What are the management options for croup?

Croup Management

Dexamethasone 0.15-0.60 mg/kg orally as a single dose is recommended for all severities of croup, with nebulized epinephrine (0.5 ml/kg of 1:1000 solution) added for moderate to severe cases. 1

Diagnosis and Assessment

Croup presents with:

• Barking cough
• Inspiratory stridor
• Hoarse voice
• Respiratory distress
• Most common in children 6 months to 6 years (peak in second year of life) 1

Severity Assessment

• Mild: Barking cough, no audible stridor at rest, minimal/no respiratory distress
• Moderate: Barking cough, audible stridor at rest, some respiratory distress
• Severe: Prominent inspiratory and expiratory stridor, significant respiratory distress, agitation or lethargy 1

Key Monitoring Parameters

• Respiratory rate
• Work of breathing
• Oxygen saturation (provide supplemental oxygen if <92%)
• Signs of deterioration (increased work of breathing, lethargy, cyanosis) 1

Treatment Algorithm

1. All Croup Cases (Mild, Moderate, Severe)

• Dexamethasone 0.15-0.60 mg/kg orally as a single dose 1
  • Maximum dose: 10-12 mg 2
  • Reduces symptoms, return visits, and length of hospitalization 1
  • For patients unable to tolerate oral medication (vomiting or severe respiratory distress), use intramuscular dexamethasone 2
  • Oral and intramuscular routes have similar efficacy 3

2. Moderate to Severe Croup (Additional Treatment)

• Nebulized epinephrine for moderate to severe cases 1, 4
  • Dosing: 0.5 ml/kg of 1:1000 solution (maximum: 5 mL = 5 mg) 1
  • Alternative: 0.05 mL/kg of 2.25% racemic epinephrine solution (maximum: 0.5 mL) in 2 mL normal saline 1
  • Observe for at least 2-3 hours after administration (effect lasts 1-2 hours) 1
  • Consider admission after 3 total doses 1

3. Supportive Care

• Maintain calm environment
• Position child comfortably
• Ensure adequate hydration
• Provide supplemental oxygen if saturation <92% 1

Hospital Admission Criteria

Consider hospital admission if any of the following are present:

• Oxygen saturation <92% or cyanosis
• Significant respiratory distress persisting after treatment
• Stridor at rest persisting after treatment
• Need for more than one dose of nebulized epinephrine
• Inability to tolerate oral fluids
• Toxic appearance 1

Important Clinical Considerations

Treatment Efficacy

• Most croup cases resolve within 2 days 1
• Only 1-8% require hospital admission 1, 4
• Less than 3% of admitted patients require intubation 4

Common Pitfalls to Avoid

1. Unnecessary imaging: Avoid routine imaging unless suspecting alternative diagnosis or failure to respond to standard therapy 1
2. Discharging too soon after epinephrine: Observe for 2-3 hours after nebulized epinephrine due to potential rebound symptoms 1
3. Humidification therapy: Has not been proven beneficial 4
4. Overlooking alternative diagnoses: Consider bacterial tracheitis, epiglottitis, foreign body aspiration, peritonsillar abscess, retropharyngeal abscess, and angioedema 4

Follow-up Care

• Review if symptoms not improving after 48 hours 1
• Educate parents about potential for symptom recurrence and when to seek medical attention

Alternative Treatments

• Nebulized budesonide (2 mg) can be used if oral dexamethasone is not tolerated 5
• Studies show similar effectiveness between nebulized budesonide, oral and parenteral dexamethasone 6