Assessment, diagnosis and treatment of children who present with stridor
Intended for healthcare professionals
Evidence and practice    

Assessment, diagnosis and treatment of children who present with stridor

Andriana Summers Doctor, emergency department, Airedale General Hospital, Airedale NHS Foundation Trust, Keighley, West Yorkshire, England

Why you should read this article:
  • To recognise the signs, symptoms and potential common and atypical causes of stridor in children

  • To understand how to identify and assess children with viral croup, the most common cause of stridor in this group

  • To enhance your knowledge of the evidence for the assessment criteria and treatment of children who present with viral croup

The presence of stridor in children signifies a partial obstruction in the upper airways, the cause of which may range from mild to life-threatening depending on aetiology. The most common causes of stridor in this population are laryngotracheobronchitis (viral croup) and foreign body aspiration.

This article gives an overview of the signs, symptoms and potential causes of stridor and the signs and symptoms of, and diagnostic criteria for, viral croup. The author also discusses evidence-based assessment criteria and treatments and criteria for admission or discharge. A case study is used for illustration.

Emergency Nurse. doi: 10.7748/en.2022.e2139

Peer review

This article has been subject to external double-blind peer review and checked for plagiarism using automated software

Correspondence

Andriana.Summers@nhs.net

Conflict of interest

None declared

Summers A (2022) Assessment, diagnosis and treatment of children who present with stridor. Emergency Nurse. doi: 10.7748/en.2022.e2139

Published online: 09 November 2022

Introduction

Stridor has been described as a high-pitched sound that may be heard during inspiration, expiration or both (biphasic) and occurs when turbulent airflow is produced in the airways (Quintero and Fakhoury 2021). The presence of stridor signifies a partial obstruction in the upper airways, the cause of which may range from mild to life-threatening depending on aetiology (Patnaik et al 2021). Stridor is more common in children than adults due to anatomical and physiological airway variations (Maloney and Meakin 2007, Lyng et al 2021). It is important to differentiate stridor from wheezing, a sound that indicates widespread lower airflow limitation, as noted in patients with asthma or bronchiolitis, and which tends to consist of multiple sounds that start and stop at different times (Quintero and Fakhoury 2021).

This article gives an overview of the signs, symptoms and causes of stridor and the signs and symptoms of and diagnostic criteria for laryngotracheobronchitis (viral croup). It also discusses evidence-based assessment criteria and treatments for viral croup and criteria for admission or discharge. Case study 1 is included for illustration.

Case study 1. Stridor

A five-year-old child was brought to the emergency department (ED) by a parent during the night. Prior to going to bed, the child had been well, but had woken up due to the sudden onset of a harsh cough, respiratory distress and noisy breathing.

On arrival at the ED, the attending clinician used the Paediatric Assessment Triangle (Dieckmann et al 1996, 2010) (see Figure 1) to make initial, rapid observations. The clinician observed that the child had a loud inspiratory stridor and was unable to speak and noted tracheal tug (abnormal drawing inwards and downwards of the trachea during inspiration) and subcostal recessions (inward movement of the chest wall below the costal margins).

Figure 1.

The Paediatric Assessment Triangle

en.2022.e2139_0001.jpg

The child was pale, sitting upright in bed with no obvious swelling to the face and lips and was not drooling. There was no visible rash or palpable cervical lymph nodes, the child was not coughing and there was no wheeze on chest auscultation.

History taking from the parent identified that the child was usually well, had an uneventful birth history, was up to date with immunisations and had no previous hospital attendances and no preceding illness.

The child’s respiratory rate was 40 breaths per minute, oxygen saturation was 98% on room air, heart rate was 143 beats per minute and temperature was 37.3°C. The child was kept calm and examination of the throat with a tongue depressor was not undertaken to avoid triggering or worsening airway obstruction. The child was diagnosed with moderate viral croup based on the Westley croup score (score of 4) (Westley et al 1978) (see Table 1).

Table 1.

