Prednisone to treat croup.CME: That characteristic cough: When to treat croup and what to use
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- CME: That characteristic cough: When to treat croup and what to use
Diagnosis and management of croup in children.
Elk Grove Village, Ill. Geelhoed G, Turner J, Macdonald W: Efficacy of a small single dose of oral dexamethasone for outpatient croup: A double blind placebo controlled clinical trial. Dowell S, Bresee J: Severe varicella associated with steroid use.
Patel H, Macarthur C, Johnson D: Recent corticosteroid use and the risk of complicated varicella in otherwise immunocompetent children. Arch Pediatr Adolesc Med ; Draft position statement: Inhaled corticosteroids and severe viral infections. News and Notes. Milwaukee, Wisc. New drug not routinely recommended for healthy children with chickenpox. Ottawa, Ontario: Canadian Pediatric Society, Rittichier K, Ledwith C: Outpatient treatment of moderate croup with dexamethasone: Intramuscular versus oral dosing.
The history and physical examination are your opportunity to exclude a number of differential diagnoses in the croup patient that can be serious or life-threatening. Bacterial tracheitis is a life-threatening infection of the trachea that may be preceded by a recent history of croup.
Most often, the child appears toxic and has a high fever. He or she has progressive respiratory distress, which typically does not improve with inhalation of racemic epinephrine. Soft-tissue radiographs of the neck may show an uneven or ragged-appearing tracheal wall.
Visual inspection of the airway reveals purulent secretions exuding from below the vocal chords. Bacterial tracheitis requires quick recognition, intravenous antibiotic therapy, and admission to an ICU to treat potential acute obstruction by the thick, purulent respiratory secretions. Acute epiglottitis supraglottitis is a life-threatening bacterial infection of the epiglottis that has become rarer but not unheard of since a vaccine against Haemophilus influenzae type B was introduced.
The patient most often exhibits a toxic appearance and high fever of sudden onset. He may refuse to speak or speaks in a very soft voice and may drool.
He usually seems frightened and refuses to lie supine, preferring to sit up with the neck extended. A lateral neck radiograph shows an abnormally thickened epiglottis. Acute epiglottitis is an airway emergency. The child must never be left unattended or transported out of an area without equipment and personnel for emergency airway management.
The epiglottis must be visualized under controlled conditions by a staff member skilled in airway management, and intubation is almost always required to secure the airway. Retropharyngeal abscess is another cause of upper airway obstruction in young children.
It results from bacterial infection of the lymph nodes that drain the head and neck to the retropharyngeal region. The infection results in expansion of what is normally a potential space, which then encroaches on the airway lumen. The diagnosis is confirmed by a lateral neck radiograph with the child positioned with the neck moderately extended.
The film reveals widening of the prevertebral space. Treatment includes careful attention to the airway, IV antibiotics, and, in some cases, surgical drainage of the abscess. Asthma, a common chronic disease in children, is characterized by coughing, wheezing, and shortness of breath. Because cough is a principal symptom of asthma, it is possible to mistake the cough of asthma for croup. Foreign body aspiration rarely presents with stridor, although it may be the presenting complaint with a high tracheal or esophageal foreign body.
It is easy to miss the diagnosis initially because the child may not have the typical history of choking on an object. Radiographs may be helpful if the foreign body is radio-opaque, but films may also be completely normal. When a foreign body is suspected, therefore, rigid bronchoscopy is appropriate to identify and remove the foreign body. Airway compression intraluminal or extraluminal has a variety of causes, including airway hemangioma, hematoma caused by trauma, cyst, tumor, lymphadenopathy, and a foreign body in the esophagus.
Although it is wise to include airway compression in the differential diagnosis of croup, the presentation is usually far more insidious, with symptoms that have gradually become evident or worse. Allergic reaction and angioneurotic edema can present as acute airway obstruction. Anaphylaxis is a severe, systemic manifestation of type I hypersensitivity and usually occurs shortly after exposure to the offending antigen.
