How to Manage Croup

There has been a bit of an epidemic of croup in our parts lately. Both croup and asthma have enjoyed a renewed interest, particularly concerning the place of steroid therapy. Whilst people are questioning the place of corticosteroids in chronic asthma (are we using too much?), the opposite (are we using too little?) may be true in the acute management of croup. Perhaps a later article could look at acute asthma management.

Clinically, croup (laryngo tracheo broncho bronchiolitis) has often been thought of as either "spasmodic" or "viral" in origin. In truth, there is often overlap, with a mild viral illness setting up the airway for eosinophilis action. This occurs in the larynx and trachea in croup, the bronchi in asthma. Again, we see considerable overlap clinically, hence the child with a croupy cough and stridor who improves with Ventolin and Atrovent, due to a bronchial component. Sometimes wheeze, being the more musical of the two sounds, is less easily heard than the stridor.

If we consider croup as an expression, in a good number of cases, of eosinophils at work, it makes sense to use corticosteroids in treatment. Recently, a number of studies have looked at the best way to go about this.

Oral steroid seems to work very well, at least as well as topical. The accompanying flow chart gives you a skeleton to work with. Fleshing it out - What to do on a home visit? How good are these parents as observers? What time of day is it? How tired is this child? - requires experience, but hopefully it will keep children at home rather than in the E.D.

Inhaled budesonide (0.5mg< 5yrs, 1mg> 5years) has an effect equal to inhaled adrenaline by two hours, though adrenaline works faster. Oral steroid (0.3mg/kg dexamethasone) reduces admission rates. The dexamethasone tastes better than prednisone; mix the tablets with water or honey.

Finally, what price the effect of hot water on cold tiles? Like the car trip in, it is sometimes curative in my experience (especially for spasmodic croup). Neither have been scientifically proven, but I wouldn't like to see us throw the baby out with the shower water.

References

Super DM, Cartelli NA, Brooks LJ, Lembo RM, Kumar ML. A prospective randomized double-blind study to evaluate the effect of Dexamethasone in acute laryngo tracheitis. J. Peadiatr 1989: 115:323-9
Husby S, Agertoft L, Mortenson S, Pederson S. Treatment of Croup with nebulized steroid (Budesonide); a double blind, placebo controlled study. Arch Dis Child 1993: 68:352-5
Klassen TP, Feldman ME, Walters LK et al. Nebulized Budesonide for children with mild to moderate croup. N Engl J Med 1994: 331:285-9
Geelhoed GC, Macdonald WBG. Oral and inhaled steroids in croup: A randomised, placebo controlled trial. Peadiatr Pulmonol (in press)
Fitzgerald D, Johnson M, McCrossin T et al. Nebulized budesonide is as efficacious as nebulized adrenaline in moderate croup (abstract). J Paediatr Child Health (in press)

Chris Ingall
Paediatrician

Croup Syndromes at the Virtual Hospital (File last updated: May 14, 1995 )