What is the treatment algorithm for croup?

Treatment Algorithm for Croup

The treatment of croup should follow a stepwise approach with oral corticosteroids for all cases regardless of severity, and nebulized epinephrine reserved for moderate to severe cases, with hospital admission considered only after three doses of racemic epinephrine are needed. 1

Assessment and Diagnosis

• Croup typically presents with sudden onset of barking cough, stridor, hoarse voice, and respiratory distress, usually without fever or other respiratory symptoms like antecedent cough or congestion 1, 2
• Assess for signs of respiratory distress: stridor, accessory muscle use, tracheal tug, sternal/subcostal/intercostal recession 2
• Radiographic studies are generally unnecessary and should be avoided unless there is concern for an alternative diagnosis 1, 2
• Important differential diagnoses include bacterial tracheitis and foreign body aspiration 1, 2

Severity Assessment

• Mild croup: barking cough without stridor at rest or minimal stridor only with agitation 3
• Moderate croup: stridor at rest with some chest wall retractions 3
• Severe croup: prominent stridor at rest, significant retractions, and signs of fatigue or hypoxemia 3, 4

Treatment Based on Severity

For All Patients with Croup (Regardless of Severity)

• Administer oral corticosteroids: dexamethasone 0.15-0.6 mg/kg as a single dose 1, 3
• Alternative if oral medication not tolerated: nebulized budesonide 2 mg 3

For Moderate to Severe Croup (Stridor at Rest or Respiratory Distress)

• Add nebulized epinephrine: 0.5 ml/kg of 1:1000 solution nebulized 5, 1
• Provide supplemental oxygen to maintain oxygen saturation ≥94% 1
• Monitor for at least 2 hours after the last dose of nebulized epinephrine to assess for rebound symptoms 1

For Severe Croup with Significant Respiratory Distress

• Ensure emergency equipment is readily available, including appropriate facemasks and airway adjuncts 2
• Consider ICU admission if there is progressive respiratory distress despite treatment 4

Hospitalization Criteria

• Consider hospital admission when three or more doses of racemic epinephrine are required 5, 1
• This approach can reduce hospitalization rates by approximately 37% without increasing revisits or readmissions 1

Important Considerations and Pitfalls

• Nebulized epinephrine should not be used in children who are shortly to be discharged or on an outpatient basis due to the risk of rebound symptoms (typically within 1-2 hours) 5, 1
• Antihistamines, decongestants, and antibiotics have no proven effect on uncomplicated viral croup 6
• Exposure to cold air or administration of cool mist are treatment interventions that are not supported by published evidence 3
• Blind finger sweeps should not be performed in cases of suspected foreign body aspiration 2

Home Care Instructions

• Adequate hydration and fever control 6
• Clear instructions on when to return for care (worsening stridor, increased work of breathing) 4
• Follow-up with primary care provider as needed 4