The Curious Incident of the Barking Cough in the Night Time: Croup in the ED

Author: Nikki Abela / Reviewer: Lizzie Binham / Codes: A2 / Published: 29/02/2016 / Reviewed: 30/04/2024

The frosted windscreen that heralds the end of the night shift is not the only thing that reminds us that Winter is here. Our paediatric emergency departments are bustling with the snuffles that this season brings and, as if that wasnt enough, the seals come out at night to play. You know the ones, typically aged between 6 months and 4 years, with the barking cough that came on quite suddenly and woke everyone in the house with a jolt.


Once you have heard the classic croupy cough, you wont forget it. The barking cough, stridor, coryzal symptoms and low-grade fever are typical of croup (a.k.a viral laryngotracheitis). The child will generally present in the evening or night/early hours of the morning, with a harsh sounding cough which comes on within a few hours. They typically can improve slightly in the morning, and when they are taken out in the cold.

Interesting new evidence from Siebert et al. (1) has shown a significant improvement in severity of symptoms when children are exposed to cold air for 30 mins on presentation. Whilst this might not be practical for patients waiting in your ED, its worthwhile discussing with parents as a way to help settle those kids who show signs of distress at home.


Dont forget, however, that there are other things that may sound similar to croup, so dont continue on autopilot without considering the differentials. If the child looks septic (if you dont know what a septic child looks like Ed Snelson gives us some insight here), or if they are sitting forward with their neck extended, start thinking of other causes. I really like the way Dont forget the Bubbles calls them The Big Four in their blog:

  1. Acute epiglottitis
  2. Bacterial tracheitis
  3. Foreign body
  4. Anaphylaxis

There are of course other differentials, including retropharyngeal abscesses, and for that I suggest you read the Dont forget the Bubbles link or the RCEM reference piece. Of course, common things like croup are common. If it sounds like croup, it probably is. But if you see enough kids with croup, one day it wont be, so dont get caught up with going through the motions and forgetting to think outside the box. Talking about the box, most croup is pretty easy to deal with, but that is not to say it is benign.

Severity Assessment

There are of course severity scores for croup, like the Westley score*.

*The Westley Score divides children with croup into four levels of severity:

  • Mild: 0-2
  • Moderate: 3-5
  • Severe: 6-11
  • Impending Resp Failure: 12-17

For the unlucky few, things can go wrong. But thankfully, most are on the mild-moderate scale and do well with steroids. Damian Roland has posted a nice video of a child with severe croup.


Some departments encourage triage nurses, when confident in the recognition of a child with croup, to give a steroid. However, if theyre not sure, or the child isnt quite right then a medical review first is a must! But what steroid and how much? I hear you ask. It is universally recognised that dexamethasone is more effective than prednisolone, but there has been a lot of debate around the dose required. Various studies have shown that 0.15mg/kg is as effective as 0.6mg/kg, and in line with this both the BNFc and NICE currently recommend this as your starting dose. As always, however, you should check your local guidelines and prescribe according to these. For a comprehensive overview of the use of steroids in croup check out this literature review by Mora et al.. (2)

Dont get too comfortable though folks, because things can go wrong with croup, and it can be a severe, life-threatening illness. Practically speaking, if the child has marked increased work of breathing accompanying a stridor at rest, then they should really be placed in an area where they can be observed and seen by a doctor immediately. These are not the ones you want your triage nurses to be giving the dex to before they wait for 2 hours in the waiting area. If they have a decreased level of consciousness or low sats at rest, get the airway team involved early (depending on where you work, this might be ENT, plus anaesthetics plus ICU). If you are worried about impending airway obstruction, you really dont want to be calling the most junior anaesthetist on call. Dont panic, distract the child (bubbles, smart phone, cuddles) and give them nebulized adrenaline (400 micrograms/kg, max 5mg of the standard 1:1000 L-epinephrine). Put that local anaesthetic on early (EMLA/Ametop) in anticipation of needing IV access. Damian Roland reminds us that as calm as you are, is as calm as shell be. If the child is really upset, do what you can to keep them calm. Remember, older children have more severe symptoms as they are more aware of the feeling of tracheal narrowing at the subglottic level, so keeping these kids calm is imperative. If shooting a syringe-full of dexamethasone down the throat of a distressed, vomiting child is going to make their severe croup worse, go for nebulized budesonide (2mg) also useful if theyve vomited or spat out the dex. Keep the child with severe croup on oxygen once the nebulizers are finished.

Airway Management

If the anesthetist hasnt arrived and/or the child is too unwell to wait for the nebulisers to work, I send you my condolences my friend, as you are going to have to intubate and very few people would want to be in your shoes right now. If ever there was a time for the difficult airway trolley, this is it. Crash call your ENT colleague to stand by your side with the tracheostomy kit if possible, and make sure you have the most experienced personnel around you. Gas induction would be ideal to avoid the distress of an IV. Always anticipate needing a smaller ET tube than estimated for the childs age and consider having the kit set up for a potential needle cricothyroidotomy. As the guys in first10EM remind us

Isolated, reversible upper airway disease is a good indication for crash ECMO if that is an option to you (it isnt for me) and you are unable to secure the airway.

Luckily, most children do not progress to anywhere near this route, and most can be discharged home once the stridor settles. You shouldnt be discharging a child who has stridor at rest, so if it fails to resolve during your observation period you should be referring them on to paeds. Once you decide they are safe for discharge, always advise the parents to re-present if the stridor returns. Luckily, because the dexamethasone takes a good 40 minutes to work, you can use this time to assess the direction of the disease trajectory your patient is taking. If its not going the right way, get the nebulized adrenaline ready, and start rehearsing because you may have to sing soft kitty (lyrics may be found here).

References/further reading:

  1. Siebert JN, Salomon C, et al. Outdoor Cold Air Versus Room Temperature Exposure for Croup Symptoms: A Randomized Controlled Trial. Pediatrics. 2023 Sep 1;152(3):e2023061365.
  2. Garzon Mora N, Jaramillo AP, et al. An Overview of the Effectiveness of Corticoids in Croup: A Systematic Literature Review. Cureus. 2023 Oct 1;15(10):e46317.
  3. Marsh AR. Croup. RCEMLearning. Reviewed in 2021.
  4. Snelson E, et al. Recognising Paediatric Sepsis. Reviewed in 2024.
  5. Russell KF, Liang Y, et al. Glucocorticoids for croup. Cochrane Database Syst Rev. 2011 Jan 19;(1):CD001955. doi: 10.1002/14651858.CD001955.pub3. Update in: Cochrane Database Syst Rev. 2018 Aug 22;8:CD001955.
  6. Riddick L. Croup, Don’t Forget the Bubbles, 2021.
  7. Fox SM. Croup. Pediatric EM Morsels, 2012.
  8. Morgenstern J. Management of severe croup. First10EM, 2015. Updated in 2019.
  9. CLASSIC CROUP: Live Diagnosis with Dr. Paul. paulthomasmd – Dr. Paul [Internet]. YouTube video, 2014.

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