eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease

Croup: Treatment & Medication

Author: 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
Coauthor(s): Rona E Molodow, MD, JD, Clinical Professor, Department of Pediatrics, Olive View-University of California Los Angeles Medical Center; Germaine L Defendi, MD, MS, FAAP, Associate Clinical Professor, Department of Pediatrics, Olive View-UCLA Medical Center
Contributor Information and Disclosures

Updated: Nov 18, 2009

Treatment

Medical Care

Any infant who presents with respiratory distress must receive a thorough evaluation to ensure the patency of the airway and maintenance of effective oxygenation and ventilation.

ED treatment of croup depends on the degree of distress. For example, a child who presents with only a croupy cough may require nothing more than parental reassurance, and the parents may only need education regarding the course of the disease. Any child who presents with respiratory complaints must have a thorough evaluation to ensure the patency of the airway and maintenance of effective oxygenation and ventilation. Infants with severe respiratory distress or compromise require 100% oxygenation with ventilation support initially with a bag-valve-mask device. If the airway and breathing require further maintenance, the patient should be intubated with an endotracheal tube. Intubation should be accomplished with an endotracheal tube that is 0.5-1 mm smaller than predicted.

  • The first rule of management is to keep the child as comfortable as possible, allowing the patient to remain in a parent's arms and avoiding unnecessary painful interventions that may cause agitation and increased oxygen requirements by the child. Persistent crying increases oxygen demands and respiratory muscle fatigue and worsens the obstruction.
  • Careful monitoring of the heart rate, respiratory rate, respiratory mechanics, and pulse oximetry are important to detect early hypoxia.
  • Throughout the 19th and most of the 20th century, cool mist administration was the mainstay of treatment. Hospitals had "croup rooms" filled with mist. Theoretically, mist moistens airway secretions, decreases their viscosity, and soothes the inflamed mucosa. Animal data show that microaerosol inhalation activates mechanoreceptors that produce a reflex slowing of respiratory flow rate and leads to improved airflow. Despite its continued widespread use, little evidence supports the clinical efficacy of cool mist. Randomized studies of children with moderate-to-severe croup revealed no difference in outcome between those who received cool mist and those who did not.3 In addition, the use of hot steam should be avoided because scalding has been reported. Also, mist tents can disperse fungus and molds if not properly cleaned and, more importantly, separates the child from the parent, which usually causes them to be agitated and worsens their symptoms.
  • The current cornerstones of treatment are glucocorticoids and nebulized epinephrine, although steroids have proven beneficial in severe, moderate, and even mild croup.
  • Corticosteroids are beneficial because of their anti-inflammatory action, whereby laryngeal mucosal edema is decreased. They also decrease the need for salvage nebulized epinephrine.
    • A single dose of dexamethasone has been shown to be effective in reducing the overall severity of croup if administered within the first 4-24 hours after onset of illness. The long half-life of dexamethasone (54 h) often allows for a single injection. Dexamethasone (0.15 mg/kg) is as effective as 0.3 mg/kg or 0.6 mg/kg in relieving symptoms of mild-to-moderate croup. It has the same efficacy if administered intravenously, intramuscularly, or orally.
    • A single oral dose of prednisolone (1 mg/kg) resulted in more return visits than a single oral dose of dexamethasone (0.15 mg/kg).4
    • Inhaled budesonide has also proven to be effective but is more expensive; in one study, oral dexamethasone resulted in better improvement than nebulized budesonide.
    • Corticosteroids should not be administered to children with varicella or untreated tuberculosis.
  • Nebulized racemic (mixture of d -isomers and l -isomers) or L-epinephrine is typically reserved for patients in moderate-to-severe distress. It works by adrenergic stimulation, which causes constriction of the precapillary arterioles, thereby decreasing capillary hydrostatic pressure. This leads to fluid resorption from the interstitium and improvement in the laryngeal mucosal edema. Its beta-2-adrenergic activity leads to bronchial smooth muscle relaxation and bronchodilation. Although a child who is symptomatic enough to receive epinephrine may be discharged after at least 3 hours of observation, anyone receiving epinephrine should also be given corticosteroids.
  • Antibiotics are not indicated.
  • Heliox is a metabolically inert, nontoxic gas that is combined with oxygen. It has low viscosity and low specific gravity, which allows for greater laminar airflow through the respiratory tract. Helium decreases the force necessary to move the gas through the airways and decreases the mechanical work of respiratory muscles, which is clinically seen as less respiratory distress.5 Several trials of heliox have demonstrated no advantage over conventional modalities; however, other trials have shown it to be equally effective in moderate-to-severe croup when compared with racemic epinephrine.6,7,8 It has also been shown to improve symptoms in very severe croup that failed to improve with racemic epinephrine.

