Pulse oximetry should be measured and supplemental humidified oxygen given. Children with croup should not be sedated except in the course of a rapid-sequence intubation. Antibiotics are not indicated for patients with a confident diagnosis of croup. Antipyretics should be given for fever to decrease the required minute ventilation and work of breathing. The least invasive route possible should be used to provide hydration, to replace insensible water losses from respiratory distress and fever. Urine output, or the number of wet diapers, should be monitored and intravenous hydration provided if necessary.
Exposure to humidified air, either cold night air or moist air from a shower, is used to treat this disease, but it is not known why this is effective. Nebulization tents, or "croup tents," are no longer used. A tent isolates the child and enshrouds it in a mist, making the child more anxious and difficult to monitor. Furthermore, it is very difficult to maintain an adequate concentration of oxygen within the tent.
In general, calculating a croup score (Table 1.2.9-3) is more useful as a research tool than as an adjunct to clinical practice. Its primary use is to provide a semiobjective scale by which to cohort patients for comparative studies. Its usefulness as a tool for clinical decision making with individual patients is much less clear. The score, if calculated, should only be used as one piece of data in the decision-making process. For example, a child with severe retractions and markedly decreased air entry may have a score of only 5 but would be considered at high risk by most clinicians and treated aggressively. Generally, healthy appearing children with stridor only when agitated do not require treatment with epinephrine. Children with stridor at rest or whom appear in distress should receive epinephrine as discussed below. All children receiving catecholamines should receive steroids as well. The use of steroids, as discussed below, is generally agreed upon in moderate to severe episodes of croup. In mild croup controversy exists regarding the absolute need of steroid treatment but there is some evidence showing benefit in this population as well. The use of steroids in the mildest cases should be decided on an individual case-by-case basis and may vary between reasonable clinicians. Further research, using clinically important endpoints and number-to-treat analysis, should help to clarify their use in this patient population.
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