Treatment of Croup
Oral corticosteroids are recommended for all cases of croup regardless of severity, with nebulized epinephrine reserved for moderate to severe cases. 1
First-Line Treatment
- Dexamethasone (0.15-0.6 mg/kg, single oral dose) is the first-line treatment for all patients with croup, including those with mild disease 1, 2
- A single dose of dexamethasone has been shown to reduce return visits, hospital admissions, and length of stay in emergency departments 2
- Lower doses of dexamethasone (0.15 mg/kg) are as effective as higher doses (0.6 mg/kg) for most cases 2
- Oral administration is the preferred route for dexamethasone, but intramuscular administration can be used for patients who are vomiting or in severe respiratory distress 3
Treatment for Moderate to Severe Croup
- Nebulized epinephrine should be added for moderate to severe cases with stridor at rest or respiratory distress 1, 4
- Dosage: 0.5 mL/kg of 1:1000 solution (maximum: 5 mL) administered by nebulizer 4
- If racemic epinephrine is not available, L-epinephrine (1:1000) can be substituted at the same dosage 4
- The effect of nebulized epinephrine is short-lived, lasting approximately 1-2 hours 1
- Nebulized epinephrine should NOT be used in children who are shortly to be discharged or on an outpatient basis due to risk of rebound symptoms 1, 5
Oxygen Therapy
- Oxygen therapy should be administered to maintain oxygen saturation ≥94% 1
- Use simple oxygen masks or tight-fitting non-rebreathing masks as needed 1
Hospitalization Criteria
- Consider hospital admission when three or more doses of racemic epinephrine are required 1, 6
- Recent guidelines have shown that limiting hospital admission until 3 doses of racemic epinephrine are needed can reduce hospitalization rates by 37% without increasing revisits or readmissions 1
Ineffective Treatments
- Humidification therapy (mist/humidified air) has not been proven beneficial and provides no demonstrable benefit in the acute setting 7, 8, 2
- Antihistamines, decongestants, and antibiotics have no proven effect on uncomplicated viral croup 9
Important Considerations
- Assess for signs of respiratory distress: stridor, accessory muscle use, tracheal tug, sternal/subcostal/intercostal recession 5
- Consider alternative diagnoses if patient fails to respond to standard croup treatment, including bacterial tracheitis, epiglottitis, foreign body aspiration, peritonsillar abscess, retropharyngeal abscess, and angioedema 7, 5
- Radiographic studies are generally unnecessary for typical croup and should be avoided unless there is concern for an alternative diagnosis 1, 5
- Most episodes of croup are mild, with only 1-8% of patients requiring hospital admission and less than 3% of admitted patients requiring intubation 7