Medication

Corticosteroids

Although a subject of controversy throughout the 1980s and 1990s, corticosteroids have since become a routine part of ED management of croup. Corticosteroids have shown to decrease hospitalization rates by 86%. Steroids are thought to decrease airway edema via their anti-inflammatory effect. In mild disease, corticosteroids have been proven to reduce the number of children returning to the ED for further treatment. In moderate-to-severe disease, they 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. 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. However, according to most authors, the relative ease, speed, and cost of administration make systemic corticosteroids preferable to nebulized formulations.


Dexamethasone (Decadron)

Several studies have shown improvement in clinical symptoms and croup score in patients who were hospitalized or treated in the ED. Dexamethasone exerts beneficial effect via anti-inflammatory action in which laryngeal mucosal edema is decreased. Onset of action occurs within 6 h for PO and IM. Long pharmacodynamic effect of 36-56 h. No studies have evaluated the effect of multiple doses.

Adult

Pediatric

0.15-0.6 mg/kg PO/IM as a single dose; not to exceed 10 mg/dose

Coadministration with barbiturates, phenytoin, or rifampin can decrease effectiveness

Documented hypersensitivity; systemic fungal infections; varicella exposure; tuberculosis

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Prolonged use has been associated with adrenal insufficiency, psychosis, immunosuppression, peptic ulcer disease, CHF, anaphylaxis, osteoporosis, pseudotumor cerebri, pancreatitis, nausea, vomiting, dyspepsia, edema, headache, dizziness, mood swings, insomnia, anxiety, hypokalemia, hypertension, hyperglycemia, cushingoid features, menstrual irregularities, ecchymosis, acne, skin atrophy, and impaired wound healing
One case report of a child developing candidal tracheitis after receiving both steroids and antibiotics while hospitalized for croup


Prednisone (Deltasone) or prednisolone (Prelone)

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

Adult

Pediatric

Not established; one randomized controlled trial demonstrated decreased duration of intubation in children receiving prednisolone 1 mg/kg PO q12h until 24 h after extubation; not to exceed 60 mg/24 h

Coadministration with barbiturates, phenytoin, or rifampin can decrease effectiveness; coadministration with estrogens can decrease clearance; concurrent use with digoxin may cause digitalis toxicity secondary to hypokalemia

Documented hypersensitivity; systemic fungal infections; tuberculosis; varicella or exposure to varicella; peptic ulcer disease; hepatic dysfunction

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Prolonged use has been associated with adrenal insufficiency, psychosis, immunosuppression, peptic ulcer disease, CHF, anaphylaxis, osteoporosis, pseudotumor cerebri, pancreatitis, nausea, vomiting, dyspepsia, edema, headache, dizziness, mood swings, insomnia, anxiety, hypokalemia, hypertension, hyperglycemia, cushingoid features, menstrual irregularities, ecchymosis, acne, skin atrophy, and impaired wound healing


Budesonide (Pulmicort Respules)

Clinical studies have documented improvement in symptoms and decrease in hospital admissions with nebulized budesonide in children with croup. Corticosteroids exert beneficial effect via anti-inflammatory action in which laryngeal mucosal edema is decreased.