The Westley croup score

en.2022.e2139_0001_tb1.jpg

The child was initially given oral dexamethasone 3mg, according to body weight of 20kg (0.15mg/kg), in line with the algorithm for assessing and managing a child presenting with croup (Marsh 2021). This was followed by a discussion with the anaesthetic consultant who assessed the child promptly and found no immediate cause for concern, such as an airway obstruction. Due to the presence of a loud stridor, the anaesthetic consultant suggested administration of nebulised adrenaline (epinephrine) or budesonide.

A discussion was also held with the paediatric consultant who advised repeat administration of 3mg of oral dexamethasone in 30 minutes if there was no improvement in symptoms, but advised against the administration of nebulised adrenaline or budesonide as the symptoms were not severe according to the Westley croup score.

After 30 minutes, the child’s condition was unchanged therefore a second dose of 3mg oral dexamethasone was given. The Westley croup score remained 4, therefore nebulised adrenaline was not given.

It was observed that when the child struggled to talk they became visibly distressed and the stridor worsened. Therefore, they were admitted to the children’s ward for continued observation and treatment and discharged home six hours later when symptoms resolved.

Common causes of stridor

In children, the most common causes of stridor are viral croup and foreign body aspiration (Sicari and Zabbo 2022). In general terms, inspiratory stridor originates from an obstruction above the vocal cords, such as in cases of viral croup or epiglottitis, while expiratory stridor indicates a pathology in the intrathoracic region, such as tracheomalacia, bronchomalacia or airway compression (Celmina and Paule 2018). Possible causes of biphasic stridor include bilateral vocal cord paralysis, laryngeal web, haemangioma, subglottic stenosis, the presence of a foreign body or bacterial tracheitis (Maloney and Meakin 2007, Quintero and Fakhoury 2021).

In 80% of cases viral croup is the cause of stridor in children, who are typically aged between six months and three years with a peak incidence at two years of age (Maloney and Meakin 2007, National Institute for Health and Care Excellence (NICE) 2022a). Viral croup is frequently characterised by a barking cough, low-grade fever, inspiratory stridor and increased respiratory effort (Maloney and Meakin 2007). These signs and symptoms are also present in children with epiglottitis, which is a medical emergency, however this condition is now seen less frequently due to scheduled immunisation against bacterial infection from Haemophilus influenzae type B (Hib) (Guerra and Waseem 2021).

Differentiating between viral croup and epiglottitis is not always easy. The presence of drooling has high sensitivity and specificity for epiglottitis, whereas the presence of coughing carries high sensitivity and specificity for viral croup (Tibballs and Watson 2011). Other reliable signs and symptoms of epiglottitis are a preference to sit, refusal to swallow and dysphagia (Tibballs and Watson 2011).

The viral agents that most commonly cause viral croup are parainfluenza (types 1 and 3) and influenza A and B, alongside other less common causes such as respiratory syncytial virus, rhinovirus, coronavirus, metapneumovirus and adenovirus, with prevalence peaking in the autumn (Rihkanen et al 2008, Sakthivel et al 2019).

Key points

  • Stridor in children indicates partial upper airway obstruction and requires prompt medical assessment

  • Viral croup is the most common cause of stridor in children

  • There are emerging cases of croup associated with COVID-19 which are linked to higher hospital admission rates

  • Oral dexamethasone 0.15mg/kg is first-line treatment alongside close observation for a minimum of two hours

  • The use of the Paediatric Assessment Triangle and Westley croup score can assist clinicians to rapidly evaluate the child’s clinical status and determine medical interventions

  • Delivering effective and safe emergency care for children with stridor requires sound clinical judgement and the support of experienced colleagues

