What are the diagnosis and treatment options for croup?

Diagnosis and Treatment of Croup

Diagnosis

Croup is diagnosed clinically based on the characteristic presentation of barking cough, hoarse voice, inspiratory stridor, and variable respiratory distress, typically in children aged 6 months to 6 years. 1, 2

Key Clinical Features to Assess Immediately:

• Severity indicators: ability to speak/cry normally, respiratory rate, heart rate, presence of stridor at rest, use of accessory muscles, and oxygen saturation 2
• Life-threatening signs: silent chest, cyanosis, fatigue/exhaustion, or poor respiratory effort 2
• Typical presentation: sudden onset of respiratory distress with coughing, gagging, stridor, or wheezing, often preceded by upper respiratory infection symptoms 2, 3

Diagnostic Considerations:

• Radiographic studies are unnecessary and should be avoided unless there is concern for an alternative diagnosis 1, 2
• Consider alternative diagnoses such as bacterial tracheitis, epiglottitis, foreign body aspiration, retropharyngeal abscess, or peritonsillar abscess 2
• The most common etiology is parainfluenza viruses (types 1-3), but identifying the specific pathogen does not alter treatment 2

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Treatment Algorithm

Oral dexamethasone should be administered immediately to ALL children with croup regardless of severity, with nebulized epinephrine reserved only for moderate to severe cases. 1, 2

Mild Croup (Stridor only with agitation, no respiratory distress):

• Administer oral dexamethasone 0.15-0.6 mg/kg (maximum 10-12 mg) as a single dose 1, 2
• Observe for 2-3 hours to ensure symptoms are improving 4
• No nebulized treatments needed 4

Moderate to Severe Croup (Stridor at rest, respiratory distress, accessory muscle use):

• Administer oral dexamethasone 0.15-0.6 mg/kg (maximum 10-12 mg) as a single dose 1, 2
• Add nebulized epinephrine 0.5 ml/kg of 1:1000 solution (maximum 5 ml) 1, 2
• The effect of nebulized epinephrine is short-lived (1-2 hours), requiring close monitoring 2, 4
• Observe for at least 2 hours after the last dose of nebulized epinephrine to assess for rebound symptoms 2, 4

Alternative Corticosteroid Option:

• Nebulized budesonide 2 mg is equally effective as oral dexamethasone and may be used when oral administration is not feasible 1, 5

Severe Croup Requiring Intubation:

• Oral prednisolone 1 mg/kg every 12 hours decreases the duration of intubation and need for reintubation 5

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Hospitalization Criteria

Consider hospital admission based on the following criteria: 1, 2

• Need for ≥3 doses of nebulized epinephrine (this reduces hospitalization rates by 37% without increasing revisits or readmissions compared to the traditional 2-dose threshold) 1, 2
• Oxygen saturation <92% 1, 2
• Age <18 months 1
• Respiratory rate >70 breaths/min 1
• Persistent difficulty in breathing 1

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Supportive Care

Oxygen Therapy:

• Administer oxygen via nasal cannulae, head box, or face mask to maintain oxygen saturation ≥94% 2
• Agitation may indicate hypoxia and requires oxygen 2

General Measures:

• Antipyretics can be used to keep the child comfortable 2
• Minimal handling may reduce metabolic and oxygen requirements 2
• Ensure adequate hydration 2
• Monitor oxygen saturation at least every 4 hours for patients on oxygen therapy 2

Positioning (for children under 2 years):

• Use a neutral head position with a roll under the shoulders to optimize airway patency 2

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Discharge Criteria

Children can be discharged home when: 1, 2

• 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, 2
• If discharged home, the child should be reviewed by a general practitioner if deteriorating or not improving after 48 hours 2

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Critical Pitfalls to Avoid

• Never discharge a patient within 2 hours of nebulized epinephrine administration due to the risk of rebound symptoms 1, 2, 4
• Never use nebulized epinephrine in outpatient settings where immediate return is not feasible 1, 2, 4
• Do not fail to administer corticosteroids in mild cases – all cases benefit from corticosteroids 1, 4
• Do not use antibiotics routinely – croup is typically viral in etiology 1
• Do not rely on cold air or humidified air treatments – these lack evidence of benefit 2
• Do not perform chest physiotherapy – it is not beneficial 2
• Do not use normal saline nebulization as a primary treatment 4
• Do not perform blind finger sweeps in suspected foreign body aspiration, as this may push objects further into the pharynx 2

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Special Considerations

Recurrent Croup:

• Consider asthma as a differential diagnosis, especially if cough worsens at night, episodes are triggered by exercise or irritants, or there is a family history of asthma or atopy 2
• Consider prophylactic inhaled corticosteroids in children with recurrent croup and atopy or gastroesophageal reflux 2