From the Guidelines
The management of croup is guided by severity as determined by the croup score, with treatment strategies aimed at reducing morbidity, mortality, and improving quality of life. For mild croup (score 0-2), characterized by occasional barky cough with no stridor at rest, observation and supportive care are recommended with reassurance to parents. For moderate croup (score 3-5), which presents with frequent barky cough, audible stridor at rest, and mild retractions, a single dose of oral dexamethasone (0.6 mg/kg, maximum 16 mg) is the mainstay of treatment, as supported by recent studies 1. For severe croup (score 6-8), featuring prominent stridor at rest, marked retractions, and agitation, treatment includes dexamethasone plus nebulized epinephrine (racemic epinephrine 2.25% 0.5 mL in 2.5 mL normal saline or L-epinephrine 1:1000 5 mL). The use of clinical guidelines and ordersets has been shown to reduce hospital admissions for croup without significant increase in revisits or readmissions 1.
Some key points to consider in the management of croup include:
- The importance of assessing the croup score to guide treatment decisions
- The use of dexamethasone and nebulized epinephrine in moderate to severe croup
- The need for observation for at least 2-4 hours after epinephrine administration due to the risk of rebound symptoms
- The potential benefits of using clinical guidelines and ordersets to reduce hospital admissions and improve outcomes, as demonstrated in a study published in Pediatrics 1
- The lack of strong evidence for the efficacy of humidified air in providing symptomatic relief, although it may still be used as a supportive measure
Overall, the goal of croup management is to provide effective treatment while minimizing the risk of complications and reducing the need for hospital admission, as supported by the most recent and highest quality studies 1.
From the Research
Management Approach for Patients with Croup Based on Their Croup Score
The management approach for patients with croup is based on the severity of their symptoms, which can be assessed using a croup score. The croup score takes into account factors such as the level of stridor, retractions, and respiratory distress.
- Mild Croup: For patients with mild croup, treatment may include mist therapy, acetaminophen for fever reduction, and observation 2.
- Moderate Croup: For patients with moderate croup, treatment may include corticosteroids, such as dexamethasone, and nebulized epinephrine 3, 4, 5.
- Severe Croup: For patients with severe croup, treatment may include heliox, a mixture of helium and oxygen, to reduce respiratory distress, as well as corticosteroids and nebulized epinephrine 6.
Croup Score Assessment
The croup score is used to assess the severity of croup symptoms. The score is based on the level of stridor, retractions, and respiratory distress.
- Croup Score: The croup score ranges from 0 to 17, with higher scores indicating more severe symptoms 6, 3, 4, 2, 5.
- Treatment Based on Croup Score: Treatment for croup is based on the croup score, with more severe symptoms requiring more intensive treatment.
Treatment Options
There are several treatment options available for croup, including:
- Corticosteroids: Corticosteroids, such as dexamethasone, are commonly used to treat croup, especially in patients with moderate to severe symptoms 3, 4, 5.
- Nebulized Epinephrine: Nebulized epinephrine is used to treat severe croup, especially in patients with significant respiratory distress 3, 4.
- Heliox: Heliox, a mixture of helium and oxygen, is used to treat severe croup, especially in patients with significant respiratory distress 6.
- Mist Therapy: Mist therapy is used to treat mild croup, especially in patients with minimal respiratory distress 2.