What is the recommended management for croup?

Management of Croup

The recommended management for croup includes a single dose of dexamethasone (0.15-0.60 mg/kg orally) for all children with croup, even mild cases, with nebulized epinephrine (0.5 ml/kg of 1:1000 solution) reserved for moderate to severe cases. 1

Assessment and Severity Classification

Proper assessment of croup severity is crucial for appropriate management:

• Westley Croup Score is recommended to determine severity 1:

  • Mild: Barking cough without stridor at rest
  • Moderate: Stridor at rest with some chest wall retractions
  • Severe: Significant stridor at rest, significant retractions, and decreased air entry

• Key assessment parameters:

  • 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)

Treatment Algorithm

For All Croup Patients:

1. Corticosteroids:

   • Single dose of dexamethasone 0.15-0.60 mg/kg orally (maximum 10-12 mg) 1, 2
   • Benefits: Reduces inflammation, improves symptoms, reduces hospitalizations and length of illness 2
   • Route alternatives:
     • Oral administration is preferred due to ease, availability, and low cost 2
     • Intramuscular administration for patients who are vomiting or in severe respiratory distress 2

2. Avoid over-the-counter cough medications:

   • Provide no benefit and may cause harm 1

For Moderate to Severe Croup:

1. Nebulized epinephrine:

   • Dosage: 0.5 ml/kg of 1:1000 solution 1
   • Benefits: Quickly reduces airway swelling
   • Important: Monitor for rebound airway obstruction for at least 2 hours after administration 3

2. Supportive care:

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

Monitoring:

• Closely monitor respiratory rate, work of breathing, and oxygen saturation
• Watch for signs of deterioration:
  • Increased work of breathing
  • Lethargy
  • Cyanosis 1

Discharge and Admission Criteria

Safe Discharge Criteria:

• Significant improvement in symptoms
• No stridor at rest after treatment
• Patient can tolerate oral fluids
• No repeated doses of epinephrine required
• Oxygen saturation ≥92% on room air 1

Hospital Admission Criteria:

• 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

Important Clinical Considerations

Differential Diagnosis:

Always consider other causes of stridor that may mimic croup 1:

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

Common Pitfalls to Avoid:

1. Underestimating mild croup: Even mild cases benefit from corticosteroid treatment 1, 4
2. Overreliance on humidification: Evidence for benefit of cool mist humidification is limited 1, 5
3. Inadequate monitoring after epinephrine: Failure to observe for rebound effects for at least 2 hours 3
4. Incorrect dosing of dexamethasone: Lower steroid dosages have proven ineffective in treating croup 3
5. Missing alternative diagnoses: Failure to consider other causes of stridor can lead to inappropriate management 1

Prognosis:

• Most episodes of croup are mild
• Only 1-8% of patients require hospital admission
• Less than 3% of admitted patients require intubation 4