The child often exhibits a combination of symptoms, including urticarial rash, respiratory distress caused by bronchospasm and airway edema, and cardiovascular collapse. Stridor may be a rare presenting symptom of anaphylaxis and should therefore be included in the differential diagnosis. Treatment entails the "ABCs," with subcutaneous epinephrine the initial drug of choice. This activity has been planned and implemented in accordance with the Essentials and Standards of the Accreditation Council for Continuing Medical Education through the joint sponsorship of Jefferson Medical College and Medical Economics, Inc.
Full disclosure of these relationships, if any, appears with the author affiliations on page 1 of the article. This CME activity is designed for practicing pediatricians and other health-care professionals as a review of the latest information in the field. Its goal is to increase participants' ability to prevent, diagnose, and treat important pediatric problems.
This credit is available for the period of October 15, , to October 15, Forms received after October 15, , cannot be processed. Although forms will be processed when received, certificates for CME credits will be issued every four months, in March, July, and November. Interim requests for certificates can be made by contacting the Jefferson Office of Continuing Medical Education at Each CME article is prefaced by learning objectives for participants to use to determine if the article relates to their individual learning needs.
Read the article carefully, paying particular attention to the tables and other illustrative materials. Type or print your full name and address in the space provided, and provide an evaluation of the activity as requested.
Many doctors believe that prednisolone and dexamethasone are equally as effective as each other, but it is not known for certain whether one might be slightly more effective. A large clinical study, currently underway in Perth, hopes to answer this question. Find GPs in Australia. In the past, only children with severe croup were treated with steroids, because of concern about possible side effects.
Even though the chances of any side-effects are very small with a single dose of steroid, more recent clinical studies have shown that much lower doses of steroids are probably just as effective as the previously used higher doses. Doctors generally now feel much more comfortable with treating mild cases of croup with steroids, because the benefit of treatment far outweighs the possible risks.
Steroid medications have revolutionised the treatment of croup over the last ten years or so. Many children who would previously have needed admission to hospital can now be treated with a single dose of steroid and allowed home sometimes after a period of observation. It is important to note that the steroids do not treat the underlying viral infection, which caused the croup. By decreasing the swelling in the airway, steroids help to prevent increasing breathing difficulty and decrease the discomfort of breathing for the child.
Unfortunately, there is no known medication to successfully treat viruses causing croup, as they are basically the same viruses as those causing the common cold in adults. Therefore, your child will continue to have a cough and other viral symptoms runny nose, mild temperature for the next week or longer, despite having treatment for croup. Previous studies of croup have reported no significant side effects for either prednisolone or dexamethasone.
Most cases of croup are from a viral infection called laryngotracheitis or are spasmodic called recurrent croup , although other conditions can mimic the symptoms of croup and need to be considered in making the differential diagnosis Table 1. This article will focus on the diagnosis and treatment of croup, however pediatricians should be aware of recurrent croup and the potential for an underlying condition that may be masked by the persistence of croup symptoms Table 2.
Croup related to a viral infection is most frequently caused by parainfluenza virus type 1 and less commonly, type 3. Diagnosis is based primarily on history and physical examination.
Most cases of viral croup are self-limiting and symptoms resolve on their own. This is followed by a barking cough and mild to severe degrees of respiratory distress, including nasal flaring, stridor, and respiratory retractions.
Read more: Using Iggy and the Inhalers to teach asthma medication compliance. The severity of respiratory distress is key to an accurate differential diagnosis as well as appropriate management, so assessment of the degree of airway obstruction is critical in the initial assessment.
For children who present with severe respiratory symptoms not from viral croup, other diagnostic imaging and lab work may be helpful along with the history and physical examination to make the differential diagnosis Table 5. A single dose of a systemic corticosteroid is currently recommended as treatment of choice for croup, even in children with mild disease.
A single dose of nebulized budesonide 2 mg is indicated based on the current best evidence for children with mild to moderate or moderate to severe croup who are vomiting or unable to take oral medications. Oral corticosteroids are preferred when tolerated, however, because they are more effective, convenient, and less expensive. Still unclear and needing further investigation is the optimal dose range of dexamethasone and whether repeated doses of corticosteroids provide additional benefit in children with severe croup.
