What are the treatment options for croup based on its severity?

Treatment Options for Croup Based on Severity

The treatment of croup should be guided by severity assessment using the Westley Croup Score, with all children receiving dexamethasone (0.15-0.60 mg/kg orally) regardless of severity, while reserving nebulized epinephrine for moderate to severe cases. 1

Severity Assessment

The Westley Croup Score is the recommended tool to determine 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

Severity classification:

• Mild: Score 0-2 (barking cough, no stridor at rest)
• Moderate: Score 3-6 (stridor at rest, some chest wall retractions)
• Severe: Score 7-11 (significant stridor at rest, significant retractions, decreased air entry)
• Impending respiratory failure: Score ≥12

Treatment Algorithm Based on Severity

1. Mild Croup (Score 0-2)

• Corticosteroids: Single dose of dexamethasone 0.15-0.60 mg/kg orally 1
• Supportive care:
  • Maintain calm environment
  • Ensure adequate hydration
  • Control fever with appropriate antipyretics
  • Provide parent education on warning signs 1

2. Moderate Croup (Score 3-6)

• Corticosteroids: Single dose of dexamethasone 0.15-0.60 mg/kg orally 1
• Consider nebulized epinephrine: 0.5 ml/kg of 1:1000 solution 1
• Supportive care as above
• Observation: Monitor for at least 2-3 hours after treatment to ensure improvement 2

3. Severe Croup (Score 7-11)

• Corticosteroids: Dexamethasone 0.6 mg/kg (oral, IM, or IV) 1, 2
• Nebulized epinephrine: 0.5 ml/kg of 1:1000 solution 1
• Oxygen therapy: If oxygen saturation <92% 1
• Close monitoring: Respiratory rate, work of breathing, oxygen saturation
• Consider hospital admission 1

4. Impending Respiratory Failure (Score ≥12)

• Immediate intervention
• Airway management: Consider consultation with pediatric critical care
• Corticosteroids and nebulized epinephrine as above
• Hospital admission: Likely ICU admission 1

Important Clinical Considerations

Medication Details

1. Corticosteroids:

   • Dexamethasone is the preferred corticosteroid with onset of action within 6 hours 2
   • The correct dosage (0.15-0.60 mg/kg) is crucial as lower doses may be ineffective 2
   • A single dose is usually sufficient 1, 3

2. Nebulized Epinephrine:

   • Provides rapid but temporary relief (30-120 minutes)
   • Monitor for rebound symptoms for at least 2 hours after administration 2
   • Children requiring two or more epinephrine treatments should be hospitalized 4

Common Pitfalls to Avoid

• Do not use over-the-counter cough medications as they provide no benefit and may cause harm 1
• Do not rely on humidification therapy alone, as recent studies show it provides no additional symptom improvement 5
• Do not prescribe antihistamines, decongestants, or antibiotics for uncomplicated viral croup 4
• Do not forget to consider other diagnoses that may mimic croup, including epiglottitis, foreign body aspiration, retropharyngeal abscess, bacterial tracheitis, and angioedema 1, 3

Discharge and Admission Criteria

Discharge criteria (all must be met) 1:

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

Admission criteria (any one warrants admission) 1:

• 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

Home Care Instructions

For patients discharged home 1, 4:

• Maintain adequate hydration
• Control fever with appropriate antipyretics
• Return to emergency department if increased work of breathing, lethargy, or inability to drink fluids
• Follow-up with primary care provider as needed