Atypical causes of stridor

Gardner and Ruch (2020) urged clinicians to consider hypocalcaemia as a differential diagnosis in the presence of stridor in children due to the potential life-threatening effects of this condition, which include cardiomyopathy, myelofibrosis and convulsions. Stridor related to hypocalcaemia is not frequently encountered in the emergency department (ED), but it is important to consider this differential diagnosis due to the link with vitamin D deficiency secondary to environmental, social, cultural and housing factors (Elidrissy and Babekir 2017). Vitamin D deficiency in children is becoming recognised as a common issue in the UK, however there is no universal screening programme in place (NICE 2022b). Therefore, it is important that clinicians consider hypocalcaemia in a child who presents with stridor, but an absence of viral symptoms, such as fever, runny nose or cough, or risk factors for alternative diagnoses, such as foreign body aspiration, tracheal injury, burn inhalation, anaphylaxis or congenital abnormalities.

In the context of coronavirus disease 2019 (COVID-19), children who contract the virus commonly experience mild illness and present with fever, cough or shortness of breath (Lu et al 2020). Other non-specific symptoms have been described, such as nausea, vomiting and fatigue (Parri et al 2020), while case reports have identified stridor and croup symptoms in children with COVID-19 (Pitstick et al 2021, Venn et al 2021). Preliminary findings suggest the Omicron variant is associated with higher numbers of hospital admissions in children due to viral croup, as Omicron exhibits an affinity for the upper airways (Halfmann et al 2022).

A study undertaken in the US between March 2020 and January 2022 (Brewster et al 2022) identified 75 children from medical record data, most <2 years of age, who were diagnosed with viral croup associated with COVID-19 on presentation to an ED. Of those 75, 61 (81%) presented during the ‘Omicron period’ (defined by the researchers as starting from 4 December 2021), seven (11%) of whom required hospital admission. Although four of these seven children required intensive care, none died or required invasive ventilation (Brewster et al 2022). Before the COVID-19 pandemic, less than 5% of children with croup, in the US and in the UK, required hospital admission (Kwong et al 2007, Smith et al 2018, Marsh 2021). Brewster et al (2022) noted that dexamethasone was administered to 73 (97%) of the children, with a median of six doses given to those who were admitted to hospital (n=7). Nebulised adrenaline, as well as dexamethasone, was given to 28 (37%) of the children – who presented before and during the Omicron period – with a median of eight doses required to control viral croup symptoms among those who were hospitalised (n=7) (Brewster et al 2022). Higher admission rates combined with the need for administration of nebulised adrenaline and repeated doses of dexamethasone may suggest that the symptoms of viral croup associated with COVID-19 are more severe. However, more research is required as treatment options for viral croup may vary across different hospitals and countries.

The child in the case study in this article tested negative for COVID-19, however it is important for clinicians to consider COVID-19 as a novel cause of stridor and to provide appropriate care while minimising the risk of transmission.

Choice of therapy

Despite the existence of NICE (2022a) guidelines on management of croup, there appears to be variation among clinicians in choice of therapy. In the case study in this article, the advice from the paediatric consultant was to repeat oral dexamethasone 30 minutes after the initial dose of 0.15mg/kg. Further, the paediatric consultant advised against administration of nebulised adrenaline or budesonide which had been suggested by the anaesthetic consultant. Nebulised budesonide of 2mg is recommended for administration in children with viral croup who are unable to tolerate oral dexamethasone, for example due to vomiting or if they are too unwell (NICE 2022a).

A Cochrane systematic review by Gates et al (2018) found that oral dexamethasone was more effective than nebulised budesonide in reducing the severity of the symptoms of viral croup assessed at six and 12 hours post administration, with improvement of symptoms observed at two hours and lasting for up to 24 hours. The authors reported that there was no additional benefit of combining these treatments because return visits and readmission rates were similar in both groups. The use of oral dexamethasone as first-line therapy in all children with mild, moderate or severe viral croup is well established (NICE 2022a). If the child is too unwell to receive oral medicines, inhaled budesonide (2mg nebulised as a single dose) or intramuscular dexamethasone (0.6mg/kg as a single dose) is recommended (NICE 2022a).

