From the Guidelines
The treatment of croup should prioritize reducing airway inflammation and supporting respiratory function, with a focus on minimizing hospital admissions and optimizing patient outcomes, as evidenced by a 37% relative reduction in hospital admission following ED encounters for croup in a recent study 1. The primary goals of croup treatment are to reduce inflammation, alleviate symptoms, and prevent complications. For mild cases, cool mist therapy and keeping the child calm may be sufficient.
Key Treatment Considerations
- For moderate to severe cases, a single dose of oral dexamethasone (0.6 mg/kg, maximum 10 mg) is the cornerstone of treatment, as it reduces inflammation and improves symptoms within hours.
- In severe cases with respiratory distress, nebulized epinephrine (racemic epinephrine 2.25% 0.5 mL in 3 mL saline or L-epinephrine 1:1000 5 mL) provides rapid but temporary relief and should be followed by steroid administration.
- Children receiving epinephrine should be observed for at least 2-3 hours as symptoms may return.
- Hospitalization is necessary for children with persistent stridor at rest, respiratory distress, hypoxemia, or those requiring multiple epinephrine treatments.
- Supplemental oxygen should be provided if oxygen saturation falls below 92%.
- Antibiotics are not indicated as croup is typically viral. The use of clinical guidelines and ordersets has been shown to reduce hospital admissions for croup, with a study demonstrating a significant decrease in admissions with no increase in revisits 1.
Reducing Hospital Admissions
- Implementing clustered interventions, including education, guideline, and orderset integration, can help reduce hospital admissions for croup 1.
- A recent study found that the implementation of a clinical guideline and orderset resulted in a 37% relative reduction in hospital admission following ED encounters for croup, with improvements sustained over 26 months 1.
From the Research
Treatment Options for Croup
- Croup is a common respiratory illness affecting 3% of children six months to three years of age, characterized by upper airway obstruction resulting from swelling of the larynx, trachea, and bronchi, leading to inspiratory stridor and a barking cough 2.
- The following interventions have been studied for the treatment of croup:
- Corticosteroids (dexamethasone, intramuscular and oral), which have been shown to improve symptoms and reduce return visits and length of hospitalization in children with croup of any severity 3, 2.
- Nebulised budesonide, which has been shown to be effective in combination with nebulised L-epinephrine for the treatment of moderate to severe croup 4.
- Heliox, which may be beneficial in the short term for children with moderate to severe croup treated with dexamethasone, but the evidence is limited and of low quality 5.
- Nebulised adrenaline (racemate and L-adrenaline [ephinephrine]), which has been shown to improve symptoms and reduce length of hospitalization in patients with moderate to severe croup 3, 6.
- Humidification, which is often used in combination with other treatments, but its effectiveness as a standalone treatment is unclear 3, 6.
Effectiveness of Treatments
- A systematic review found that corticosteroids, such as dexamethasone, are effective in reducing the severity of croup symptoms and the need for hospitalization 3.
- Another study found that the combination of nebulised L-epinephrine and systemic or nebulised corticosteroid was more effective than cool mist and systemic corticosteroids in reducing croup scores and improving symptoms in children with moderate to severe croup 4.
- The use of heliox has been studied, but the evidence is limited and of low quality, and it is unclear whether it is more effective than standard treatments 5.
Safety of Treatments
- Corticosteroids, such as dexamethasone, are generally considered safe and well-tolerated in children with croup 3, 2.
- Nebulised L-epinephrine has been shown to be safe and effective in children with moderate to severe croup, with no significant adverse effects reported 4.
- Heliox has been used in some studies, but the evidence on its safety and effectiveness is limited, and it is unclear whether it is associated with any adverse effects 5.