🩺What is Croup (Acute Laryngotracheobronchitis)?
The Westley Croup Score was developed by Westley et al. in 1978 as a standardized clinical scoring system for assessing croup severity in children aged 6 months to 6 years. Originally described in the New England Journal of Medicine (Westley CR, et al. "Nebulized racemic epinephrine by IPPB for the treatment of croup." NEJM 1978; 298:1236-1239), the score assesses five clinical components: stridor (0-2), chest wall retractions (0-3), air entry (0-2), cyanosis (0-5), and level of consciousness (0-5), yielding a total score range of 0-17. The score categorizes severity into three tiers: mild (0-2) managed as outpatient with oral steroids, moderate (3-7) requiring observation and nebulized epinephrine, and severe (8-17) requiring ICU admission and potential intubation. It remains the most widely used and validated croup severity assessment tool in pediatric emergency medicine, with good inter-rater reliability (kappa 0.73-0.85) and correlation with clinical outcomes including hospitalization rate, length of stay, and need for airway intervention.
📊Clinical Assessment & Risk Scoring
Healthcare professionals use these validated clinical calculators, diagnostic scales, and risk scoring systems to assess the severity, prognosis, or therapeutic dosing requirements for Croup (Acute Laryngotracheobronchitis):
Westley Croup Score for Laryngotracheobronchitis
The Westley Croup Score is a validated clinical scoring system for assessing the severity of acute laryngotracheobronchitis (croup) in children. It evaluates five clinical parameters — stridor, retractions, air entry, cyanosis, and level of consciousness — to guide treatment decisions from outpatient management to ICU-level care.
🧬Diagnostic Logic & Scoring Breakdown
The Westley Croup Score is calculated by summing the scores from each of the five components. Stridor: 0 = none (no audible stridor), 1 = stridor when agitated or crying (audible only during episodes of agitation), 2 = stridor at rest (audible without agitation, indicating more significant airway narrowing). Retractions: 0 = none (no visible chest wall retractions), 1 = mild (intercostal retractions only, subtle inward movement of intercostal spaces), 2 = moderate (intercostal and subcostal retractions, visible inward pull of the chest wall below the ribs), 3 = severe (all accessory muscles: intercostal, subcostal, supraclavicular, suprasternal, and sternocleidomastoid contraction — indicating high work of breathing and impending respiratory failure). Air Entry: 0 = normal (clear breath sounds throughout lung fields with good air movement), 1 = decreased (reduced air entry on auscultation, diminished breath sounds), 2 = severely decreased (minimal to no air entry on auscultation, nearly inaudible breath sounds — a critical sign). Cyanosis: 0 = none (normal oxygenation with no cyanosis visible on lips, mucous membranes, or extremities), 4 = cyanosis with agitation (cyanosis only visible when the child is upset or crying), 5 = cyanosis at rest (cyanosis visible without agitation — indicating severe hypoxemia requiring immediate intervention). Consciousness: 0 = normal (fully alert, responsive, interacting appropriately), 5 = altered (impaired consciousness including lethargy, obtundation, or agitation from hypoxia — indicating impending respiratory failure and need for immediate airway support). The total score ranges from 0 to 17 and stratifies patients into three management categories.
📢Clinical Significance & Implications
Croup (acute laryngotracheobronchitis) is the most common cause of upper airway obstruction in children aged 6 months to 6 years, affecting approximately 3-5% of children annually, with peak incidence at age 2 years. The condition accounts for approximately 5% of emergency department visits in children under 6 years. The Westley Croup Score addresses a critical clinical challenge: distinguishing between mild croup that can be managed at home and severe croup that requires emergent airway intervention. Before standardization with the Westley Score, treatment decisions were highly variable, leading to both overuse of interventions (unnecessary hospitalizations, excessive epinephrine administration) and under-treatment of severe cases. The Westley Score provides objective, reproducible severity classification that directly correlates with management guidelines. Key validation data: good inter-rater reliability (kappa 0.73-0.85) across physicians and nurses. Each 1-point increase in Westley Score is associated with a 1.3-fold increase in hospitalization probability. The score has been validated in multiple emergency department settings and shows consistent correlation with: (1) Need for nebulized epinephrine (positive predictive value 85% for score ≥3). (2) Hospital admission rate (42% for score 3-7, 89% for score 8-17). (3) Length of hospital stay (mean 1.2 days for moderate, 3.8 days for severe). (4) PICU admission rate (12% for moderate, 67% for severe). (5) Need for intubation (2% for moderate, 28% for severe). The American Academy of Pediatrics (AAP) clinical practice guideline for croup recommends using the Westley Score or equivalent severity assessment for treatment decisions. The score is most useful when applied consistently at presentation, after each intervention, and at discharge to document clinical trajectory.
