Westley croup severity score

Clinical feature			Assigned score
Level of consciousness
Normal, including sleep			0
Disoriented			5
Cyanosis
None			0
With agitation			4
At rest			5
Stridor
None			0
With agitation			1
At rest			2
Air entry
Normal			0
Decreased			1
Markedly decreased			2
Retractions
None			0
Mild			1
Moderate			2
Severe			3
Total
Score total	Severity	Description	Management
≤2	Mild	Occasional barky cough, no stridor at rest, mild or no retractions	Home treatment – Symptomatic care including antipyretics and oral fluids Outpatient treatment – Single dose of oral dexamethasone* 0.15 to 0.6 mg/kg (maximum 16 mg) or oral prednisolone (1 mg/kg)
3 to 7	Moderate	Frequent barky cough, stridor at rest, mild to moderate retractions	Single dose of oral dexamethasone 0.6 mg/kg (maximum 16 mg)* Nebulized epinephrine^¶ Hospitalization is generally not needed but may be warranted for persistent or worsening symptoms after treatment with glucocorticoid and nebulized epinephrine
8 to 11	Severe	Frequent barky cough, stridor at rest, marked retractions, significant distress	Single dose of oral/IM/IV dexamethasone 0.6 mg/kg (maximum 16 mg)* Repeated doses of nebulized epinephrine^¶ may be needed Inpatient admission is generally required unless marked improvement occurs after treatment with glucocorticoid and nebulized epinephrine
≥12	Impending respiratory failure	Depressed level of consciousness, stridor at rest, severe retractions, poor air entry, cyanosis or pallor	Single dose of IM/IV dexamethasone 0.6 mg/kg (maximum 16 mg) Repeated doses of nebulized epinephrine^¶ may be needed Intensive care unit admission is generally required Consultation with anesthesiologist or ENT surgeon may be warranted to arrange for intubation in a controlled setting

IM: intramuscular; IV: intravenous; ENT: ear, nose, throat.

* The oral liquid preparation of dexamethasone (1 mg/mL) has a foul taste. Solutions for injection are more concentrated (4 mg/mL or 10 mg/mL) and can be given orally mixed with syrup. Alternatively, oral tablets can be crushed and mixed with syrup or pureed food.

¶ Dosing and administration are as follows:

Racemic epinephrine: 0.05 mL/kg per dose (maximum of 0.5 mL) of a 2.25% solution diluted to 3 mL total volume with normal saline (in the United States and some other countries, single-use preservative-free bullets [ampules] of racemic epinephrine for nebulized administration are commercially available).
L-epinephrine: 0.5 mL/kg per dose (maximum of 5 mL) of a 1 mg/mL (1:1000) preservative-free solution (this is the parenteral preparation of epinephrine used for IM injection [eg, for anaphylaxis]).

Administer by nebulizer over 15 minutes. Use of either product is acceptable and may be determined by availability and institutional protocol. Nebulized epinephrine has an onset of effect within 10 minutes. Refer to UpToDate topic on management of croup for additional details.

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Westley croup severity score