Treatment of croup with nebulised steroid (budesonide): a double blind, placebo controlled study

Prophylactic inhaled corticosteroids for the management of recurrent croup

OBJECTIVES

Croup is characterized by a barky cough, inspiratory stridor, hoarseness and varying degrees of respiratory distress. Acute croup episodes are often treated with oral, inhaled, or intravenous corticosteroids. Recurrent croup, defined as more than 2-3 episodes of acute croup in the same patient, can mimic asthma. We hypothesized that inhaled corticosteroids (ICS) given at the first sign of a respiratory viral prodrome can be a safe treatment to reduce the frequency of recurrent croup episodes in children without fixed airway lesions.

METHODS

A retrospective chart review of patients being treated over an 18-month period was performed at a large tertiary care pediatric hospital following Institutional Review Board (IRB) approval. Patients under 21 years old referred to Pediatric Pulmonology, Otolaryngology, or Gastroenterology for recurrent croup were analyzed for their demographics, medical history, evaluation, treatment and clinical improvement. A Fisher's two-tailed exact test was used to compare the number of croup episodes before and after interventions.

RESULTS

124 patients were included in our analysis: 87 male and 34 female with a mean age of 54 months. Of these, 78 had >5 episodes of croup, 45 had 3-5, and 3 had 2 episodes prior to their first visit for recurrent croup. Operative direct laryngoscopy/bronchoscopy was performed in 35 patients (27.8%), with 60% showing a normal exam without fixed lesions. Ninety-two patients (74.2%) were treated with ICS, 24 were lost to follow up. Of the remaining 68 treated patients, 59 (86.7%) saw improvement with reduced severity and overall number of episodes of croup. Additionally, patients with >5 episodes of croup (47) as compared to <5 (12) were more likely to improve with ICS, (p = 0.003). There were no adverse reactions reported with ICS treatment.

CONCLUSION

The novel initiation of ICS at the earliest sign of a viral upper respiratory infection shows promise as a safe preventative treatment to mitigate the frequency of recurrent croup episodes.

Glucocorticoids for croup in children

BACKGROUND

Glucocorticoids are the mainstay for the treatment of croup. The existing evidence demonstrates that glucocorticoids are effective in the treatment of croup in children. However, updating the evidence on their clinical relevance in croup is imperative. This is an update to a review first published in 1999, and updated in 2004, 2011, and 2018.

OBJECTIVES

To investigate the effects and safety of glucocorticoids in the treatment of croup in children aged 18 years and below.

SEARCH METHODS

We searched the Cochrane Library, which includes the Cochrane Central Register of Controlled Trials (CENTRAL; 2022 Issue 9), Ovid MEDLINE Epub Ahead of Print, In-Process & Other Non-Indexed Citations and Ovid MEDLINE (1946 to 4 March 2022), Embase (Ovid) (1974 to 4 March 2022). We also searched the WHO ICTRP and ClinicalTrials.gov on 4 March 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in children (aged 18 years and below) with croup. We assessed the effect of glucocorticoids compared to the following: placebo, any other pharmacologic agents, any other glucocorticoids, any combination of other glucocorticoids, given by different modes of administration, or given in different doses. The included studies must have assessed at least one of our primary outcomes (defined as the change in croup score or return visits, (re)admissions to the hospital or both) or secondary outcomes (defined as the length of stay in hospital or emergency departments, patient improvement, use of additional treatments, or adverse events).

DATA COLLECTION AND ANALYSIS

Review authors independently extracted data, with another review author verified. We entered the data into Review Manager 5 for meta-analysis. Two review authors independently assessed studies for risk of bias using the Cochrane risk of bias tool. Two review authors assessed the certainty of the evidence for the primary outcomes using the GRADE approach.

MAIN RESULTS

This updated review includes 45 RCTs with a total of 5888 children, an increase of two RCTs with 1323 children since the last update. We also identified one ongoing study and one study awaiting classification. We assessed most studies (98%) as at high or unclear risk of bias.  Any glucocorticoid compared to placebo  Compared to placebo, glucocorticoids may result in greater reductions in croup score after two hours (standardised mean difference (SMD) -0.65, 95% confidence interval (CI) -1.13 to -0.18; 7 RCTs, 426 children; low-certainty evidence); six hours (SMD -0.76, 95% CI -1.12 to -0.40; 11 RCTs, 959 children; low-certainty evidence); and 12 hours (SMD -1.03, 95% CI -1.53 to -0.53; 8 RCTs, 571 children; low-certainty evidence). The evidence for change in croup score after 24 hours is very uncertain (SMD -0.86, 95% CI -1.40 to -0.31; 8 RCTs, 351 children; very low-certainty evidence).  One glucocorticoid compared to another glucocorticoid There was little to no difference between prednisolone and dexamethasone for reduction in croup score at two-hour post-baseline score (SMD 0.06, 95% CI -0.06 to 0.18; 1 RCT, 1231 children; high-certainty evidence). There was likely little to no difference between prednisolone and dexamethasone for reduction in croup score at six-hour post-baseline score (SMD 0.21, 95% CI -0.21 to 0.62; 1 RCT, 99 children; moderate-certainty evidence). However, dexamethasone probably reduced the return visits or (re)admissions for croup by almost half (risk ratio (RR) 0.55, 95% CI 0.28 to 1.11; 4 RCTs, 1537 children; moderate-certainty evidence), and showed a 28% reduction in the use of supplemental glucocorticoids as an additional treatment (RR 0.72, 95% CI 0.53 to 0.97; 2 RCTs, 926 children).  Dexamethasone given in different doses Compared to 0.15 mg/kg, 0.60 mg/kg dexamethasone probably reduced the severity of croup as assessed by the croup scoring scale at 24-hour postbaseline score (SMD 0.63, 95% CI 0.16 to 1.10; 1 RCT, 72 children; moderate-certainty evidence); however, this was not the case at two hours (SMD -0.27, 95% CI -0.76 to 0.22; 2 RCTs, 861 children; high-certainty evidence). There was probably no reduction at six hours (SMD -0.45, 95% CI -1.26 to 0.35; 3 RCTs, 178 children; moderate-certainty evidence), and the evidence at 12 hours is very uncertain (SMD -0.60, 95% CI -4.39 to 3.19; 2 RCTs, 113 children; very low-certainty evidence). There was little to no difference between doses of dexamethasone in return visits or (re)admissions of children or both (RR 0.91, 95% CI 0.71 to 1.17; 3 RCTs, 949 children; high-certainty evidence) or length of stay in the hospital or emergency department (mean difference 0.12, 95% CI -0.32 to 0.56; 2 RCTs, 892 children). The need for additional treatments, such as epinephrine (RR 0.78, 95% CI 0.34 to 1.75; 2 RCTs, 885 children); intubation (risk difference 0.00, 95% CI -0.00 to 0.00; 2 RCTs, 861 children); or use of supplemental glucocorticoids (RR 0.77, 95% CI 0.51 to 1.15; 2 RCTs, 617 children), also did not differ between doses of dexamethasone.  There were moderate to high levels of heterogeneity in the analyses for most comparisons. Adverse events were observed for some of the comparisons reported in the review.

AUTHORS' CONCLUSIONS

The evidence that glucocorticoids reduce symptoms of croup at two hours, shorten hospital stays, and reduce the rate of return visits or (re)admissions has not changed in this update. A smaller dose of 0.15 mg/kg of dexamethasone may be as effective as the standard dose of 0.60 mg/kg. More RCTs are needed to strengthen the evidence for effectiveness of low-dose dexamethasone at 0.15 mg/kg to treat croup.

