Nuevos conceptos de la laringotraqueítis en niños (crup viral) / New concepts of laryngotracheitis in children (viral croup)

El propósito de este artículo de actualización es brindar información de la epidemiología, etiología manifestaciones clínicas para un diagnóstico preciso, recomendaciones para solicitar exámenes de laboratorio y gabinete y finalmente el tratamiento sintomático con corticoides y cuando hacer uso de epinefrina o adrenalina. La laringotraqueítis es una infección respiratoria aguda desencadenada por una infección viral de la vía aérea superior que afecta al 3% de los niños de seis meses a tres años. Es responsable del 7% de las hospitalizaciones anuales por fiebre y/o enfermedad respiratoria aguda en niños (as) menores de 5 años. Es la causa más frecuente de obstrucción de la vía aérea superior, secundaria a la inflamación de la laringe, la tráquea y los bronquios que genera estridor respiratorio y tos perruna o de foca. En la mayoría de los casos, el agente causal de la enfermedad es el virus parainfluenza. Si bien, muchos niños experimentan fiebre de bajo grado, su presencia no es necesaria para el diagnóstico, el cual es esencialmente clínico y rara vez se necesitan exámenes de laboratorio y gabinete para este propósito. El cultivo viral y la prueba rápida para identificar antígenos, tienen mínimo impacto en el tratamiento y no se recomiendan de rutina. La radiografía y la laringoscopia deben reservarse cuando se sospechan diagnósticos alternativos. El tratamiento es sintomático con el uso habitual de corticoides y en ocasiones epinefrina o adrenalina. Una sola dosis de dexametasona oral, intramuscular o endovenosa mejora los síntomas y disminuye las visitas de retorno, readmisiones y la duración de hospitalización en niños con LT de cualquier gravedad. La adición de epinefrina nebulizada mejora los síntomas en niños con LT moderada o severa, disminuye el porcentaje de intubación y evita la insuficiencia respiratoria. La intervención oportuna al inicio de la enfermedad, disminuye la severidad de los síntomas, la atención médica en servicios de urgencia pediátrica y la internación hospitalaria.

The purpose of this update article is to provide information on the epidemiology, etiology, clinical manifestations for an accurate diagnosis, recommendations for requesting laboratory and cabinet tests, and finally symptomatic treatment with corticosteroids and when to use epinephrine or adrenaline. Laryngotracheitis (LT) is an acute respiratory infection triggered by a viral infection of the upper airway that affects 3% of children from six months to three years. It is responsible for 7% of annual hospitalizations for fever and / or acute respiratory illness in children under 5 years. It is the most frequent cause of obstruction of the upper airway, secondary to inflammation of the larynx, trachea and bronchi that causes respiratory stridor and barking cough. In most cases, the causative agent of the disease is the parainfluenza virus. While many children experience low-grade fever, their presence is not necessary for diagnosis, which is essentially clinical and laboratory and cabinet tests are rarely needed for this purpose. Viral culture and rapid test to identify antigens have minimal impact on treatment and are not recommended routinely. Radiography and laryngoscopy should be reserved when alternative diagnoses are suspected. The treatment is symptomatic with the usual use of corticosteroids and sometimes epinephrine or adrenaline. A single dose of oral, intramuscular or intravenous dexamethasone improves symptoms and decreases return visits, readmissions and length of hospitalization in children with LT of any severity. The addition of nebulized epinephrine improves symptoms in children with moderate or severe LT, decreases the percentage of intubation and prevents respiratory failure. Timely intervention at the onset of the disease, decreases the severity of symptoms, medical attention in pediatric emergency services and hospitalization.

Seasonality and etiology of croup in pediatric patients hospitalized with lower respiratory tract infections: A long-term study between 2009 and 2017

