Académique Documents
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Julie C Brown
Divisions of General Academic Pediatrics, Department of Pediatrics, University of Washington
School of Medicine, and Childrens Hospital and Regional Medical Center, Seattle, Washington, USA
Correspondence to:
Julie C Brown MD,
Childrens Hospital and
Regional Medical Center,
4800 Sand Point Way NE,
PO Box 5371/CH-04,
Seattle,
WA 98105-0371, USA
Croup is an acute respiratory illness caused by inflammation and narrowing of the subglottic region of the larynx. It manifests variously as a
barking cough, hoarseness, stridor and respiratory distress, with or
without concomitant symptoms of viral upper respiratory infection.
Parainfluenza viruses account for most cases of viral croup, with types 1,
2 and 3 identified in three-quarters of all isolates1. Other aetiological
agents include respiratory syncytial virus, influenza viruses A and B, and
Mycoplasma pneumoniae. In general, the symptoms and signs of croup
can be differentiated clinically from those of epiglottitis, foreign body
aspiration and anatomical upper airway obstruction. When the diagnosis
is uncertain, croup should be considered a diagnosis of exclusion, after
appropriate evaluation for these alternate diagnoses.
Croup is a common childhood illness, resulting in 30 primary care visits
per 1000 children per year in the US1. Fewer than 2% of cases are admitted
to hospital and only 0.51.5% of these require intubation. Death from
croup is rare, with mortality rates in intubated patients of less than 0.5%2.
The total economic cost of croup is difficult to quantify. In the US,
emergency visits and hospitalizations resulting from parainfluenza virus
types 1 and 2 alone result in annual costs of $20 million and $56 million,
respectively, and about 25% of these visits are due to croup3.
Traditionally, researchers emphasized differences between spasmodic
(recurrent) croup and laryngotracheitis (viral croup). Some argued that
Validated?
Westley
Modified Westley
Taussig
Kristjansson
Muhlendahl
Downes and Raphaely
Geelhoed
Kuusela
Syracuse
Y
N
N
N
N
N
Y
N
Y
Total
points
Stridor
Retractions
Air
entry
Cyanosis
LOC
17
17
14
15
18
10
6
3
11
02
04
02
03
03
02
03
02
02
03
03
03
03
0 or 2
02
03
02
0, 4 or 5
04
03
03
0, 4 or 5
02
0 or 5
03
03
02
02
0, 2 or 3
0,4 or 5
Cough
Dyspnoea
03
03
01
02
HR
RR
01
01
03
03
01
01
02
, Increased; , decreased; LOC, level of consciousness; HR, heart rate; RR, respiratory rate.
Reprinted with permission from BMJ Books.
190
191
Treatment Comparison
Budesonide vs Placebo
Dexamethasone vs Placebo
Time
# Studies /
Effect Size
(hours)
# Patients
(95% CI)
5 / 327
12
2 / 142
8 / 739
12
5 / 339
24
4 / 189
13 / 1066
12
7 / 481
24
5 / 256
Corticosteroid Better
-3
-1
-2
-1
Corticosteroid Better
-3
-2
This meta-analysis supports the use of corticosteroids in both the inpatient and the out-patient setting. These conclusions are supported by
additional outcomes research: in a hospital that established a policy of
mandatory dexamethasone therapy for all children admitted with croup,
transfer rates to the intensive care unit dropped from 12% to 3%14.
Glucocorticoids route of administration
193
Glucocorticoids nebulized
194
Glucocorticoids dosing
195
Treatment with moist air probably stems from the late 19th century, when
parents used steam from tea kettles or hot tubs to treat croup in their
children. Hospitals adopted the practice of croup kettles long before
clinical trials were routine6. The use of hot steam at home has never been
studied, and there are case reports of scald injury resulting from this
therapy24. Cool mist and humidified oxygen are used by some hospitals,
although there are limited data to support their use. The only published
randomized, controlled trial evaluating mist therapy in croup was a study
of 16 children that compared delivery of 8795% relative humidity for 12
h via a perspex covered cot, with no treatment25. The two groups were
compared using the Westley croup score, plus pulse rate, respiratory rate,
transcutaneous oxygen and transcutaneous carbon dioxide, at 0, 1, 2, 3, 4,
5, 6, and 12 h. The study failed to demonstrate statistically significant
associations between the method of treatment and the above measurements.
