (5):722-5. [View Abstract]

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.

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.