Westley Croup Score
- Consider croup (laryngotracheobronchitis) in patients aged 6 months to 6 years with acute-onset syndrome of stridor, barking cough, hoarseness, and respiratory distress, sometimes concurrently with URI symptoms.
- Croup is a clinical diagnosis based on history and physical exam. Severity of croup can be quantified via the Westley Croup Score, though, clinically it is not used to guide therapy. Instead, it is used to measure a patient’s response to therapy.
- Researchers have attempted to separate this entity from “spasmodic” (i.e., recurrent, short-lived) croup, which may be due to allergic reaction of viral antigens.
- Presentation and pathology may be the same, which makes response to treatment difficult to determine. As a result, many authorities consider these entities part of the same disease spectrum
- This score is traditionally used for clinical research purposes in order to track patient response over time to treatment.
- Has been used with moderate reliability to assess for post-extubation upper airway obstruction.
- The original score (Westley 1978) was derived to objectively measure a clinical state in order to allow comparisons over time in response to treatment.
- Developed to compare the response of nebulized racemic epinephrine versus saline, not to derive a prognostic scoring system.
- The range of values for each of the five items was arbitrary and each was weighted based on the clinical implications of the most critical form of each sign.
- Follow-up studies demonstrated construct validity (Klassen 1999), with multiple studies showing high inter-rater reliability (Klassen 1999, Super 1989).
- Most commonly used scoring system for croup.
- Designed to measure severity for research settings, but often applied to prognosticate. May be useful in determining treatment efficacy and patient disposition.
- Has fair inter-rater reliability in clinical users (though better in research studies).
- Change in score correlates well with patient disposition and global assessment as rated by both parents and ED physicians.
- Continues to be used in studies for treatment of croup since its validity and reliability among users were demonstrated.
Please fill out required fields.
- Definitions of croup severity are neither widely accepted nor rigorously derived.
- A more clinically relevant classification scheme was developed by the Alberta Medical Association Clinical Practice Guideline Working Group.
- Severity classifications are correlated with Westley Croup Scores.
- Treatment algorithms differ among institutions.
- A 2012 Cochrane review showed that glucocorticoids improved the Westley Croup Score at 6 and 12 hours, prevented repeat visits, and decreased length of stay (Russell 2011).
- The optimal dose of glucocorticoid has not yet been determined, though conventionally, the dose used is 0.6mg/kg of dexamethasone, administered IV or orally (Russell 2011).
- A small study in Thailand compared 0.15mg/kg to 0.6mg/kg and found no difference in Westley Croup Score, though this was a small study (n = 41) and patients also received racemic epinephrine nebulization prior to steroid administration (Chubb-Uppakarn 2007).
The Westley Croup Score was designed to track changes in the presentation of croup over time, and is primarily used in research studies. Croup remains a clinical diagnosis, with the hallmark symptoms of barky cough, hoarse voice, with or without stridor.
5 items using a Likert-type scale with zero representing the normal state. Points assigned as above.
Facts & Figures
|Level of Severity||Characteristics||Corresponding Westley |
|Mild||Occasional barking cough||0-2|
|None - limited stridor at rest|
|None to mild suprasternal and/or intercostal indrawing |
(retractions of the skin of the chest wall)
|Moderate||Frequent barking cough||3-5|
|Easily audible stridor at rest|
|Suprasternal and sternal wall retraction at rest|
|Little to no distress or agitation|
|Severe||Frequent barking cough||6-11|
|Prominent inspiratory and occasionally expiratory stridor|
|Marked sternal wall retractions|
|Significant distress and agitation|
|Impending Respiratory |
|Barking cough (often non prominent)||12-17|
|Audible stridor at rest (occasionally hard to hear)|
|Sternal wall retractions (may not be marked)|
|Lethargy or decreased level of consciousness|
|Often dusky complexion without supplemental oxygen|
*Adapted from Bjornson 2005.
- The “Stridor” and “Retractions” items were modified in the 2 validation studies with the intention of increasing inter-rater reliability.