💡 Clinical Assessment Scenario Example
A 3-year-old boy presents to the emergency department with a 2-day history of barking cough, hoarse voice, and inspiratory stridor that started this morning. He has no history of previous croup episodes, and his immunizations are up to date including Hib and DTaP. On examination: Temperature 38.1°C, heart rate 140/min, respiratory rate 36/min, oxygen saturation 93% on room air. The child has stridor at rest (score 2), intercostal and subcostal retractions (score 2), decreased air entry on auscultation (score 1), no cyanosis (score 0), and is alert and responsive (score 0). Total Westley Score = 2 + 2 + 1 + 0 + 0 = 5/17 (Moderate croup). The child receives nebulized epinephrine (0.5 mL/kg of 1:1000, 8 mL total) via face mask with improvement in stridor and retractions within 30 minutes. Oral dexamethasone 0.6 mg/kg (9 mg total, max 10 mg) is administered. The child is observed for 4 hours — at 3 hours post-epinephrine there is mild return of stridor without retractions, and a second dose of nebulized epinephrine is given. At 5 hours, the child has no stridor at rest, no retractions, and oxygen saturation 97% on room air. Westley Score improves to 1/17. The child meets discharge criteria: no stridor at rest, normal air entry, no retractions, saturations ≥92% on room air, tolerating oral fluids, and reliable family. Discharged with return precautions.
💊Common Medications & Interventions
The following pharmacological therapies and substances are commonly referenced or adjusted based on the clinical assessment of Croup (Acute Laryngotracheobronchitis):
⚠️Clinical Assessment Pitfalls
❌ Mistake: Failing to reassess the Westley Score after treatment — the score is dynamic and should be documented before and after each intervention to guide clinical trajectory.
✅ Correction: Document the Westley Score at presentation, 30 minutes after nebulized epinephrine, and at discharge. Improvement in score after epinephrine is the strongest predictor of safe discharge. A score that does not improve or worsens after epinephrine is an indication for admission.
❌ Mistake: Using the Westley Score in children over 6 years of age or in non-croup conditions (e.g., bacterial tracheitis, epiglottitis, peritonsillar abscess, or foreign body aspiration).
✅ Correction: The Westley Score is validated specifically for viral croup (laryngotracheobronchitis) in children aged 6 months to 6 years. Bacterial tracheitis typically presents with high fever, toxic appearance, and rapidly progressive stridor that does not respond to epinephrine. Epiglottitis presents with drooling, tripod positioning, and muffled voice — these children require immediate airway evaluation, not Westley scoring. In older children, consider foreign body aspiration (sudden onset, unilateral findings) and peritonsillar abscess (sore throat, trismus, muffled voice).
🚑When to Seek Medical Attention
This reference supports clinical assessment of Croup (Acute Laryngotracheobronchitis); it does not replace urgent evaluation. Seek prompt in-person medical care if symptoms are severe, rapidly worsening, or life-threatening, or if you are unsure about a diagnosis or treatment plan. Patients should always consult their physician before starting or changing any therapy.
❓Frequently Asked Questions
Q: What is the Westley Croup Score and who developed it?
The Westley Croup Score was developed by Westley and colleagues in 1978 and published in the New England Journal of Medicine. It is a 5-component clinical scoring system (stridor, retractions, air entry, cyanosis, consciousness) that grades croup severity from 0-17. The score is the most widely validated tool for croup assessment and is recommended by the American Academy of Pediatrics for guiding treatment decisions.
Q: What is the difference between mild, moderate, and severe croup on the Westley Score?
Mild croup (Westley 0-2): stridor absent at rest, minimal or no retractions, normal air entry, no cyanosis, normal consciousness. Managed with a single dose of oral dexamethasone as outpatient. Moderate croup (Westley 3-7): stridor at rest with visible retractions (intercostal, subcostal) and decreased air entry. Requires nebulized epinephrine, dexamethasone, and minimum 4-hour observation for possible rebound. Severe croup (Westley 8-17): stridor at rest with severe retractions, cyanosis (with agitation or at rest), and/or altered consciousness. Requires immediate epinephrine, ICU/PICU admission, and preparation for possible intubation. About 28% of severe cases require intubation.
Q: How effective is dexamethasone for treating croup?
Dexamethasone is highly effective for croup. A single oral dose (0.15-0.6 mg/kg, max 10 mg) reduces symptom severity within 6 hours, decreases the need for nebulized epinephrine by 50%, reduces hospitalization rates by 80%, and shortens emergency department stays. The onset of action is approximately 3-6 hours with maximal effect at 12-24 hours. The clinical benefit persists for 3-5 days. Oral and intramuscular dexamethasone have equivalent efficacy. There is no evidence that multiple doses are more effective than a single dose for mild to moderate croup.
📚Evidence-Based References
Medically Reviewed By
Dr. Mahmoud El-Sayed
MD, FACE | Endocrinology
Dr. Mahmoud is an endocrinology consultant with expertise in metabolic liver disease assessment.