What is the correct management of viral croup?

  1. The degree of airways obstruction must be continually observed.
  2. Keep the child comfortable and calm as crying worsens the airways obstruction.
  3. Keeping the room warm helps. Humidifying the air may also help. Do not accidently burn the child with steam from a kettle. Cold mist does not help.
  4. If the child has fever above 38 °C give paracetamol.
  5. Continue to give frequent, small amounts of oral fluid unless the airway obstruction is severe. Continue breastfeeding if the child is not distressed.
  6. The child can be closely observed at home if the airways obstruction is mild and the home circumstances are adequate. Communication and transport to the nearest health facility are needed if the child is to be managed at home.
  7. Oral dexamethasone 0.5 mg/kg as a single dose (not if measles or herpes is the cause of the stridor). If no improvement, repeat after 24 hours. Steroids are the most important treatment in severe viral croup.
  8. There is no indication for antibiotics or bronchodilators in viral croup.
  9. Move to hospital if the airways obstruction becomes worse, especially if there is both inspiratory and expiratory stridor. It is best to move the child to hospital if there is stridor when the child is at rest. If possible, give oxygen during transport.
  10. Nebulised adrenaline (1:1000 solution) in hospital is the treatment of choice for worsening or severe airways obstruction. It will often provide temporary relief. If the child responds to the nebulised adrenaline admit the child to hospital for 24 hours to observe for rebound airway obstruction as the effect of adrenaline usually last only about 2 hours.
  11. Intubation or tracheotomy under general anaesthetic is only needed if respiratory failure develops (cyanosis, restlessness, severe chest wall indrawing or inadequate oxygen saturation in room air). Intubation must be seriously considered if the child has expiratory stridor and uses the chest and abdominal muscles during expiration.
  12. Oxygen should only be given in cases of severe airway obstruction as the method of delivering (e.g. nasal prongs) could make the child frightened and agitated and worsen the airway obstruction.

Mix 1 ml of 1:1000 adrenaline with 1 ml saline. Nebulise the entire volume with oxygen. Repeat every 15 minutes until the expiratory obstruction has resolved. Observe the child very carefully for signs of deterioration. Laryngoscopy to look for other causes of stridor is important in children who require intubation.

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