Guide — Neonatal & Pediatric
Croup & Pediatric Upper Airway Obstruction
Stridor in a child — the spectrum of upper-airway obstruction from viral croup to epiglottitis and bacterial tracheitis, how to grade severity, and the management that turns it around: keep the child calm, racemic epinephrine, and corticosteroids.
9 min read · Neonatal & Pediatric
Written by Apex Respiratory Editorial Team
Educational use only. This material supports respiratory therapy education and exam review. It is not medical advice and is not a substitute for clinical judgment, institutional protocols, or physician orders. Always follow facility policies and current provider orders, and verify calculations independently before clinical use.
Overview
Upper-airway obstruction in children produces inspiratory stridor and a barking cough. Viral croup (laryngotracheobronchitis) is by far the most common cause; the critical RT skill is distinguishing it from the airway emergencies — epiglottitis, bacterial tracheitis, and foreign body — and managing the child without provoking agitation.
| Severity | Findings | Management |
|---|---|---|
| Mild | Barky cough, no stridor at rest | Dexamethasone; supportive care, discharge |
| Moderate | Stridor at rest with retractions | Dexamethasone + racemic epinephrine; observe |
| Severe | Stridor at rest, marked retractions, agitation or decreased air entry | Racemic epinephrine, oxygen; prepare advanced airway |
| Impending failure | Lethargy, cyanosis, fatigue | Secure airway in a controlled setting |
Key Concepts
- Croup is viral and subglottic. It is a viral (most often parainfluenza) inflammation of the subglottic airway in children roughly 6 months to 3 years old. It causes a barking, seal-like cough, inspiratory stridor, hoarseness, and a low-grade fever, classically worse at night. The subglottic narrowing produces the “steeple sign” on an AP neck film.
- Severity is a spectrum. It grades from mild (barky cough, no stridor at rest) to moderate (stridor at rest with retractions) to severe (stridor at rest, marked retractions, agitation or decreased air entry) to impending failure (lethargy, cyanosis, fatigue).
- Stridor localizes the obstruction. Inspiratory stridor is extrathoracic/upper airway, biphasic is mid-tracheal, and expiratory is lower airway. A loud stridor that becomes quiet as a child tires reflects falling airflow and is ominous, not improvement.
- Know the differentials. Epiglottitis (bacterial, now rare thanks to the Hib vaccine — a toxic, drooling, tripoding child with no cough and rapid onset), bacterial tracheitis, foreign-body aspiration, retropharyngeal abscess, and anaphylaxis.
| Stridor Phase | Obstruction Location | Note |
|---|---|---|
| Inspiratory | Extrathoracic / upper airway | Classic croup |
| Biphasic | Mid-tracheal | Fixed lesion or tracheitis |
| Expiratory | Lower airway | Intrathoracic obstruction |
Assessment & Findings
- Croup. A barking cough plus inspiratory stridor and a hoarse voice, with gradual onset after a viral prodrome.
- Epiglottitis red flags. Rapid onset, high fever, a toxic appearance, drooling and difficulty swallowing, a muffled “hot potato” voice, the tripod position, and the absence of a barking cough — a true emergency. Keep the child calm, do not examine the throat, and prepare for a controlled airway.
RT Priorities & Interventions
- Keep the child calm. Agitation increases turbulent airflow, work of breathing, and oxygen demand. Let a caregiver hold the child and minimize painful interventions; this is genuinely therapeutic.
- Croup management. Corticosteroids (a single dose of dexamethasone) for essentially all severities, and nebulized racemic epinephrine for moderate-to-severe disease (it causes rapid mucosal vasoconstriction; observe for 3-4 hours for symptom rebound). Provide humidified air or oxygen and blow-by oxygen if hypoxic.
- Prepare for the airway in severe disease. For severe disease or impending failure, prepare for an advanced airway and have an endotracheal tube smaller than predicted ready (the subglottis is narrowed).
- Suspected epiglottitis. Do NOT agitate the child or inspect the throat; keep the child upright with a caregiver and arrange for the airway to be secured in a controlled setting.
Common Pitfalls
- Agitating a child with stridor (throat exams, IV attempts, separating from a parent) can precipitate complete obstruction, most dangerously in epiglottitis.
- Mistaking a quieting stridor in a tiring child for improvement — it signals worsening obstruction and less airflow.
- Withholding steroids in “mild” croup (they help across severities) or relying on racemic epinephrine alone without observing for rebound.
Board Exam Pearls
- Croup is viral and subglottic with a barking cough plus inspiratory stridor and the “steeple sign.”
- Epiglottitis is bacterial and supraglottic with drooling, a tripod posture, a toxic appearance, the “thumb sign,” and NO cough — an airway emergency; do not agitate.
- Croup treatment is dexamethasone (all severities) plus racemic epinephrine for moderate-to-severe stridor at rest.
- Racemic epinephrine works by mucosal vasoconstriction that reduces edema, not by bronchodilation.
- A child whose loud stridor goes quiet while tiring is deteriorating.
FAQ
How do I tell croup from epiglottitis?
Croup is viral and gradual, with a barking cough, inspiratory stridor, and hoarseness. Epiglottitis is bacterial and rapid, with a high fever and a toxic, drooling child sitting forward in a tripod position with a muffled voice and NO barking cough - a true airway emergency. (See the Croup vs Epiglottitis chart.)
Why give racemic epinephrine, and why observe afterward?
Nebulized racemic epinephrine causes rapid mucosal vasoconstriction that shrinks subglottic edema and relieves stridor within minutes. Because the effect can wear off in a few hours and symptoms can rebound, the child is observed for several hours after a dose.
Should every croup patient get steroids?
Yes. A single dose of dexamethasone benefits croup across the severity spectrum, including mild cases, reducing return visits and progression. Racemic epinephrine is added for moderate-to-severe stridor at rest.
Why is keeping the child calm part of the treatment?
Crying and agitation increase turbulent airflow, work of breathing, and oxygen demand and can worsen a marginal airway - most dangerously in epiglottitis. Letting a caregiver hold the child and minimizing painful interventions is genuinely therapeutic.
Put it to work
When the work of breathing tires a child out, the blood gas confirms it. Practice the interpretation.
Open the ABG Interpreter →Related Resources
Sources
- Kacmarek RM, Stoller JK, Heuer AJ. Egan's Fundamentals of Respiratory Care. 12th ed. Elsevier; 2021. Pediatric upper airway disorders chapters.
- Bjornson CL, Johnson DW. Croup in children. CMAJ. 2013;185(15):1317-1323.