Treatment of croup

Pre-hospital stage and basic care

Care must begin with breaking the pathological physiological pattern: the child's fear leads to forced breathing, which only worsens airway obstruction. It is important to establish a protective regimen — pick up the patient and calm them down as much as possible.

In parallel, physical methods are used:

• Create a high-humidity environment ("tropical atmosphere", steam inhalations), which helps reduce mucosal edema and facilitates secretion clearance.
• To stimulate the cough reflex, a reflex action can be applied — mechanically pressing the root of the tongue with a tongue depressor.

Regardless of the severity of the condition, a supply of fresh, humidified air, a comfortable body position, and continuous monitoring of vital functions (respiratory and heart rate, pulse oximetry) are important. Antipyretics are prescribed for fever.

Indications for hospitalization

The choice of treatment setting is based on the severity of respiratory failure and the presence of aggravating factors. An absolute indication is grade II laryngeal stenosis and worse — such children are hospitalized in 100% of cases.

If the child has grade I stenosis, hospitalization is relative and is required in the presence of the following risk factors:

• Age-related: infants under one year of age, history of prematurity.
• Clinical: no response to initial therapy, comorbid conditions, congenital laryngeal anomalies.
• Pharmacological: prior administration of systemic glucocorticoids the day before.
• Non-medical: unfavorable social or epidemiological conditions.

Pharmacotherapy: glucocorticoids

The foundation of pathogenetic treatment for croup is glucocorticoids (GCs). They exert a powerful anti-inflammatory effect, reduce capillary permeability, and directly relieve exudation and laryngeal tissue edema.

1. Topical steroids (first line): Micronized budesonide suspension via nebulizer is used. Standard regimen: 2 mg at once or 1 mg twice with an interval of 30 minutes. The drug acts strictly topically, causing vasoconstriction. Clinical improvement occurs within 15–30 minutes, peaking at 3–6 hours.
2. Systemic steroids: Administered parenterally. Dexamethasone (0.6 mg/kg) or prednisolone (2–5 mg/kg) is used. The effect develops within 15–45 minutes and lasts from 4 to 8 hours. In case of recurrent stenosis, repeat dosing is permitted.

Therapy of comorbid conditions and convalescence

The scope of medical care is expanded in the presence of additional syndromes:

• Bronchial obstruction: When the lower respiratory tract is involved, inhalations of bronchodilators (short-acting beta2-agonists — salbutamol, or combinations — ipratropium bromide + fenoterol) are prescribed along with budesonide suspension.
• Atopy: In patients with a burdened allergic history and grade I–II stenosis, the addition of 2nd-generation antihistamines (H1-receptor blockers) is justified.

In the post-stenotic period, when laryngeal edema is completely eliminated but a cough persists, tactics change. The main goal becomes improving mucociliary clearance. To thin sputum, mucolytics (ambroxol, acetylcysteine, carbocisteine) are prescribed orally or via inhalation. In children over 2 years of age, fenspiride may be used.

Important: Antiviral drugs are effective only in the first 48 hours of illness. Antibiotics are not indicated for viral croup and are prescribed exclusively upon clinical and laboratory confirmation of bacterial complications.

Discharge and outpatient management

Transfer of the patient to home treatment is permitted only upon achieving complete stabilization, which includes three mandatory conditions:

1. Complete disappearance of stenosis symptoms (no stridor and use of accessory muscles at rest).
2. Stable normalization of body temperature.
3. No signs of secondary bacterial infection.

After discharge, symptomatic therapy of the underlying disease (ARVI) is continued. The district pediatrician is required to conduct an active home visit the next day. Routine vaccination is temporarily prohibited — a medical exemption is given for at least 2 weeks after complete clinical recovery.

Class and exam questions

What else to study on this topic

• Assessment of the severity of laryngeal stenosis (grades I–IV)
• Pathogenesis and anatomical and physiological prerequisites for croup in children
• Differential diagnosis with epiglottitis and foreign body aspiration
• Mechanisms of respiratory failure development in upper airway obstruction

Other topics in "Chapter 13. Main syndromes requiring emergency care"

Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.