Treatments for Croup ==================== þ Mist Treatment for Croup - traditional but not studied. One study of high humidity (not the same as mist -- mist has large droplets that may deposit preferentially in the affected area of the trachea) found no benefit. [Bourchier D, Dawson KP, Fergusson DM. Humidification in viral croup: a controlled trial. Aust Paediatr J 1984; 20:289-291.] Abstract: Scolnik, D., A. L. Coates, et al. (2006). "Controlled delivery of high vs low humidity vs mist therapy for croup in emergency departments: a randomized controlled trial." JAMA 295(11): 1274-80. CONTEXT: Children with croup are often treated with humidity even though this is not scientifically based, consumes time, and can be harmful. Although humidity using the traditional blow-by technique is similar to room air and no water droplets reach the nasopharynx, particles sized for laryngeal deposition (5-10 microm) could be beneficial. OBJECTIVE: To determine whether a significant difference in the clinical Westley croup score exists in children with moderate to severe croup who were admitted to the emergency department and who received either 100% humidity or 40% humidity via nebulizer or blow-by humidity. DESIGN AND SETTING: A randomized, single-blind, controlled trial conducted between 2001 and 2004 in a tertiary care pediatric emergency department. PARTICIPANTS: A convenience sample of 140 previously healthy children 3 months to 10 years of age with Westley croup score of more than 1 or 2 or higher (scoring system range, 0-17); 21 families refused participation. INTERVENTION: Thirty-minute administration of humidity using traditional blow-by technique (commonly used placebo, n = 48), controlled delivery of 40% humidity (optimally delivered placebo, n = 46), or 100% humidity (n = 46) with water particles of mass median diameter 6.21 microm. MAIN OUTCOME MEASURE: A priori defined change in the Westley croup score from baseline to 30 and 60 minutes in the 3 groups. RESULTS: Groups were comparable before treatment. At 30 minutes the difference in the improvement in the croup score between the blow-by and low-humidity groups was 0.03 (95% confidence interval [CI], -0.72 to 0.66), between low- and high-humidity groups, 0.16 (95% CI, -0.86 to 0.53), and between blow-by and high-humidity groups, 0.19 (95% CI, -0.87 to 0.49). Results were similar at 60 minutes. Differences between groups in pulse and respiratory rates and oxygen saturation changes were insignificant, as were proportions of excellent responders; proportions with croup score of 0 at study conclusion; and proportions receiving dexamethasone, epinephrine, or requiring additional medical care or hospitalization. CONCLUSIONS: One hundred percent humidity with particles specifically sized to deposit in the larynx failed to result in greater improvement than 40% humidity or humidity by blow-by technique. This study does not support the use of humidity for moderate croup for patients treated in the emergency department. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT00230841. þ Epinephrine Aerosols for Croup - give 2.25% solution, 0.5cc/4ccNS. - reduces obstruction [Kelley PB, Simon JE. Racemic epinephrine use in croup and disposition. Am J Emerg Med 1992 May;10(3):181-3.] - lasts about 2 hours ? rebound at 2 hours vs. worsening of primary problem "use of racemic epi means admission" used to be dogma, - now is accepted to observe for 2-4 hours and send home if Croup Score is 3-4 or less, and also treated with steroids. More on the "rebound phenomenon" - "Plain" epi is as good as racemic epi [Waisman Y, Klein BL, Boenning DA, Young GM, Chamberlain JM, O'Donnell R, Ochsenschlager DW. Prospective randomized double-blind study comparing L-epinephrine and racemic epinephrine aerosols in the treatment of laryngotracheitis (croup). Pediatrics 1992(Feb);89(2):302-6.] Abstract: [Martinez Fernandez A, Sanchez Gonzalez E, Rica Etxebarria I, Echaniz Urcelay I, Alonso Diez M, Vilella Ciriza M, Garate Aranzadi J. [Randomized double-blind study of treatment of croup with adrenaline and/or dexamethasone in children] Estudio randomizado doble ciego del tratamiento del crup en la infancia con adrenalina y/o dexametasona. An Esp Pediatr 1993(Jan);38(1):29-32. (Published in Spanish)] Abstract: - albuterol aerosol also effective based on anecdotal evidence þ Steroids for Croup: - For patients requiring hospitalization, steroids cause more rapid improvement, per recent studies: + 0.5-0.6 mg/kg (or slightly more for PO) dexamethasone (Decadron) is standard, 1-2 doses. [Cruz MN, Stewart G, Rosenberg N. Use of dexamethasone in the outpatient management of acute laryngotracheitis. Pediatrics 1995 Aug;96(2 Pt 1):220-3.] [Geelhoed GC, Macdonald WB. Oral and inhaled steroids in croup: a randomized, placebo-controlled trial. Pediatr Pulmonol 1995 Dec;20(6):355-61.] + Studies looking at low doses (0.15-0.2 mg/kg) found it as useful as bigger doses. [Geelhoed GC, Turner J, Macdonald WB. Efficacy of a small single dose of oral dexamethasone for outpatient croup: a double blind placebo controlled clinical trial. BMJ 1996 Jul 20;313(7050):140-2.] Abstract: [Geelhoed GC, Macdonald WB. Oral dexamethasone in the treatment of croup: 0.15 mg/kg versus 0.3 mg/kg versus 0.6 mg/kg. Pediatr Pulmonol 1995 Dec;20(6):362-8.] Abstract: + but more recent studies showed higher doses needed 0.9 mg/kg) [Super, 1989.] + Some recommend single dose of 1.0-1.5 mg/kg of dexamethasone. - oral dexamethasone (0.6mg.kg) is effective, give IM if vomits + tastes better than Prednisone [Ledwith CA, Shea LM, Mauro RD. Safety and efficacy of nebulized racemic epinephrine in conjunction with oral dexamethasone and mist in the outpatient treatment of croup. Ann Emerg Med 1995(Mar);25(3):331-7.] Abstract: - can also use inhaled steroids as well as IM/PO but this seems to offer only statistical rather than clinical advantage over PO/IM: [Klassen et al. Nebulized budesonide for children with mild-to-moderate croup. N Engl J Med 1994; 331:285-9.] [Klassen, TP, et al. The efficacy of nebulized budesonide in dexamethasone-treated outpatients with croup. Pediatrics 1996;97(4):463.] Abstract: [Husby S, Agertoft L, Mortensen S, Pedersen S. Treatment of croup with nebulised steroid (budesonide): a double blind, placebo controlled study. Arch Dis Child 1993 Mar;68(3):352-5.] [Fitzgerald D, Mellis C, Johnson M, Allen H, Cooper P, Van Asperen P. Nebulized budesonide is as effective as nebulized adrenaline in moderately severe croup. Pediatrics 1996 May;97(5):722-5.] - inhaled steroids seem to add to oral steroids but the effect xis temporary [Johnson DW, Schuh S, Koren G, Jaffee DM. Outpatient treatment of croup with nebulized dexamethasone [see comments] Arch Pediatr Adolesc Med 1996 Apr;150(4):349-55.] þ Antibiotics for Croup: - in kids more than 5-6 years old, Mycoplasma infection is found in about 10-20%, so treat with Pediazole or EES-400.