Indian Guidelines on Nebulization Therapy

Inhalational therapy, today, happens to be the mainstay of treatment in obstructive airway diseases (OADs), such as asthma, chronic obstructive pulmonary disease (COPD), and is also in the present, used in a variety of other pulmonary and even non-pulmonary disorders. Hand-held inhalation devices may often be difficult to use, particularly for children, elderly, debilitated or distressed patients. Nebulization therapy emerges as a good option in these cases besides being useful in the home care, emergency room and critical care settings. With so many advancements taking place in nebulizer technology; availability of a plethora of drug formulations for its use, and the widening scope of this therapy; medical practitioners, respiratory therapists, and other health care personnel face the challenge of choosing appropriate inhalation devices and drug formulations, besides their rational application and use in different clinical situations. Adequate maintenance of nebulizer equipment including their disinfection and storage are the other relevant issues requiring guidance. Injudicious and improper use of nebulizers and their poor maintenance can sometimes lead to serious health hazards, nosocomial infections, transmission of infection, and other adverse outcomes. Thus, it is imperative to have a proper national guideline on nebulization practices to bridge the knowledge gaps amongst various health care personnel involved in this practice. It will also serve as an educational and scientific resource for healthcare professionals, as well as promote future research by identifying neglected and ignored areas in this field. Such comprehensive guidelines on this subject have not been available in the country and the only available proper international guidelines were released in 1997 which have not been updated for a noticeably long period of over two decades, though many changes and advancements have taken place in this technology in the recent past. Much of nebulization practices in the present may not be evidence-based and even some of these, the way they are currently used, may be ineffective or even harmful. Recognizing the knowledge deficit and paucity of guidelines on the usage of nebulizers in various settings such as inpatient, out-patient, emergency room, critical care, and domiciliary use in India in a wide variety of indications to standardize nebulization practices and to address many other related issues; National College of Chest Physicians (India), commissioned a National task force consisting of eminent experts in the field of Pulmonary Medicine from different backgrounds and different parts of the country to review the available evidence from the medical literature on the scientific principles and clinical practices of nebulization therapy and to formulate evidence-based guidelines on it. The guideline is based on all possible literature that could be explored with the best available evidence and incorporating expert opinions. To support the guideline with high-quality evidence, a systematic search of the electronic databases was performed to identify the relevant studies, position papers, consensus reports, and recommendations published. Rating of the level of the quality of evidence and the strength of recommendation was done using the GRADE system. Six topics were identified, each given to one group of experts comprising of advisors, chairpersons, convenor and members, and such six groups (A-F) were formed and the consensus recommendations of each group was included as a section in the guidelines (Sections I to VI). The topics included were: A. Introduction, basic principles and technical aspects of nebulization, types of equipment, their choice, use, and maintenance B. Nebulization therapy in obstructive airway diseases C. Nebulization therapy in the intensive care unit D. Use of various drugs (other than bronchodilators and inhaled corticosteroids) by nebulized route and miscellaneous uses of nebulization therapy E. Domiciliary/Home/Maintenance nebulization therapy; public & health care workers education, and F. Nebulization therapy in COVID-19 pandemic and in patients of other contagious viral respiratory infections (included later considering the crisis created due to COVID-19 pandemic). Various issues in different sections have been discussed in the form of questions, followed by point-wise evidence statements based on the existing knowledge, and recommendations have been formulated.

Treatment of the most common respiratory infections in children

Acute respiratory infections are the most common group of infective diseases in the pediatric population. Although the improvement of health care and vaccination program has led to a significant reduction in the incidence of certain respiratory infections, the combination of a high prevalence in vulnerable pediatric categories and uncritical prescription of antibiotics, due to the inability to adequately distinguish between viruses and bacterial etiology, still represents a significant challenge for the public health system. In order to promote rational antibiotic therapy with an overall improvement of both diagnostic and therapeutic principles, acute respiratory diseases have been the subject of consideration in numerous publications and national guidelines. Nonspecific clinical manifestations with pathogen heterogeneity and both anatomical and physiological characteristics of the child's respiratory system during growth and development have created the need for individualized therapy. Since the guidelines emphasize the undoubtful and crucial benefits of symptomatic therapy (e.g. analgesics in acute otitis media, supplemental oxygen in lower respiratory tract infections with hypoxemia), the use of antibiotics and corticosteroids is indicated in selected cases with a severe clinical picture. The choice of antibiotic depends on the clinical condition, presumed causative agent, and local epidemiologic circumstances. Respiratory support (oxygen therapy and/or artificial ventilation) is reserved for inpatient treatment of cases with a particularly severe clinical picture and associated complications.

Inter-society consensus for the use of inhaled corticosteroids in infants, children and adolescents with airway diseases

Background

In 2019, a multidisciplinary panel of experts from eight Italian scientific paediatric societies developed a consensus document for the use of inhaled corticosteroids in the management and prevention of the most common paediatric airways disorders. The aim is to provide healthcare providers with a multidisciplinary document including indications useful in the clinical practice. The consensus document was intended to be addressed to paediatricians who work in the Paediatric Divisions, the Primary Care Services and the Emergency Departments, as well as to Residents or PhD students, paediatric nurses and specialists or consultants in paediatric pulmonology, allergy, infectious diseases, and ear, nose, and throat medicine.

Methods

Clinical questions identifying Population, Intervention(s), Comparison and Outcome(s) were addressed by methodologists and a general agreement on the topics and the strength of the recommendations (according to the GRADE system) was obtained following the Delphi method. The literature selection included secondary sources such as evidence-based guidelines and systematic reviews and was integrated with primary studies subsequently published.

Results

The expert panel provided a number of recommendations on the use of inhaled corticosteroids in preschool wheezing, bronchial asthma, allergic and non-allergic rhinitis, acute and chronic rhinosinusitis, adenoid hypertrophy, laryngitis and laryngospasm.

Conclusions

We provided a multidisciplinary update on the current recommendations for the management and prevention of the most common paediatric airways disorders requiring inhaled corticosteroids, in order to share useful indications, identify gaps in knowledge and drive future research.

Safety of corticosteroids in young children with acute respiratory conditions: a systematic review and meta-analysis

OBJECTIVE

Adverse events (AEs) associated with short-term corticosteroid use for respiratory conditions in young children.

DESIGN

Systematic review of primary studies.

DATA SOURCES

Medline, Cochrane CENTRAL, Embase and regulatory agencies were searched September 2014; search was updated in 2017.

ELIGIBILITY CRITERIA

Children <6 years with acute respiratory condition, given inhaled (high-dose) or systemic corticosteroids up to 14 days.

DATA EXTRACTION AND SYNTHESIS

One reviewer extracted with another reviewer verifying data. Study selection and methodological quality (McHarm scale) involved duplicate independent reviews. We extracted AEs reported by study authors and used a categorisation model by organ systems. Meta-analyses used Peto ORs (pORs) and DerSimonian Laird inverse variance method utilising Mantel-Haenszel Q statistic, with 95% CI. Subgroup analyses were conducted for respiratory condition and dose.

RESULTS

Eighty-five studies (11 505 children) were included; 68 were randomised trials. Methodological quality was poor overall due to lack of assessment and inadequate reporting of AEs. Meta-analysis (six studies; n=1373) found fewer cases of vomiting comparing oral dexamethasone with prednisone (pOR 0.29, 95% CI 0.17 to 0.48; I²=0%). The mean difference in change-from-baseline height after one year between inhaled corticosteroid and placebo was 0.10 cm (two studies, n=268; 95% CI -0.47 to 0.67). Results from five studies with heterogeneous interventions, comparators and measurements were not pooled; one study found a smaller mean change in height z-score with recurrent high-dose inhaled fluticasone over one year. No significant differences were found comparing systemic or inhaled corticosteroid with placebo, or between corticosteroids, for other AEs; CIs around estimates were often wide, due to small samples and few events.

CONCLUSIONS

Evidence suggests that short-term high-dose inhaled or systemic corticosteroids use is not associated with an increase in AEs across organ systems. Uncertainties remain, particularly for recurrent use and growth outcomes, due to low study quality, poor reporting and imprecision.

Glucocorticoids for croup in children

BACKGROUND

Glucocorticoids are commonly used for croup in children. This is an update of a Cochrane Review published in 1999 and previously updated in 2004 and 2011.

OBJECTIVES

To examine the effects of glucocorticoids for the treatment of croup in children aged 0 to 18 years.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, Issue 2, 2018), which includes the Cochrane Acute Respiratory Infections Group's Specialised Register, Ovid MEDLINE Epub Ahead of Print, In-Process & Other Non-Indexed Citations and Ovid MEDLINE (1946 to 3 April 2018), and Embase (Ovid) (1996 to 3 April 2018, week 14), and the trials registers ClinicalTrials.gov (3 April 2018) and the World Health Organization International Clinical Trials Registry Platform (ICTRP, 3 April 2018). We scanned the reference lists of relevant systematic reviews and of the included studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that investigated children aged 0 to 18 years with croup and measured the effects of glucocorticoids, alone or in combination, compared to placebo or another pharmacologic treatment. The studies needed to report at least one of our primary or secondary outcomes: change in croup score; return visits, (re)admissions or both; length of stay; patient improvement; use of additional treatments; and adverse events.