Oral dexamethasone 0.15mg/kg appears to work equally as well as 0.3mg/kg and 0.6mg/kg in reducing the severity of viral croup symptoms and reducing the need for administration of nebulised adrenaline (Geelhoed and Macdonald 1995). This is supported by Germain (2016) who conducted a literature review to examine whether the dose of dexamethasone administered to children with croup affected outcomes and concluded that an oral dexamethasone dose >0.15mg/kg was of little clinical benefit.

The role of nebulised adrenaline is questionable and its clinical effectiveness uncertain. In a multicentre, randomised, double-blind, parallel group study of 66 hospitalised children with viral or spasmodic croup, Fitzgerald et al (1996) showed no clinically significant difference in croup symptoms or duration of symptoms when comparing nebulised budesonide 2mg with nebulised adrenaline 4mg.

A dose of 1 in 1,000 (1mg/mL) nebulised adrenaline solution alongside close clinical monitoring is recommended when symptoms of severe croup or impending respiratory failure are present, such as fatigue, pallor, lethargy and sternal/intercostal recessions (NICE 2022c). Other research has indicated short-term rather than sustained, long-lasting benefits of nebulised adrenaline (Waisman et al 1992, Bjornson and Johnson 2008), with clinical effects lasting at least one hour, but usually subsiding two hours after administration (NICE 2022c).

Sakthivel et al (2019) discussed the ‘rebound phenomenon’ – which occurs when the sudden discontinuation of a medicine results in the relapse of symptoms that are worse than those before the treatment – in children with stridor related to viral croup. The authors concluded that although re-emergence of symptoms may develop after administration of nebulised adrenaline, these were not worse than baseline and were less severe in children who had concurrent treatment with oral or parenteral dexamethasone.

Criteria to treat, discharge or admit

Emergency assessment of children can be challenging; they may be too young, frightened or physically unable to respond to questions (Hohenhaus 2006). This is compounded by age-based variability in vital signs, where heart rate and respiratory rate have suboptimal specificity (Dieckmann et al 2010). Assessment of unwell children must always follow the ABCDE approach, as per Paediatric Advanced Life Support Guidelines (Skellett et al 2021), taking into consideration the vital signs and general appearance of the child:

  • Airway (plus cervical spine stabilisation for the injured child).

  • Breathing.

  • Circulation (with haemorrhage control in the injured child).

  • Disability (level of consciousness and neurological status).

  • Exposure to ensure full examination (while respecting the child’s dignity and ensuring body temperature conservation).

The use of the Paediatric Assessment Triangle (PAT) (Dieckmann et al 1996, 2010) can also assist clinicians to quickly identify the category and severity of illness, management priorities and initial treatment (Horeczko and Gausche-Hill 2011). The PAT is a simple, rapid observational tool that can be completed in less than a minute and has been proven to reliably identify high-acuity patients when performed by triage nurses (Horeczko et al 2013, Ogden 2016). The aim of PAT is to support clinicians to decide if the child is ‘sick or not sick’ at a first glance, regardless of the presenting complaint and underlying diagnosis, based on their first impressions and observation of visual clues about the child’s general appearance, work of breathing and circulation to the skin (Horeczko and Gausche-Hill 2011).

The child in the case study was recognised as being ‘sick’ based on the clinician’s rapid observation (using the PAT) of stridor, rapid respiratory rate and subcostal recessions, which necessitated prompt initiation of therapies and pre-alerting senior specialist teams. The initial assessment revealed that the child was in respiratory distress alone without features of shock, respiratory failure or cardiac failure.

One problem with use of the PAT is that outcomes are dependent on the observer’s assessment skills, knowledge and experience (Fernández et al 2017) which infers that some clinicians may be over-cautious while others may underestimate the severity of the child’s condition. An example is the volume of stridor which may be alarming when it is very loud and harsh, but this does not correlate with the severity of the obstruction (Maloney and Meakin 2007, Celmina and Paule 2018). Additionally, a progressive decrease in the volume of stridor may be an alarming sign (Maloney and Meakin 2007), implying that the child is becoming more tired and hypoxic. Clinicians are urged to have a very low threshold for prompt referral and appropriate treatment of the child with stridor due to the significant risk of rapid airway obstruction (Pfleger and Eber 2016).