PURPOSE: Croup is a common respiratory disease in children. The aim of this study was to analyze the epidemiology, etiology, and seasonal variations of respiratory virus infections in children with croup. METHODS: From October 2009 to September 2017, children admitted with croup to Gachon University Gil Medical Center under the age of 18 years were enrolled in this study. We retrospectively reviewed patients' medical records. RESULTS: A total of 1,053 of 27,330 patients (3.9%) infected with lower respiratory infections were diagnosed as having croup. In the age distribution, croup was most common (50.0%) in children aged 1 to <2 years. There were 2 peaks, the major in summer (July to August) and the minor in spring (March to May). Parainfluenza virus type 1 (15.8%) was most prevalent and coincided with the summer peaks of croup. Influenza virus type B and parainfluenza virus type 3 were the most frequent etiologic agents in a spring peak of croup. Although parainfluenza virus type 1 was predominant of all ages, human coronavirus was a significant cause of croup in children younger than 1 year, whereas influenza virus played an important role in children above the age of 3 years. CONCLUSION: Seasonality and epidemiology of croup varied with age and regions. Two peaks of seasonal fluctuation were in summer and spring, which were related to the seasonality of respiratory viruses in croup. These results may be helpful in planning clinical and research needs.

Progress in the diagnosis and treatment of croup / 国际儿科学杂志

The croup is a common disease of upper airway obstruction in children,with high incidence rate.In severe case,it is life-threatening.Because there is no guidelines or consensus on diagnosis and treatment in China,the evidence-based research on Chinese children's croup is also seriously lacking.Therefore,the article mainly reviews the recent research progress of croup abroad.

Progress in the diagnosis and treatment of croup / 国际儿科学杂志

The croup is a common disease of upper airway obstruction in children, with high incidence rate.In severe case, it is life-threatening.Because there is no guidelines or consensus on diagnosis and treatment in China, the evidence-based research on Chinese children′s croup is also seriously lacking.Therefore, the article mainly reviews the recent research progress of croup abroad.

Seasonal patterns and etiologies of croup in children during the period 2010–2015: A multicenter retrospective study

PURPOSE: Croup is known to have epidemics in seasonal and biennial trends, and to be strongly associated with epidemics of parainfluenza virus. However, seasonal and annual epidemics of croup have not been clearly reported in Korea. This study aimed to examine the seasonal/annual patterns and etiologies of childhood croup in Korea during a consecutive 6-year period. METHODS: Pediatric croup data were collected from 23 centers in Korea from 1 January 2010 to 31 December 2015. Electronic medical records, including multiplex reverse transcription polymerase chain reaction (RT-PCR) results, demographics and clinical information were cross-sectionally reviewed and analyzed. RESULTS: Overall, 2,598 childhood croup patients requiring hospitalization were identified during the study period. Among them, a total of 927 who underwent RT-PCR were included in the analysis. Males (61.5%) predominated, and most (63.0%) of them were younger than 2 years of age (median, 19 months; interquartile range, 11–31 months). Peak hospitalization occurred in 2010 and 2012 in even-numbered years, and parainfluenza virus (PIV, 39.7%) was the most common cause of childhood croup requiring hospitalization, followed by respiratory syncytial virus (14.9%), human rhinovirus (12.5%), Mycoplasma pneumonaie (10.6%), and human coronavirus (7.3%). CONCLUSION: It is concluded that croup hospitalization has a biennial pattern in even-numbered years. PIV may be the most common cause of childhood croup; however, croup epidemics could be attributed to other viruses.

Epidemiology and Clinical Severity of the Hospitalized Children with Viral Croup

PURPOSE: In this study, the clinical and epidemiological characteristics of patients admitted for viral croup were analyzed to evaluate disease severity based on the organism that caused the infection. METHODS: We retrospectively reviewed the medical records of 302 patients who were admitted to the Department of Pediatrics at the Wonju Severance Hospital between May 2013 and December 2016 for viral croup. Patients who showed positive results on multiplex polymerase chain reaction were subsequently diagnosed with respiratory virus infection. The Westley scoring system was used to evaluate the severity of viral croup. RESULTS: Of the 302 patients, 149 were admitted due to severe viral croup, including 88 boys and 61 girls, with a boy-to-girl ratio of 1.44:1. About 110 cases of parainfluenza virus infection have been reported, which accounted for almost half of the total cases. The other identified viruses included influenza virus, human rhinovirus, and respiratory syncytial virus. Analysis of the association between severe viral croup and causative pathogen revealed that only parainfluenza type 2 virus showed a significantly high risk. Parainfluenza type 2 virus did not show an age-based difference in frequency but showed relatively a higher frequency of infections during the summer and fall. CONCLUSIONS: In this study, parainfluenza virus type 2 was the only virus associated with severe viral croup. To facilitate proper preventive management, treatment, and prognosis evaluation of viral croup, prospective and multicenter studies should assess the additional variables and the severity of the virus. Additionally, further studies should be conducted to assess age-dependent influences, as well as the regional and seasonal incidence of viral infection.