DATA COLLECTION AND ANALYSIS

One author extracted data from each study and another verified the extraction. We entered the data into Review Manager 5 for meta-analysis. Two review authors independently assessed risk of bias for each study using the Cochrane 'Risk of bias' tool and the certainty of the body of evidence for the primary outcomes using the GRADE approach.

MAIN RESULTS

We added five new RCTs with 330 children. This review now includes 43 RCTs with a total of 4565 children. We assessed most (98%) studies as at high or unclear risk of bias. Compared to placebo, glucocorticoids improved symptoms of croup at two hours (standardised mean difference (SMD) -0.65, 95% confidence interval (CI) -1.13 to -0.18; 7 RCTs; 426 children; moderate-certainty evidence), and the effect lasted for at least 24 hours (SMD -0.86, 95% CI -1.40 to -0.31; 8 RCTs; 351 children; low-certainty evidence). Compared to placebo, glucocorticoids reduced the rate of return visits or (re)admissions or both (risk ratio 0.52, 95% CI 0.36 to 0.75; 10 RCTs; 1679 children; moderate-certainty evidence). Glucocorticoid treatment reduced the length of stay in hospital by about 15 hours (mean difference -14.90, 95% CI -23.58 to -6.22; 8 RCTs; 476 children). Serious adverse events were infrequent. Publication bias was not evident. Uncertainty remains with regard to the optimal type, dose, and mode of administration of glucocorticoids for reducing croup symptoms in children.

AUTHORS' CONCLUSIONS

Glucocorticoids reduced symptoms of croup at two hours, shortened hospital stays, and reduced the rate of return visits to care. Our conclusions have changed, as the previous version of this review reported that glucocorticoids reduced symptoms of croup within six hours.

Severe upper airway obstruction following bilateral ventral bulla osteotomy in a cat

A cat that underwent bilateral ventral bulla osteotomy (VBO) for treatment of otitis media and otitis interna secondary to bilateral inflammatory polyps, developed upper airway obstruction (UAO) soon after tracheal extubation. The cat was re-intubated but the UAO did not resolve at the next extubation. Eventually, tracheostomy was performed. Upper airway obstruction is a potential postoperative complication of bilateral VBO in cats.

Clinical respiratory scales: which one should we use?

INTRODUCTION

There are countless clinical respiratory scales for acute dyspnoea. Most healthcare professionals choose one based on previous personal experience or following local practice, unaware of the implications of their choice. The lack of critical comparisons between those different tools has been a widespread problem that only recently has begun to be addressed via score validation studies. Here we try to assess and compare the quality criteria of measurement properties of acute dyspnoea scores. Areas covered: A literature review was conducted by searching the PubMed database. Forty-five documents were deemed eligible as they reported the use or building of clinical scales, using at least two parameters, and applied these to an acute episode of respiratory dyspnoea. Our primary focus was the description of the validity, reliability and utility of 41 suitable scoring instruments. Differences in sample selection, study design, rater profiles and potential methodological shortcomings were also addressed. Expert commentary: All acute dyspnoea scores lack complete validation. In particular, the areas of measurement error and interpretability have not been addressed correctly by any of the tools reviewed. Frequent modification of pre-existing scores (in items composition and/or name), differences in study design and discrepancies in reviewed sources also hinder the search for an adequate tool.

Association of croup with asthma in children: A cohort study

Asthma and croup are common inflammatory airway diseases involving the bronchus in children. However, no study has reported the effects of urbanization, sex, age, and bronchiolitis on the association of croup and its duration with asthma development. We used the Taiwan Longitudinal Health Insurance Database (LHID) to perform this population-based cohort study; here, the cluster effect caused by hospitalization was considered to evaluate the association between croup and asthma development and the risk factors for asthma in children of different age groups. We evaluated children with croup aged <12 years (n = 1204) and age-matched control patients (n = 140,887) by using Cox proportional hazards regression analysis within a hospitalization cluster. Of all 142,091 patients, 5799 (including 155 with croup [419 per 1000 person-y] and 5644 controls [106 per 1000 person-y]) had asthma during the 5-year follow-up period. During the 5-year follow-up period, the hazard ratios (HRs [95% CIs]) for asthma were 2.10 (1.81-2.44) in all children with croup, 2.13 (1.85-2.46) in those aged 0 to 5 years, and 2.22 (1.87-2.65) in those aged 6 to 12 years. Children with croup aged 7 to 9 years had a higher HR for asthma than did those in other age groups. Boys with croup had a higher HR for asthma. The adjusted HR for asthma was 1.78 times higher in children with croup living in urban areas than in those living in rural areas. In conclusion, our analyses indicated that sex, age, bronchiolitis, and urbanization level are significantly associated with croup and asthma development. According to our cumulative hazard rate curves, younger children with croup should be closely monitored for asthma development for at least 3 years.

Telephone Out Patient Score: The Derivation and Validation of a Telephone Follow-up Assessment Tool for Use in Clinical Research in Children With Croup

OBJECTIVE

The objective was to derive a simple clinical scoring instrument for assessing children with croup by telephone for use in clinical research studies.

METHODS

We reviewed published literature on croup scores, surveyed experienced pediatric emergency nurses and physicians, and conducted a prospective cohort study. Score items were derived from published literature and surveys of experienced clinicians. We enrolled children with croup attending an urban pediatric emergency department. Families of children enrolled were contacted daily by telephone and asked standardized questions about their child's clinical symptoms and family functioning. Data from this survey were used to derive the clinical score.

RESULTS

We identified 11 unique croup scores from the literature and interviewed 6 experienced clinicians. We enrolled 330 children and achieved complete follow-up for 301. Of the various groupings of items and duration of assessment, the 2-item score (barky cough and stridor) was the simplest and most reliable. Three days of follow-up yielded optimal correlations.

CONCLUSIONS

We derived a 2-item Telephone Out Patient score assessed daily for 3 days after an emergency department visit. Validation of this score in a future, independent prospective cohort is needed.

Viral croup: diagnosis and a treatment algorithm

Viral croup is a frequent disease in early childhood. Although it is usually self-limited, it may occasionally become life-threatening. Mild croup is characterized by the presence of stridor without intercostal retractions, whereas moderate-to-severe croup is accompanied by increased work of breathing. A single dose of orally administered dexamethasone (0.15-0.6 mg/kg) is the mainstay of treatment with addition of nebulized epinephrine only in cases of moderate-to-severe croup. Nebulized budesonide (2 mg) can be given alternatively to children who do not tolerate oral dexamethasone. Exposure to cold air or administration of cool mist are treatment interventions for viral croup that are not supported by published evidence, but breathing heliox can potentially reduce the work of breathing related to upper airway obstruction. In summary, corticosteroids may decrease the intensity of viral croup symptoms irrespective to their severity on presentation to the emergency department.

Nebulized epinephrine for croup in children

BACKGROUND

Croup is a common childhood illness characterized by barky cough, stridor, hoarseness and respiratory distress. Children with severe croup are at risk for intubation. Nebulized epinephrine may prevent intubation.

OBJECTIVES

To assess the efficacy (measured by croup scores, rate of intubation and health care utilization such as rate of hospitalization) and safety (frequency and severity of side effects) of nebulized epinephrine versus placebo in children with croup, evaluated in an emergency department (ED) or hospital setting.

SEARCH METHODS

We searched CENTRAL 2013, Issue 6, MEDLINE (1966 to June week 3, 2013), EMBASE (1980 to July 2013), Web of Science (1974 to July 2013), CINAHL (1982 to July 2013) and Scopus (1996 to July 2013).

SELECTION CRITERIA

Randomized controlled trials (RCTs) or quasi-RCTs of children with croup evaluated in an ED or admitted to hospital. Comparisons were: nebulized epinephrine versus placebo, racemic nebulized epinephrine versus L-epinephrine (an isomer) and nebulized epinephrine delivered by intermittent positive pressure breathing (IPPB) versus nebulized epinephrine without IPPB. Primary outcome was change in croup score post-treatment. Secondary outcomes were rate and duration of intubation and hospitalization, croup return visit, parental anxiety and side effects.

