Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

mild (no stridor at rest)

1st line – corticosteroid + supportive care

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ACUTE
|
mild (no stridor at rest)
1st line – 

corticosteroid + supportive care

A single dose of oral dexamethasone is given as soon as the clinical diagnosis of croup has been made. Its effect in reducing the clinical signs of croup is seen within 2 hours, with further beneficial effects noted up to 10 hours following administration.[42]

Traditionally, a dose of 0.6 mg/kg/dose was used for croup; however, evidence now supports the use of a smaller dose of 0.15 mg/kg/dose.[62]

Care should be taken to avoid frightening the child, as agitation may cause worsening of symptoms.[19] Especially in mild croup, parental assurance and education to the self-limited nature of the illness is important.

Historically mist or humidified air have been widely employed, but there is now convincing evidence that these are ineffective and even harmful in some instances.[19][88][89][90][91][92][93]​​

Primary options

dexamethasone: 0.15 to 0.6 mg/kg orally as a single dose

moderate (stridor at rest; no agitation or lethargy)

1st line – corticosteroid + supportive care

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ACUTE
|
moderate (stridor at rest; no agitation or lethargy)
1st line – 

corticosteroid + supportive care

A single dose of oral dexamethasone is given as soon as the clinical diagnosis of croup has been made. Its effect in reducing the clinical signs of croup is seen within 2 hours, with further beneficial effect noted up to 10 hours following administration.[42]

Traditionally, a dose of 0.6 mg/kg/dose was used for croup; however, evidence now supports the use of a smaller dose of 0.15 mg/kg/dose.[62]

Nebulized budesonide is preferable in severe hypoxia, persistent vomiting, or respiratory distress preventing administration of an oral dose.

Intramuscular dexamethasone is another alternative.

Care should be taken to avoid frightening the child, as agitation may cause worsening of symptoms.[19] Historically mist or humidified air have been widely employed, but there is now convincing evidence that these are ineffective​ and even harmful in some instances.[19][88][89][90][91][92][93]

Primary options

dexamethasone: 0.15 to 0.6 mg/kg orally as a single dose

OR

budesonide inhaled: 2 mg nebulized as a single dose

OR

dexamethasone sodium phosphate: 0.6 mg/kg intramuscularly as a single dose

Plus – nebulized epinephrine

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ACUTE
|
moderate (stridor at rest; no agitation or lethargy)
Plus – 

nebulized epinephrine

Treatment recommended for ALL patients in selected patient group

In children presenting with stridor, sternal indrawing at rest and persistent or increasing agitation, nebulized epinephrine should be administered in addition to dexamethasone. It provides temporary relief of the airway obstruction while awaiting the effects of corticosteroid treatment.[71] [ Cochrane Clinical Answers logo ]

The clinical effects of nebulized epinephrine last on average at least 1 hour, but usually subside 2 hours after administration.[37]

The use of one dose at a time of nebulized epinephrine has not been associated with any clinically significant increases in BP or heart rate, neither has it been associated with any adverse events.[72][73][78][83]​​​[84][85][86]​ Caution should be used with multiple doses of nebulized epinephrine. Careful observation is advisable if epinephrine treatment is deemed necessary.

Although racemic epinephrine has traditionally been used to treat children with croup, L-epinephrine is as effective in moderate to severe croup.[78] In North America, L-epinephrine availability may be limited. The same dose is used regardless of weight, as the effective dose of drug delivered to the airway is regulated by individual tidal volume.[79][80][81][82]

Primary options

racepinephrine (racemic epinephrine) inhaled: (2.25% solution) 0.5 mL diluted to 2-4 mL with normal saline nebulized as a single dose

OR

epinephrine (adrenaline): (1:1000 solution of L-epinephrine) 5 mL undiluted nebulized as a single dose

severe (stridor at rest with agitation or lethargy)

1st line – corticosteroid + supportive care

Back
ACUTE
|
severe (stridor at rest with agitation or lethargy)
1st line – 

corticosteroid + supportive care

A single dose of oral dexamethasone is given as soon as the clinical diagnosis of croup has been made. Its effect in reducing the clinical signs of croup is seen by 2 hours, with further beneficial effect noted up to 10 hours following administration.[42]

Traditionally, a dose of 0.6 mg/kg/dose was used for croup; however, evidence now supports the use of a smaller dose of 0.15 mg/kg/dose.[62]

Nebulized budesonide is preferable in severe hypoxia, persistent vomiting, or respiratory distress preventing administration of an oral dose.

