Croup medical therapy: Difference between revisions

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(/* Medical Therapy Based on the MedicationAdapted from Lancet. 2008;371(9609):329–339. {{cite journal|last1=Bjornson|first1=Candice L|last2=Johnson|first2=David W|title=Croup|journal=The Lancet|volume=371|issue=9609|year=2008|pages=329–339|issn=014...)
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__NOTOC__
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{{CMG}}
{{Croup}}
{{Croup}}
{{CMG}} {{AE}} {{LRO}}
==Overview==
The primary medical therapy used to treat croup depends on the severity of the case. For mild croup, [[glucocorticoid]] therapy is primarily used to alleviate symptoms by reducing [[trachea|tracheal]] swelling and [[inflammation]]. The main [[corticosteroids]] used are [[dexamethasone]] and/or [[budesonide]], administered orally or, rarely, via a [[parenteral]] method. These are usually effective beginning 6 hours post-treatment. For moderate and severe croup, [[epinephrine]] is used in conjunction with [[glucocorticoid|glucocorticoids]]. The primary [[epinephrine]] therapies used are [[racemic]] [[epinephrine]] or L-[[epinephrine]], both in nebulized form. [[Epinephrine]] alleviates symptoms within 10-30 minutes, but they usually return within 2 hours, requiring repeated dosing for long-term relief. Hospitalization is rarely required and is primarily used for observation and symptom management in children. [[Intubation]] is a rare necessary treatment for hospitalized children with the most severe croup cases.


==Medical Therapy==
==Medical Therapy==
The treatment of croup depends on the severity of symptoms.
===[[Glucocorticoids]]===
 
*[[Corticosteroids]] are used to alleviate croup symptoms, effective beginning 6 hours post-treatment.<ref name="RussellLiang2011">{{cite journal|last1=Russell|first1=Kelly F|last2=Liang|first2=Yuanyuan|last3=O'Gorman|first3=Kathleen|last4=Johnson|first4=David W|last5=Klassen|first5=Terry P|last6=Klassen|first6=Terry P|title=Glucocorticoids for croup|year=2011|doi=10.1002/14651858.CD001955.pub3}}</ref>
One of the simplest ways to treat croup is to inhale hot steam.  This was the sole treatment for croup throughout the nineteenth and most of the twentieth century. [[Hospital]]s today use a "blowby" apparatus for this purpose. Simpler remedies include taking the child outside in moist night air, or alternatively exposing the child to steam from a hot bath or a humidifier. These techniques may help in some cases, but there is little hard evidence to support their efficacy.
**Symptom reduction is a result of reduced [[inflammation]] and swelling of the [[trachea]].
 
*For croup cases of all severities, the following [[glucocorticoid]] therapies are recommended:<ref name="PetrocheilouTanou2014">{{cite journal|last1=Petrocheilou|first1=Argyri|last2=Tanou|first2=Kalliopi|last3=Kalampouka|first3=Efthimia|last4=Malakasioti|first4=Georgia|last5=Giannios|first5=Christos|last6=Kaditis|first6=Athanasios G.|title=Viral croup: Diagnosis and a treatment algorithm|journal=Pediatric Pulmonology|volume=49|issue=5|year=2014|pages=421–429|issn=87556863|doi=10.1002/ppul.22993}}</ref>
Mild croup with no [[stridor]], or stridor only on agitation, and just a cough may simply be observed, or a dose of inhaled, oral, or injected steroids may be given. When steroids are given, [[dexamethasone]] is often used, due to its prolonged physiologic effects.
**'''[[Dexamethasone]]''': 0.60 mg/kg PO/IM/IV, single dose (max. 10 mg)
 
**'''[[Budesonide]]''': 2mg nebulized
Moderate to severe croup may require [[nebulizer|nebulized]] [[adrenaline]] in addition to steroids. [[Oxygen]] may be needed if [[Hypoxia (medical)|hypoxia]] develops. Children with moderate or severe croup are typically hospitalized for observation, usually for less than a day. [[Intubation]] is rarely needed (less than 1% of hospitalized patients).
*Dosing is usually administered orally for mild cases, but a [[parenteral]] method may be used for severe croup.<ref name="Everard2009">{{cite journal|last1=Everard|first1=Mark L.|title=Acute Bronchiolitis and Croup|journal=Pediatric Clinics of North America|volume=56|issue=1|year=2009|pages=119–133|issn=00313955|doi=10.1016/j.pcl.2008.10.007}}</ref>
 