DATA COLLECTION AND ANALYSIS

Two authors independently identified potentially relevant studies by title and abstract (when available) and examined relevant studies using a priori inclusion criteria, followed by methodological quality assessment. One author extracted data while the second checked accuracy. We use the standard methodological procedures expected by the Cochrane Collaboration.

MAIN RESULTS

Eight studies (225 participants) were included. In general, children included in the studies were young (average age less than two years in the majority of included studies). Severity of croup was described as moderate to severe in all included studies. Six studies took place in the inpatient setting, one in the ED and one setting was not specified. Six of the eight studies were deemed to have a low risk of bias and the risk of bias was unclear in the remaining two studies.Nebulized epinephrine was associated with croup score improvement 30 minutes post-treatment (three RCTs, standardized mean difference (SMD) -0.94; 95% confidence interval (CI) -1.37 to -0.51; I(2) statistic = 0%). This effect was not significant two and six hours post-treatment. Nebulized epinephrine was associated with significantly shorter hospital stay than placebo (one RCT, MD -32.0 hours; 95% CI -59.1 to -4.9). Comparing racemic and L-epinephrine, no difference in croup score was found after 30 minutes (SMD 0.33; 95% CI -0.42 to 1.08). After two hours, L-epinephrine showed significant reduction compared with racemic epinephrine (one RCT, SMD 0.87; 95% CI 0.09 to 1.65). There was no significant difference in croup score between administration of nebulized epinephrine via IPPB versus nebulization alone at 30 minutes (one RCT, SMD -0.14; 95% CI -1.24 to 0.95) or two hours (SMD -0.72; 95% CI -1.86 to 0.42). None of the studies sought or reported data on adverse effects.

AUTHORS' CONCLUSIONS

Nebulized epinephrine is associated with clinically and statistically significant transient reduction of symptoms of croup 30 minutes post-treatment. Evidence does not favor racemic epinephrine or L-epinephrine, or IPPB over simple nebulization.The authors note that data and analyses were limited by the small number of relevant studies and total number of participants and thus most outcomes contained data from very few or even single studies.

Interobserver variability of croup scoring in clinical practice

BACKGROUND

Viral laryngotracheobronchitis croup is the most common cause of acute upper airway obstruction in young children. Clinical assessment of children with croup is often performed using 'croup scores'; however, these scores have not been validated outside of the research setting.

OBJECTIVE

To determine the reliability of clinical observation items in croup scores in a paediatric emergency department (ED) setting.

DESIGN

Literature review identified 12 observation items (level of consciousness or mental status, inspiratory breath sounds, air entry, stridor, cough, cyanosis or colour, anxiety or air hunger, retractions and/or flaring, respiratory rate and heart rate, oxygen saturation and respiratory distress); overlapping items were combined, yielding 10 variables. In a prospective cohort study over 13 months, patients presenting with croup were observed independently, and croup scores were assigned by the triage nurse, ED nurse and the ED physician before treatment. Agreement among observers for clinical observations was analysed using Cohen's quadratic weighted kappa.

SETTING

University-affiliated, paediatric hospital ED providing primary care to an urban area (population 330,000).

PATIENTS

Children aged three months to five years presenting with viral croup (preceding history of at least one day of upper respiratory tract symptoms associated with barking cough and/or hoarseness and/or stridor).

RESULTS

One hundred fifty-eight children meeting inclusion criteria for croup were assessed by three observers within 1 h of each other's assesments and before treatment. Interobserver agreement among the three observers using weighted kappa was greater than chance for all clinical observation items and ranged from fair to moderate (0.2 to 0.4 and 0.4 to 0.6, respectively).

CONCLUSIONS

In the busy practice setting of a paediatric ED, substantial interobserver variability exists among health care providers in the measurement of respiratory signs associated with croup in young children. Based on the present study in a practice setting and two research studies, the most reliable items of all of the published items included in croup scoring systems were stridor and retractions.

How fast does oral dexamethasone work in mild to moderately severe croup? A randomized double-blinded clinical trial

OBJECTIVE

For children with croup controversy remains over dosage and time to onset of action of oral steroids. The Cochrane Collaboration and other reviews have suggested 0.6 mg/kg dexamethasone be used (despite some evidence that 0.15 mg/kg is effective) with no expectation of benefit before 4-6 h. This randomized double-blinded clinical trial examines whether 0.15 mg/kg dexamethasone works by 30 min.

METHODS

Children with croup aged above 6 months presenting to a tertiary paediatric ED with a Westley croup score of mild to moderate range (scores 1-6 out of 17) were randomized to receive either 0.15 mg/kg dexamethasone or oral placebo solution. Vital signs and croup score were recorded at study entry and every 10 min up to 1 h after administration of the study drug. The main outcome measure was croup score at 30 min.

RESULTS

Each group contained 35 children. Baseline characteristics were similar, except for respiratory rate, which was higher in the placebo group. There was a growing trend to a lower croup score in the dexamethasone group, evident from 10 min and statistically significant from 30 min.

CONCLUSION

For children with croup an oral dose of 0.15 mg/kg dexamethasone offers benefit by 30 min, much earlier than the 4 h suggested by the Cochrane Collaboration. This result might encourage doctors to treat more children with all severities of croup being less worried about potential side-effects and delayed benefit.

Nebulized epinephrine for croup in children

BACKGROUND

Croup is a common childhood illness characterized by barky cough, stridor, hoarseness and respiratory distress. Children with severe croup are at risk for intubation. Nebulized epinephrine (NE) may prevent intubation.

OBJECTIVES

To evaluate the efficacy and safety of NE in children presenting to emergency department (ED) or admitted to hospital with croup.

SEARCH STRATEGY

We searched CENTRAL (The Cochrane Library 2010, Issue 4), containing the Cochrane Acute Respiratory Infections Group's Specialized Register, MEDLINE (1966 to November Week 1, 2010), EMBASE (1980 to November 2010), Web of Science (1974 to November 2010), CINAHL (1982 to November 2010) and Scopus (1996 to November 2010).

SELECTION CRITERIA

Randomized controlled trials (RCTs) or quasi-RCTs of children with croup evaluated in an ED or admitted to hospital. Comparisons were: NE versus placebo, racemic NE versus L-epinephrine (an isomer), and NE delivered by intermittent positive pressure breathing (IPPB) versus NE without IPPB. Primary outcome was change in croup score post-treatment. Secondary outcomes were rate and duration of intubation and hospitalization, croup return visit, parental anxiety and side effects.

DATA COLLECTION AND ANALYSIS

Two authors independently identified potentially relevant studies by title and abstract (when available) and examined relevant studies using a priori inclusion criteria, followed by methodologic quality assessment. One author extracted data while the second checked accuracy. We performed standard statistical analyses.

MAIN RESULTS

Eight studies (225 participants) were included. NE was associated with croup score improvement 30 minutes post-treatment (three RCTs, standardized mean difference (SMD) -0.94; 95% confidence interval (CI) -1.37 to -0.51; I(2) statistic = 0%). This effect was not significant two and six hours post-treatment. NE was associated with significantly shorter hospital stay than placebo (one RCT, mean difference -32.0 hours; 95% CI -59.1 to -4.9). Comparing racemic and L-epinephrine, no difference in croup score was found after 30 minutes (SMD 0.33; 95% CI -0.42 to 1.08). After two hours, L-epinephrine showed significant reduction compared with racemic epinephrine (one RCT, SMD 0.87; 95% CI 0.09 to 1.65). There was no significant difference in croup score between administration of NE via IPPB versus nebulization alone at 30 minutes (one RCT, SMD -0.14; 95% CI -1.24 to 0.95) or two hours (SMD -0.72; 95% CI -1.86 to 0.42).

AUTHORS' CONCLUSIONS

NE is associated with clinically and statistically significant transient reduction of symptoms of croup 30 minutes post-treatment. Evidence does not favor racemic epinephrine or LE, or IPPB over simple nebulization. 

Glucocorticoids for croup

BACKGROUND

Since the initial publication of this systematic review in 1997, several randomized trials examining the benefit of glucocorticoids have been published. The objective of this review is to provide evidence to guide clinicians in their treatment of patients with croup by determining the effectiveness of glucocorticoids and to identify areas requiring future research.

OBJECTIVES

To determine the effect of glucocorticoids for children with croup.

