Croup management in Australia and New Zealand: a PREDICT study of physician practice and clinical practice guidelines.

OBJECTIVE: Comparison of clinical practice guideline (CPG) recommendations and reported physician management of croup at PREDICT (Paediatric Research in Emergency Departments International Collaborative) sites as baseline for planned randomized controlled trials. METHODS: Review of CPGs for croup from PREDICT sites and survey of specialist pediatric emergency physicians regarding croup management. PREDICT sites included 8 tertiary pediatric hospitals and 3 large mixed emergency departments in Australia and New Zealand. RESULTS: Nine of the 11 sites had a CPG for croup. Response rate was 94% (78/83). Adrenaline was recommended for moderate croup (3%), severe croup (52%), and life-threatening croup by (100%). Steroid therapy was recommended for mild croup (45%), for moderate croup (97%), for severe croup (97%), and for life-threatening croup (96%). Steroid choice was oral dexamethasone (60%) and oral prednisolone (38%). In severe croup, 77% used intravenous/intramuscular dexamethasone, 10% used intravenous/intramuscular methylprednisolone, and 8% used nebulized budesonide. Commonest dosage regimens were 0.15 mg/kg dexamethasone or 1 mg/kg prednisolone. A standard volume dosage regimen for nebulized adrenaline was used by 54%, whereas 39% used a weight-based formula. Clinical practice guidelines recommended 5 mg (11%) or 10 mg (33%) for standard volume dosing, and all CPGs using weight-based dosing recommend 0.5 mg/kg with maximum doses ranging from 5 to 15 mg. CONCLUSIONS: Croup management at PREDICT emergency departments is similar, based on oral steroids and nebulized adrenaline. The steroid and adrenaline regimens used by respondents and their CPGs were not consistent. This reflects limitations of available evidence for management of this common disease, highlighting the need for definitive trials, particularly in the management of mild croup.

A randomized trial of a single dose of oral dexamethasone for mild croup.

BACKGROUND: The benefits of dexamethasone treatment for moderate-to-severe croup are well established. However, most children with croup have mild symptoms, and it is unknown whether they would derive the same degree of benefit from dexamethasone treatment as children with more severe disease. METHODS: We conducted a double-blind trial at four pediatric emergency departments in which 720 children with mild croup were randomly assigned to receive one oral dose of either dexamethasone (0.6 mg per kilogram of body weight) or placebo. The children had mild croup, as defined by a score of < or =2 on the croup scoring system of Westley et al. The primary outcome was a return to a medical care provider for croup within seven days after treatment. The secondary outcome was the presence of ongoing symptoms of croup on days 1, 2, and 3 after treatment. Other outcomes included economic costs, hours of sleep lost by the child, and stress on the part of the parent in relation to the child's illness. RESULTS: Baseline clinical characteristics were similar in the two groups. Return to medical care was significantly lower in the dexamethasone group (7.3 percent vs. 15.3 percent, P<0.001). In the dexamethasone group, there was quicker resolution of croup symptoms (P=0.003), less lost sleep (P<0.001), and less stress on the part of the parent (P<0.001). CONCLUSIONS: For children with mild croup, dexamethasone is an effective treatment that results in consistent and small but important clinical and economic benefits. Although the long-term effects of this treatment are not known, our data support the use of dexamethasone in most, if not all, children with croup.

Intramuscular versus oral dexamethasone for the treatment of moderate-to-severe croup: a randomized, double-blind trial.