 
==Medical Therapy Based on the Medication<SMALL><SMALL><SMALL><SMALL><SMALL>Adapted from Lancet. 2008;371(9609):329–339. <ref name="BjornsonJohnson2008">{{cite journal|last1=Bjornson|first1=Candice L|last2=Johnson|first2=David W|title=Croup|journal=The Lancet|volume=371|issue=9609|year=2008|pages=329–339|issn=01406736|doi=10.1016/S0140-6736(08)60170-1}}</ref></SMALL></SMALL></SMALL></SMALL></SMALL>==
 
<SMALL><font color="#FF4C4C">'''▸ Click on the following categories to expand treatment regimens.'''</font></SMALL>
 
{|
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<font color="#FFF">
'''Croup Medical Therapy'''
</font>
</div>
 
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<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Glucocorticoids'''
</font>
</div>
 
<div class="mw-customtoggle-table02" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Epinephrine'''
</font>
</div>


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===[[Epinephrine]]===
<font color="#FFF">
*[[Epinephrine]] is indicated for '''moderate''' and '''severe''' cases of croup.<ref name="Everard2009">{{cite journal|last1=Everard|first1=Mark L.|title=Acute Bronchiolitis and Croup|journal=Pediatric Clinics of North America|volume=56|issue=1|year=2009|pages=119–133|issn=00313955|doi=10.1016/j.pcl.2008.10.007}}</ref>
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Oxygen'''
*Symptoms are usually alleviated within 10-30 minutes, but typically return after 2 hours post-treatment.<ref name="BjornsonRussell2013">{{cite journal|last1=Bjornson|first1=Candice|last2=Russell|first2=Kelly|last3=Vandermeer|first3=Ben|last4=Klassen|first4=Terry P|last5=Johnson|first5=David W|last6=Bjornson|first6=Candice|title=Nebulized epinephrine for croup in children|year=2013|doi=10.1002/14651858.CD006619.pub3}}</ref>
</font>
*[[Epinephrine]] is usually administered as either of the following:<ref name="BjornsonRussell2013">{{cite journal|last1=Bjornson|first1=Candice|last2=Russell|first2=Kelly|last3=Vandermeer|first3=Ben|last4=Klassen|first4=Terry P|last5=Johnson|first5=David W|last6=Bjornson|first6=Candice|title=Nebulized epinephrine for croup in children|year=2013|doi=10.1002/14651858.CD006619.pub3}}</ref>
</div>
**'''Nebulized [[racemic]] [[epinephrine]] (2.25%)''': 0.05 mL/kg (max. 0.5mL) in 3mL of normal [[saline]] for 15 minutes.
**'''Nebulized L-[[epinephrine]]''': 0.5mL/kg (max 5mL) for 15 minutes.
***Repeated as necessary.
*[[Glucocorticoids]] are used in conjunction with [[epinephrine]] for moderate and severe croup cases.<ref name="PetrocheilouTanou2014">{{cite journal|last1=Petrocheilou|first1=Argyri|last2=Tanou|first2=Kalliopi|last3=Kalampouka|first3=Efthimia|last4=Malakasioti|first4=Georgia|last5=Giannios|first5=Christos|last6=Kaditis|first6=Athanasios G.|title=Viral croup: Diagnosis and a treatment algorithm|journal=Pediatric Pulmonology|volume=49|issue=5|year=2014|pages=421–429|issn=87556863|doi=10.1002/ppul.22993}}</ref>


