What is the treatment protocol for a pediatric patient with croup and stridor?

Treatment Protocol for Breaking Stridor in Pediatric Patients with Croup

For pediatric patients with croup and stridor, administer dexamethasone 0.15-0.60 mg/kg orally as a single dose for all severity levels, and use nebulized epinephrine (0.5 ml/kg of 1:1000 solution) for moderate to severe cases (Westley Croup Score ≥3). 1

Assessment of Severity

The Westley Croup Score should be used to assess severity:

Parameter	0 points	1 point	2 points	3 points	4 points	5 points
Stridor	None	When agitated	At rest	-	-	-
Retractions	None	Mild	Moderate	Severe	-	-
Air entry	Normal	Decreased	Markedly decreased	-	-	-
Cyanosis	None	-	-	With agitation	At rest	-
Level of consciousness	Normal	-	-	-	-	Altered

• Mild croup: Score 0-2
• Moderate croup: Score 3-5
• Severe croup: Score 6-11
• Impending respiratory failure: Score ≥12

Treatment Algorithm

Step 1: Initial Management for All Patients

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

Step 2: Medication Based on Severity

• Mild Croup (Score 0-2):

  • Dexamethasone 0.15-0.60 mg/kg orally as a single dose 1, 2

• Moderate to Severe Croup (Score ≥3):

  • Dexamethasone 0.15-0.60 mg/kg orally as a single dose 1
  • PLUS nebulized epinephrine (0.5 ml/kg of 1:1000 solution) 1
  • If oral administration is not tolerated, use intramuscular dexamethasone at the same dose 2, 3
  • Alternative: Nebulized budesonide 2 mg for children who cannot tolerate oral dexamethasone 4

Step 3: Monitoring After Treatment

• Monitor for at least 2-3 hours after nebulized epinephrine administration to observe for rebound symptoms 1, 2
• Reassess the croup score 15-30 minutes after initial treatment and regularly thereafter 1
• Continuous oxygen saturation monitoring in moderate to severe cases 1

Step 4: Criteria for Hospital Admission

Consider hospital admission if any of the following are present:

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

Step 5: Discharge Criteria

Patients can be discharged if:

• Significant improvement in symptoms
• Able to tolerate oral fluids
• Do not require repeated doses of epinephrine 1
• Arrange follow-up within 48 hours if symptoms persist

Important Considerations

• Avoid routine imaging unless there is suspicion of an alternative diagnosis or failure to respond to standard therapy 1
• Avoid nebulized epinephrine for children who will be discharged shortly, as the effect is short-lived (1-2 hours) and rebound symptoms may occur 1
• Correct dosage of dexamethasone is critical, as lower steroid dosages have proven ineffective in treating croup 2
• Simultaneous administration of corticosteroid and epinephrine reduces the rate of intubation in patients with severe croup and impending respiratory failure 3
• Heliox can potentially reduce the work of breathing related to upper airway obstruction in severe cases 4
• Flexible bronchoscopy should be considered in cases of persistent/unexplained stridor that does not respond to standard therapy, to rule out anatomical abnormalities 5

Differential Diagnosis Considerations

Always consider other causes of stridor that may mimic croup:

• Epiglottitis
• Foreign body aspiration
• Retropharyngeal abscess
• Bacterial tracheitis
• Airway hemangioma 5
• Congenital anomalies of the larynx 5

Proper identification of the cause of stridor is essential for appropriate management, as treatment approaches differ significantly between these conditions.