Clinical presentation of croup in children according to causative viruses

PURPOSE: We evaluated the clinical features of croup in children according to viral etiology. METHODS: This study enrolled pediatric patients with croup, who showed positive results on respiratory virus reverse transcriptase polymerase chain reaction performed between January 2012 and December 2017. We retrospectively reviewed the medical records. RESULTS: A total of 179 patients (119 boys and 60 girls) were enrolled with the mean age of 18.9±14.7 months. The viruses commonly identified were parainfluenza, respiratory syncytial virus, rhinovirus, and influenza. Among these 4 viruses, patients with rhinovirus infection showed significantly shorter fever and admission durations. Patients with parainfluenza infection showed significantly lower incidences of epinephrine nebulization and patients with influenza infections showed significantly higher incidences of steroid treatment. CONCLUSION: Clinical manifestations of croup differ according to causative viruses. Further studies should be conducted to evaluate the severity and prognosis of croup according to viral etiology.

Comparison of etiology and clinical presentation between children with laryngotracheobronchopneumonitis and croup

PURPOSE: Croup, a common childhood respiratory illness with various severities, has many unanswered questions. Laryngotracheobronchopneumonitis (LTBP) is a disease entity considered to be an extension of croup to the lower respiratory tract. The object of this study was to compare epidemiology, clinical characteristics, and viral etiologic spectrum between croup and LTBP. METHODS: Patients hospitalized with croup at Gachon University Gil Hospital from January 2010 to April 2016 were recruited. LTBP was defined as pneumonia confirmed on radiographs of patients with croup. Clinical findings and demographic data were reviewed of patients whose nasopharyngeal swabs were done for viral analysis. RESULTS: A total of 371 patients with only croup and 63 patients with LTBP were included. Croup was found to be significantly associated with parainfluenza virus type 1 (P=0.006). LTBP was related to parainfluenza virus type 3, respiratory syncytial virus, and human bocavirus (P=0.001, P=0.030, and P=0.019, respectively). The duration of fever was longer in patients with LTBP than in those with croup (3.87±1.85 days vs. 2.86±1.80 days, P<0.001). CONCLUSION: Specific etiologic viruses might be associated with the progression from croup to LTBP. Pronged fever is also associated with progression from croup to LTBP.

Clinical characteristics of children and adolescents with croup and epiglottitis who visited 146 Emergency Departments in Korea / 소아과

PURPOSE: Croup is a common pediatric respiratory illness with symptoms of varying severity. Moreover, epiglottitis is a rare disease that can rapidly progress to life-threatening airway obstruction. Although the clinical course and treatments differ between croup and epiglottitis, they are difficult to differentiate on presentation. We aimed to compare the clinical characteristics of croup and epiglottitis in Emergency Department patients. METHODS: The 2012 National Emergency Department Information System database of 146 Korean Emergency Departments was used to investigate patients aged < or =18 years presenting with croup or epiglottitis. RESULTS: We analyzed 19,374 croup patients and 236 epiglottitis patients. The male:female sex ratios were 1.9:1 and 2.3:1 and mean ages were 2.2+/-2.0 and 5.6+/-5.8 years, respectively. The peak incidence of croup was observed in July and that of epiglottitis was observed in May. The hospitalization rate was lower in croup than in epiglottitis patients, and the proportion of patients treated in the intensive care unit was lower among croup patients. The 3 most common chief complaints in both croup and epiglottitis patients were cough, fever, and dyspnea. Epiglottitis patients experienced dyspnea, sore throat, and vomiting more often than croup patients (P<0.05). CONCLUSION: Both groups had similar sex ratios, arrival times, 3 most common chief complaints, and 5 most common comorbidities. Epiglottitis patients had a lower incidence rate, higher mean age of onset, and higher hospitalization rate and experienced dyspnea, sore throat, and vomiting more often than croup patients. Our results may help in the differential diagnosis of croup and epiglottitis.

Croup, tratamiento actual / Croup management

Croup is a frequent cause of outpatient and emergency consultation. It is frequently triggered by a viral respiratory infection and characterized by an abrupt onset. We describe current studies about the treatment of croup. The use of systemic corticosteroids stands out as choice treatment, and nebulized epinephrine as short term therapy while waiting for the anti-inflammatory effect of steroids.