<div class="mw-customtoggle-table05" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background: #4479BA;">
===Hospitalization===
<font color="#FFF">
*1 to 5% of children with croup will require hospitalization in addition to [[glucocorticoid]] and [[epinephrine]] therapy.<ref name="pmid23939212">{{cite journal |vauthors=Bjornson CL, Johnson DW |title=Croup in children |journal=CMAJ |volume=185 |issue=15 |pages=1317–23 |year=2013 |pmid=23939212 |pmc=3796596 |doi=10.1503/cmaj.121645 |url=}}</ref>
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Antibiotics'''
*Hospitalization is primarily used for observation and symptom management of children with moderate and severe croup.<ref name="PetrocheilouTanou2014">{{cite journal|last1=Petrocheilou|first1=Argyri|last2=Tanou|first2=Kalliopi|last3=Kalampouka|first3=Efthimia|last4=Malakasioti|first4=Georgia|last5=Giannios|first5=Christos|last6=Kaditis|first6=Athanasios G.|title=Viral croup: Diagnosis and a treatment algorithm|journal=Pediatric Pulmonology|volume=49|issue=5|year=2014|pages=421–429|issn=87556863|doi=10.1002/ppul.22993}}</ref>
</font>
*Less than 3% of admitted children will require [[intubation]].<ref name="pmid23939212">{{cite journal |vauthors=Bjornson CL, Johnson DW |title=Croup in children |journal=CMAJ |volume=185 |issue=15 |pages=1317–23 |year=2013 |pmid=23939212 |pmc=3796596 |doi=10.1503/cmaj.121645 |url=}}</ref>
</div>
 
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<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Heliox'''
</font>
</div>
 
| valign=top |
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table01" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Glucocorticoids}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Mild to Moderate Croup
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Dexamethasone]] 0.60 mg/kg PO/IM/IV, single dose  (max. 10 mg)''''' <br> OR <br> ▸ '''''[[Budesonide]] 2mg nebulized'''''
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Severe Croup
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Dexamethasone]] 0.60 mg/kg IM/IV, single dose''''' <br> OR <br> ▸ '''''[[Budesonide]] 2mg nebulized'''''
|-
|}
|}
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table02" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Epinephrine}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Mild Croup
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | There are no indications for nebulized epinephrine in mild croup
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Moderate to Severe Croup
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''Nebulized racemic [[epinephrine]] (2.25%) 0.05 mL/kg (max. 0.5mL) in 3mL of normal saline for 15 min''''' <br> OR <br>  ▸ '''''Nebulized L-[[epinephrine]] 0.5mL/kg (max 5mL) for 15 min'''''  <br>                ''Repeat as needed''
|-
|}
|}
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table03" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Oxygen}}
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ Humidified oxygen should be given to patients with hypoxia or severe respiratory distress
|-
|}
|}
 
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table05" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Antibiotics}}
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''Antibiotic are not indicated to treat viral croup''''' <br> ▸ '''''Antibiotics are use for complications, such as bacterial tracheitis or epiglottitis'''''
|-
|}
|}
 