The Westley croup score (Table 1) is validated tool that is commonly used in clinical practice. Using the Westley croup score and local guidelines can enable the ED team to plan immediate treatment and assess the need for longer observation if appropriate. According to the Westley croup score there are four levels of severity (Westley et al 1978, Marsh 2021):

  • Mild (croup score 0-2).

  • Moderate (croup score 3-5).

  • Severe (croup score 6-11).

  • Impending respiratory failure (croup score 12-17).

Initial management and follow-on care and treatment are therefore determined by the way the child presents, the severity of symptoms and the underlying trigger for stridor. An algorithm for assessing and managing a child who presents with croup (Marsh 2021) can be found on the Royal College of Emergency Medicine website at: www.rcemlearning.co.uk/reference/croup/#1568728785135-df3bff44-26c4

Treatment with dexamethasone for children with viral croup has been shown to shorten length of hospital stay by around 15 hours (range 6-24 hours) and halve the rate of return visits, admissions and readmissions in 24 hours (Gates et al 2018). The child in the case study was discharged from the paediatric ward within six hours of admission and there is no record of their reattendance.

Viral croup is a self-limiting illness and death is estimated to be one in 30,000 cases (Bjornson and Johnson 2013, Sakthivel et al 2019) and is therefore extremely rare. The condition resolves spontaneously within 48 hours and children can be safely managed at home unless they are less than three months of age, have underlying heart, respiratory, immunological or congenital conditions or live far away from hospital, in case they need to reattend due to deterioration (NICE 2022a). The child in the case study did not have any of these risk factors, however short-term admission was warranted in view of persistent stridor and signs of respiratory recessions at rest.

Conclusion

The presence of stridor in children is always alarming. Stridor in this population indicates partial upper airway obstruction and requires prompt medical assessment to prevent rapid deterioration in the child’s condition. Viral croup is the most common cause of stridor in children, although foreign body aspiration and epiglottitis must also be considered.

Cases of viral croup associated with COVID-19 are being identified and are linked to higher hospital admission rates and the need for repeated doses of dexamethasone and administration of nebulised adrenaline. Oral dexamethasone 0.15mg/kg is the first-line treatment and close observation for a minimum of two hours is required before clinical improvement may be noted.

The use of the PAT is invaluable for ED clinicians in rapidly evaluating the clinical status of the child and determining the type and urgency of medical interventions. The Westley croup score can assist clinicians in decision-making about management according to ongoing assessment and response to treatment. Delivering effective and safe emergency care for children with stridor requires sound clinical judgement and the support of experienced colleagues.

