Current Therapy for Croup
The current standard of care for croup is oral corticosteroids for all cases regardless of severity, with nebulized epinephrine reserved for moderate to severe cases. 1, 2, 3
Assessment and Diagnosis
- Croup presents with a sudden onset of respiratory distress with barking cough, hoarse voice, stridor, and variable respiratory distress 3
- Radiographic studies are generally unnecessary and should be avoided unless there is concern for an alternative diagnosis 3
- Important differential diagnoses include bacterial tracheitis, epiglottitis, foreign body aspiration, peritonsillar abscess, retropharyngeal abscess, and angioedema 4
Treatment Algorithm Based on Severity
First-Line Treatment for All Cases
- Oral dexamethasone 0.15-0.6 mg/kg (maximum 10-12 mg) is recommended for all cases of croup, regardless of severity 1, 2, 5
- Lower doses of dexamethasone (0.15 mg/kg) appear to have similar efficacy to higher doses (0.6 mg/kg) 6, 5
For Mild Croup
- No need for nebulized treatments 1
- Observation for 2-3 hours to ensure symptoms are improving 1
- Discharge with clear return precautions for parents 3
For Moderate to Severe Croup
- Nebulized epinephrine (0.5 ml/kg of 1:1000 solution, maximum 5 ml) in addition to oral corticosteroids 1, 2, 3
- The effect of nebulized epinephrine is short-lived (1-2 hours), requiring close monitoring 1, 3
- Patients should be observed for at least 2 hours after the last dose of nebulized epinephrine to assess for symptom rebound 1, 3
Hospitalization Criteria
- Consider hospital admission if three or more doses of nebulized epinephrine are required 1, 3
- Recent guidelines show that limiting hospital admission until 3 doses of racemic epinephrine are needed can reduce hospitalization rates by 37% without increasing revisits or readmissions 7, 2, 3
Treatments Not Recommended
- Humidification therapy (mist/humidified air) has not been proven beneficial 4, 8
- Normal saline nebulization is not recommended as a primary treatment 1
- Cold air therapy lacks evidence of benefit 3
- Antibiotics have no proven effect on uncomplicated viral croup 9
- Antihistamines and decongestants are not effective for croup 9
Discharge Criteria
- Resolution of stridor at rest 1
- Minimal or no respiratory distress 1
- Adequate oral intake 1
- Parents able to recognize worsening symptoms and return if needed 1
Common Pitfalls to Avoid
- Discharging patients too early after nebulized epinephrine (before the 2-hour observation period) 1, 3
- Failing to administer corticosteroids in mild cases 1
- Using nebulized epinephrine in children who are shortly to be discharged or on an outpatient basis due to the risk of rebound symptoms 1, 3
- Not providing clear return precautions to parents 1
- Performing blind finger sweeps in cases of suspected foreign body aspiration, as this may push objects further into the pharynx 3