Croup Treatment & Management

Urgent care or emergency department treatment of croup depends on the patient's degree of respiratory distress. In mild croup, a child may present with only a croupy cough and may just require parental guidance and reassurance, given alertness, baseline minimal respiratory distress, proper oxygenation, and stable fluid status. Caregivers may only need education regarding the course of the disease and supportive homecare guidelines.

Most children with mild croup symptoms can be successfully treated at home by their caregivers. Cool mist from a humidifier and/or sitting with the child in a bathroom (not in the shower) filled with steam generated by running hot water from the shower, help minimize symptoms. An adult caregiver should stay with the child during mist treatment. Engaging the child in a calming activity, such as reading a favorite book, can help decrease the child's anxiety and minimize crying, which can worsen stridor. Other suggestions for home treatment of mild croup include:

• Treat fever with an antipyretic such as acetaminophen or ibuprofen. 
• Encourage oral intake.
• Coughing can be treated with warm, clear fluids to loosen mucus in the oropharynx  
• Frozen juice popsicles also can be given to ease throat soreness
• Avoid smoking in the home; smoke can worsen a child's cough.
• Keep the child's head elevated.

  • An infant can be placed in a car seat.
  • A child may be propped up in bed with an extra pillow.
  • Pillows should not be used with infants younger than 12 months of age.
• At nighttime, parents/caregivers should stay in close proximity to the ill child so that they can immediately assist the child, if he or she begins to have difficulty breathing.

Any infant/child who presents with significant respiratory distress/complaints with "stridor at rest" must have a thorough medical evaluation to ensure the patency of the airway and maintenance of effective oxygenation and ventilation. Young children should be kept as comfortable as possible, allowing him or her to remain in a parent's arms and avoiding unnecessary painful interventions that may cause agitation, respiratory distress, and lead to increased oxygen requirements. Persistent crying increases oxygen demands, and respiratory muscle fatigue can worsen the airway obstruction.

Concurrently, careful monitoring of heart rate (for tachycardia), respiratory rate (for tachypnea), respiratory mechanics (for sternal wall retractions), and pulse oximetry (for hypoxia) are important. Given the risk of increased insensible losses from fever, tachypnea and a history of decreased oral intake, assessment of the patient’s hydration status is imperative.

Current treatment approaches in the urgent care clinics or emergency departments are corticosteroids and nebulized epinephrine; steroids have proven beneficial in severe, moderate, and even mild croup. ^[23]  In the straightforward cases of croup, antibiotics are not prescribed, as the etiology is viral. Lack of improvement or worsening of symptoms can be due to a secondary bacterial process, which requires the use of antimicrobials for treatment. Typically, patients with a bacterial component would have had moderate-to-severe croup assessment scores, requiring inpatient care and observation.

Infants and children with severe respiratory distress or compromise may require oxygenation with ventilation support, initially with a bag-valve-mask device. If the airway and breathing require further stabilization due to increasing respiratory fatigue and hence, worsening hypercarbia, (as evident by ABG), 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. Once airway stabilization is achieved, these patients are transferred for their ongoing care to a pediatric intensive care unit.

Cool mist administration

Historically, cool mist administration was the mainstay of treatment for croup. Hospitals had "croup rooms" filled with cool 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.

However, despite its continued widespread use, further evidence does not strongly support the clinical efficacy of cool mist or humidification therapy. 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. ^[24] However, cool mist tents are still used in the inpatient hospital setting. Besides having the potential to disperse fungus and molds if not properly cleaned, the tents separate child from parent by creating a “plastic barrier;" thus causing anxiety and agitation with potential to worsen the child’s symptoms and hinder required ongoing clinical assessment. ^{[25, 26]} In the home, cool mist humidifiers can be used; however vaporizers (heated humidification) producing hot steam to moisten the air should not be used to avoid the risk of scalding or burns.

