Management

Indications for hospitalization are (1):

• cyanosis
• pallor
• respiratory distress
• hypoxaemia
• stridor at rest
• toxic-looking child
• suspected epiglottitis

The management is as follows:

• sitting the child upright may improve the croup
• humidification using warm steam , either from a source of hot water - with care to protect the child at all times - or with an ultrasonic humidifier
  • however there has been no evidence of clinical benefit with this intervention in patients with moderate croup, delivery of 100%, 40% and blow-by humidity did not differ for change in croup scores (2)
    
    
• in mild croup (seal-like barking cough - however no stridor or sternal/intercostal recession at rest/respiratory distress) - a sytematic review has suggested that a a single dose of oral dexamethasone (0.15 mg/kg) to be taken immediately is of benefit in mild croup (3) compared with placebo.

In most cases the child will improve within minutes. More severe croup may require hospital admission, although some of the following treatments may be used to buy time in the home.

• if admitting a patient to hospital:
  • controlled supplementary oxygen to all children with symptoms of severe illness or impending respiratory failure
  • oral oral dexamethasone (0.15 mg/kg)
    • if child unable to take oral medication then
      • alternative possible interventions whilst awaiting admission are inhaled budesonide (2 mg nebulised as a single dose) or intramuscular dexamethasone (0.6 mg/kg as a single dose)
        
        
• steroid treatment
  • oral dexamethasone 0.15mg per kg, or prednisolone 1-2mg per kg, is helpful in reducing upper airway inflammation, stridor and respiratory distress (3,4)
  • nebulised steroids
    • there is evidence that the use of nebulised steroids reduces the need for inhaled adrenaline (4)
    • however nebulised budesonide 2mg is more expensive than oral dexamethasone or prednisolone and no more effective
      • may be helpful if oral treatment is difficult.
        
        
• nebulised adrenaline may be used at a dose of 5 ml of 1:1000 but ought to be considered as buying time with a short term benefit. At this point a child should be nursed in a high dependency area. A transient improvement for 30-60 minutes is usually seen
  
  
• oxygen should be used with caution; if it is required then the child is seriously ill and in danger of respiratory arrest; its use may make the monitoring of oxygen saturations difficult
  
  
• a helium-oxygen mixture has a lower viscosity and is therefore easier to breathe through a tight airway; however it is unlikely that this will be available
  • no certainty of clinical benefit of this intervention (3)
    
    
• intubation and ventilation is the final way to secure the airway and prevent respiratory arrest in life threatening croup. The alternative to this is ventilation via a tracheostomy.

Notes:

• emergency management in primary care:
  • if a child has croup that is severe or might cause complications then the child can be given either oral prednisolone 1-2mg/kg or oral dexamethasone (2mg/5mL oral solution) 150micrograms/kg, before transfer to hospital (5)
    
    
• the Cochrane review noted (4):
  • glucocorticoids reduced symptoms of croup at two hours, shortened hospital stays, and reduced the rate of return visits to care
  • uncertainty remains with regard to the optimal type, dose, and mode of administration of glucocorticoids for reducing croup symptoms in children
    • no significant difference in length of stay in the hospital or emergency department between children treated with dexamethasone compared to budesonide, or with dexamethasone compared to prednisolone
    • compared to those treated with betamethasone, children treated with dexamethasone were at a significantly increased risk for needing epinephrine
    • no significant difference between children treated with dexamethasone and those treated with prednisolone in the need for epinephrine or supplemental glucocorticoids

Reference:

• (1) Doug Knutson, Viral Croup. Am Fam Physician.2004;69:535-40,541-2
• (2) Scolnik D et al. Controlled delivery of high vs low humidity vs mist therapy for croup in emergency departments: a randomized controlled trial. JAMA 2006;295:1274-80.
• (3) Johnson DW. Croup. BMJ Clin Evid. 2014; 2014: 0321
• (4) Gates A et al. Glucocorticoids for croup in children.Cochrane Database Syst Rev. 2018 Aug 22;8:CD001955
• (5) Drug and Therapeutics Bulletin 2005; 43(11):81-4.