El Croup (laringitis aguda) es motivo frecuente de consulta en servicios de urgencia y policlínicos pediátricos. Generalmente es gatillado por una infección respiratoria viral y se caracteriza por un inicio abrupto. En el presente texto se describen los estudios vigentes acerca de su tratamiento. Destacan los corticoides sistémicos como terapia de elección y la adrenalina nebulizada como terapia de acción corta en espera de la acción antinflamatoria esteroidal.

Unexpected and severe postintubation croup after a very short day surgery in a pediatric patient: a case report / 대한마취과학회지

An 18 month-old boy underwent endoscopic foreign body removal under anesthesia on an outpatient basis and the operation took approximately 5 minutes. Stridor developed in both lung fields 6 hours after emergence from anesthesia, and severe croup developed, with cyanosis of the lips and aggravated stridor 20 hours after the end of the procedure. The croup resolved with oxygen therapy, intravenous dexamethasone, and epinephrine nebulization therapy. In this report, we suggest that thorough investigations of the patient's past history, including history of any airway problems, and careful monitoring after emergence from anesthesia be done in order to decide the proper discharge time of the patient. Further, proper prophylaxis following risk stratification is important, especially in patients at high risk of postoperative airway obstruction.

Unexpected and severe postintubation croup after a very short day surgery in a pediatric patient: a case report / 대한마취과학회지

An 18 month-old boy underwent endoscopic foreign body removal under anesthesia on an outpatient basis and the operation took approximately 5 minutes. Stridor developed in both lung fields 6 hours after emergence from anesthesia, and severe croup developed, with cyanosis of the lips and aggravated stridor 20 hours after the end of the procedure. The croup resolved with oxygen therapy, intravenous dexamethasone, and epinephrine nebulization therapy. In this report, we suggest that thorough investigations of the patient's past history, including history of any airway problems, and careful monitoring after emergence from anesthesia be done in order to decide the proper discharge time of the patient. Further, proper prophylaxis following risk stratification is important, especially in patients at high risk of postoperative airway obstruction.

Los corticoides orales, son más o menos eficaces que el budesonide inhalado, para tratar la laringitis subglótica, leve a moderada, en niños? / Are oral corticosteroids more or less effective than inhaled budesonide in treating mild to moderate croup in children?

El tratamiento de la laringitis aguda en los niños, sigue siendo muy controvertido. Mientras que algunos sugieren no tratar las laringitis leves argumentando que se trata de un proceso benigno y autolimitado, otros están a favor de brindar tratamiento farmacológico, ya que éste puede ofrecer beneficios. Tanto el budesonide nebulizado como los corticoides orales, han demostrado mejorar la sintomatología inicial de la laringitis leve a moderada, disminuir el tiempo de estadía en el área de observación de urgencias, disminuir los ingresos hospitalarios y la necesidad de intubacíón. La revisión de la literatura mostró que el budesonide y la dexametasona oral, en monodosis, son igualmente eficaces. A la hora de elegir una vía de administración de los corticoides, debe tenerse en cuenta la disponibilidad de la droga, la edad y la colaboración del paciente y de sus padres. Considerando estos parámetros, parecería que la dexametasona oral se convierte en el tratamiento de elección para niños con laringitis leve a moderada, ya que es más económica, está más disponible que el budesonide, y su administración es más sencilla que la nebulización.

Dexametasona versus adrenalina más dexametasona en pacientes con laringotraqueitis / Dexamethasone vs epinefrine and dexamethasone in treating croup

