From the Guidelines
The initial treatment of croup should focus on supportive care and reducing airway inflammation, with a single dose of oral dexamethasone (0.6 mg/kg, maximum 10 mg) being the cornerstone of treatment for moderate to severe cases, as it reduces inflammation in the upper airway and improves symptoms within hours 1. For mild croup, cool mist therapy and keeping the child calm are often sufficient. In severe cases with respiratory distress, nebulized epinephrine (racemic epinephrine 2.25% solution 0.5 mL in 2.5 mL normal saline, or L-epinephrine 1:1000 solution 5 mL) may be administered in an emergency setting, providing temporary relief through vasoconstriction and reduced mucosal edema. Children receiving epinephrine should be observed for at least 2-3 hours after treatment due to potential symptom rebound. Oxygen should be provided to maintain saturation above 92%. Most children with croup can be managed as outpatients, but those with stridor at rest, respiratory distress, or inadequate oral intake may require hospitalization. The effectiveness of these interventions stems from their ability to reduce laryngeal inflammation and edema, thereby improving airflow through the narrowed subglottic region that causes the characteristic barking cough and stridor of croup. Some studies have shown that the implementation of clinical guidelines for croup can lead to improved patient outcomes and reduced healthcare costs, with a significant reduction in hospital admissions and neck radiograph utilization 1. However, the use of nebulized adrenaline (0.5 ml/kg of a 1:1000 solution) should be limited to avoiding intubation, stabilizing children prior to transfer to intensive care, and in stridor following intubation, as its effect is short-lived (1-2 hours) and it should not be used in children who are shortly to be discharged or on an outpatient basis 1. Overall, the goal of treatment is to reduce morbidity, mortality, and improve quality of life for children with croup. Key considerations in the treatment of croup include:
- Providing supportive care and reducing airway inflammation
- Using oral dexamethasone as the cornerstone of treatment for moderate to severe cases
- Administering nebulized epinephrine in severe cases with respiratory distress
- Observing children receiving epinephrine for at least 2-3 hours after treatment
- Providing oxygen to maintain saturation above 92%
- Managing most children with croup as outpatients, but hospitalizing those with stridor at rest, respiratory distress, or inadequate oral intake.
From the Research
Initial Treatment of Croup
The initial treatment of croup typically involves supportive care and may include the use of corticosteroids and nebulised epinephrine (adrenaline) in moderate to severe cases 2. The goal of treatment is to relieve respiratory distress and reduce the risk of further deterioration.
Corticosteroids in Croup Treatment
Corticosteroids, such as dexamethasone and prednisolone, are commonly used in the treatment of croup. They have been shown to improve symptoms and reduce the need for hospitalization 3, 4. A single oral dose of dexamethasone 0.15 mg/kg is often used, although prednisolone 1 mg/kg may also be effective 3, 5.
Heliox in Croup Treatment
Helium-oxygen (heliox) inhalation has been studied as a potential treatment for croup, particularly in moderate to severe cases. Some evidence suggests that heliox may provide short-term benefits in relieving respiratory distress, although its effectiveness compared to standard treatments is unclear 2, 6.
Key Points in Croup Management
- Assess airway, breathing, and circulation, focusing on airway 5
- Use corticosteroids, such as dexamethasone or prednisolone, in mild to moderate croup 3, 4, 5
- Consider heliox inhalation in moderate to severe croup, although its effectiveness is uncertain 2, 6
- Use nebulised epinephrine (adrenaline) in severe or life-threatening croup 5