From the Guidelines
Croup treatment should prioritize reducing airway inflammation and supporting breathing, with a focus on minimizing hospital admissions through the use of clinical guidelines and ordersets, as evidenced by a 37% relative reduction in hospital admission following ED encounters for croup 1.
Treatment Approach
For mild cases, home management includes:
- Keeping the child calm
- Providing cool mist from a humidifier
- Taking them into a steamy bathroom
- Exposure to cool night air to reduce inflammation
Medication
For moderate to severe cases, a single dose of oral dexamethasone (0.6 mg/kg, maximum 10 mg) is the standard treatment, which reduces inflammation and symptoms within hours and lasts for several days 1. In severe cases with significant respiratory distress, nebulized epinephrine (racemic epinephrine 2.25% solution, 0.5 mL in 2.5 mL saline) may be given in an emergency setting, providing temporary relief for 1-2 hours.
Supportive Care
Children who receive epinephrine should be observed for at least 2-3 hours as symptoms may return. Oxygen support is provided if oxygen levels are low. Most croup cases resolve within 3-7 days, though the barking cough may persist longer. Antibiotics are not effective since croup is typically viral. Seek immediate medical attention if the child has severe breathing difficulty, drooling, blue-tinged skin, or extreme lethargy.
Quality Improvement
The use of clinical guidelines and ordersets has been shown to reduce hospital admissions for croup without increasing revisits or readmissions 1, highlighting the importance of evidence-based practice in improving patient outcomes.
From the Research
Treatment Options for Croup
- Croup treatment usually involves a single dose of systemic dexamethasone combined with nebulized epinephrine 2, 3.
- A single dose of oral, intramuscular, or intravenous dexamethasone improves symptoms and reduces return visits and length of hospitalization in children with croup of any severity 3.
- The addition of nebulized epinephrine improves symptoms and reduces length of hospitalization in patients with moderate to severe croup 3, 4.
- Low-dose 1:1000 l-epinephrine was not inferior in croup score reduction to the conventional dose in patients with moderate to severe croup 2.
- Nebulized epinephrine is associated with clinically and statistically significant transient reduction of symptoms of croup 30 minutes post-treatment 4.
Dosage and Administration
- A 0.15 mg/kg dose of oral dexamethasone is as effective as larger doses 5.
- Nebulized budesonide (2 mg) can be given alternatively to children who do not tolerate oral dexamethasone 6.
- Low-dose (0.1 mg/kg) nebulized l-epinephrine was compared to the conventional dose (0.5 mg/kg) and found to be not inferior in croup score reduction 2.
Other Treatment Interventions
- Breathing heliox can potentially reduce the work of breathing related to upper airway obstruction, but its role in moderate to severe croup remains uncertain 6, 5.
- Humidified air provides no demonstrable benefit in the acute setting 5.
- Exposure to cold air or administration of cool mist are treatment interventions for viral croup that are not supported by published evidence 6.