Invalid URLNov 14, Author: In mild croup, a child may present with only a croupy cough and may croup steroid treatment side effects require parental guidance human growth hormone kuwait reassurance, given alertness, baseline minimal respiratory distress, proper oxygenation, and stable fluid status. Caregivers may only need education regarding the course of the disease and supportive homecare guidelines. Most children with mild croup symptoms can be successfully treated at home by their caregivers. An adult caregiver should stay with the child during mist treatment.
Croup Treatment & Management: Approach Considerations, Corticosteroids, Epinephrine
Nov 14, Author: In mild croup, a child may present with only a croupy cough and may just require parental guidance and reassurance, given alertness, baseline minimal respiratory distress, proper oxygenation, and stable fluid status. Caregivers may only need education regarding the course of the disease and supportive homecare guidelines.
Most children with mild croup symptoms can be successfully treated at home by their caregivers. An adult caregiver should stay with the child during mist treatment. Other suggestions for home treatment of mild croup include:. Young children should be kept as comfortable as possible, allowing him or her to remain in a parent's arms and avoiding unnecessary painful interventions that may cause agitation, respiratory distress, and lead to increased oxygen requirements.
Persistent crying increases oxygen demands, and respiratory muscle fatigue can worsen the airway obstruction. Concurrently, careful monitoring of heart rate for tachycardia , respiratory rate for tachypnea , respiratory mechanics for sternal wall retractions , and pulse oximetry for hypoxia are important. Current treatment approaches in the urgent care clinics or emergency departments are corticosteroids and nebulized epinephrine; steroids have proven beneficial in severe, moderate, and even mild croup.
Lack of improvement or worsening of symptoms can be due to a secondary bacterial process, which requires the use of antimicrobials for treatment.
Typically, patients with a bacterial component would have had moderate-to-severe croup assessment scores, requiring inpatient care and observation. Infants and children with severe respiratory distress or compromise may require oxygenation with ventilation support, initially with a bag-valve-mask device. If the airway and breathing require further stabilization due to increasing respiratory fatigue and hence, worsening hypercarbia, as evident by ABG , the patient should be intubated with an endotracheal tube.
Intubation should be accomplished with an endotracheal tube that is 0. Once airway stabilization is achieved, these patients are transferred for their ongoing care to a pediatric intensive care unit.
Historically, cool mist administration was the mainstay of treatment for croup. Hospitals had "croup rooms" filled with cool mist. Theoretically, mist moistens airway secretions, decreases their viscosity, and soothes the inflamed mucosa.
Animal data show that microaerosol inhalation activates mechanoreceptors that produce a reflex slowing of respiratory flow rate and leads to improved airflow. However, despite its continued widespread use, little evidence supports the clinical efficacy of cool mist or humidification therapy. Randomized studies of children with moderate-to-severe croup revealed no difference in outcome between those who received cool mist and those who did not.
Corticosteroids are beneficial due to their anti-inflammatory action. Their use decreases both laryngeal mucosal edema and the need for salvage nebulized epinephrine. Corticosteroids may be warranted even in those children who present with mild symptoms. Treatment of croup with corticosteroids has not shown significant adverse effects; however despite the low risk, their use should be carefully evaluated for children with diabetes, an underlying immunocompromised state, or those recently exposed to or diagnosed with varicella or tuberculosis, due to the potential risk of exacerbating the co-current disease process.
A single dose of dexamethasone has been shown to be effective in reducing the overall severity of croup, if administered within the first hours after the onset of illness.
The long half-life of dexamethasone h often allows for a single injection or dose to cover the usual symptom duration of croup. Studies have shown that dexamethasone dosed at 0. Despite this knowledge, clinicians still tend to favor the dose of 0. This dosage, in fact, is more effective for patients diagnosed with severe croup and remains the optimal amount for safety, benefit and cost-effectiveness.
Dexamethasone has shown the same efficacy if administered intravenously, intramuscularly, or orally. The use of inhaled corticosteroids budesonide with systemic treatment has not shown additional benefit. Nebulized racemic epinephrine is a 1: Its use is typically reserved for patients in the hospital setting with moderate-to-severe respiratory distress.
Epinephrine works by adrenergic stimulation, which causes constriction of the precapillary arterioles, thereby decreasing capillary hydrostatic pressure. This leads to fluid resorption from the interstitium and improvement in the laryngeal mucosal edema. Its effectiveness is immediate with evidence of therapeutic benefit within the first 30 minutes and then, a lasting effect from minutes 1. Patients can be discharged home only if they demonstrate clinical stability with good air entry, baseline consciousness, no stridor at rest and have received a dose of corticosteroids.
Delivery to the patient is via nasal cannula, face mask, or hood. It has low viscosity and low specific gravity, which allows for greater laminar airflow through the respiratory tract. Helium facilitates the movement of oxygen through the airways and decreases the mechanical work of respiratory muscles. This clinical response reduces respiratory distress.
Several trials of heliox have demonstrated no advantage over conventional modalities; however, other trials have shown it to be equally effective in moderate to severe croup when compared with racemic epinephrine.
Currently, the evidence is not sufficient to establish the beneficial effect of heliox in pediatric croup management. Anecdotal evidence suggests that heliox does help relieve respiratory distress. Medscape Reference by WebMD. American Academy of Pediatrics. Elk Grove Village, IL: American Academy of Pediatrics; Role of human coronavirus NL63 in hospitalized children with croup. Pediatr Infect Dis J.
Human metapneumovirus and lower respiratory tract disease in otherwise healthy infants and children. N Engl J Med. Nebulized epinephrine for croup in children. Cochrane Database Syst Rev. Croup hospitalizations in Ontario: Is bacterial tracheitis changing?
A month experience in a pediatric intensive care unit. Bacterial tracheitis as a complication of viral croup. Sobol SE, Zapata S. Otolaryngol Clin North Am. Correlating the clinical course of recurrent croup with endoscopic findings: Ann Otol Rhinol Laryngol. Guideline for the diagnosis and management of croup. Alberta Clinical Practice Guidelines Update. Guidelines for the diagnosis and management of croup.
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Controlled delivery of high vs low humidity vs mist therapy for croup in emergency departments: Cool mist is an effective therapy in the management of croup. Humidified air inhalation for treating croup [database online]. Cochrane Database of Systematic Reviews; A randomized trial of a single dose of oral dexamethasone for mild croup. A comparison of nebulized budesonide, and intramuscular, and oral dexamethasone for treatment of croup.
Int J Pediatr Otorhinolaryngol. Chub-Uppakarn S, Sangsupawanich P. A randomized comparison of dexamethasone 0. Comparison between single-dose oral prednisolone and oral dexamethasone in the treatment of croup: Steroid treatment of laryngotracheitis: Oral betamethasone versus intramuscular dexamethasone for the treatment of mild to moderate viral croup: Budesonide offers no advantage when added to oral dexamethasone in the treatment of croup.
Sparrow A, Geelhoed G. Prednisolone versus dexamethasone in croup: Helium-oxygen therapy in the emergency department. Vorwerk C, Coats TJ.
Use of helium-oxygen mixtures in the treatment of croup: Heliox treatment of severe croup. Am J Emerg Med. The effect of heliox on croup: A randomized comparison of helium-oxygen mixture Heliox and racemic epinephrine for the treatment of moderate to severe croup. Vorwerk C, Coats T. Heliox for croup in children.