URTObstruction - Diseases
Introduction Physical Examination Differential Diagnosis Specific Diseases Epiglottitis Viral croup Clinical Treatment Other types Foreign body aspiration Retropharyngeal abscess References Other Lectures		Treatment is symptomatic; cool mist, oxygen when needed and hydration, either IV or PO. Antibiotics are not necessary, unless there is an associated bacterial illness (otitis media or tonsillitis). Croup scores are primarily used as research tools, although serial scores, when used with other criteria, may be helpful in managing severely ill patients. Vaponephrine, an equimolar mixture of the D and L isomers of epinephrine, can be administered by nebulized aerosol via a face mask (IPPB is not necessary) for acute but sometimes temporary relief of obstructive symptoms. The dose is 0.5 mL (0.25 mL < 6 months old) in 3 mL of normal saline. It can be repeated as needed, as long as a good clinical response continues to occur and no cardiac toxicity (hypertension, tachyarrhythmias) is seen. Steroids are clearly beneficial in croup. Although there are some statistical complaints (e.g. small number of patients) concerning the reported trials, steroids have become the standard treatment for croup. The usual drug used is dexamethasone. Recent randomized trials have definitively demonstrated that a single PO dose of 0.6 mg/kg (maximum 8 mg) is effective and safe. It has also been shown that the IV and PO routes are equally effective. Since helium is much less dense than either oxygen or nitrogen, its use will increase ventilation in patients with upper airway obstruction. Therefore, a trial of Heliox, a helium-oxygen mixture, may be beneficial. However, the therapeutic benefits from helium are only found when it makes up 60 to 80% of the inspired gas. Therefore, the patient who requires more than 35 to 40% oxygen is not a candidate for Heliox. In the severely ill patient, blood gases must be monitored and elective intubation considered, depending on a number of clinical factors. Fortunately, less than 1% of patients admitted to the hospital with croup will require intubation. The current standard of care for moderate to severe croup is to administer nebulized epinephrine and steroids and to monitor these patients for 3 to 6 hours in the ER. If rebound stridor has not occurred and certain criteria are met, they can be discharged from the ER. Return to top of page