Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Croup Medication

  • Author: Germaine L Defendi, MD, MS, FAAP; Chief Editor: Russell W Steele, MD  more...
 
Updated: Jun 17, 2015
 

Medication Summary

As previously mentioned, the current cornerstones in the treatment of croup are corticosteroids and nebulized epinephrine; steroids have proven beneficial in severe, moderate, and even mild croup. The anti-inflammatory action of corticosteroids reduces laryngeal mucosal edema and decreases the need for salvage nebulized epinephrine.

Nebulized racemic epinephrine (mixture of dextro isomers and levo isomers) or L-epinephrine is typically reserved for patients in moderate to severe distress. Epinephrine constricts the precapillary arterioles through adrenergic stimulation, thereby decreasing capillary hydrostatic pressure. This leads to fluid resorption from the interstitium and improvement in the laryngeal mucosal edema.

Next

Corticosteroids

Class Summary

Steroids are thought to decrease airway edema via their anti-inflammatory effect. Although a subject of controversy throughout the 1980s and 1990s, corticosteroids have since become a routine part of ED management of croup. Corticosteroids have been shown to reduce hospitalization rates by 86%, and in mild disease, they have been proven to reduce the number of children returning to the ED for further treatment.

In moderate to severe disease, corticosteroids improve croup scores within 12-24 hours and decrease hospitalization rates. Most trials have used dexamethasone at 0.6 mg/kg (intramuscular or oral), but oral doses as low as 0.15 mg/kg are effective.[45] Oral and intramuscular routes appear equally beneficial. Prednisolone (1 mg/kg) has been proven effective but may be associated with a greater return of children to the ED.

Inhaled corticosteroids also have demonstrated efficacy, with most trials using budesonide. According to most authors, however, the relative ease, speed, and cost of administration make systemic corticosteroids preferable to nebulized formulations.

Dexamethasone (Baycadron)

 

Several studies have shown improvement in clinical symptoms and croup score in hospitalized and ED patients who received dexamethasone. The drug exerts a beneficial effect via anti-inflammatory action that decreases laryngeal mucosal edema. The onset of action occurs within 6 hours after oral or intramuscular administration. Dexamethasone has a long pharmacodynamic effect of 36-56 hours. No studies have evaluated the effect of multiple doses of the drug.

Prednisone

 

Several studies have shown improvement in clinical symptoms and croup score in patients who were treated while hospitalized or in the ED. Corticosteroids exert beneficial effect via anti-inflammatory action in which laryngeal mucosal edema is decreased. In calculating an appropriate prednisone dose, it is important to know that dexamethasone is 6.67 times more potent and has a long half-life of 36-56 hours, versus a median half-life of 18-36 hours for prednisone.

Prednisolone (Prelone, Pediapred, Millipred)

 

Corticosteroids exert beneficial effect via anti-inflammatory action in which laryngeal mucosal edema is decreased. Like with prednisone, in calculating an appropriate prednisolone dose, it is important to know that dexamethasone is 6.67 times more potent and has a long half-life of 36-56 hours, versus a median half-life of 18-36 hours for prednisolone.

Budesonide inhaled (Pulmicort Respules, Pulmicort Flexhaler)

 

Clinical studies have documented improvement in symptoms and decrease in hospital admissions with nebulized budesonide in children with croup. Inhaled budesonide has been shown in several studies to be equivalent to oral dexamethasone.

Corticosteroids exert beneficial effect via anti-inflammatory action in which laryngeal mucosal edema is decreased.

Previous
Next

Nebulized Vasoconstrictors

Class Summary

Epinephrine stimulates alpha receptors and beta2 receptors. It constricts the precapillary arterioles, thus decreasing airway edema. Because of the potential adverse effects of tachycardia and hypertension, it is reserved for children with moderate to severe disease.[23]

The effects of epinephrine are transient, and most trials show alleviation of symptoms for no longer than 2 hours. In the 1980s and early 1990s, a rebound phenomenon was thought to occur, necessitating admission of all children who received the drug. However, patient discharge after 3-4 hours of observation has since become acceptable, as long as the patient has no stridor at rest, normal air entry, normal color, and normal consciousness and has received a dose of steroids.

