What is the treatment for croup?

From the Guidelines

The treatment for croup depends on its severity, and the most effective approach is to use a clinical guideline and orderset to reduce hospital admissions, as shown in a recent study published in Pediatrics 1. For mild cases, home management with cool mist humidification, hydration, and comfort measures is often sufficient. Moderate to severe croup typically requires medical intervention with dexamethasone (0.6 mg/kg, maximum 16 mg) given as a single oral, intramuscular, or intravenous dose, which reduces airway inflammation and symptoms within hours and lasts for several days 1. Some key points to consider when treating croup include:

• For severe respiratory distress, nebulized epinephrine (racemic epinephrine 2.25% solution 0.5 mL in 3 mL saline or L-epinephrine 1:1000 solution 5 mL) may be administered in a medical setting, providing temporary relief for 1-2 hours.
• Children receiving epinephrine should be observed for at least 2-3 hours after treatment as symptoms may return.
• Supplemental oxygen is provided if oxygen saturation falls below 92%.
• Most children improve rapidly with appropriate treatment, though symptoms may persist for several days.
• Parents should seek immediate medical attention if their child develops increased work of breathing, stridor at rest, difficulty swallowing, or appears anxious or fatigued. A recent quality improvement initiative demonstrated a significant decrease in hospital admissions for croup without an increase in revisits, highlighting the importance of evidence-based guidelines in managing this condition 1. The use of a clinical guideline and orderset has been shown to be effective in reducing hospital admissions for croup, with a 37% relative reduction in hospital admission following ED encounters for croup, as reported in a study published in Pediatrics 1. Overall, the treatment of croup should prioritize reducing morbidity, mortality, and improving quality of life, and the use of evidence-based guidelines and clinical protocols is essential in achieving these goals.

From the Research

Croup Treatment Overview

• Croup is a disease that is commonly seen in children younger than the age of 6 years, caused by viral infections, with parainfluenza viruses and RSV being the two most common pathogens 2.
• Treatment consists primarily of supportive care, with parents usually trying humidification and cool air exposure before presenting to the emergency department 2.

Medications Used in Croup Treatment

• Corticosteroids, such as oral dexamethasone, improve symptoms but take time for a full effect to be achieved, and are often used in combination with nebulised epinephrine (adrenaline) for moderate to severe cases 3, 2, 4.
• Nebulised epinephrine may result in dose-related adverse effects, including tachycardia, arrhythmias, and hypertension, and its benefit may be short-lived 3.
• Helium-oxygen (heliox) inhalation has shown therapeutic benefit in initial treatment of acute respiratory syncytial virus (RSV) bronchiolitis and may prevent morbidity and mortality in ventilated neonates, with some evidence suggesting a short-term benefit in children with moderate to severe croup 3.

Treatment Approaches

• For mild croup, treatment with humidified oxygen may be equivalent to heliox, suggesting that heliox is not indicated in this group of patients provided that 30% oxygen is available 3.
• For moderate to severe croup, treatment with corticosteroids and nebulised epinephrine is often required, with some studies suggesting that low-dose nebulized epinephrine may be effective and not inferior to conventional doses 5.
• Multidose nebulized epinephrine may be used in the outpatient management of croup, with a retrospective analysis suggesting that patients requiring multidose nebulized epinephrine are less likely to return for further care if discharged from the emergency department 6.

Key Considerations

• Diagnosis and assessment of severity of croup remain clinical, with the Westley scale scores used to measure the severity of croup 5.
• Safety of discharge from an emergency department after treatment with corticosteroids and nebulized epinephrine has been established, but no evidence exists regarding risk associated with discharge after multidose nebulized epinephrine 6.