Croup Treatment & ManagementCroup is a common illness responsible for up to 15 percent of emergency department visits due to respiratory disease in children in the United States. Croup symptoms cdoup start like test enanthate 250 prices upper respiratory tract infection, with low-grade fever and coryza followed by a barking cough and various degrees of respiratory distress. In most children, the symptoms subside quickly with resolution of the cough within two days. Croup is often caused by viruses, with parainfluenza virus types 1 to 3 as the most common. However, physicians should consider other diagnoses, steroids for croup dose bacterial tracheitis, epiglottitis, foreign steroids for croup dose aspiration, peritonsillar abscess, retropharyngeal abscess, and angioedema. Humidification therapy has not been proven beneficial.
Clinical Practice Guidelines : Croup (Laryngotracheobronchitis)
The Canadian Paediatric Society gives permission to print single copies of this document from our website. For permission to reprint or reproduce multiple copies, please see our copyright policy. Croup is one of the most common causes of upper airway obstruction in young children. It is characterized by sudden onset of barky cough, hoarse voice, inspiratory stridor and respiratory distress caused by upper airway inflammation secondary to a viral infection.
Published guidelines for the diagnosis and treatment of croup advise using steroids as the mainstay treatment for all children who present to emergency department ED with croup symptoms. Dexamethasone, given orally as a single dose at 0. Despite the evidence supporting the use of steroids as the cornerstone of croup treatment, there is significant practice variation among physicians treating croup in the ED.
This practice point discusses evidence-based management of typical croup in the ED. Corticosteroids , Croup , Dexamethasone , Epinephrine , Heliox. However, croup accounts for significant rates of ED visits and hospitalizations in Canada, with one population-based study in Alberta reporting that 3.
Endotracheal intubation is rare at 0. There is considerable variation in clinical practice for croup. In small Canadian centres, children with croup are less likely to receive steroids than in larger centres, while the use of antibiotics and beta-agonists which are rarely indicated in the care of children with croup is more frequent than in larger centres  . Croup is caused by viral infections of the respiratory tract and most commonly by parainfluenza types 1 and 3 viruses.
Other implicated viruses are influenza A and B, adenovirus, respiratory syncytial virus and metapneumovirus . These infections cause generalized airway inflammation and edema of the upper airway mucosa. The subglottic region becomes narrowed, causing upper airway obstruction and the symptoms typically associated with croup. Classical croup symptoms have a rapid onset and include barky cough, inspiratory stridor, hoarseness and respiratory distress. Nonspecific symptoms of an upper respiratory illness usually precede the typical croup symptoms, which often worsen at night.
Typical croup usually affects children between 6 months and 3 years of age. Symptoms are short-lived, usually lasting 3 to 7 days. In Canada, croup season peaks over the fall and winter   . Prolonged duration of croup symptoms associated with fever may be seen with secondary bacterial infection . Toxic appearance, drooling and dysphagia are important red flags suggestive of more serious conditions Table 1.
Clinical scores used in research studies have not been shown to improve clinical care  . Most clinicians characterize respiratory distress as mild, moderate, severe or impending respiratory failure. Using this classification, an algorithm for the outpatient management of croup in children was developed through expert consensus .
Children presenting with severe distress or impending respiratory failure should be referred to paediatric intensive care or to anaesthesia for advanced care when clinical response to initial treatment is poor or not sustained.
Overall, the recommended treatment for croup involves the following measures Figure 1. Children should be made comfortable and health care providers must take special care not to frighten them during assessment and treatment.
There is no evidence to support the treatment of croup with the use of humidified air . Mist tents separate children from their caregivers, can disperse fungus and therefore are not recommended . The use of antipyretics is beneficial for reducing fever and discomfort. The clinical benefit of corticosteroids in croup is well established   -  and should be considered for treating all children presenting with croup and symptoms ranging from mild to severe.
Improvement generally begins within 2 to 3 hours after a single oral dose of dexamethasone and persists for 24 to 48 hours   . Two studies compared oral dexamethasone with oral prednisolone. In one study, dexamethasone was found to be superior, and in the other, both therapies were equally effective .
Administering corticosteroids by the oral or intramuscular route is as efficacious or superior to the nebulized form of medication  . Adding inhaled budesonide to oral dexamethasone was not found to provide extra benefit in children admitted with croup . From a practical perspective, oral dexamethasone is less associated with vomiting .
The oral route is preferred. When the child with croup has persistent vomiting or significant respiratory distress, administering corticosteroids by the intramuscular route may be indicated . The dexamethasone dose used in most clinical trials is 0. It is unclear from studies using doses of 0.
One meta-analysis of six studies suggested that a higher dose could be more beneficial in children with severe disease . Overall, children treated with corticosteroids have fewer return visits or admissions to the hospital. Fully one-half of children with mild croup treated with corticosteroids are unlikely to need further medical care for ongoing symptoms.
Their sleep is improved and their parents report less stress . In children with moderate to severe croup treated with corticosteroids, there was a reported average reduction of 12 hours in length of stay in the ED or hospital.
There have been no adverse events associated with a single dose of corticosteroids for treatment of croup. Nebulized epinephrine is recommended for moderate to severe croup. Reports of administering epinephrine in children with severe croup have demonstrated a lower number of cases requiring intubation or tracheotomy .
When compared with a placebo, nebulized epinephrine improved signs of respiratory distress within 10 to 30 minutes of initiating treatment. Clinical effect is sustained for at least 1 hour, but disappears after 2 hours . The first prospective trial assessing safe discharge after treating paediatric outpatients with a combination of dexamethasone and nebulized epinephrine, and including observation for 2 to 4 hours, supported the safety of this measure .
There were no adverse outcomes. These results, along with data from two retrospective cohort studies, clearly support the safe discharge of children, providing that symptoms of croup do not recur 2 to 4 hours after treatment   . Traditionally, racemic epinephrine has been used to treat children with croup. Racemic epinephrine is not readily available in Canada. However, one randomized controlled trial demonstrated that nebulized 1: Equivalent doses of either 0.
These standard doses can be used in all patients irrespective of their age and weight . A heliox or helium-oxygen mixture can reduce respiratory distress in children with severe croup.
A possible mechanism of action is that the lower density of helium gas decreases airflow turbulence in a narrowed airway. Heliox is occasionally used in severe cases to avoid intubation. Heliox has not been shown to improve croup symptoms when compared with standard treatments and therefore is not routinely recommended . An otorhinolaryngology ORL consultation for airway evaluation is indicated when croup symptoms are persistently severe despite treatment. Outpatient referral to ORL is recommended for children with multiple croup episodes and for those who present outside the usual age group for typical croup Figure 1.
Algorithm for the outpatient management of crop in children, by level of severity. The recommendations in this position statement do not indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account individual circumstances, may be appropriate.
Internet addresses are current at time of publication. Skip to Content Menu. Home Position statements and…. Practice Point Acute management of croup in the emergency department Posted: Abstract Croup is one of the most common causes of upper airway obstruction in young children.
High fever, neck pain, sore throat and dysphagia followed by torticollis, drooling, respiratory distress and stridor. Croupy cough, choking episode, wheezing, hoarseness, biphasic stridor, dyspnea and decreased air entry. Rapid onset of dysphagia, wheezing, stridor and possible cutaneous allergic signs, such as urticarial rash. CNS Central nervous system. Modified from Bjornson and Johnson .