References

  1. Bjornson CL, Johnson DW (2008) Croup. The Lancet. 371, 9609, 329-339. doi: 10.1016/S0140-6736(08)60170-1
  2. Bjornson CL, Johnson DW (2013) Croup in children. Canadian Medical Association Journal. 185, 15, 1317-1323. doi: 10.1503/cmaj.121645
  3. Brewster RC, Parsons C, Laird-Gion J et al (2022) COVID-19-associated croup in children. Pediatrics. 149, 6, e2022056492. doi: 10.1542/peds.2022-056492
  4. Celmina M, Paule S (2018) Stridor in children. Breathe. 14, 3, e111-e117. doi: 10.1183/20734735.017018
  5. Dieckmann RA, Brownstein D, Gausche-Hill M (1996) Pediatric Education for Paramedics Course Student Manual. California Emergency Medical Services Authority, Florida Emergency Medicine Foundation, Orlando FL.
  6. Dieckmann RA, Brownstein D, Gausche-Hill M (2010) The pediatric assessment triangle: a novel approach for the rapid evaluation of children. Pediatric Emergency Care. 26, 4, 312-315. doi: 10.1097/PEC.0b013e3181d6db37
  7. Elidrissy AT, Babekir JS (2017) Hypocalcemic rachitic stridor: a neglected warning sign in infants. Global Journal of Rare Diseases. 2, 1, 11-14. doi: 10.17352/2640-7876.000008
  8. Fernández A, Ares MI, Garcia S et al (2017) The validity of the pediatric assessment triangle as the first step in the triage process in a pediatric emergency department. Pediatric Emergency Care. 33, 4, 234-238. doi: 10.1097/PEC.0000000000000717
  9. Fitzgerald D, Mellis C, Johnson M et al (1996) Nebulized budesonide is as effective as nebulized adrenaline in moderately severe croup. Pediatrics. 97, 5, 722-725. doi: 10.1542/peds.97.5.722
  10. Gardner A, Ruch A (2020) Not all stridor is croup. Pediatric Emergency Care. 36, 1, e14-e17. doi: 10.1097/PEC.0000000000001624
  11. Gates A, Gates M, Vandermeer B et al (2018) Glucocorticoids for croup in children. Cochrane Database of Systematic Reviews. Issue 8. CD001955. doi: 10.1002/14651858.CD001955.pub4
  12. Geelhoed GC, Macdonald WB (1995) Oral dexamethasone in the treatment of croup: 0.15 mg/kg versus 0.3 mg/kg versus 0.6 mg/kg. Pediatric Pulmonology. 20, 6, 362-368. doi: 10.1002/ppul.1950200605
  13. Germain C (2016) Dose of Dexamethasone in Croup. http://bestbets.org/bets/bet.php?id=2879 (Last accessed: 10 October 2022.)
  14. Guerra A, Waseem M (2021) Epiglottitis. In: StatPearls. StatPearls Publishing, Treasure Island (FL).
  15. Halfmann P, lida S, Iwatsuki-Horimoto K et al (2022) SARS-Cov-2 Omicron virus causes attenuated disease in mice and hamsters. Nature. 603, 7902, 687-692. doi: 10.1038/s41586-022-04441-6
  16. Hohenhaus SM (2006) Someone watching over me: observations in pediatric triage. Journal of Emergency Nursing. 32, 5, 398-403. doi: 10.1016/j.jen.2006.07.002
  17. Horeczko T, Gausche-Hill M (2011) The paediatric assessment triangle: a powerful tool for the prehospital provider. Journal of Paramedic Practice. 3, 1, 20-25. doi: 10.12968/jpar.2011.3.1.20
  18. Horeczko T, Enriquez B, McGrath NE et al (2013) The Pediatric Assessment Triangle: accuracy of its application by nurses in the triage of children. Journal of Emergency Nursing. 39, 2, 182-189. doi: 10.1016/j.jen.2011.12.020
  19. Kwong K, Hoa M, Coticchia JM (2007) Recurrent croup presentation, diagnosis, and management. American Journal of Otolaryngology. 28, 6, 401-407. doi: 10.1016/j.amjoto.2006.11.013
  20. Lu X, Zhang L, Du H et al (2020) SARS-CoV-2 infection in children. New England Journal of Medicine. 382, 17, 1663-1665. doi: 10.1056/NEJMc2005073
  21. Lyng J, Harris M, Mandt M et al (2021) Prehospital pediatric respiratory distress and airway management training and education: an NAEMSP position statement and resource document. Prehospital Emergency Care. 26, sup 1, 102-110. doi: 10.1080/10903127.2021.1992551