Epinephrine (Adrenalin)

 

This agent is a levo isomer. It stimulates alpha-, beta1-, and beta2-adrenergic receptors, which results in bronchodilatation, increased peripheral vascular resistance, hypertension, increased chronotropic cardiac activity, and positive inotropic effects. Epinephrine causes alpha-adrenergic receptor–mediated vasoconstriction of edematous tissues, thus reversing upper airway edema.

Previous
 
Contributor Information and Disclosures
Author

Germaine L Defendi, MD, MS, FAAP Associate Clinical Professor, Department of Pediatrics, Olive View-UCLA Medical Center

Germaine L Defendi, MD, MS, FAAP is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Coauthor(s)

Antonio Muñiz, MD Professor of Emergency Medicine and Pediatrics, University of Texas Medical School at Houston; Medical Director of the Pediatric Emergency Department, Children's Memorial Hermann Hospital

Antonio Muñiz, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Pediatrics, American College of Emergency Physicians, American Heart Association, American Medical Association, Society for Academic Emergency Medicine, Southern Medical Association

Disclosure: Nothing to disclose.

Rona E Molodow, MD, JD Clinical Professor, Department of Pediatrics, Olive View-UCLA Medical Center

Rona E Molodow, MD, JD is a member of the following medical societies: American Academy of Pediatrics, American Professional Society on the Abuse of Children

Disclosure: Nothing to disclose.

Chief Editor

Russell W Steele, MD Clinical Professor, Tulane University School of Medicine; Staff Physician, Ochsner Clinic Foundation

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, Southern Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

Joseph Domachowske, MD Professor of Pediatrics, Microbiology and Immunology, Department of Pediatrics, Division of Infectious Diseases, State University of New York Upstate Medical University

Joseph Domachowske, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Society for Microbiology, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

References
  1. Benson BE, Baredes S, Schwartz RA. Stridor. Medscape Reference by WebMD. January 26, 2010. [Full Text].

  2. American Academy of Pediatrics. Parainfluenza Viral Infections. Pickering LK, ed. Red Book: 2003 Report of the Committee on Infectious Diseases. 26th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2003. 479-81.

  3. Sung JY, Lee HJ, Eun BW, et al. Role of human coronavirus NL63 in hospitalized children with croup. Pediatr Infect Dis J. 2010 Sep. 29(9):822-6. [Medline].

  4. Williams JV, Harris PA, Tollefson SJ, et al. Human metapneumovirus and lower respiratory tract disease in otherwise healthy infants and children. N Engl J Med. 2004 Jan 29. 350(5):443-50. [Medline]. [Full Text].

  5. Worrall G. Croup. Can Fam Physician. 2008 Apr. 54(4):573-4. [Medline].

  6. Bjornson C, Russell KF, Vandermeer B, et al. Nebulized epinephrine for croup in children. Cochrane Database Syst Rev. 2011 Feb 16. CD006619. [Medline].

  7. Segal AO, Crighton EJ, Moineddin R, Mamdani M, Upshur RE. Croup hospitalizations in Ontario: a 14-year time-series analysis. Pediatrics. 2005 Jul. 116(1):51-5. [Medline].

  8. Bernstein T, Brilli R, Jacobs B. Is bacterial tracheitis changing? A 14-month experience in a pediatric intensive care unit. Clin Infect Dis. 1998 Sep. 27(3):458-62. [Medline].

  9. Donnelly BW, McMillan JA, Weiner LB. Bacterial tracheitis: report of eight new cases and review. Rev Infect Dis. 1990 Sep-Oct. 12(5):729-35. [Medline].

  10. Edwards KM, Dundon MC, Altemeier WA. Bacterial tracheitis as a complication of viral croup. Pediatr Infect Dis. 1983 Sep-Oct. 2(5):390-1. [Medline].

