Management of croup in outpatient and emergency department settings

ED: emergency department; ETT: endotracheal tube; IM: intramuscular; IV: intravenous; PICU: pediatric intensive care unit.

* Signs of impending respiratory failure include: fatigue and listlessness, profound retractions, decreased or absent breath sounds, depressed level of consciousness, tachycardia out of proportion to fever (note that tachycardia may also be caused by epinephrine), and/or poor color (cyanosis or pallor).

¶ When administering oral dexamethasone, we either crush an oral tablet and mix it with pureed food, or we use the IV solution and administer it orally (as-is or mixed with flavored syrup). This is because the available oral dexamethasone preparations have several limitations, including unpleasant taste, high ethanol content, and lower drug concentration compared with the IV solution (meaning that the child must swallow a larger volume of medication for a given dose).

Δ Dosing and administration are as follows:

• Racemic epinephrine: 0.05 mL/kg per dose (maximum of 0.5 mL) of a 2.25% solution diluted to 3 mL total volume with normal saline (in the United States and some other countries, single-use preservative-free bullets [ampules] of racemic epinephrine for nebulized administration are commercially available).
• L-epinephrine: 0.5 mL/kg per dose (maximum of 5 mL) of a 1 mg/mL preservative-free solution (this is the parenteral preparation of epinephrine used for IM injection [eg, for anaphylaxis]).

Administer by nebulizer over 5 to 15 minutes. Use of either product is acceptable and may be determined by availability and institutional protocol. Nebulized epinephrine has an onset of effect within 10 minutes. Refer to UpToDate topic on management of croup for additional details.

◊ A single dose of nebulized budesonide, if available, may provide an alternative to IM or IV dexamethasone for children with vomiting and no IV access.

§ For children requiring inpatient admission for croup, the level of care (inpatient ward versus PICU) is determined by croup severity. PICU care is warranted for children with any of the following:

• Respiratory failure requiring endotracheal intubation
• Persistent severe symptoms requiring frequent nebulized epinephrine dosing
• Underlying conditions placing the child at high risk for progressive respiratory failure (eg, neuromuscular disease, bronchopulmonary dysplasia, congenital or acquired anatomical airway anomalies)

¥ Poor response to nebulized epinephrine in conjunction with high fever and toxic appearance should prompt consideration of bacterial tracheitis. Refer to UpToDate topic on evaluation and diagnosis of croup for a guide to the differential diagnosis.