Objetivo: el objetivo principal es demostrar que las laringotraqueitis en los grados I y II pueden ser tratadas en un lapso de internación corto en un servicio de emergencias. Por otro lado también queremos instituir un protocolo estandarizado de manejo. Diseño: ensayo clínico a simple ciego, de aleatorización simple. Lugar: el estudio fue conducido en el Servicio de Emergencias (área de observación) del Hospital del Niño "Ovidio Aliaga Uría" de la ciudad de La Paz. Pacientes: participaron en el estudio 79 pacientes con el diagnóstico de laringotraqueitis grados: I, II y III, 39 pacientes aceptados en el grupo A (dexametasona + adrenalina) y 40 en el grupo B (dexametasona sola). No existieron pérdidas en el seguimiento de ambos grupos: se excluyeron del estudio pacientes con laringotraqueitis grado IV. Intervención: una vez que se realizó la medición de la línea de base los pacientes fueron divididos en dos grupos por aleatorización simple, luego se siguió el protocolo de acuerdo al flujograma del estudio Mediciones del resultado principal: se realizaron las mediciones del tiempo de inicio de la mejoría, el requerimiento de dosis adicional o nueva de adrenalina, fracaso del tratamiento e internación. Resultados: los pacientes del grupo A en los tres grados respondieron al tratamiento en un promedio de 99 minutos, los pacientes del grupo B en el mismo tiempo. El tiempo de comienzo de la mejoría tuvo un RRR de 21 % el RRA de 16%. el NNT de 6. La dosis adicional de adrenalina tuvo un RRR de 25%; con RRA de 20%; con NNT de 5. Conclusiones: esta investigación ha demostrado una vez más la efectividad de la dexametasona en el manejo de la laringotraqueitis. Es posible el manejo de la laringotraqueitis en grados I, II y III en forma ambulatoria en un Servicio de emergencias, evitando de esta manera internaciones innecesarias. por lo tanto disminuyendo costos de internación.

Objetive: the main objcctive of the study is to demonstrate that all types of laringotracheitis can be treated in the emergency room over a short period of time; also lo develop a standardized treatment protocol. Design: blind clinical assay aleatory study. Location: the study was performed at the emergency department of the Hospital del Niño "Ovidio Aliaga" Patients: there were 79 patients diagnosed with laryngotracheitis grade I, II and III. 30 patients were included in group A to be medicated with dexametasone and epinephrine, Group B had to be medicated with only dexametasone. All patients were followed-up, grade IV cases were excluded from the study. Intervention: once patients were separated in categories. they were further randomly divided in two groups and they were studied according to the protocol and floor chart. Evaluation of main results: we evaluated how soon each patient started to get better, if new or extra doses of epinephrine were necessary, failure to respond to treatment and eventual need for admission. Results: all patients in group I and II with different degrees of laringotracheitis responded to treatment in an average lapse of 99 minutes. The initial time had an RRR of 21%; the RRA of 16%, the NNT of 6. The initial dosage of epinephrine had a RRR of 25%; with RRA of 20%; with NNT of 5. Conclusions: the study demonstrates the efficacy of dexametasone in the treatment of laryngotracheitis and that it is possible to manage all degrees of this ailment in the emergency department avoiding the burden of having to admit these patients.

Clinical Characteristics of Acute Viral Lower Respiratory Tract Infections in Hospitalized Children / 소아알레르기및호흡기학회지

PURPOSE: Causes of acute lower respiratory tract infections (ALRI) in children are diverse. But virus is the most common cause of ALRI, so it is important to understand the etiology and epidemiology of ALRI. This study was performed to investigate the etiologic organisms, age distribution, clinical manifestations and seasonal occurrence of ALRI in hospitalized children. METHODS: We confirmed viral etiologies using nasopharyngeal aspirates in 377 patients of the ages of 15 years or younger who were hospitalized for ALRI from March, 1996 to February, 1999 at Samsung Seoul Hospital, Seoul, Korea. Viral agents were detected by virus isolation and antigen detection by indirect immunofluorescent staining. RESULTS: The viral pathogens identified were influenza A (22.2%), influenza B (9.0 %), adenovirus (21.2%), parainfluenza virus type 1 (8.8%), type 2 (3.4%), type 3 (15.1%) and respiratory syncytial virus (RSV) (20.2%). The occurrence of ALRIs was high under 2 year old. The clinical patterns of viral ALRI include pneumonia (49.9%), croup (20.2%), bronchiolitis (22.0%), tracheobronchitis (8.0%). The specific viruses are frequently associated with specific clinical syndrome of ALRI. The respiratory agents and associated syndromes frequently have characteristic seasonal patterns. CONCLUSION: This study will help us to estimate the etiologic agents of ALRI, and to avoid inappropriate antibiotic therapy. An annual nationwide survey is necessary to understand the viral epidemiology associated with respiratory illness.