  11. Jones R, Santos JI, Overall JC Jr. Bacterial tracheitis. JAMA. 1979 Aug 24-31. 242(8):721-6. [Medline].

  12. Sobol SE, Zapata S. Epiglottitis and croup. Otolaryngol Clin North Am. 2008 Jun. 41(3):551-66, ix. [Medline].

  13. Hoa M, Kingsley EL, Coticchia JM. Correlating the clinical course of recurrent croup with endoscopic findings: a retrospective observational study. Ann Otol Rhinol Laryngol. 2008 Jun. 117(6):464-9. [Medline].

  14. Johnson D. Croup. Clin Evid (Online). 2009 Mar 10. 2009:[Medline]. [Full Text].

  15. [Guideline] Alberta Medical Association. Guideline for the diagnosis and management of croup. Alberta Clinical Practice Guidelines 2005 Update. [Full Text].

  16. Guidelines for the diagnosis and management of croup. 2008 update. Alberta Medical Association. 2011.

  17. Chun R, Preciado DA, Zalzal GH, Shah RK. Utility of bronchoscopy for recurrent croup. Ann Otol Rhinol Laryngol. 2009 Jul. 118(7):495-9. [Medline].

  18. Delany DR, Johnston DR. Role of direct laryngoscopy and bronchoscopy in recurrent croup. Otolaryngol Head Neck Surg. 2015 Jan. 152 (1):159-64. [Medline].

  19. Wald EL. Croup: common syndromes and therapy. Pediatr Ann. 2010 Jan. 39(1):15-21. [Medline].

  20. Swingler GH, Zwarenstein M. Chest radiograph in acute respiratory infections. Cochrane Database Syst Rev. 2008. (1):CD001268. [Medline].

  21. Huang CC, Shih SL. Images in clinical medicine. Steeple sign of croup. N Engl J Med. 2012 Jul 5. 367(1):66. [Medline].

  22. Kirks DR. The respiratory system. Practical Pediatric Imaging: Diagnostic Radiology of Infants and Children. 3rd ed. Philadelphia, Pa: Lippincott-Raven; 1998. 651-53.

  23. Bjornson C, Russell KF, Vandermeer B, Durec T, Klassen TP, Johnson DW. Nebulized epinephrine for croup in children. Cochrane Database Syst Rev. 2011 Feb 16. CD006619. [Medline].

  24. Scolnik D, Coates AL, Stephens D, Da Silva Z, Lavine E, Schuh S. Controlled delivery of high vs low humidity vs mist therapy for croup in emergency departments: a randomized controlled trial. JAMA. 2006 Mar 15. 295(11):1274-80. [Medline].

  25. Colletti JE. Myth: Cool mist is an effective therapy in the management of croup. CJEM. 2004 Sep. 6(5):357-8. [Medline].

  26. Humidified air inhalation for treating croup [database online]. Cochrane Database of Systematic Reviews; 2006.

  27. Moore M, Little P. Humidified air inhalation for treating croup: a systematic review and meta-analysis. Fam Pract. 2007 Sep. 24(4):295-301. [Medline].

  28. Zoorob R, Sidani M, Murray J. Croup: an overview. Am Fam Physician. 2011 May 1. 83(9):1067-73. [Medline].

  29. Bjornson CL, Klassen TP, Williamson J, et al. A randomized trial of a single dose of oral dexamethasone for mild croup. N Engl J Med. 2004 Sep 23. 351(13):1306-13. [Medline].

  30. Cetinkaya F, Tufekci BS, Kutluk G. A comparison of nebulized budesonide, and intramuscular, and oral dexamethasone for treatment of croup. Int J Pediatr Otorhinolaryngol. 2004 Apr. 68(4):453-6. [Medline].

  31. Chub-Uppakarn S, Sangsupawanich P. A randomized comparison of dexamethasone 0.15 mg/kg versus 0.6 mg/kg for the treatment of moderate to severe croup. Int J Pediatr Otorhinolaryngol. 2007 Mar. 71(3):473-7. [Medline].

