What is the treatment for croup (laryngotracheobronchitis)?

From the Guidelines

Croup treatment should primarily focus on managing symptoms and reducing airway inflammation, with a single dose of oral dexamethasone (0.15-0.6 mg/kg, maximum 10 mg) being the mainstay treatment for moderate to severe cases, as it reduces inflammation and improves symptoms within hours 1.

Key Considerations

• For mild croup, cool mist therapy and keeping the child calm are often sufficient.
• In emergency settings, nebulized epinephrine (racemic epinephrine 2.25% solution, 0.5 mL in 2.5 mL saline, or L-epinephrine 1:1000,5 mL) may be used for temporary relief of severe symptoms, but this requires monitoring as symptoms can return.
• Hospitalization is necessary for children with severe respiratory distress, oxygen saturation below 92%, or those who don't respond to initial treatments.
• Antibiotics are not effective since croup is typically viral.

Patient Advice

• Parents should be advised to keep children well-hydrated, positioned upright for easier breathing, and to seek immediate medical attention if the child develops blue lips, severe difficulty breathing, drooling, or inability to swallow.
• Steroids work by reducing inflammation in the larynx and trachea, which helps decrease the characteristic barking cough and stridor associated with croup.

Evidence-Based Practice

• A recent study found that croup quality improvement interventions were associated with a significant decrease in hospital admissions with no increase in revisits 1.
• The use of a clinical guideline and orderset to reduce hospital admissions for croup has been shown to be effective in reducing admissions by 37% 1.

From the Research

Croup Treatment Overview

• Croup is a common respiratory illness affecting children, characterized by upper airway obstruction resulting from swelling of the larynx, trachea, and bronchi, leading to inspiratory stridor and a barking cough 2.
• The mainstay of croup treatment is a single dose of oral, intramuscular, or intravenous dexamethasone, which improves symptoms and reduces return visits and length of hospitalization in children with croup of any severity 2, 3, 4.

Medication Dosage

• A single dose of orally administered dexamethasone (0.15-0.6 mg/kg) is effective in treating croup, with 0.15 mg/kg being as effective as 0.3 or 0.6 mg/kg in relieving symptoms and resulting in a similar duration of hospitalization 5.
• Nebulized epinephrine provides effective additional therapy for more severe cases, with a low dose (0.1 mg/kg) being not inferior to the conventional dose (0.5 mg/kg) in patients with moderate to severe croup 6.

Treatment Approaches

• In patients with moderate to severe croup, the addition of nebulized epinephrine improves symptoms and reduces length of hospitalization 2, 3.
• Nebulized budesonide (2 mg) can be given alternatively to children who do not tolerate oral dexamethasone 4.
• Breathing heliox can potentially reduce the work of breathing related to upper airway obstruction, although limited data are available 3, 4.

Diagnostic Considerations

• Laboratory studies are seldom needed for diagnosis of croup, and viral cultures and rapid antigen testing have minimal impact on management and are not routinely recommended 2.
• Radiography and laryngoscopy should be reserved for patients in whom alternative diagnoses are suspected 2.