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Key Feature 1b: In patients with croup: provide that assistance when indicated. Skill: Clinical Reasoning Phase: Treatment Key Feature 5: In patients with a diagnosis of croup, use steroids (do not under treat mild-to-moderate cases of croup). Skill: Clinical Reasoning Phase: Treatment Key Feature 6: In a patient presenting with croup, address parental concerns (ex: not minimizing the symptoms and their impact on the parents), acknowledging fluctuating course of the disease, providing a plan anticipating recurrence of the symptoms. Skill: Clinical Reasoning, Communication Phase: Treatment, Follow-up In a patient who is found to have airway compromise and/or respiratory distress, as may be the case in a kiddo with croup, it's important to
The basic approach to the ABCs is to look for signs of distress from airway, breathing, and circulatory compromise, among others, and provide life-preserving resuscitation maneuvers as indicated. In a patient who is in distress from croup, they are likely to present with airway and breathing difficulties. When it comes to airway resuscitation, general interventions to consider are as follows:
Now let's approach the above menu in the setting of a child who presents with distress from croup. It would be likely that they have stridor, which is a sound that indicates upper airway obstruction at the level of the larynx. Note that this sound is distinct from the sound of stertor (which is essentially the same sound as snoring), which also indicates upper airway obstruction but that which occurs at the level of the oropharynx rather than the larynx. So in the child with suspected croup, with an audible sign of laryngeal obstruction rather than oropharyngeal obstruction, we would recognize that basic airway management maneuvers are not indicated. Would we consider definitive airway management? If the child was already decompensating and the distress was so severe that they were unable to maintain their airway or were at impending risk of this, then yes, we would definitely consider placement of a definitive airway. Assuming the patient has distress from croup that is significant but not warranting placement of a definitive airway just yet, we would move on to our options for supporting the patient's respiration. In a patient with severe respiratory distress, sitting upright is generally the ideal position to optimise breathing, and the head of the patient's bed would be raised to support this. Note that if the patient feels there is another position that best supports their breathing, they should not be prevented from assuming this position instead. This is particularly important when it comes to the child with respiratory distress, as any increased discomfort may further agitate them and lead to even greater work of breathing, thereby increasing their demand for oxygen and putting them at increased risk of respiratory decompensation. After optimising positioning, the next maneuver to consider is ventilation support. This would be indicated for the child who has decompensated after prolonged respiratory effort, which can happen in severe circumstances. Much like intubating the airway, this is a maneuver that must be considered if the situation is dire enough, and if so cannot be delayed as it can make the difference between life and death. If the child is still supporting their own breathing effort, we would move on to providing supplemental oxygen if indicated, which would be if pulse oximetry showed their oxygen saturation as less than 95%. The choice of delivery system would depend on the severity of their hypoxia, and could range from providing blow-by oxygen, to delivering oxygen by nasal prongs, simple face mask, or non-rebreather. If supporting a patient's respiratory effort, you may also find it very helpful to have a respiratory therapist involved in the management of this. Now once the most critical life-saving airway and breathing resuscitation measures are underway, it is important to quickly consider if there are any rapidly reversible life-threatening causes for the airway and breathing difficulties. In a patient with stridor secondary to a suspected infection and the associated airway swelling it causes (as may be the case with croup, epiglottitis, or bacterial tracheitis) this would call for a dose of epinephrine, which can start to act within seconds to minutes to decrease swelling and corresponding obstruction. The dose to prescribe is: racemic epinephrine 0.05 mL/kg (max dose 0.5mL) diluted to 3mL with NS nebulized over 15 min q1-2h PRN. For patients who present with croup, regardless of whether or not they are severe enough to warrant epinephrine, they do merit a dose of dexamethasone (0.6 mg/kg dose). This is not as important to give quickly like epinephrine in the case of severe acute respiratory distress from croup, because it takes a few hours to have an effect, but it once it does start working it last for up to three days. It deceases inflammation and swelling of the affected upper airway tissue, decreasing signs of airway obstruction and reducing the respiratory symptoms that come with. There is minimal harm from giving a one-time dose of dexamethasone, and there is much benefit, both for the patient and the health care system as it significantly decreases the number of repeat visits to the ED for the same bout of illness (per the UpToDate article, "Croup: Pharmacologic and supportive interventions" (2018)). The fact that I mentioned that giving dexamethasone decreases repeat presentations for medical care for the same bout of croup suggests that presenting repeatedly for croup is a thing. If you haven't yet heard a child with stridor, then I encourage you to watch the video clip I plan to put in my next post. Quite frankly, it can sound quite scary, and it can be a real cause for concern when severe. On the other hand, mild croup is extremely common, and does not pose much of a threat at all unless it worsens. But it is hard for parents to know when exactly they ought and ought not be worried, because even mild croup in a child may appear worrisome to a parent who is not used to seeing their child without any sort or respiratory symptoms. Much of the management of croup then involves parental education about what are the differences between mild and severe croup, and what to do when the croup is severe and when it isn't. The UpToDate patient handouts (among many other useful patient resources) on croup are one tool to help parents know when and when not to worry from a medical point of view. All of the UpToDate handouts are free online at can be found here. I have attached the UpToDate Croup handout below, as it provides a framework for important thing to consider when counselling a parent on taking care of their child with croup. 
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