UNLABELLED: Glucocorticoids are an effective treatment for croup, although the most beneficial route of administration remains unclear. Recent studies have concluded that both intramuscular dexamethasone and oral dexamethasone are effective treatments, but there are few data directly comparing the two for moderate-to-severe croup. OBJECTIVES: The authors' primary objective was to determine whether there is a difference in proportion of children with resolution of symptoms attributable to croup at 24 hours, when treated with oral or intramuscular dexamethasone. Secondarily, the authors sought to estimate whether there is a difference in proportion of children with resolution of symptoms attributable to croup at 10 days and to estimate the interval to complete resolution of symptoms between these two routes. METHODS: The authors performed a prospective, randomized, double-blind trial involving children aged 3-84 months with moderate-to-severe croup, presenting to a suburban teaching emergency department (ED). Patients were eligible for enrollment if they had inspiratory stridor or a barky cough and a croup score of 2 or greater after 10-15 minutes of cool mist therapy. The patients were randomized to one of two intervention groups. In both groups, the parents were not present in the treatment room during study drug administration. One group received 0.6 mg/kg of intramuscular dexamethasone and an oral placebo, while the other group received 0.6 mg/kg of oral dexamethasone and direct pressure on their thigh with the hub of a syringe. A nurse placed a Band-Aid on the site of the real or mock injection. Parents were contacted by telephone approximately 1 and 10 days after the index visit to ask about their child's symptoms using a standardized questionnaire. Data were analyzed using an intention-to-treat approach. RESULTS: Of 126 patients eligible, 96 were recruited, with complete follow-up on 95. The groups were similar in all baseline characteristics, treatments received in the ED, and disposition. At 24 hours and 10 days after the visit, there were no statistical differences between the groups for the proportion with stridor, expiratory sounds, barky cough, sleep pattern, the degree of improvement, or the proportion with complete resolution of symptoms at one day. CONCLUSIONS: No statistical differences for any parameters were observed between intramuscular and oral dexamethasone treatments for children with moderate-to-severe croup at 24 hours or at any time the week after treatment. The durations of symptoms were similar between the treatment groups.

A randomized controlled trial of mist in the acute treatment of moderate croup.

OBJECTIVE: To determine whether the use of mist improves clinical symptoms in children presenting to the emergency department (ED) with moderate croup. METHODS: Children 3 months to 6 years of age were eligible for the study if they presented to the ED with moderate croup. Moderate croup was defined as a croup score of 2-7. The patients were randomly assigned to receive either mist (humidified oxygen) via mist stick or no mist. The patients had croup scores measured at baseline and every 30 minutes for up to two hours. At these intervals the following parameters were also measured: heart rate, respiratory rate, oxygen saturation, and patient comfort score. The patients were treated until the croup score was less than 2 or until two hours had elapsed. All patients initially received a dose of oral dexamethasone (0.6 mg/kg). Other treatments, such as racemic epinephrine or inhaled budesonide, were given at the discretion of the treating physician. The research assistants were unaware of the assigned treatments. RESULTS: There were 71 patients enrolled in the study; 35 received mist and 36 received no mist. The two treatment groups had similar characteristics at baseline. The median baseline croup score was 4 in both groups. The outcomes were measured as the change from baseline at 30, 60, 90, and 120 minutes. The change in the croup score from baseline in the mist group was not statistically different from the croup score change in the group that did not receive mist (p = 0.39). There was also no significant difference in improvement of oxygen saturation, heart rate, or respiratory rate at any of the assessment times. There was no adverse effect from the mist therapy. CONCLUSIONS: Mist therapy is not effective in improving clinical symptoms in children presenting to the ED with moderate croup.

Relation of two different subtypes of croup before age three to wheezing, atopy, and pulmonary function during childhood: a prospective study.

OBJECTIVE: Some retrospective evidence suggests that children with a history of croup may be at increased risk of subsequently developing asthma, atopy, and diminished pulmonary function. The objective of this study was to determine the long-term outcome of croup (as diagnosed by a physician) in early life. METHODS: Lower respiratory illnesses (LRIs) in the first 3 years of life were assessed in 884 children who were enrolled in a large longitudinal study of airway diseases at birth. Pulmonary function tests, markers of atopy, and wheezing episodes were studied at different ages between birth and 13 years. RESULTS: Ten percent of children had croup with wheeze (Croup/Wheeze), 5% had croup without wheeze (Croup/No Wheeze), 36% had another LRI (Other LRI), and 48% had no LRI. Respiratory syncytial virus was more frequently isolated in children with Croup/Wheeze and Other LRI than in those with Croup/No Wheeze. There was no association between croup in early life and markers of atopy measured during the school years. Only children with Croup/Wheeze and with Other LRI had a significant risk of subsequent persistent wheeze later in life. Significantly lower levels of indices of intrapulmonary airway function were observed at ages <1 (before any LRI), 6, and 11 years in children with Croup/Wheeze and Other LRI compared with children with No LRI. Conversely, inspiratory resistance before any LRI episode was significantly higher in infants who later developed Croup/No Wheeze than in the other 3 groups. CONCLUSIONS: We distinguish 2 manifestations of croup with and without wheezing. Children who present with croup may or may not be at increased risk of subsequent recurrent lower airway obstruction, depending on the initial lower airway involvement, and preillness and postillness abnormalities in lung function associated with this condition.