Corticosteroids are beneficial due to their anti-inflammatory action. Their use decreases both laryngeal mucosal edema and the need for salvage nebulized epinephrine. Corticosteroids may be warranted even for those children who present with mild symptoms. Treatment of croup with corticosteroids has not shown significant adverse effects; however despite the low risk, their use should be carefully evaluated for children with diabetes, an underlying immunocompromised state, or those recently exposed to or diagnosed with varicella or tuberculosis, due to the potential risk of exacerbating the co-current disease process. ^{[27, 28, 29, 30, 31, 32]} An updated 2018 Cochrane Review reported that glucocorticoids (ie, prednisone, dexamethasone) reduced symptoms of croup at 2 hours, shortened hospital stays, and reduced the rate of return visits for patient care. This conclusive report has changed, as the previous version of Cochrane Review reported that glucocorticoids reduced symptoms of croup within 6 hours post administration. ^[33]

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 the onset of illness. The long half-life of dexamethasone (36-54 h) often allows for a single injection or dose to cover the usual symptom duration of croup. Studies have shown that dexamethasone dosed at 0.15 mg/kg is as effective as 0.3 mg/kg or 0.6 mg/kg (with a maximum daily dose of 10 mg) in relieving the symptoms of mild-to-moderate croup. Despite this knowledge, clinicians still tend to favor the dose of 0.6 mg/kg for initial treatment of croup. This dosage, in fact, is more effective for patients diagnosed with severe croup and remains the optimal amount for safety, benefit and cost-effectiveness. ^{[34, 33]}

Dexamethasone has shown the same efficacy if administered intravenously (IV), intramuscularly (IM), or orally (PO). ^[35] The route of administration is patient-dependent as based on the patient’s age, ability to tolerate orals, and severity of presenting illness. The use of inhaled corticosteroids (budesonide) with systemic treatment has not shown additional benefit. ^[36]

Patients given a single oral dose of prednisolone (1 mg/kg) were found to have made more return visits, than those patients who received a single oral dose of dexamethasone (0.15 mg/kg). ^[37] This is due to the lesser potency to reduce inflammation and shortened half-life of prednisolone (18-36 h), when compared with dexamethasone (36-54 h).

Nebulized racemic epinephrine is a 1:1 mixture of dextro (D) isomers and levo (L) isomers of epinephrine with the L form (L-epinephrine) as the active component. Its use is typically reserved for patients in the hospital setting with moderate-to-severe respiratory distress. Epinephrine 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. ^[23] Epinephrine’s beta2-adrenergic activity leads to bronchial smooth muscle relaxation and bronchodilation. Its effectiveness is immediate with evidence of therapeutic benefit within the first 30 minutes and then, has a lasting effect from 90-120 minutes (1.5-2 h).

Patients who receive nebulized racemic epinephrine in the emergency department should be observed for at least 3 hours post last treatment because of concerns for a return of bronchospasm, worsening respiratory distress, and/or persistent tachycardia. Patients can be discharged home only if they demonstrate clinical stability with good air entry, baseline consciousness, no stridor at rest and have received a dose of corticosteroids.

A study by Bagwell et al compiled information on 95,403 croup patients, ages 0 to 11 years, from the Pediatric Health Information System (2004-2014). These patients were initially evaluated and treated in various pediatric emergency departments (EDs) over this 10-year period. Their data analyses found that patients who received corticosteroids and single-dose nebulized epinephrine were managed differently from those who required multidose nebulized epinephrine. Patients who were treated with corticosteroids and multidose nebulized epinephrine, and subsequently discharged from the ED, were less likely to return for further care; however, if discharge from the ED did not occur, these patients were hospital-admitted at a higher rate when compared to patients receiving a single-dose nebulized epinephrine treatment in the ED setting. ^[38]

Heliox is a gas that contains a mixture of helium and oxygen (with not less than 20% oxygen). Delivery to the patient is via nasal cannula, face mask, or hood. It has low viscosity and low specific gravity, which allows for greater laminar airflow through the respiratory tract. Helium facilitates the movement of oxygen through the airways and decreases the mechanical work of respiratory muscles. This clinical response reduces respiratory distress. ^{[39, 40]}

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. ^{[41, 42, 43]} Heliox has also been shown to improve symptoms in very severe croup that failed to improve with nebulized racemic epinephrine. Currently, the evidence is not sufficient to establish the beneficial effect of heliox in pediatric croup management. ^[44]  However, heliox has been used during emergency transport of children with severe croup. Anecdotal evidence suggests that heliox does help relieve respiratory distress. ^[45]