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table06" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Heliox}}
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ There is no sufficient data that recommends the general use of heliox in patients with croup.<ref name="WeberChudnofsky2001">{{cite journal|last1=Weber|first1=J. E.|last2=Chudnofsky|first2=C. R.|last3=Younger|first3=J. G.|last4=Larkin|first4=G. L.|last5=Boczar|first5=M.|last6=Wilkerson|first6=M. D.|last7=Zuriekat|first7=G. Y.|last8=Nolan|first8=B.|last9=Eicke|first9=D. M.|title=A Randomized Comparison of Helium-Oxygen Mixture (Heliox) and Racemic Epinephrine for the Treatment of Moderate to Severe Croup|journal=PEDIATRICS|volume=107|issue=6|year=2001|pages=e96–e96|issn=0031-4005|doi=10.1542/peds.107.6.e96}}</ref><ref name="BeckmannBrueggemann2000">{{cite journal|last1=Beckmann|first1=Kathleen R.|last2=Brueggemann|first2=William Martin|title=HELIOX TREATMENT OF SEVERE CROUP|journal=The American Journal of Emergency Medicine|volume=18|issue=6|year=2000|pages=735–736|issn=07356757|doi=10.1016/S0735-6757(00)90309-7}}</ref><ref name="GuptaCheifetz2005">{{cite journal|last1=Gupta|first1=Vineet K.|last2=Cheifetz|first2=Ira M.|title=Heliox administration in the pediatric intensive care unit: An evidence-based review|journal=Pediatric Critical Care Medicine|volume=6|issue=2|year=2005|pages=204–211|issn=1529-7535|doi=10.1097/01.PCC.0000154946.62733.94}}</ref>
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ Some studies have shown a short-term benefit of heliox inhalation in children with moderate to severe croup.<ref>{{Cite journal
| author = [[Irene Moraa]], [[Nancy Sturman]], [[Treasure McGuire]] & [[Mieke L. van Driel]]
| title = Heliox for croup in children
| journal = [[The Cochrane database of systematic reviews]]
| volume = 12
| pages = CD006822
| year = 2013
| month =
| doi = 10.1002/14651858.CD006822.pub4
| pmid = 24318607
}}</ref><ref>{{Cite journal | author = [[Sarah Kline-Krammes]], [[Christina Reed]], [[John S. Jr Giuliano]], [[Hamilton P. Schwartz]], [[Michael Forbes]], [[John Pope]], [[James Besunder]], [[Michael D. Gothard]], [[Kerry Russell]] & [[Michael T. Bigham]] | title = Heliox in children with croup: a strategy to hasten improvement | journal = [[Air medical journal]] | volume = 31 | issue = 3 | pages = 131–137 | year = 2012 | month = May-June | doi = 10.1016/j.amj.2011.08.004 | pmid = 22541348 }}</ref>
 
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==Medical Therapy Based on the Severity <SMALL><SMALL><SMALL><SMALL><SMALL>Adapted from Pediatric Pulmonology 49:421–429 (2014) <ref name="PetrocheilouTanou2014">{{cite journal|last1=Petrocheilou|first1=Argyri|last2=Tanou|first2=Kalliopi|last3=Kalampouka|first3=Efthimia|last4=Malakasioti|first4=Georgia|last5=Giannios|first5=Christos|last6=Kaditis|first6=Athanasios G.|title=Viral croup: Diagnosis and a treatment algorithm|journal=Pediatric Pulmonology|volume=49|issue=5|year=2014|pages=421–429|issn=87556863|doi=10.1002/ppul.22993}}</ref> </SMALL></SMALL></SMALL></SMALL></SMALL>==
 
<SMALL><font color="#FF4C4C">'''▸ Click on the following categories to expand treatment regimens.'''</font></SMALL>
 
{|
| valign=top |
<div style="border-radius: 5px 5px 0 0; border: solid 1px #20538D; border-bottom: 0px; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background: #A1BCDD; text-align: center;">
<font color="#FFF">
'''Disease Severity'''
</font>
</div>
 
<div class="mw-customtoggle-table07" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Mild'''
</font>
</div>
 
<div class="mw-customtoggle-table08" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Moderate'''
</font>
</div>
 
<div class="mw-customtoggle-table09" style="cursor: pointer; border-radius: 0 0 5px 5px; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Severe'''
</font>
</div>
 
| valign=top |
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table07" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Mild}}
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Dexamethasone]] 0.60 mg/kg PO single dose  (max. 10 mg)''''' <br> OR <br> ▸ '''''[[Budesonide]] 2mg nebulized'''''
|-
|}
|}
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table08" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Moderate}}
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''Nebulized racemic [[epinephrine]] (2.25%) 0.05 mL/kg (max. 0.5mL) in 3mL of normal saline for 15 min''''' <br> OR <br>  ▸ '''''Nebulized L-[[epinephrine]] 0.5mL/kg (max 5mL) for 15 min'''''  <br>                ''Repeat as needed''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Dexamethasone]] 0.60 mg/kg PO/IM single dose  (max. 10 mg)''''' <br> OR <br> ▸ '''''[[Budesonide]] 2mg nebulized'''''
|-
|}
|}
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table09" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Severe}}
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''Nebulized racemic [[epinephrine]] (2.25%) 0.05 mL/kg (max. 0.5mL) in 3mL of normal saline for 15 min''''' <br> OR <br>  ▸ '''''Nebulized L-[[epinephrine]] 0.5mL/kg (max 5mL) for 15 min'''''  <br>                ''Repeat as needed''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Dexamethasone]] 0.60 mg/kg IM/IV single dose  (max. 10 mg)'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | AND
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ Hospital admission
|-
|}
|}
|}


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}
[[Category:Needs overview]]
[[Category:Pediatrics]]
[[Category:Pediatrics]]
[[Category:Infectious disease]]
 
[[Category:Pulmonology]]
[[Category:Pulmonology]]
[[Category:Emergency medicine]]
[[Category:Emergency medicine]]

Latest revision as of 17:30, 18 September 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Luke Rusowicz-Orazem, B.S.