SEARCH STRATEGY

We searched CENTRAL (2010, Issue 3), which contains the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE (1966 to July week 2, 2010) and EMBASE.com (1974 to July 2010). We also contacted authors of identified croup trials published in the last 10 years to inquire about additional published or unpublished trials.

SELECTION CRITERIA

Randomised controlled trials (RCTs) that examine children with croup and objectively measure the effectiveness of glucocorticoids.

DATA COLLECTION AND ANALYSIS

Two review authors identified studies for potential relevance based on the review of the title and abstract (when available). Two review authors independently reviewed studies for relevance using a priori inclusion criteria and assessed trial quality. Differences were resolved by consensus. One review author extracted data using a structured form and another review author checked the results for accuracy. We performed standard statistical analyses.

MAIN RESULTS

Thirty-eight studies were included (n = 4299). Glucocorticoids were associated with an improved Westley score (maximum 17 points) at six hours with a mean difference of -1.2 (95% confidence interval (CI) -1.6 to -0.8) and at 12 hours -1.9 (95% CI -2.4 to -1.3); at 24 hours this improvement was no longer significant (-1.3, 95% CI -2.7 to 0.2). Fewer return visits and/or (re)admissions occurred in participants treated with glucocorticoids (risk ratio (RR) 0.5; 95% CI 0.3 to 0.7). Length of time spent in accident and emergency or hospital (mean difference 12 hours, five to 19 hours) was significantly decreased for participants treated with glucocorticoids. Use of epinephrine decreased for children treated with a glucocorticoid (risk difference 10%; 95% CI 1 to 20).

AUTHORS' CONCLUSIONS

Dexamethasone and budesonide are effective in relieving the symptoms of croup as early as six hours after treatment. Fewer return visits and/or (re)admissions are required and the length of time spent in hospital is decreased. Research is required to examine the most beneficial method for disseminating croup practice guidelines and to increase the uptake of evidence.

Inhaled corticosteroids as rescue medication in acute severe asthma

Systemic corticosteroids (CS) should be considered as first-line treatment for acute asthma exacerbations, especially severe exacerbations. They may sometimes require a few hours or more to achieve their maximum effect. This time delay observed between administration of CS and improvement in lung function or hospital admissions is consistent with the belief that these effects of CS, involving the modification of gene expression, occur with a time lag of hours or days (genomic effect). On the other hand, CS also have effects initiated by specific interactions with membrane-bound or cytoplasmic receptors for CS, or nonspecific interactions with the cell membrane, with a much more rapid response (seconds or minutes; nongenomic effect). This review analyzes the clinical evidence regarding the use of inhaled CS in acute asthma patients, according to the characteristics of the nongenomic effect, and presents a proposal for the use of inhaled CS as a rescue medication in the emergency-department setting.

27 years of croup: an update highlighting the effectiveness of 0.15 mg/kg of dexamethasone

OBJECTIVE

To update an earlier observational study (1980-1995) documenting dramatic improvements in the management of croup with the mandatory use of a single oral dose of dexamethasone and to ascertain whether a reduction from a dose of 0.6 to 0.15 mg/kg in 1995 maintained these improved outcomes over the next 11 years.

METHODS

We evaluated retrospectively the experience of children with croup in Princess Margaret Hospital for Children, the only tertiary paediatric hospital in Western Australia, over the subsequent 11 year period from 1996 to 2006 inclusive. Data were updated from ED, general hospital and the intensive care unit records to show the numbers of children presenting to the hospital, admitted, transferred to intensive care and intubated. We also recorded the length of hospital stay and representation rate of all cases within 7 days.

RESULTS

The dramatic improvements in outcomes for croup, including reduced admission rates, length of stay, transfers to the intensive care unit, intensive care unit days and number of intubations as reported in our earlier paper, were maintained using 0.15 mg/kg dexamethasone. Admission rates for croup have fallen from 30% in the early 1990s to less than 15% in recent years, whereas the representation rate has risen slightly.

CONCLUSION

The improved outcomes for children with croup presenting to our paediatric ED have been maintained with a reduced, single oral dose of 0.15 mg/kg of dexamethasone.

Aerosolized L-epinephrine vs budesonide for post extubation stridor: a randomized controlled trial

OBJECTIVE

To compare the efficacy and adverse effects of aerosolized L-epinephrine vs budesonide in the treatment of post-extubation stridor.

STUDY DESIGN

Randomized controlled trial.

SETTING

Pediatric intensive care unit (PICU) of a tertiary teaching and referral hospital.

SUBJECTS

Sixty two patients with a stridor score ?4 following extubation.

INTERVENTION

Patients were randomized to receive either aerosolized L-epinephrine (n=32) or budesonide (n =30). Respiratory rate, heart rate, stridor score, blood pressure and oxygen saturation were recorded from 0 min to 24 hours.

OUTCOME MEASURES

Stridor score remaining at >4, need for renebulization and reintubation between 20 min to 24 hours were primary outcome measures. Tachycardia (HR > normal for age), hypertension (BP >95th centile for age) and hypoxia (SpO2 < 92% for 5 min) were secondary outcome measures.

RESULTS

Both drugs showed a significant and comparable decline in the median (95% CI) stridor scores from baseline to 60 min [4 (4.10-4.50) to 2.00 (1.46-2.67) for budesonide vs 4 (4.12-5.00) to 2.00 (1.31 -2.75) for epinephrine]. At 2 hours, the stridor scores were significantly lower in the epinephrine as compared to budesonide group [0.00 (0.69-1.81) vs 3.00(1.75-3.32); P =0.02)]. However, the proportion of patients with stridor score >4 at any time between 20 min to 24 hrs (53.3% vs 53.1%; P=0.99), need for renebulization (40% vs 43.8%; P=0.76) and reintubation (20% vs 25%, P=0.638), and adverse effects were similar in both groups.

CONCLUSIONS

Both aerosolized L-epinephrine and budesonide were equally effective in their initial therapeutic response in post-extubation stridor. However, epinephrine showed a more sustained effect.

[Inhaled corticosteroids in the treatment of asthma exacerbations: essential concepts]

The use of systemic corticosteroids reduces hospitalizations in patients suffering an asthma attack and improves lung function within 6 to 12 hours of administration. However, despite the considerable body of positive evidence published in the last decade, doubts remain in regard to the effectiveness of inhaled corticosteroids. Analysis of this evidence has been cursory; crucial data on the mechanism of action of corticosteroids have been overlooked and there has been a failure to distinguish between antiinflammatory effects and so-called nongenomic effects. This review considers the biological basis for the effects of inhaled corticosteroids and analyzes the best data available on the use and therapeutic implications of inhaled corticosteroids for the treatment of asthma exacerbations.

Current pharmacological options in the treatment of croup

Croup is one of the most common respiratory illnesses seen in the acute paediatric setting. It can be a cause of acute stridor and/or respiratory distress in young children. Research has shown that therapy aimed at reducing symptoms and inflammation can reduce complications such as the need for intubation, hospitalisation and improve quality of life for parents and children. Corticosteroids are the primary treatment option that will accomplish both goals and can be used in out-patient and in-patient settings. Corticosteroids may be given orally, parenterally or in wet nebulised form; however, oral administration is the preferred route. Wet nebulised adrenaline (racaemic or l-adrenaline) is also an effective treatment for more severe cases of croup. Recent studies have shown that mist/humidified air provides no additional symptom improvement, nor does it alter the overall cause of the disease process. Currently, there is insufficient randomised controlled trial evidence to support the role of heliox in the short-term treatment of croup.

The assessment and management of croup

The treatment of croup has changed considerably over the last 25 years with the liberalisation of the use of systemic corticosteroids for mild to moderate croup. The administration of corticosteroids in croup has reduced the severity of the condition, dramatically reduced the need for endotracheal intubation, shortened the duration of intubation, reduced the length of hospital stay, reduced the need for hospital admission and reduced daycare/preschool absenteeism and improved sleep in milder cases. Despite studies showing the efficacy of nebulised and intramuscular corticosteroids, the use of oral corticosteroids remains the recommended option in most, if not all, cases of croup presenting for medical assessment.