Intramuscular or intravenous dexamethasone is another alternative. However, there is significant potential to increase agitation and respiratory distress when an intravenous line is inserted in a child with severe croup.

Wherever possible, the child should be kept in a calm environment with his/her caregiver. Care should be taken to minimize interventions that would increase the child’s agitation. Historically mist or humidified air have been widely employed, but there is now convincing evidence that these are ineffective and even harmful in some instances.[19][88][89][90][91][92][93]​​

Primary options

dexamethasone: 0.15 to 0.6 mg/kg orally as a single dose

OR

budesonide inhaled: 2 mg nebulized as a single dose

OR

dexamethasone sodium phosphate: 0.6 mg/kg intramuscularly as a single dose

Secondary options

dexamethasone sodium phosphate: 0.15 to 0.6 mg/kg intravenously as a single dose

Plus – nebulized epinephrine

Back
ACUTE
|
severe (stridor at rest with agitation or lethargy)
Plus – 

nebulized epinephrine

Treatment recommended for ALL patients in selected patient group

In children presenting with stridor, sternal/intercostal indrawing at rest and persistent or increasing agitation, nebulized epinephrine should be administered in addition to dexamethasone. It provides temporary relief of the airway obstruction while awaiting the effects of corticosteroid treatment.[71] [ Cochrane Clinical Answers logo ]

The clinical effects of nebulized epinephrine last on average at least 1 hour, but usually subside 2 hours after administration.[37]

The use of one dose at a time of nebulized epinephrine has not been associated with any clinically significant increases in BP or heart rate, neither has it been associated with any adverse events.[72][73][78][83]​​​[84][85][86]​ Caution should be used with multiple doses of nebulized epinephrine.​[87]​​ Careful observation is advisable if epinephrine treatment is deemed necessary.

Although racemic epinephrine has traditionally been used to treat children with croup, L-epinephrine is as effective in moderate to severe croup.[78] In North America, L-epinephrine availability may be limited. The same dose is used regardless of weight, as the effective dose of drug delivered to the airway is regulated by individual tidal volume.[79][80][81][82]

Primary options

racepinephrine (racemic epinephrine) inhaled: (2.25% solution) 0.5 mL diluted to 2-4 mL with normal saline nebulized as a single dose

OR

epinephrine (adrenaline): (1:1000 solution of L-epinephrine) 5 mL undiluted nebulized as a single dose

Plus – supplemental oxygen

Back
ACUTE
|
severe (stridor at rest with agitation or lethargy)
Plus – 

supplemental oxygen

Treatment recommended for ALL patients in selected patient group

Humidified oxygen is given to children demonstrating significant signs and symptoms of respiratory distress, preferably as blow-by oxygen via tubing held a few centimeters from the child's nose and mouth.

In the event that oxygenation is insufficient using this method, 100% oxygen via a nonrebreather mask is administered. However, the application of the mask to the face carries the potential for increasing agitation and preparations (experienced personnel, intubation equipment, medications) should be made to secure the airway if the clinical situation worsens to impending respiratory failure.

Oxygen saturation monitoring should occur, providing this does not increase the child's level of agitation.

Primary options

oxygen: 8 to 10 L/min blow-by

Secondary options

oxygen: 100% by nonrebreather mask

Consider – intubation

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ACUTE
|
severe (stridor at rest with agitation or lethargy)
|
with impending respiratory failure
Consider – 

intubation

Treatment recommended for SOME patients in selected patient group

Indicated in children progressing to asynchronous chest wall and abdominal movement, fatigue, and signs of hypoxia (pallor or cyanosis) and hypercapnia (decreased level of consciousness secondary to rising PaCO₂).

Becoming increasingly uncommon (in only 1% to 3% of children admitted with croup) and performed as rapid sequence induction in a controlled setting with experienced personnel and equipment.[52][53][54][55]

Advisable to have a selection of endotracheal tubes of smaller sizes at hand, as subglottic edema may cause difficulty when intubating with a standard sized endotracheal tube.

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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