  22. Maloney E, Meakin GH (2007) Acute stridor in children. Continuing Education in Anaesthesia, Critical Care & Pain. 7, 6, 183-186. doi: 10.1093/bjaceaccp/mkm041
  23. Marsh AR (2021) Croup. RCEM Learning. http://rcemlearning.co.uk/reference/croup/#1568728736132-3fe5fe50-05ce (Last accessed: 10 October 2022.)
  24. National Institute for Health and Care Excellence (2022a) Clinical Knowledge Summaries. Croup. http://cks.nice.org.uk/topics/croup/ (Last accessed: 10 October 2022.)
  25. National Institute for Health and Care Excellence (2022b) Clinical Knowledge Summaries. Vitamin D Deficiency in Children. http://cks.nice.org.uk/topics/vitamin-d-deficiency-in-children/ (Last accessed: 10 October 2022.)
  26. National Institute for Health and Care Excellence (2022c) Treatment Summaries. Croup. http://bnf.nice.org.uk/treatment-summary/croup.html (Last accessed: 10 October 2022.)
  27. Ogden K (2016) The use of the Paediatric Assessment Triangle in the management of the sick child. Emergency Medicine Journal. 33, 9, e4. http://emj.bmj.com/content/33/9/e4.4
  28. Parri N, Lenge M, Buonsenso D (2020) Children with COVID-19 in pediatric emergency departments in Italy. New England Journal of Medicine. 383, 2, 187-190. doi: 10.1056/NEJMc2007617
  29. Patnaik S, Zacharias G, Jain MK et al (2021) Etiology, clinical profile, evaluation, and management of stridor in children. The Indian Journal of Pediatrics. 88, 11, 1115-1120. doi: 10.1007/s12098-021-03722-8
  30. Pfleger A, Eber E (2016) Assessment and causes of stridor. Paediatric Respiratory Reviews. 18, 64-72. doi: 10.1016/j.prrv.2015.10.003
  31. Pitstick CE, Rodriguez KM, Smith AC et al (2021) A curious case of croup: laryngotracheitis caused by COVID-19. Pediatrics. 147, 1, e2020012179. doi: 10.1542/peds.2020-012179
  32. Quintero DR, Fakhoury K (2021) Assessment of Stridor in Children. http://uptodate.com/contents/assessment-of-stridor-in-children (Last accessed: 10 October 2022.)
  33. Rihkanen H, Beng ER, Nieminen T et al (2008) Respiratory viruses in laryngeal croup of young children. Journal of Pediatrics. 152, 5, 661-665. doi: 10.1016/j.jpeds.2007.10.043
  34. Sakthivel M, Elkashif S, Al Ansari K (2019) Rebound stridor in children with croup after nebulised adrenaline: does it really exist? Breathe. 15, 1, e1-e7. doi: 10.1183/20734735.0011-2019
  35. Sicari V, Zabbo CP (2022) Stridor. http://ncbi.nlm.nih.gov/books/NBK525995/ (Last accessed: 10 October 2022.)
  36. Skellett S, Maconochie I, Bingham B et al (2021) Paediatric Advanced Life Support Guidelines. http://resus.org.uk/library/2021-resuscitation-guidelines/paediatric-advanced-life-support-guidelines (Last accessed: 10 October 2022.)
  37. Smith DK, McDermott AJ, Sullivan JF (2018) Croup diagnosis and management. American Family Physician. 97, 9, 575-580.
  38. Tibballs J, Watson T (2011) Symptoms and signs differentiating croup and epiglottitis. Journal of Paediatrics and Child Health. 47, 3, 77-82. doi: 10.1111/j.1440-1754.2010.01892.x
  39. Venn AM, Schmidt JM, Mullan PC (2021) Pediatric croup with COVID-19. American Journal of Emergency Medicine. 43, 287.e1-287.e3. doi: 10.1016/j.ajem.2020.09.034
  40. Waisman Y, Klein BL, Boenning DA et al (1992) Prospective randomized double-blind study comparing L-epinephrine and racemic epinephrine aerosols in the treatment of laryngotracheitis (croup). Pediatrics. 89, 2, 302-306.
  41. Westley CR, Cotton EK, Brooks JG (1978) Nebulized racemic epinephrine by IPPB for the treatment of croup: a double-blind study. American Journal of Diseases of Children. 132, 5, 484-487. doi: 10.1001/archpedi.1978.02120300044008

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