Do not use nebulized dexamethasone in croup because it is inferior to intravascular, intramuscular, or enteral dexamethasone

Do not use nebulized dexamethasone in croup because it is inferior to intravascular, intramuscular, or enteral dexamethasone: Excerpt from Avoiding Common Pediatric Errors

Author: Caroline Rassbach, MD

What to Do - Make a Decision

Viral croup is the most common form of airway obstruction in children 6 months to 6 years of age. When symptoms are severe enough to seek medical attention, oral dexamethasone is the preferred therapy because of cost, ease of administration, and efficacy. Intravascular and intramuscular dexamethasone are reasonable alternatives. Nebulized steroids are more expensive and less efficacious than oral dexamethasone for the treatment of croup. Croup is a viral illness caused most commonly by parainfluenza viruses (types 1, 2, and 3). Croup can also be caused by influenza A and B, adenovirus, respiratory syncytial virus, rhinovirus, and enteroviruses. Croup can affect the larynx, trachea, bronchi, and lungs, causing inflammation and swelling. The subglottic area is particularly affected, resulting in a narrowed airway. Classic symptoms of croup include a barking cough, hoarse voice, inspiratory stridor, and varying degrees of respiratory distress. Croup most commonly affects children between 6 months and 6 years of age, with a peak incidence at 2 years. The incidence in children younger than 6 years of age is approximately 6 per 100 annually. The illness predominates in the fall and winter.

When a child presents with stridor, other diagnoses such as foreign body aspiration, angioedema, epiglottitis, and bacterial tracheitis must be considered in the differential. Croup is diagnosed clinically based on its characteristic history. It begins with 12 to 72 hours of nasal congestion and low-grade fevers, followed by hoarseness and a barky cough. Patients may also have inspiratory stridor and respiratory distress. Symptoms of croup are worse at night, when in the supine position, and with agitation and crying. Symptoms peak between 24 and 48 hours, and usually resolve within 1 week.

Patients with croup usually have normal oxygen saturation. Neck radiographs may be performed if the diagnosis is uncertain; however, the classic "steeple sign" is present in only about 50% of cases. Laryngoscopy should be performed in children with suspected croup if they have a long-standing history of stridor, were previously intubated, or are younger than 4 months of age. Croup is usually managed in the outpatient setting with mist therapy, steroids, and close follow-up. Mist is thought to work by moistening secretions, decreasing airway inflammation, and decreasing the viscosity of secretions. Any child with croup and respiratory distress is a candidate for steroid treatment. Steroids have been shown to improve symptoms within 6 hours. For hospitalized children, steroids also result in shorter hospital stays and less use of epinephrine. One study to determine the efficacy of oral dexamethasone compared with nebulized budesonide showed that both are equally effective, although oral dexamethasone is cheaper and easier to administer than nebulized budesonide. Another study comparing oral versus nebulized dexamethasone showed greater improvement in symptoms and less need for subsequent medical intervention in patients treated with oral dexamethasone. As a result, oral dexamethasone in a single dosage of 0.15mg/kgisusedforthetreatmentofmild-to-moderatecroup.Intravenous and intramuscular routes are equally effective when oral administration is not feasible.

For patients with moderate respiratory distress, nebulized racemic epinephrine may also be used. Racemic epinephrine reduces bronchial and tracheal secretions as well as mucosal edema through its α-and β-adrenergic properties. This usually results in decreased inspiratory stridor and intercostals retractions within 30 minutes of administration. The benefits of racemic epinephrine last approximately 2 hours. Only a small number of patients with croup will require hospitalization. Patients should be hospitalized for croup if they have hypoxemia or cyanosis, altered mental status, worsening stridor or respiratory distress, stridor at rest, restlessness, or toxic appearance. Patients who have received steroids and racemic epinephrine in the outpatient setting can safely be discharged home if they do not show signs of respiratory distress at least 3 hours after racemic epinephrine.

Croup is a self-limited viral illness resulting from inflammation and swelling of the upper airway. When respiratory distress is present, patients should receive oral dexamethasone to decrease airway swelling. Intravenous and intramuscular dexamethasone are alternatives. Patients may also receive racemic epinephrine and mist therapy to alleviate symptoms.

Suggested Readings

Klassen TP, Craig WR, Moher D, et al. Nebulized budesonide and oral dexamethasone for treatment of croup: a randomized controlled trial. JAMA. 1998;279(20):1629–1632.
Knutson D, Aring A. Viral croup. Am Fam Physician. 2004;69(3):535–540.
Luria JW, Gonzalez-del-Rey JA, DiGiulio GA, et al. Effectiveness of oral or nebulized dexa methasone for children with mild croup. Arch Pediatr Adolesc Med. 2001;(155):1340–1345.

Book Source Details

• Book Title: Avoiding Common Pediatric Errors
• Author(s): Anthony D Slonim MD, DrPH; Lisa Marcucci MD
• Year of Publication: 2008
• Copyright Details: Avoiding Common Pediatric Errors, Copyright © 2008 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Avoiding Common Pediatric Errors Authors: Anthony D Slonim MD, DrPH; Lisa Marcucci MD Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7489-6

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