Figure 1 is an algorithm for outpatient management of croup based on illness severity. 25 – 34 Keeping a symptomatic child calm by avoiding distressing procedures is important because agitation may worsen airway obstruction. Positioning the child so that he or she is comfortable is appropriate because no particular position has been shown to be more beneficial in the assessment. Oxygen should be administered when the child is hypoxic or in severe respiratory distress. Heliox, a helium-oxygen mixture, has been used to reduce airflow resistance and turbulence. Although case reports have been encouraging, a systematic review found insufficient evidence that heliox is beneficial for croup. 35 Likewise, studies do not support the routine use of exposure to cold air, antipyretics, analgesics, antitussives, decongestants, or prophylactic antibiotics.
What will they do for you in the ER? As they evaluate your child, they should encourage you to hold him in your lap, remember to keep him calm. They might measure his blood oxygen level, with an oximeter or “pulse-ox.” This uses a small light source that is wrapped around a finger or toe and helps determine how your child is breathing. They might have you blow cool mist in front of your child’s face. If your child’s croup is severe enough (which is why you’re in the ER), they may give him vaporized Epinephrine to breathe with the cool mist. This works quickly to open the airways. Depending on the situation, the ER physician may recommend a short course of steroids. Don’t worry; this is not the “body-building” type of steroids. These will help keep the air passages open over the next few hours to days. Your child will only be on the steroids for a few days, there are no side effects to worry about when used for this short time. The first dose often needs to be given as an injection, since the child with severe breathing difficulty is in no mood to take an oral medication, or he may throw it up.