Laryngotracheitis and laryngotracheobronchitis (croup)

Viral infection in children aged 3 months to 4 years.

Clinical features

– Typical barking cough, hoarse voice or cry.

– Inspiratory stridor (abnormal high pitched sound on inspiration):
• Croup is considered mild or moderate if the stridor only occurs with agitation;
• Croup is considered severe if there is stridor at rest, especially when it is accompanied by respiratory distress.

– Wheezing may also be present if the bronchi are involved.


– In the absence of inspiratory stridor or retractions, treat symptomatically: ensure adequate hydration, seek medical attention if symptoms worsen (e.g. respiratory difficulty, noisy breathing and inability to tolerate oral fluids).

– If stridor is only present with agitation (moderate croup):
• Hospitalize for treatment and observation (risk of worsening).
• Assure adequate hydration.
• dexamethasone1  PO (use IV preparation flavoured with sugar water, 10% or 50% glucose or juice) or IM if child is vomiting: 0.6 mg/kg single dose (see table).

– If danger signs are present (stridor at rest, respiratory distress), admit in intensive care:
• Oxygen continuously: at least 5 litres/minute or to maintain the SpO2 between 94 and 98%.
• Insert a peripheral IV line and provide IV hydration.
 epinephrine (adrenaline) via nebulizer (1 mg/ml, 1 ml ampoule): 0.5 mg/kg (max. 5 mg) to be repeated every 20 minutes if danger signs persist.
Monitor heart rate during nebulization (if heart rate greater than 200, stop the nebulization).


3 months

4-6 months

7-9 months

10-11 months

1-4 years


6 kg

7 kg

8 kg

9 kg

10-17 kg

Dose in mg

3 mg

3.5 mg

4 mg

4.5 mg

5 mg

Dose in ml

3 ml

3.5 ml

4 ml

4.5 ml

5 ml

NaCl 0.9%*

1 ml

1 ml

 Add sufficient NaCl 0.9% to obtain a total volume of 4 to 4.5 ml in the nebulizing chamber.
 Epinephrine is intended exclusively for nebulized administration and should not be given IV or IM in croup.

• dexamethasone 1 (4 mg/ml, 1 ml ampoule) IM or IV: 0.6 mg/kg single dose


3-11 months

1-2 years

3-4 years


6-9 kg

10-13 kg

14-17 kg

Dose in mg

4 mg

8 mg

10 mg

Dose in ml

1 ml

2 ml

2.5 ml

Suspect bacterial tracheitis in a critically ill appearing child2 with croup who does not improve with the above treatment.

– If wheezing is present:
salbutamol aerosol (using a spacer): 2 to 3 puffs every 20 to 30 minutes as needed

– If the patient has a complete airway obstruction, intubation if possible or emergency tracheotomy.

Ref Notes
1 Administer orally if possible in order to avoid causing agitation in the child as this may worsen symptoms. [ a b ]
2 Critically ill appearing child: weak grunting or crying, drowsiness, difficult to arrouse, does not smile, unconjugate or anxious gaze, pallor or cyanosis, general hypotonia.