More: A new model for hospital-based pediatric care. For children with moderate to severe croup, the addition of nebulized epinephrine is indicated by the current best evidence. Although the optimal dose of nebulized epinephrine in this setting is unknown, a dose of 3 ml of L-epinephrine, solution, has been recommended.
Background Croup is most commonly caused by the Parainfluenza virus, but a variety of respiratory viruses may be responsible Symptoms are usually more prominent at night Most cases are mild and do not require admission Severe cases can be life-threatening due to potential airway compromise.
Assessment Do not upset the child — this will exacerbate the symptoms The severity of the stridor is not an indication of the severity of croup History Ask about the onset and duration of symptoms: Coryza Cough Stridor Increased work of breathing. Possibility of inhaled foreign body or anaphylaxis Past history — e.
Examination It is important not to exacerbate the symptoms by upsetting the child — keep your assessment short and as non-invasive as possible. Keep the child in their most comfortable position e. Work of breathing: Degree mild, moderate or severe Recession sternal, intercostal, subcostal, tracheal tug. Monitor for signs of impending respiratory exhaustion.
Differential diagnoses Underlying congenital abnormality eg: laryngomalacia, tracheomalacia Inhaled foreign body Anaphylaxis Epiglottitis Bacterial tracheitis.
Management All children who present to Emergency Department with croup should receive corticosteroids Additional treatments depend on the severity and may include nebulised adrenaline See Croup Management Flowchart.
Croup Management Flowchart Click on the image to download a high resolution PDF Resuscitation Life threatening croup: Transfer the child to the Resuscitation Room, activate the resuscitation team Give nebulised adrenaline internal WA Health only immediately , 0.
Initial management Severe croup is treated as above with high flow oxygen and nebulised adrenaline. Medications Corticoteroids Steroids start working by 30 minutes and reduce time in hospital, transfers to PCC, the chances of intubation for inpatients, and also reduce the likelihood of relapse after discharge home.
Steroid therapy is extremely successful in treating stridor, but does not resolve the underlying viral symptoms. A single dose of steroid is usually all that is required in mild to moderate croup. Medication Dose Route Treatment Dexamethasone 1 0. Dexamethasone 1 0. Can give if oral steroids are not tolerated e. Adrenaline The effect of nebulised adrenaline is short lived and is thought not to change the natural history of croup.
This is a plain English summary of an original research article. Corticosteroids reduce symptoms of croup in children within two hours and continue to do so for at least 24 hours.
This Cochrane review assessed the effectiveness of corticosteroids such as dexamethasone and budesonide compared with placebo. It updates a previous review which concluded that corticosteroids reduce symptoms of croup at six hours. The review also found that dexamethasone is more effective than budesonide at reducing croup symptoms at 6 and 12 hours - and lessens the need for adrenaline.
The findings support recommendations that all children with mild, moderate, or severe croup should be treated immediately with corticosteroids. Croup, or laryngotracheobronchitis, is a common childhood respiratory condition, characterised by the sudden onset of a seal-like barking cough, often accompanied by high-pitched wheezing, a hoarse voice, and difficulty breathing.
The current review is an update of a Cochrane Systematic Review that was first published in and updated in and It incorporates five newly published studies and is the first time that risk of bias in the included studies, and the certainty of the evidence, have been assessed with the respective Cochrane tools. The review compared the effectiveness of corticosteroids to placebo for treating croup in children.
It assessed whether they reduced croup symptoms, minimised return visits or shortened length of hospital stay, reduced the need for additional treatments, or had side effects. The 43 studies including five new to this update covered 4, children. The corticosteroids investigated included beclomethasone, betamethasone, budesonide, dexamethasone, fluticasone, and prednisolone. Most studies compared corticosteroids to placebo, although some compared them to adrenaline, to another corticosteroid, or combination of corticosteroids; or compared corticosteroids given in different ways, or amounts.
Few studies had a low overall risk of bias, and many biases were unclear from the reporting. However, using the GRADE system the certainty of evidence was thought to be moderate meaning that readers can be moderately confident in the effect estimate.
The NICE Clinical Knowledge Summary on croup updated in recommends that all children with mild, moderate, or severe croup should receive a single dose of oral dexamethasone 0.