Delivery of nebulized budesonide is affected by nebulizer type and breathing pattern

The aim of this study was to determine the output in-vitro of budesonide from two different nebulizers under simulated breathing conditions. The BimboNeb and Nebula nebulizers were used to nebulize 2 mL of budesonide (500 microg) suspension. Particle size was determined by inertial impaction after a 5-min nebulization. Total outputs of the drug from both nebulizers were measured using a sinus flow pump to create simulated breathing conditions. Paediatric and adult breathing patterns were used, with drug output measured after 5 and 10 min nebulization. The mass median aerodynamic diameter of budesonide using the BimboNeb (4.5 microm) was significantly greater than that from the Nebula (3.4 microm) (P<0.01). With the simulated adult breathing pattern, the total drug output after 5 min with the BimboNeb (61.5 microg) was twice that from the Nebula (30.7 microg). For the paediatric breathing pattern, total outputs were very similar for both nebulizers. In all cases, nebulizing for 10 min produced greater drug outputs compared with those after 5 min, particularly for the paediatric breathing pattern. The amount of aerosolized drug available for inhalation needs to be assessed for each nebuliser used and the effect of the patient's breathing pattern should also be taken into account.

Budesonide offers no advantage when added to oral dexamethasone in the treatment of croup

OBJECTIVE

To evaluate the effect of adding inhaled budesonide (2 mg) to oral dexamethasone 0.15 mg/kg in children hospitalized with croup.

SETTING

Observation ward of a Tertiary Paediatric Hospital Emergency Department.

SUBJECTS

Seventy-two children (age range 3 to 126 months) hospitalized with croup.

INTERVENTION

Children randomized to receive either 2 mg of nebulized budesonide or placebo, with all children receiving a single oral dose of 0.15 mg/kg dexamethasone.

OUTCOME MEASURES

Primary outcome was duration of hospital stay. Other measures included croup scores from 0 to 12 hours, use of nebulized epinephrine, duration of croup symptoms, duration of viral symptoms, and return to medical care for croup or for any other reason following discharge from hospital.

RESULTS

Baseline characteristics for the 2 groups were similar. There was no difference in time to discharge for the 2 groups or for other outcome measures with a risk ratio of 1.3 (95% confidence intervals of 0.82 and 2.1).

CONCLUSIONS

The addition of inhaled budesonide (2 mg) to oral dexamethasone (0.15 mg/kg) offers no advantage in the treatment of children hospitalized with croup.

Serum ECP and total IgE levels in children with acute laryngotracheobronchitis

OBJECTIVE

Eosinophilic cationic protein (ECP) and immunoglobulin E (IgE) are important mediators of allergic inflammation and they are commonly used in the diagnosis and follow-up of allergic diseases. But serum levels of these molecules can also be elevated by some other diseases including viral infections. Acute laryngotracheobronchitis (ALTB) is an important viral infection of upper airway and serum levels of ECP and IgE may increase in patients with ALTB.

METHODS

In the present study serum ECP and IgE levels were measured before treatment and on the third day and third week after treatment in 27 patients with ALTB aged 10 months to 5 years and were compared with a age matched healthy controls. All patients were treated with nebulized budesonide.

RESULTS

We found that pre-treatment ECP levels were significantly higher than post-treatment third days and third weeks (28.3+/-2.3 ng/ml versus 20.2+/-3.2 ng/ml and 11.4+/-1.1 ng/ml, respectively). Similarly, the mean pre-treatment serum IgE values were significantly higher than post-treatment values (131.6+/-17.5 IU/ml versus 83.6+/-12.4 IU/ml and 68.2+/-6.7 IU/ml). A positive correlation was found between serum ECP and IgE values for pre-treatment and post-treatment third week values (r=062, p=0.01 and r=0.64, p=0.01, respectively). The pre-treatment serum ECP and IgE levels were significantly higher than those of controls (10.8+/-1.5 ng/ml and 43.8+/-6.6 IU/ml, respectively p<0.05).

CONCLUSION

In this study it was shown that, serum ECP and IgE levels increase in the acute phase of infection and return to normal after treatment in patients with ALTB such as in allergic patients. This effect of ALTB on serum ECP and total IgE levels should be kept in mind and these parameters should not be used in the diagnosis and follow-up of allergic diseases in children who had had ALTB in recent weeks.

The Role of Corticosteroids in the Treatment of Croup

Since the 1960s, corticosteroids have been used in the treatment of laryngotracheobronchitis, commonly called croup. Initially, their use for croup was controversial and highly debated in the literature. The evidence over the last 2 decades has strongly favored corticosteroid use in croup management. It has now become the standard of care to use corticosteroids in moderate-to-severe croup. Corticosteroid use in these patients has been shown to reduce hospitalizations, length of illness, and subsequent treatments when compared with placebo. By extrapolation, corticosteroids may even play a role in patients with milder croup presenting for medical assessment. The current recommendation is to treat patients with moderate-to-severe croup with oral dexamethasone in a dose of 0.6 mg/kg (maximum 10-12 mg) because of its ease of administration, easy availability, and low cost. Intramuscular dexamethasone is reserved for patients who are vomiting or who are in severe respiratory distress and unable to tolerate oral medication. Nebulized budesonide, used commonly in some geographic locations, has been found to be effective, but is often not used in favor of the oral corticosteroids. Controversy still exists over the use of corticosteroids in mild and potentially self-limiting disease. Some evidence exists for treating these patients; some clinicians use corticosteroids for all patients with croup who seek care regardless of the severity of the illness. Patients with mild disease may be candidates for lower doses of dexamethasone such as 0.15-0.3 mg/kg. Corticosteroid-induced complications in croup are rare. Overall, corticosteroids have gained universal acceptance for the treatment of croup and have been found to be effective, well tolerated, and inexpensive.

Glucocorticoids for croup

BACKGROUND

Since the initial version of this systematic review in 1997, a number of randomised trials examining the benefit of glucocorticoids have been published, reflecting a continued interest in the use of glucocorticoids to treat patients with croup. The objective of this review was to provide evidence to guide clinicians in their treatment of patients with croup by determining the effectiveness of glucocorticoids and to identify areas of uncertainty for future research.

OBJECTIVES

To determine the effect of glucocorticoids for children with croup.

SEARCH STRATEGY

We searched The Cochrane Central Register of Controlled Trials (CENTRAL) (issue 1, 2003), MEDLINE (January 1966 to April 2003) and Excerpta Medica/EMBASE (January 1974 to August 2003). We also contacted authors of identified croup trials published in the last ten years to inquire about additional published or unpublished trials.

SELECTION CRITERIA

Randomised controlled trials that examine children with croup and objectively measure the effectiveness of glucocorticoid treatment.

DATA COLLECTION AND ANALYSIS

Based on review of the title and abstract (when available), two researchers identified studies for potential relevance. The complete text was retrieved and using a priori inclusion criteria, the studies were independently reviewed for relevance by two reviewers. Two observers independently assessed quality. Differences with respect to inclusion status and quality assessment were resolved by consensus. Data were extracted using a structured form by one reviewer and checked for accuracy by a second reviewer. Standard statistical analyses were performed.

MAIN RESULTS

Thirty-one studies were deemed relevant for inclusion (N = 3736). Glucocorticoid treatment was associated with an improvement in the Westley score at six hours with a weighted mean difference of -1.2 (95% confidence interval -1.6 to -0.8) and at 12 hours -1.9 (-2.4 to -1.3); at 24 hours this improvement was no longer significant (-1.3, -2.7 to 0.2). Fewer return visits and/or (re)admissions occurred in patients treated with glucocorticoids (relative risk 0.50; 0.36 to 0.70). Length of time spent in accident and emergency or hospital (weighted mean difference 12 hours, five to 19 hours) was significantly decreased for patients treated with glucocorticoids. Use of epinephrine decreased for children treated with a glucocorticoid (risk difference 10%; 1 to 20). No other decreases in additional treatments were found in the primary analysis. Publication bias does not impact results importantly. No between-trial significant differences were found between populations with mild and moderate croup. Oral dexamethasone may be superior to intramuscular dexamethasone.

REVIEWER'S CONCLUSIONS

Dexamethasone and budesonide are effective in relieving the symptoms of croup as early as six hours after treatment. Fewer return visits and/or (re)admissions are required and the length of time spent in hospital is decreased in inpatients. Dexamethasone is also effective in mild croup populations. Research is required to examine the most beneficial method for disseminating croup practice guidelines and to increase the uptake of evidence to improve outcomes.

