Which intervention is appropriate for severe croup?

• A. Immediate endotracheal intubation in the operating room
• B. Sedation and observation in the ED
• C. Transfer to ICU for monitoring
• D. Place on a T-piece CPAP

Answer: (D)

Severe croup causes significant airway narrowing from subglottic edema, so the goal is to support the airway without immediately resorting to invasive procedures. Placing the patient on a T-piece CPAP provides continuous positive airway pressure that helps splint the narrowed upper airway, reduces the work of breathing, and improves ventilation. This noninvasive support can prevent progression to respiratory failure and delay or avoid the need for intubation, while allowing time for medical therapies such as systemic steroids and, if indicated, nebulized epinephrine to take effect. Sedating the child or simply observing won’t address the airway obstruction, and while close monitoring in ICU may be necessary, initiating CPAP directly targets the mechanical problem and is appropriate for severe but potentially reversible obstruction.