Pulsus paradoxus: an objective measure of severity in croup.

We used a noninvasive monitor of arterial pressure to determine the utility of pulsus paradoxus (PP) as an objective severity measure in croup. We performed a prospective, blinded comparison of PP in children with croup versus healthy control subjects, analyzed the relationship between PP and Westley croup score (WCS), and observed the effect of racemic epinephrine (RE) on PP and WCS in a subgroup of patients with severe croup. The PP and WCS were measured at presentation and in severe patients after treatment with RE. Mean PP was 6.1 +/- 1.8 (SD) mm Hg (n = 29) in control subjects compared with a mean of 17.8 +/- 11.2 (SD) mm Hg (n = 28) in patients with croup (p < 0.00001). There was significant concordance between baseline WCS and PP (Spearman's rho: 0.68; p = 0.0001). The mean decrease in PP after RE was 7.5 +/- 11.8 (SD) mm Hg (p = 0.05; n = 12). The magnitude of decrease in PP after RE has significant concordance with the concurrent decrease in WCS (Spearman's rho: 0.73; p < 0.007). PP is elevated in children with croup, and the magnitude of elevation correlates with severity as measured by the WCS. PP may have utility as a research tool to objectively measure the severity of upper airway obstruction in croup.

Use of racemic epinephrine, dexamethasone, and mist in the outpatient management of croup.

This study aims to determine whether a subpopulation of children with croup, given mist and dexamethasone, can be treated with nebulized racemic epinephrine and safely discharged after observation in the emergency department. A prospective study was designed, enrolling children aged three months to six years with a clinical diagnosis of croup. Croup scores were assigned on arrival, after 30 minutes of saline mist, and 30, 120, and 240 minutes after nebulized racemic epinephrine. All children received mist; those with a croup score > 3 after mist were given nebulized racemic epinephrine. All patients received intramuscular dexamethasone. Patients were discharged if they were significantly improved after four hours of observation. Phone follow-up occurred 24 to 48 hours after discharge. Sixty children received racemic epinephrine for croup. The median croup score on arrival was 5, and there was no difference in arrival croup score by disposition. The two-hour croup score was significantly higher for admitted patients (P < 0.05 by the Mann-Whitney U test). Forty children (66%) were discharged after nebulized racemic epinephrine and four hours of observation. No patients returned to the emergency department within 24 hours for further treatment. Two patients could not be contacted. The 95% confidence interval for 0/38 patients with a negative outcome is (0-9.3%). We conclude that children with croup treated with dexamethasone and mist, receiving one nebulized racemic epinephrine treatment, can be discharged after a four-hour period of observation if they appear clinically well to an experienced physician, and if close follow-up can be established.

Management of children hospitalized for laryngotracheobronchitis.

During a 12-month period, 527 consecutive admissions for laryngotracheobronchitis (LTB) were reviewed to determine the epidemiology of hospitalized LTB patients and to better define patients who may benefit from therapy other than close observation. Viral cultures were obtained in 442 patients and were positive in 70%. Disease severity at the time of admission was unrelated to patient age or sex. Duration of hospitalization, however, was inversely related to age (p less than 0.001). Laboratory investigations were rarely abnormal or of therapeutic value. Patients who on admission had stridor without sternal and chest wall retractions recovered rapidly and spontaneously; they were frequently discharged within 48 hours and never required artificial airways. Children who had sternal and chest wall retractions on admission experienced longer hospitalizations, frequently received medical intervention such as aqueous mist therapy or racemic epinephrine, and had a 6% risk of requiring artificial airway support. This group of children should be studied selectively for the benefits of specific medical therapies and diagnostic evaluations.