Croup: assessment and evidence‐based management

Croup affects about 2% of preschool-aged children every year. Most children have mild croup and are managed at home, often after review by a general practitioner, who may decide that a single dose of oral corticosteroid is indicated (eg, if a risk factor for hospital admission exists). A minority of children develop moderate or severe croup. They should be reviewed in an emergency department and may need hospital admission. More liberal use of systemic corticosteroids for croup (in both primary care and emergency department settings) has been associated with reduced rates of hospital admission, reduced admissions to the intensive care unit and a reduced need for endotracheal intubation. We discuss the assessment and evidence-based management of a child with mild croup presenting to a GP and a child with moderately severe croup presenting to an emergency department. We present a flow chart summarising an approach to assessing and treating croup in the emergency department.

Management of croup

Croup, or laryngotracheobronchitis, is a common childhood illness most often caused by viral infections. It is usually a benign, self-limiting disease, but can result in life-threatening upper airway obstruction. Until recently, it was not uncommon for children with severe croup to be admitted to intensive care for intubation. Management used to be limited to supportive measures, including mist therapy. The use of corticosteroids in patients with croup was controversial for many years but has, in the last decade, transformed the management of this disorder. Although corticosteroids do not alter the history of the viral infection, an adequate dose of oral or parenteral dexamethasone or nebulized budesonide has been shown to have a beneficial effect on the symptoms of croup.

New approaches to respiratory infections in children. Bronchiolitis and croup

Croup is a disease that is commonly seen in children younger than the age of 6 years. The cause is viral, with parainfluenza viruses and RSV being the two most common pathogens. Treatment consists primarily of supportive care, and parents usually have tried humidification and cool air exposure before the child presents to the ED. Children with moderate to severe croup are usually seen in the ED. The use of steroids in an oral preparation results in a clinical improvement of outpatients with mild to moderate croup and reduces the need for hospitalization. The dosage range for oral dexamethasone is 0.15 mg/kg to 0.6 mg/kg. Nebulized budesonide may also be used. Racemic or L-epinephrine, both of which are equally effective, can be used for symptomatic treatment in severe croup. After administration of racemic or L-epinephrine, hospitalization is not automatic and patients can be discharged safely from the ED after a 3-hour of observation period. There should be no respiratory distress, and the patient should have access to follow-up and emergency care if needed.

Budesonide Inhalation Suspension

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Budesonide inhalation suspension: a review of its use in infants, children and adults with inflammatory respiratory disorders

Budesonide, a topically active corticosteroid, has a broad spectrum of clinically significant local anti-inflammatory effects in patients with inflammatory lung diseases including persistent asthma. In infants and young children with persistent asthma, day- and night-time symptom scores, and the number of days in which beta2-agonist bronchodilators were required, were significantly lower during randomised, double-blind treatment with budesonide inhalation suspension 0.5 to 2 mg/day than placebo in 3 multicentre trials. Significantly fewer children discontinued therapy with budesonide inhalation suspension than with placebo because of worsening asthma symptoms in a study that included children who were receiving inhaled corticosteroids at baseline. Recent evidence indicates that budesonide inhalation suspension is significantly more effective than nebulised sodium cromoglycate in improving control of asthma in young children with persistent asthma. At a dosage of 2 mg/day, budesonide inhalation suspension significantly reduced the number of asthma exacerbations and requirements for systemic corticosteroids in preschool children with severe persistent asthma. In children with acute asthma or wheezing, the preparation was as effective as, or more effective than oral prednisolone in improving symptoms. In children with croup, single 2 or 4mg dosages of budesonide inhalation suspension were significantly more effective than placebo and as effective as oral dexamethasone 0.6 mg/kg or nebulised L-epinephrine (adrenaline) 4mg in alleviating croup symptoms and preventing or reducing the duration of hospitalisation. Early initiation of therapy with budesonide inhalation suspension 1 mg/day appears to reduce the need for mechanical ventilation and decrease overall corticosteroid usage in preterm very low birthweight infants at risk for chronic lung disease. In adults with persistent asthma, budesonide inhalation suspension < or =8 mg/day has been compared with inhaled budesonide 1.6 mg/day and fluticasone propionate 2 mg/day administered by metered dose inhaler. Greater improvements in asthma control occurred in patients during treatment with budesonide inhalation suspension than with budesonide via metered dose inhaler, whereas fluticasone propionate produced greater increases in morning peak expiratory flow rates than nebulised budesonide. Several small studies suggest that the preparation has an oral corticosteroid-sparing effect in adults with persistent asthma and that it may be as effective as oral corticosteroids during acute exacerbations of asthma or chronic obstructive pulmonary disease. The frequency of adverse events was similar in children receiving budesonide inhalation suspension 0.25 to 2 mg/day or placebo in 12-week studies. During treatment with budesonide inhalation suspension 0.5 to 1 mg/day in 3 nonblind 52-week studies, growth velocity in children was generally unaffected; however, a small but statistically significant decrease in growth velocity was detected in children who were not using inhaled corticosteroids prior to the introduction of budesonide inhalation suspension. Hypothalamic-pituitary-adrenal axis function was not affected by short (12 weeks) or long (52 weeks) term treatment with nebulised budesonide. In conclusion, budesonide inhalation suspension is the most widely available nebulised corticosteroid, and in the US is the only inhaled corticosteroid indicated in children aged > or =1 year with persistent asthma. The preparation is suitable for use in infants, children and adults with persistent asthma and in infants and children with croup.

Nebulised steroid in the treatment of croup: a systematic review of randomised controlled trials

BACKGROUND

Croup is one of the commonest respiratory complaints among children. There is growing evidence that steroids may be an effective treatment.

AIM

To assess the effectiveness of treatment with nebulised steroid for children with croup.

METHOD

Systematic review of randomised controlled trials comparing administration of nebulised steroid with placebo. Trials were identified from searches of three bibliographic databases, the Cochrane Controlled Trials Register, correspondence with the manufacturers of nebulised steroid, and one round of manual citation searching.

RESULTS

Eight randomised controlled trials were identified including 574 children with mild to severe croup. Overall, the mean age was 25.2 months and 72% of children were male. All trials were hospital-based and of good methodological quality, with adequate concealment of treatment allocation and blind outcome assessment. Children treated with nebulised steroid were significantly more likely to show an improvement in croup score by five hours (combined relative risk = 1.48, 95% confidence interval [CI] = 1.27 to 1.74) and significantly less likely to need hospital admission after attending the emergency department (combined relative risk = 0.56, 95% CI = 0.42 to 0.75) than the placebo group. The funnel plot indicated the presence of publication bias, with smaller studies showing the larger effects, but this could also be owing to less pronounced effects in studies of older children with milder croup.

CONCLUSIONS

Nebulised steroids are effective in the treatment of children attending hospital departments with croup. A meta-analysis based on individual patient data could clarify to what extent the effect depends on age and severity of disease. New trials are needed to define the indications for, and effectiveness of, steroid treatment of croup in the community.

Glucocorticoids for croup

BACKGROUND

Since the last meta-analysis in 1989, a number of randomised trials on the benefit of glucocorticoids have been published, resulting in an increasing interest in the use of glucocorticoids to treat outpatients with croup. The objective of this review was to provide evidence to guide clinicians in their treatment of patients with croup, to examine the effectiveness of glucocorticoids in these patients, and to identify areas of uncertainty for future research.

OBJECTIVES

To determine the effect of glucocorticoids for children with croup.

SEARCH STRATEGY

We searched The Cochrane Controlled Trials Register, MEDLINE (January 1966 to August 1997) and Excerpta Medica/EMBASE (January 1974 to August 1997). We also contacted (by mail) authors of identified croup trials published in the last five years to inquire about other trials, published or unpublished.

SELECTION CRITERIA

Meta-analysis of randomised controlled trials that examine the effectiveness of glucocorticoid treatment in children with croup.

DATA COLLECTION AND ANALYSIS

Data were extracted using a structured form, which captured patient status (inpatient or outpatient), intervention and control, with the name of the drug, route of administration and dose. Data were also collected on the primary outcome measures comprised of a clinical croup score at baseline (as well as any other subsequent assessment times), length of stay (hours), patients status improved (yes/no), and use of co-interventions. The quality of the trials was assessed using empirically derived items that involved scales and components. Two researchers (TPK, MA) then selected studies as being potentially relevant based on a review of the titles and abstracts, if available. The complete text of these studies was then retrieved. All studies that had been retrieved were reviewed independently by two reviewers (AS, TPK). Data were extracted by one reviewer (MA) and checked for accuracy by a second reviewer (TPK). Two observers independently assessed quality (MA, JK), and inter rater agreement was measured by the intra class correlation. Differences were resolved by consensus.