Clinical characteristics of acute viral lower respiratory tract infections in hospitalized children in Seoul, 1996-1998

This study was performed to investigate the etiologic agents, age distribution, clinical manifestations and seasonal occurrence of acute viral lower respiratory tract infections in children. We confirmed viral etiologies using nasopharyngeal aspirates in 237 patients of the ages of 15 years or younger who were hospitalized for acute lower respiratory tract infection (ALRI) from March 1996 to February 1998 at Samsung Seoul Hospital, Seoul, Korea. The overall isolation rate was 22.1%. The viral pathogens identified were adenovirus (12.7%), influenza virus type A (21.1%), -type B (13.9%), parainfluenza virus type 1 (13.5%), -type 2 (1.3%), -type 3 (16.0%) and respiratory syncytial virus (21.5%). The occurrence of ALRIs was highest in the first year of life, although parainfluenza virus type 1 infection occurred predominantly in the second year of life and influenza virus caused illnesses in all age groups. The specific viruses are frequently associated with specific clinical syndromes of ALRI. The respiratory agents and associated syndromes frequently have characteristic seasonal patterns. This study will help us to estimate the etiologic agents of ALRI, and establish a program for the prevention and treatment. An annual nationwide survey is necessary to understand the viral epidemiology associated with respiratory illnesses in Korea.

Prospective Randomized Study Comparing L-epinephrine and Budesonide Aerosols in the Treatment of Moderate to Severe Croup

PURPOSE: The aim of this prospective, randomized study was to evaluate the effects and adverse effects of nebulized L-epinephrine compared with nebulized budesonide in children with moderate to severe croup. METHODS: Children were eligible for the study if their croup scores fell in the moderate to severe range(scores>4) in the AMC from May 1995 till May 1996. The patients were randomly assigned to receive either 5ml(1 : 1000) of L-epinephrine aerosols(n=9) or 500microgram of budesonide aerosols (n=8). Croup score, O2 saturation by pulse oximeter, heart rate, and blood pressure were recorded before treatment and at 5, 15, 30, 60, 120 minutes after aerosol treatment. Nine patients were enrolled in the nebulized L-epinephrine group and 8 in the nebulized budesonide group, respectively. There were no statistical differences in age, sex and croup score before treatment between the two groups. RESULTS: Total croup score significantly decreased at 15 minutes after treatment in the L-epinephrine group(P<0.05) but at 120 minutes after treatment in the budesonide group(P<0.05). Treatment failed in 1(1/9) patient in the L-epinephrine group and 2(2/8) patients in the budesonide group, who received intramuscular dexamethasone injections. The rebound phenomenon at 120 minutes after treatment was found in 1 patient from both groups. There were no significant changes of heart rate and blood pressure before and after treatment in both groups. CONCLUSION: The treatment using nebulized L-epinephrine showed a more prompt clinical improvement than the treatment using nebulized budesonide and without any significant adverse effects. So it can be recommended for emergent management in children with moderate to severe croup.

Prospective Randomized Study Comparing L-epinephrine and Budesonide Aerosols in the Treatment of Moderate to Severe Croup

PURPOSE: The aim of this prospective, randomized study was to evaluate the effects and adverse effects of nebulized L-epinephrine compared with nebulized budesonide in children with moderate to severe croup. METHODS: Children were eligible for the study if their croup scores fell in the moderate to severe range(scores>4) in the AMC from May 1995 till May 1996. The patients were randomly assigned to receive either 5ml(1 : 1000) of L-epinephrine aerosols(n=9) or 500microgram of budesonide aerosols (n=8). Croup score, O2 saturation by pulse oximeter, heart rate, and blood pressure were recorded before treatment and at 5, 15, 30, 60, 120 minutes after aerosol treatment. Nine patients were enrolled in the nebulized L-epinephrine group and 8 in the nebulized budesonide group, respectively. There were no statistical differences in age, sex and croup score before treatment between the two groups. RESULTS: Total croup score significantly decreased at 15 minutes after treatment in the L-epinephrine group(P<0.05) but at 120 minutes after treatment in the budesonide group(P<0.05). Treatment failed in 1(1/9) patient in the L-epinephrine group and 2(2/8) patients in the budesonide group, who received intramuscular dexamethasone injections. The rebound phenomenon at 120 minutes after treatment was found in 1 patient from both groups. There were no significant changes of heart rate and blood pressure before and after treatment in both groups. CONCLUSION: The treatment using nebulized L-epinephrine showed a more prompt clinical improvement than the treatment using nebulized budesonide and without any significant adverse effects. So it can be recommended for emergent management in children with moderate to severe croup.