Adult

Pediatric

2 mL (0.5 mg) of solution inhaled via nebulizer

Documented hypersensitivity; active bacterial or fungal infection

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Prolonged use may increase the systemic absorption of corticosteroids; hypothalamic-pituitary axis suppression; hyperglycemia; glycosuria

Nebulized vasoconstrictors

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


Epinephrine, racemic (microNefrin) 2.25%

Mixture of dextro and levo isomers. Causes adrenergic stimulation, which constricts precapillary arterioles, thus decreasing capillary hydrostatic pressure. This leads to fluid resorption from the interstitium and improvement in the laryngeal mucosal edema, although its beta2 activity leads to bronchial smooth muscle relaxation.

Adult

Pediatric

Administer 2.25% solution for nebulization (dose according to weight listed below) mixed with 3 mL saline:
<20 kg: 0.25 mL
20-40 kg: 0.5 mL
>40 kg: 0.75 mL
May repeat q20-30min

Inhaled anesthetics may enhance cardiac irritability; nonselective beta-blockers leave alpha effects unopposed, increasing risk of hypertension and tachycardia

Documented hypersensitivity; angle-closure glaucoma; obstruction of ventricular outflow, as in tetralogy of Fallot

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Adverse effects include tachycardia (discontinue if heart rate >200 bpm), dysrhythmias, palpitations, hypertension, tremor, agitation, nausea, vomiting, headache; randomized controlled trials in children with croup reported no adverse effects, particularly tachycardia; one case report of a previously healthy 11-year-old child who developed ventricular tachycardia after receiving 3 doses in 60 min and was later found to have experienced a small MI


Epinephrine (Adrenalin)

Levo isomer. Stimulates alpha-, beta1-, and beta2-adrenergic receptors, which results in bronchodilatation, increased peripheral vascular resistance, hypertension, increased chronotropic cardiac activity, and positive inotropic effects. Causes alpha-adrenergic receptor–mediated vasoconstriction of edematous tissues, thus reversing upper airway edema.

Adult

Pediatric

5 mL (5 mg) of 1:1000 solution diluted in 2 mL saline administered via nebulization; may repeat q20-30min

Increases toxicity of beta- and alpha-blocking agents and that of halogenated inhalational anesthetics

Documented hypersensitivity; cardiac arrhythmias; angle-closure glaucoma; during labor (may delay second stage of labor)

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in cardiovascular disease, tachycardia (especially with HR >200 bpm), diabetes mellitus, hyperthyroidism, and cerebrovascular insufficiency

More on Croup

Overview: Croup
Differential Diagnoses & Workup: Croup
Treatment & Medication: Croup
Follow-up: Croup
Multimedia: Croup
References
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Keywords

croup, barking cough, laryngotracheitis, stridor, laryngotracheobronchitis, spasmodic croup, influenza A, inspiratory stridor, parainfluenza virus 1, parainfluenza virus II, parainfluenza virus III, steeple sign, upper respiratory infection

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Contributor Information and Disclosures

Author

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, and Southern Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Rona E Molodow, MD, JD, Clinical Professor, Department of Pediatrics, Olive View-University of California Los Angeles Medical Center
Rona E Molodow, MD, JD is a member of the following medical societies: American Academy of Pediatrics and American Professional Society on the Abuse of Children
Disclosure: Nothing to disclose.

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.

Medical Editor

David Jaimovich, MD, Chief Medical Officer, Joint Commission International and Joint Commission Resources
David Jaimovich, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

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.

CME Editor

Robert W Tolan Jr, MD, Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine
Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility
Disclosure: GlaxoSmithKline Honoraria Speaking and teaching; MedImmune Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; sanofi pasteur Honoraria Speaking and teaching; Baxter Healthcare Honoraria Speaking and teaching

Chief Editor

Russell W Steele, MD, Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine
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, and Southern Medical Association
Disclosure: None None None

 
 
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