MAIN RESULTS

Twenty-four studies were deemed relevant for inclusion (N=2221). Glucocorticoid treatment was associated with an improvement in the croup severity score at 6 hours with an effect size of -1.0 (95% confidence interval -1.5 to -0.6) and at 12 hours -1.0 (-1.6 to -0. 4); at 24 hours this improvement was no longer significant (-1.0, -2. 0 to 0.1). There was a decrease in the number of adrenaline treatments needed in children treated with glucocorticoids: a decrease of 9% (95% confidence interval 2 to 16%) among those treated with budesonide and of 12% (4 to 20%) among those treated with dexamethasone. There was also a decrease in the length of time spent in accident and emergency (-11 hours, 95% confidence interval -18 to 4 hours), and for inpatients hospital stay was reduced by 16 hours (-31 to 1 hour). Publication bias seems to play a part in these results.

REVIEWER'S CONCLUSIONS

Dexamethasone and budesonide are effective in relieving the symptoms of croup as early as 6 hours after treatment. Fewer co-interventions are used and the length of time spent in hospital is decreased in patients treated with glucocorticoids.

Croup. A current perspective

In the past decade, much progress has been made in the management of patients with croup. Where glucocorticoids have been adopted into practice, evidence shows that a decrease of health-care-service use is occurring in terms of fewer admissions to intensive care units and hospitals. The evidence may be summarized as follows. All children with croup symptoms who demonstrate increased work of breathing in the clinics or emergency departments should be treated with glucocorticoids. This treatment may be with nebulized budesonide (2 mg) or PO or IM dexamethasone (dose may be 0.15-0.6 mg/kg). Oral dexamethasone may be the best option because of its ease of administration, widespread availability, and lower cost. L-Epinephrine (5 mL of 1:1000) or racemic epinephrine (0.5 mL) should be considered for children with croup who have moderate or severe distress. No evidence supports the effectiveness of mist therapy, and physicians are in need of a randomized, controlled trial for this.

[Childhood croup]

Hoarseness, whooping cough and stridor are elements of a syndrome of upper airway obstruction. In childhood, acute laryngotracheobronchitis is by far the commonest cause of this syndrome. Yet, the differential diagnosis includes a number of rare and severe entities. In many cases, the traditional distinction between viral and spasmodic types is not possible. The value of humidifying therapy has not been established. In severe cases, nebulized adrenaline is of benefit but should be reserved for hospital. The effect lasts only two hours and at times a rebound effect is observed. It is now realized that some patients treated with adrenaline can safely be discharged after a two to three hours observation. There is a large body of evidence that all children arriving at the emergency department with croup should receive steroids without delay. This policy results in a much better outcome, with important reduction in hospitalizations, intensive care unit admissions and incubations. Oral dexamethasone is the drug of choice: it is as effective, easier to administer and cheaper than nebulised budesonide. In most studies, dexamethasone has been used at a dose of 0.6 mg/kg but there is some evidence that 0.15 mg/kg may be just as effective.

Early effects of inhaled steroids on airway hyperreactivity and pulmonary function in asthma

While inhaled steroids (IS) are increasingly recognized as having a more rapid onset of action than was once thought, little is known about the early changes in objective measures of respiratory function that follow the inhalation of repeated doses. These early effects were examined in a randomized, double-blind, placebo-controlled, crossover study of 20 children aged 10-16 years with stable mild asthma. Beclomethasone dipropionate (BDP) 2,000 mcg, fluticasone propionate (FP) 400 mcg, and placebo were given twice daily for three doses. Airway hyperreactivity (AHR) to methacholine (PC20), pulmonary function tests (PFT: FVC, FEV1, FEF25-75%), and the rate of recovery from methacholine-induced bronchospasm following administration of salbutamol were determined at 8 h (after 1 dose) and at 32 h (after three doses). At 8 h, minor improvements in AHR were demonstrated, averaging 0.32 doubling doses in PC20. At 32 h, significant improvements in AHR and PFTs were present, averaging 0.92 doubling doses in PC20, 3.96% of predicted values in FEV1, and 7.74% of predicted values in FEF25-75%. No significant changes occurred in FVC. There were no significant differences between the effects of BDP and FP. Inhaled steroids were associated with a slower response to salbutamol following methacholine challenge testing at 32 h. We conclude that IS, given in repeated high doses, result in significant improvements within 32 h in both AHR and PFTs, along with changes in response to beta2 agonists. These effects are likely to be the result of the topical activity of IS.

Repeated dose inhaled budesonide versus placebo in the treatment of croup

OBJECTIVE

To investigate the efficacy and tolerance of 12-hourly dosing with 2 mg 4 mL-1 of inhaled budesonide versus placebo in patients admitted to hospital with moderate/severe croup.

METHOD

Eighty-two children hospitalised with croup received either 2 mg 4 mL-1 of budesonide or placebo 12 hourly (maximum four doses) via Ventstream nebuliser in a randomised, double-blind manner. Croup scores were performed at 0, 2, 6, 12, 24, 36 and 48 h from initial nebulisation whilst the patient remained hospitalised. Follow-up assessments were made 1 and 3 days after discharge.

RESULTS

Improvement was observed in the budesonide group over the 12-h dosing interval when compared to placebo (P = 0.04). Time to attain a significant clinical improvement was superior in the budesonide group (P = 0.01). Three days after discharge seven of 32 placebo-treated patients and one of 34 budesonide-treated patients had sought further medical follow-up (P = 0.02).

CONCLUSION

Twelve-hourly dosing with inhaled budesonide significantly improved symptoms of croup as well as decreased relapse rates when compared with placebo.

Treatment of croup with glucocorticoids

Croup is a common upper airway disease in children that can range from mild and self-limiting to severe and fulminating. Typical treatment in the past has been mist therapy, although its effectiveness is still being debated. Studies have been published evaluating the efficacy of oral, nebulized, and intramuscular dexamethasone and nebulized budesonide, in a number of combinations and concentrations, in patients ranging in age from 3 to 72 months. The majority of the subjects in the studies were males and more than one-third of the patients in one study previously had croup. The studies have consistently pointed out that the use of oral, intramuscular, and nebulized steroids have been beneficial in patients with varying severity of croup. Nebulized budesonide has been shown to be effective, but is not currently available in the US. Based on this information, intramuscular or oral dexamethasone has been shown to be effective and, in some studies, safe and could be administered to patients presenting with moderate-to-severe croup.

A comparison of nebulized budesonide, intramuscular dexamethasone, and placebo for moderately severe croup

BACKGROUND

In children with croup, treatment with nebulized budesonide decreases symptoms, but it is uncertain how budesonide compares with dexamethasone, the conventional therapy for croup, and whether either reduces the rate of hospitalization.

METHODS

We performed a double-blind, randomized trial involving 144 children with moderately severe croup. The children were treated with racepinephrine and a single dose of 4 mg of nebulized budesonide (48 children), 0.6 mg of intramuscular dexamethasone per kilogram of body weight (47 children), or placebo (49 children). The children were assessed before treatment and then hourly for five hours after treatment. Physicians who were unaware of the treatment assignments determined the children's need for further treatment and hospitalization.

RESULTS

The characteristics of the groups were similar at base line, including the types of viruses identified, the types of croup, and the clinical severity of the illness. The overall rates of hospitalization were 71 percent in the placebo group (35 of 49 children), 38 percent in the budesonide group (18 of 48 children), and 23 percent in the dexamethasone group (11 of 47 children) (unadjusted P=0.001 for the comparison of budesonide with placebo, P<0.001 for the comparison of dexamethasone with placebo, and P=0.18 for the comparison of budesonide with dexamethasone). Children treated with budesonide or dexamethasone had a greater improvement in croup scores than those given placebo (P=0.03 and P<0.001, respectively), and those treated with dexamethasone had a greater improvement than those treated with budesonide (P=0.003).

CONCLUSIONS

In children with moderately severe croup, treatment with intramuscular dexamethasone or nebulized budesonide resulted in more rapid clinical improvement than did the administration of placebo, with dexamethasone offering the greatest improvement. Treatment with either glucocorticoid resulted in fewer hospitalizations.