The Treatment of Croup with Nebulized Budesonide and Intramuscular Dexamethasone

PURPOSE: Steroids have anti-inflammatory effects which reduces inflammation and edema of the tissue. Thus, corticosteroids have been used for treatment of croup. The aim this study is to compare and assess the effects of intramuscularly injected dexamethasone and nebulized budesonide in treatment of moderate or severe croup. METHODS: Between July 1995 to June 1996, we have assessed 44 inpatients with croup syndrome, of which 20 patients have been treated by intramuscularly injected dexamethasone and 24 patients by nebulized budesonide. We measured the croup symptom scores and arterial oxygen saturation at initial, at 4 hours, 12 hours and 24 hours after treatment. RESULTS: The sex ratio and mean age of patients were 2.3:1 and 18.7 +/- 9.1 months in budesonide treatment group and 3:1 and 22.3 +/- 13.1 months in dexamethasone treatment group, respectively. There was no significant difference (P>0.05) among the two groups. In budesonide treatment group, the symptom scores were 7.5 +/- 4.5 at initial and 4.5 +/- 1.3 at 4 hours after treatment. These were statistically significant (P<0.005). In the dexamethansone treatment group, the symptom scores were 7.6 +/- 1.2 at initial and 5.1 +/- 1.2 at 4 hours after treatment. They were statistically significant (P<0.005). Arterial oxygen saturations were significantly different (P<0.005) between initial and 4 hours after treatment in both groups. There were no side effects in the budesonide treatment group. CONCLUSION: Nebulized budesonide has the same effects with intramuscularly injected dexamethasone in treatment of croup whether the severity is moderate or extreme. Therefore it should provide an effective means of treatment for moderate or severe croup patients without systemic side effects.

Serum Eosinophil Cationic Protein Levels in Patients with Recurrent Croup

PURPOSE: Most patients suffer from croup only once in a life time. However, a small group of patients suffer from it several times. A type of croup from which they suffer more than 3 times is called recurrent croup. The cause of recurrent croup has not been clearly described, but in recent years the allergic reaction is considered as a cause of recurrent croup. ECP is one of the 4 major basic proteins of eosinophil, means eosinophil activation, and has been reported as a clinical indicator of bronchial asthma and other an allergic diseases. We measured serum ECP levels in recurrent croup patients in order to evaluate the roles of ECP as a diagnostic tools and eosinophil activation as part of the pathophysiology of recurrent croup. METHODS: 25 patients with 1st croup episode were enrolled in the study between April and August 1994. We phoned the 22 patients if they had ever caught any respiratory and allergic diseases including croup about 2 years since their discharge from the hospital. Three patients could not be connected. We divided these patients into two groups according to the recurrent rate of attack after discharge. The patients with more than three times of episode were diagnosed as recurrent croup patients, and others with one time of episode were diagnosed as single croup patients. The patients with two times episode were dropt out. Non-allergic 10 patients of the same age with acute viral enteritis were enrolled as a control group. Blood sampling was done at admission. Serum ECP levels were measured by ECP radioimmunosorbent assay kit (Phamarcia, Sweden). RESULTS: 1) Recurrent croup (n=9): The ECP level was 52.1+/-17.3 g/L. Single croup (n=12): The ECP level was 11.6+/-7.0 g/L. Control (n=10): The ECP level was 6.3+/-3.2 g/L. 2) There was no meaningful difference between the control and the single croup patients (p>0.05). 3) There was a meaningful difference between the control and the recurrent croup patients (p<0.05). 4) There was a meaningful difference between the single croup and the recurrent croup patients (p<0.05). 5) There was a linear correlation between eosinophil count and serum ECP levels (r=0.63, p<0.01). 6) For 2 years after discharge, pneumoniae was developed in 2 single croup patients. The recurrent rate of croup was 3-6 times in recurrent croup patients. Asthma was developed in 4 recurrent croup patients. And bronchiolitis was developed in 2 recurrent croup patients. CONCLUSIONS: The investigation of serum ECP levels enables us to distinguish recurrent croup patients from single croup patients. It suggests that eosinophil activation may play an important role in the pathophysiology of recurrent croup.