If the child is too unwell to receive medication, inhaled budesonide 2 mg nebulised as a single dose or intramuscular dexamethasone 0. The findings of this large, high quality review reinforce current recommendations and practice with a moderate degree of certainty. They suggest that corticosteroids rapidly reduce symptoms of croup in children, within about 2 hours and that the effect lasts for at least 24 hours. The findings may support earlier escalation of therapy following a lack of response at 2 hours.
Glucocorticoids for croup in children. Cochrane Database Syst Rev. NHS website. London: Department of Health and Social Care; updated Clinical Knowledge Summary. Why was this study needed? What does current guidance say View commentaries on this research This is a plain English summary of an original research article Corticosteroids reduce symptoms of croup in children within two hours and continue to do so for at least 24 hours.
What did this study do? What did it find? The rates of return visits or re admissions or both were halved by corticosteroids risk ratio 0. When given corticosteroids, of every 1, children treated will return for medical care, compared with of every 1, children treated with placebo. What does current guidance say on this issue?
What are the implications? Comments Expert commentary This update has introduced new methodology to reduce possible study bias and thus strengthen the certainty of their findings. The new conclusion since the review that symptom improvement can be seen as quickly as two hours rather than six hours will not change the clinical practice of using nebulised or oral corticosteroids for infants with significant croup.
However, perhaps now a lack of response by two hours may be a signal to offer additional therapy. The benefit at two hours identified in this review helps put to bed the four hour lag suggested by some for an initial steroid response. Early use of a single dose even in milder croup should be prescribed at the earliest opportunity.
Hopefully, in time, we will better understand which children are at highest risk of rebound after an initial dose. Alert How to improve care for people with severe mental illness and a lung condition Alert Many children and teenagers are reluctant to have a COVID vaccine Alert Smoking bans in prisons improve health and reduce medications Themed Review Researching long COVID: addressing a new global health challenge Alert One in two people hospitalised with COVID develop complications and may need support Alert Combination inhaler is effective in mild asthma Alert Rapid tests for flu in hospital led to earlier isolation, and less serious illness.
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Corticosteroids are beneficial due to their anti-inflammatory action. Their use decreases both laryngeal mucosal edema and the need for salvage. The findings support recommendations that all children with mild, moderate, or severe croup should be treated immediately with corticosteroids. The findings support recommendations that all children with mild, moderate, or severe croup should be treated immediately with corticosteroids. Steroids are effective in the management of all children presenting to emergency departments with croup, whether mild, moderate, or severe. Studies have found. Although most cases of croup resolve on their own, children with even mild disease are now routinely treated with corticosteroids and those. Hospitals vary in their use of these medications; some use dexamethasone, while some use prednisolone. Bacterial tracheitis is a life-threatening infection of the trachea that may be preceded by a recent history of croup. Cherry JD, Clinical practice. Nonetheless, the American Academy of Pediatrics and the American Academy of Allergy and Immunology advise caution in using steroids in children with croup who have been exposed to varicella. Skolnik N: Treatment of croup: A critical review.Go to whole of WA Government Search. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient.
Clinicians should also consider the local skill level available and their local area policies before following any guideline. Click on the image to download a high resolution PDF. Severe croup is treated as above with high flow oxygen and nebulised adrenaline. Adrenaline can be repeated 15 minutely as required.
Moderate croup will need observation e. ED short stay unit until there is no stridor at rest. All children requiring an adrenaline nebuliser should be observed for at least 3 hours. Mild croup will not need observation and can be discharged home, after administration of oral steroid. Oxygen delivery at less than 8 litres per minute will not drive the nebuliser adequately. This document can be made available in alternative formats on request for a person with a disability.
Skip to main content Skip to navigation Site map Accessibility Contact us. Search this site. Search all sites. Definition Croup laryngotracheobronchitis is an upper respiratory illness characterised by a hoarse voice, barking cough, and stridor.
The clinical symptoms are a result of inflammation and narrowing of the upper airway larynx, trachea and bronchi. Background Croup is most commonly caused by the Parainfluenza virus, but a variety of respiratory viruses may be responsible Symptoms are usually more prominent at night Most cases are mild and do not require admission Severe cases can be life-threatening due to potential airway compromise.