Overview

The primary medical therapy used to treat croup depends on the severity of the case. For mild croup, glucocorticoid therapy is primarily used to alleviate symptoms by reducing tracheal swelling and inflammation. The main corticosteroids used are dexamethasone and/or budesonide, administered orally or, rarely, via a parenteral method. These are usually effective beginning 6 hours post-treatment. For moderate and severe croup, epinephrine is used in conjunction with glucocorticoids. The primary epinephrine therapies used are racemic epinephrine or L-epinephrine, both in nebulized form. Epinephrine alleviates symptoms within 10-30 minutes, but they usually return within 2 hours, requiring repeated dosing for long-term relief. Hospitalization is rarely required and is primarily used for observation and symptom management in children. Intubation is a rare necessary treatment for hospitalized children with the most severe croup cases.

Medical Therapy

Glucocorticoids

  • Corticosteroids are used to alleviate croup symptoms, effective beginning 6 hours post-treatment.[1]
  • For croup cases of all severities, the following glucocorticoid therapies are recommended:[2]
  • Dosing is usually administered orally for mild cases, but a parenteral method may be used for severe croup.[3]

Epinephrine

  • Epinephrine is indicated for moderate and severe cases of croup.[3]
  • Symptoms are usually alleviated within 10-30 minutes, but typically return after 2 hours post-treatment.[4]
  • Epinephrine is usually administered as either of the following:[4]
    • Nebulized racemic epinephrine (2.25%): 0.05 mL/kg (max. 0.5mL) in 3mL of normal saline for 15 minutes.
    • Nebulized L-epinephrine: 0.5mL/kg (max 5mL) for 15 minutes.
      • Repeated as necessary.
  • Glucocorticoids are used in conjunction with epinephrine for moderate and severe croup cases.[2]

Hospitalization

  • 1 to 5% of children with croup will require hospitalization in addition to glucocorticoid and epinephrine therapy.[5]
  • Hospitalization is primarily used for observation and symptom management of children with moderate and severe croup.[2]
  • Less than 3% of admitted children will require intubation.[5]

References

  1. ↑ Russell, Kelly F; Liang, Yuanyuan; O'Gorman, Kathleen; Johnson, David W; Klassen, Terry P; Klassen, Terry P (2011). "Glucocorticoids for croup". doi:10.1002/14651858.CD001955.pub3.
  2. ↑ 2.0 2.1 2.2 Petrocheilou, Argyri; Tanou, Kalliopi; Kalampouka, Efthimia; Malakasioti, Georgia; Giannios, Christos; Kaditis, Athanasios G. (2014). "Viral croup: Diagnosis and a treatment algorithm". Pediatric Pulmonology. 49 (5): 421–429. doi:10.1002/ppul.22993. ISSN 8755-6863.
  3. ↑ 3.0 3.1 Everard, Mark L. (2009). "Acute Bronchiolitis and Croup". Pediatric Clinics of North America. 56 (1): 119–133. doi:10.1016/j.pcl.2008.10.007. ISSN 0031-3955.
  4. ↑ 4.0 4.1 Bjornson, Candice; Russell, Kelly; Vandermeer, Ben; Klassen, Terry P; Johnson, David W; Bjornson, Candice (2013). "Nebulized epinephrine for croup in children". doi:10.1002/14651858.CD006619.pub3.
  5. ↑ 5.0 5.1 Bjornson CL, Johnson DW (2013). "Croup in children". CMAJ. 185 (15): 1317–23. doi:10.1503/cmaj.121645. PMC 3796596. PMID 23939212.

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