  32. Fifoot AA, Ting JY. Comparison between single-dose oral prednisolone and oral dexamethasone in the treatment of croup: a randomized, double-blinded clinical trial. Emerg Med Australas. 2007 Feb. 19(1):51-8. [Medline].

  33. Russell K, Wiebe N, Saenz A, et al. Glucocorticoids for croup. Cochrane Database Syst Rev. 2004. CD001955. [Medline].

  34. Kairys SW, Olmstead EM, O'Connor GT. Steroid treatment of laryngotracheitis: a meta-analysis of the evidence from randomized trials. Pediatrics. 1989 May. 83(5):683-93. [Medline].

  35. Russell KF, Liang Y, O'Gorman K, Johnson DW, Klassen TP. Glucocorticoids for croup. Cochrane Database Syst Rev. 2011. (1):CD001955. [Medline].

  36. Amir L, Hubermann H, Halevi A, Mor M, Mimouni M, Waisman Y. Oral betamethasone versus intramuscular dexamethasone for the treatment of mild to moderate viral croup: a prospective, randomized trial. Pediatr Emerg Care. 2006 Aug. 22(8):541-4. [Medline].

  37. Geelhoed GC. Budesonide offers no advantage when added to oral dexamethasone in the treatment of croup. Pediatr Emerg Care. 2005 Jun. 21(6):359-62. [Medline].

  38. Sparrow A, Geelhoed G. Prednisolone versus dexamethasone in croup: a randomised equivalence trial. Arch Dis Child. 2006 Jul. 91(7):580-3. [Medline]. [Full Text].

  39. McGee DL, Wald DA, Hinchliffe S. Helium-oxygen therapy in the emergency department. J Emerg Med. 1997 May-Jun. 15(3):291-6. [Medline].

  40. Vorwerk C, Coats TJ. Use of helium-oxygen mixtures in the treatment of croup: a systematic review. Emerg Med J. 2008 Sep. 25(9):547-50. [Medline].

  41. Beckmann KR, Brueggemann WM Jr. Heliox treatment of severe croup. Am J Emerg Med. 2000 Oct. 18(6):735-6. [Medline].

  42. Terregino CA, Nairn SJ, Chansky ME, Kass JE. The effect of heliox on croup: a pilot study. Acad Emerg Med. 1998 Nov. 5(11):1130-3. [Medline].

  43. Weber JE, Chudnofsky CR, Younger JG, et al. A randomized comparison of helium-oxygen mixture (Heliox) and racemic epinephrine for the treatment of moderate to severe croup. Pediatrics. 2001 Jun. 107(6):E96. [Medline].

  44. Vorwerk C, Coats T. Heliox for croup in children. Cochrane Database Syst Rev. 2010 Feb 17. CD006822. [Medline].

  45. Dobrovoljac M, Geelhoed GC. 27 years of croup: an update highlighting the effectiveness of 0.15 mg/kg of dexamethasone. Emerg Med Australas. 2009 Aug. 21(4):309-14. [Medline].

  46. Cruz CI, Patel D. Impacted Button-Battery Masquerading as Croup. J Emerg Med. 2013 Jan 30. [Medline].

  47. Elbuluk O, Shiba T, Shapiro NL. Laryngomalacia presenting as recurrent croup in an infant. Case Rep Otolaryngol. 2013. 2013:649203. [Medline]. [Full Text].

  48. Ibrahimov M, Yollu U, Akil F, Aydin F, Yener M. Laryngeal foreign body mimicking croup. J Craniofac Surg. 2013 Jan. 24(1):e7-8. [Medline].

 
Previous
Next
 
Child with croup. Note the steeple or pencil sign of the proximal trachea evident on this anteroposterior film. Courtesy of Dr. Kelly Marshall, CHOA at Scottish Rite.
Steeple sign on radiograph.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.