- Modified “Stridor” item used in 2 validation studies.
|Validated “Stridor” Item**|
|At rest, with stethoscope||+1|
|At rest, without stethoscope||+2|
**Adapted from Super 1989.
- Differing definitions of “Retractions” used in original Westley score vs 2 validation studies.
|Definition of 'Retractions' item|
|Westley 1978||4-point scale (as above) otherwise unspecified|
|Super 1989||Take highest of each independently scored site (i.e., alar, intercostal, |
supraclavicular, & subcostal) on the 4-point scale
|Klassen 1999||Severity at the intercostal & subcostal regions on 4-point scale|
- Methodology for original and follow-up validation studies (Klassen 1999, Super 1989) was rigorous: prospective double-blind, randomized, placebo-controlled trials with a stringent definition of croup, and exclusion of the most mild or short-lived cases through pre-enrollment standardized mist therapy for all patients.
- The primary outcome common to many treatment trials that used the Westley Croup Score is a positive clinical response defined as a reduction in the score by 2 points, or return to a score of 0-1.
- Mild, moderate, and severe classifications and standardized treatments were studied and developed years later.
- In the inter-rater reliability analysis performed by Super et al (1989), investigators had identical scores in 75% cases while the remaining scores different by only one unit, for a weighted kappa of 0.75.
- Inter-rater reliability analysis in Klassen et al (1999) demonstrated a weighted kappa of 0.95 ± 0.02 amongst research assistants and primary investigators.
- Since 1994, the score has been further validated and is the main scoring criteria used in evaluation of the patient’s response to treatment in clinical trials (Russell 2011).
- In 2012, the Cochrane group updated the meta-analysis of glucocorticoids for croup. They identified 41 trials of glucocorticoids versus placebo or any other treatment modality. Their analysis showed an improved Westley Croup Score for patients at 6 and 12 hours that was significant. The Westley Croup Score was considered a primary outcome. Secondary outcomes included length of stay and use of another treatment modality (Russell 2011).
Original/Primary ReferenceWestley CR, Cotton EK, Brooks JG. Nebulized racemic epinephrine by IPPB for the treatment of croup: a double-blind study. Am J Dis Child. 1978 May;132(5):484-7.
ValidationSuper DM, et al. A Prospective Randomized Double-Blind Study to Evaluate the Effect of Dexamethasone in Acute Laryngotracheitis. J Pediatr. 1989; 115: 323-9.Klassen TP. Croup. A current perspective. Pediatr. Clin. North Am. 1999;46 (6): 1167–78. doi:10.1016/S0031-3955(05)70180-2. PMID 10629679.
Clinical Practice GuidelinesGuideline for the Diagnosis and Management of Croup. Alberta, ON, Canada: Alberta Medical Association, 2008 update. (Accessed Jan 26, 2015)
Other ReferencesBjornson CL, Johnson DW. Croup – Treatment update. Pediatric Emergency Care. 2005; 21(12): 863-73.Cherry JD. Clinical practice. Croup. N. Engl. J. Med. 2008;358 (4): 384–91. doi:10.1056/NEJMcp072022. PMID 18216359.Johnson D. Croup. Clin Evid (Online) 2009.PMC 2907784. PMID 19445760.Russell KF, Liang Y, O'gorman K, Johnson DW, Klassen TP. Glucocorticoids for croup. Cochrane Database Syst Rev. 2011;(1):CD001955.Chub-uppakarn S, Sangsupawanich P. A randomized comparison of dexamethasone 0.15 mg/kg versus 0.6 mg/kg for the treatment of moderate to severe croup. Int J Pediatr Otorhinolaryngol. 2007;71(3):473-7
About the Creator
Terry Klassen, MD, is the CEO and Scientific Director for the Children’s Hospital Research Institute of Manitoba. He is also head of the Department of Pediatrics and Child Health and scientific director of the George and Fay Yee Centre for Healthcare Innovation at the University of Manitoba. Dr. Klassen co-founded StaR Child Health to improve child-focused randomized control trial design, implementation and publication.
To view Dr. Terry Klassen's publications, visit PubMed
- Joshua Beiner, MD
- Matthew Lecuyer, MD