Assessment Do not upset the child — this will exacerbate the symptoms The severity of the stridor is not an indication of the severity of croup History Ask about the onset and duration of symptoms: Coryza Cough Stridor Increased work of breathing. Possibility of inhaled foreign body or anaphylaxis Past history — e. Examination It is important not to exacerbate the symptoms by upsetting the child — keep your assessment short and as non-invasive as possible.
Keep the child in their most comfortable position e. Work of breathing: Degree mild, moderate or severe Recession sternal, intercostal, subcostal, tracheal tug.
Monitor for signs of impending respiratory exhaustion. Differential diagnoses Underlying congenital abnormality eg: laryngomalacia, tracheomalacia Inhaled foreign body Anaphylaxis Epiglottitis Bacterial tracheitis.
Management All children who present to Emergency Department with croup should receive corticosteroids Additional treatments depend on the severity and may include nebulised adrenaline See Croup Management Flowchart. Croup Management Flowchart Click on the image to download a high resolution PDF Resuscitation Life threatening croup: Transfer the child to the Resuscitation Room, activate the resuscitation team Give nebulised adrenaline internal WA Health only immediately , 0.
Initial management Severe croup is treated as above with high flow oxygen and nebulised adrenaline. Medications Corticoteroids Steroids start working by 30 minutes and reduce time in hospital, transfers to PCC, the chances of intubation for inpatients, and also reduce the likelihood of relapse after discharge home.
Steroid therapy is extremely successful in treating stridor, but does not resolve the underlying viral symptoms. A single dose of steroid is usually all that is required in mild to moderate croup. Medication Dose Route Treatment Dexamethasone 1 0. Dexamethasone 1 0. Can give if oral steroids are not tolerated e. Adrenaline The effect of nebulised adrenaline is short lived and is thought not to change the natural history of croup. It may be repeated after 15 minutes if necessary.
Children receiving adrenaline need to be observed for a minimum of 3 hours afterwards. Oxygen delivery at less than 8 litres per minute will not drive the nebuliser adequately Admission criteria As a 'rule of thumb' children without stridor do not need to be admitted This decision would be influenced by the distance parents live from the hospital, the reported severity of symptoms at home and past history of severe croup. Infection control Children presenting to hospital with croup should be managed with droplet precautions.
Discharge criteria The child must meet all of the following criteria: Clinically improved Steroids received No stridor at rest No other clinical or social concerns. Nursing Minimal nursing intervention is encouraged to avoid distressing the child and increasing respiratory distress. Patients should remain in a position of comfort. Children with croup require close observation. Record baseline observations: heart rate, respiratory rate, oxygen saturations and temperature on the Observation and Response Tool and document additional observations on the Clinical Comments chart.
The presence or absence of the following clinical features should be assessed and documented: stridor barking cough degree and type of recession i. Observations should be recorded at least hourly whilst in the emergency department. Any significant changes should be reported immediately to the medical team.
Oxygen saturations and ECG monitoring is recommended if adrenaline is given. Before applying consider whether the risk of distress negates the accuracy of monitoring. Assessment and management of viral croup in children: Viral croup.
Prescriber 27, 32— Bjornson, C. Nebulized epinephrine for croup in children. Cochrane Database Syst. Chub-Uppakarn, S. A randomized comparison of dexamethasone 0. Parker, C. Oral dexamethasone in the treatment of croup: 0. Efficacy of a small single dose of oral dexamethasone for outpatient croup: a double blind placebo controlled clinical trial. Sixteen years of croup in a Western Australian teaching hospital: effects of routine steroid treatment.
A randomised double blinded trial. Emergency Medicine Australasia. Australian Edition. Back to top. Barking cough No stridor at rest No sternal recession or tracheal tug Normal behaviour. Dexamethasone 1. All croup presentations should be treated with oral dexamethasone. Prednisolone 2. If oral dexamethasone is not available.
Rarely required. For severe cases of croup PCC candidates. Doses of 5mL can be given undiluted. To be given with oxygen at 8 litres per minute via nebuliser.
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