Westley Croup Score

Why Use

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.

When to Use

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.

Formula

Pearls / Pitfalls

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 ).

Management

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 ).

Critical Actions

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.

Advice

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.

More Information

Score interpretation*: Level of Severity Characteristics Corresponding Westley Croup Score 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 Failure 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 . Notes 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** None 0 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