However, the study size was small, increasing the chance of missing a true
difference between the two groups (beta error). In addition, the initial croup
scores were low (means 3.75 and 3.00 for the humidity and control groups,
respectively, out of a possible 17 points), limiting the potential for
improvement with therapy.
There is a currently unpublished, blinded, randomized controlled pilot
study of 27 patients comparing treatment with a Mist stick (humidified
oxygen) to no treatment26. The groups were comparable at baseline, and
both received 0.6 mg/kg (maximum 10 mg) of dexamethasone at the
onset of mist therapy. Two patients in each group received racemic
epinephrine. The two groups were compared using the Westley croup
score, pulse rate, respiratory rate, transcutaneous oxygen at 0, 0.5, 1,
1.5 and 2 h. The study failed to demonstrate statistically significant
associations between the method of treatment and croup score at any of
the time intervals, or overall (P = 0.27). However, there was a consistent
196
Humidification
Racemic epinephrine
197
L-epinephrine
The use of L-epinephrine has been proposed as a less expensive and more
readily available treatment for croup. Many practitioners who do not
routinely stock racemic epinephrine have L-epinephrine available as a
resuscitation medication. One randomized controlled trial has compared
L-epinephrine, 5 mg of a 1:1000 dilution in normal saline with racemic
epinephrine 0.5 cc of 2.25% (5 mg) in normal saline36. All patients aged
6 months to 6 years presenting with croup were evaluated and those
with a Downes and Raphaely croup score of 6 after 2025 min of mist
therapy were included. Patients with a croup score > 8 or oxygen
saturation < 95% also received i.m. dexamethasone. Sixteen patients
were treated with racemic epinephrine and 15 with L-epinephrine. Both
groups had an initial improvement in croup score following treatment,
but repeated measures ANOVA revealed no statistical differences in
improvement between the two groups at 5, 15, 30, 60, 90 or 120 min
following treatment. L-epinephrine thus appears to be as efficacious as
racemic epinephrine in the out-patient management of severe croup,
although the number of patients studied is small and clinically important
differences between the two groups could have been missed.
198
used their own croup score, and did not comment on the initial or
discharge croup scores for those patients who returned to care.
In an additional prospective cohort study of 60 children aged 3
months to 6 years presenting to the emergency department with viral
croup35, all eligible children received mist and intramuscular
dexamethasone. Children with continued symptoms after 30 min
received racemic epinephrine and were followed. Sixty children received
racemic epinephrine, and 20 had continued symptoms and were
admitted. All admitted patients who did not receive further racemic
epinephrine treatments within 2 h (16/20) had modified Westley croup
scores 2 at 2 h. Forty patients were discharged, 32 with a croup score
of 0 or 1 and only 1 with a croup score of 3 (the remaining 7 presumably
had a croup score of 2). Thirty-eight patients were followed-up. Two
patients returned 3236 h following racemic epinephrine treatment with
worsening symptoms of croup and were admitted. The croup scores of
these two patients at discharge were not mentioned. The sensitivity and
specificity of the croup score at 2 h for predicting admission after
observation for 4 h could not be determined from the data provided.
Although these studies are not conclusive, it appears that roughly 5%
of patients discharged from the emergency department after receiving
dexamethasone and racemic epinephrine for symptomatic croup will
return to care. Relapse within 24 h is unlikely in patients with minimal
symptoms (croup score 01) 2 h after racemic epinephrine treatment.
Heliox
Future research
There is limited evidence in many areas of croup therapy. In particular,
studies have not clearly established the roles of humidified oxygen and
lower doses of dexamethasone, or the optimal duration of observation
following treatment with epinephrine. Further research is also needed to
determine the efficacy of prednisolone versus dexamethasone for acute
croup and the efficacy and safety of repeated doses of dexamethasone
after 24 or 48 h, for patients with continued symptoms. Although we are
likely to continue to manage croup for years to come, early intervention
with corticosteroids and new therapies for severe disease will likely
continue to lower morbidity and mortality due to this common childhood
illness.
199
Acknowledgement
This chapter summarizes and updates work presented previously in Moyer
VA. (ed) Evidence Based Pediatrics and Child Health. London: BMJ Books,
2000.
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