In most cases of croup, the home-based approach of steam alter¬nating with cool air is enough to make your child comfortable and get him through the night. However, if your child is having difficulty breathing, medical intervention may be necessary. This is especially important when the breathing difficulty is caused by acute swelling in the airway.
Steroids are one of the most effective medicines used to treat severe croup and stridor. These potent anti-inflammatories rap¬idly reduce swelling inside the airway. Steroids have a bad repu¬tation because after prolonged use, they can be associated with complications such as high blood pressure, weight gain, and skin changes. However, when used for a short duration (less than two weeks) and in relatively low doses, steroids are safe medicines with few side effects. In most cases of croup or stridor associated with respiratory distress, steroids are typically given for one to three days. Sometimes they are used only once. They can be given by injection, by mouth, or in a mist that is blown into the child’s mouth and down into his lungs. The use of a mist is called a nebulized treatment
Sometimes a muscle relaxant called albuterol is used to help ease respiratory distress. This medicine relaxes the muscles that line the airway and lungs, so that the tubes (bronchi) carrying air can open to their maximum size. For this reason, albuterol is called a bronchodilator. Albuterol is effective only when the muscles are clenched tight or in spasm. Therefore, if the cause of croup or stridor is obstruction in the uppermost part of the airway and is not associated with airway muscle spasm, albuterol is inef¬fective. Albuterol can be given in a liquid or nebulized form.
If the stridor results from severe allergy and anaphylaxis, a shot of epinephrine may be used on its own or in addition to steroids. Epinephrine also can be inhaled in a nebulized form. It works by a different mechanism than steroids. Like albuterol, it is a muscle relaxant, which means that it opens up the airways in the lungs. But it is much more potent than albuterol. Epinephrine occurs naturally in the body, but it can be supplemented with the manufactured form. It is administered in life-threatening situa¬tions ranging from respiratory distress to cardiac arrest.
When epinephrine is used in the emergency setting, it often quickly improves a child’s breathing, causing stridor to subside. When the medicine wears off, however, the labored breathing and stridor may return. This is why a child who receives epineph¬rine will need to be observed for three to four hours before being discharged home.
When stridor is caused by a bacterial infection, antibiotics must be used. In severe cases, antibiotics are given intravenously (directly into the bloodstream) because a child with a swollen air¬way will have trouble swallowing medications. IV forms are also faster acting and often more potent.
A child with a bacterial infection of the airway – such as epiglottitis – has an airway emergency. He may need to have his airway examined by someone skilled in airway management, either in the emergency department or in the operating room.