The steroid-croup controversy: an analytic review of methodologic problems

Glucocorticoids for croup

BACKGROUND

Since the initial publication of this systematic review in 1997, several randomized trials examining the benefit of glucocorticoids have been published. The objective of this review is to provide evidence to guide clinicians in their treatment of patients with croup by determining the effectiveness of glucocorticoids and to identify areas requiring future research.

OBJECTIVES

To determine the effect of glucocorticoids for children with croup.

SEARCH STRATEGY

We searched CENTRAL (2010, Issue 3), which contains the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE (1966 to July week 2, 2010) and EMBASE.com (1974 to July 2010). We also contacted authors of identified croup trials published in the last 10 years to inquire about additional published or unpublished trials.

SELECTION CRITERIA

Randomised controlled trials (RCTs) that examine children with croup and objectively measure the effectiveness of glucocorticoids.

DATA COLLECTION AND ANALYSIS

Two review authors identified studies for potential relevance based on the review of the title and abstract (when available). Two review authors independently reviewed studies for relevance using a priori inclusion criteria and assessed trial quality. Differences were resolved by consensus. One review author extracted data using a structured form and another review author checked the results for accuracy. We performed standard statistical analyses.

MAIN RESULTS

Thirty-eight studies were included (n = 4299). Glucocorticoids were associated with an improved Westley score (maximum 17 points) at six hours with a mean difference of -1.2 (95% confidence interval (CI) -1.6 to -0.8) and at 12 hours -1.9 (95% CI -2.4 to -1.3); at 24 hours this improvement was no longer significant (-1.3, 95% CI -2.7 to 0.2). Fewer return visits and/or (re)admissions occurred in participants treated with glucocorticoids (risk ratio (RR) 0.5; 95% CI 0.3 to 0.7). Length of time spent in accident and emergency or hospital (mean difference 12 hours, five to 19 hours) was significantly decreased for participants treated with glucocorticoids. Use of epinephrine decreased for children treated with a glucocorticoid (risk difference 10%; 95% CI 1 to 20).

AUTHORS' CONCLUSIONS

Dexamethasone and budesonide are effective in relieving the symptoms of croup as early as six hours after treatment. Fewer return visits and/or (re)admissions are required and the length of time spent in hospital is decreased. Research is required to examine the most beneficial method for disseminating croup practice guidelines and to increase the uptake of evidence.

Heliox administration in the pediatric intensive care unit: an evidence-based review

OBJECTIVE

To provide a comprehensive, evidence-based review of helium-oxygen gas mixtures (heliox) in the management of pediatric respiratory diseases.

DATA SOURCE

A thorough, computerized bibliographic search of the preclinical and clinical literature regarding the properties of helium and its application in pediatric respiratory disease states.

DATA SYNTHESIS

After an overview of the potential benefits and technical aspects of helium-oxygen gas mixtures, the role of heliox is addressed for asthma, aerosolized medication delivery, upper airway obstruction, postextubation stridor, croup, bronchiolitis, and high-frequency ventilation. The available data are objectively classified based on the value of the therapy or intervention as determined by the study design from which the data are obtained.

CONCLUSIONS

Heliox administration is most effective during conditions involving density-dependent increases in airway resistance, especially when used early in an acute disease process. Any beneficial effect of heliox should become evident in a relatively short period of time. The medical literature supports the use of heliox to relieve respiratory distress, decrease the work of breathing, and improve gas exchange. No adverse effects of heliox have been reported. However, heliox must be administered with vigilance and continuous monitoring to avoid technical complications.

Glucocorticoids for croup

BACKGROUND

Since the initial version of this systematic review in 1997, a number of randomised trials examining the benefit of glucocorticoids have been published, reflecting a continued interest in the use of glucocorticoids to treat patients with croup. The objective of this review was to provide evidence to guide clinicians in their treatment of patients with croup by determining the effectiveness of glucocorticoids and to identify areas of uncertainty for future research.

OBJECTIVES

To determine the effect of glucocorticoids for children with croup.

SEARCH STRATEGY

We searched The Cochrane Central Register of Controlled Trials (CENTRAL) (issue 1, 2003), MEDLINE (January 1966 to April 2003) and Excerpta Medica/EMBASE (January 1974 to August 2003). We also contacted authors of identified croup trials published in the last ten years to inquire about additional published or unpublished trials.

SELECTION CRITERIA

Randomised controlled trials that examine children with croup and objectively measure the effectiveness of glucocorticoid treatment.

DATA COLLECTION AND ANALYSIS

Based on review of the title and abstract (when available), two researchers identified studies for potential relevance. The complete text was retrieved and using a priori inclusion criteria, the studies were independently reviewed for relevance by two reviewers. Two observers independently assessed quality. Differences with respect to inclusion status and quality assessment were resolved by consensus. Data were extracted using a structured form by one reviewer and checked for accuracy by a second reviewer. Standard statistical analyses were performed.

MAIN RESULTS

Thirty-one studies were deemed relevant for inclusion (N = 3736). Glucocorticoid treatment was associated with an improvement in the Westley score at six hours with a weighted mean difference of -1.2 (95% confidence interval -1.6 to -0.8) and at 12 hours -1.9 (-2.4 to -1.3); at 24 hours this improvement was no longer significant (-1.3, -2.7 to 0.2). Fewer return visits and/or (re)admissions occurred in patients treated with glucocorticoids (relative risk 0.50; 0.36 to 0.70). Length of time spent in accident and emergency or hospital (weighted mean difference 12 hours, five to 19 hours) was significantly decreased for patients treated with glucocorticoids. Use of epinephrine decreased for children treated with a glucocorticoid (risk difference 10%; 1 to 20). No other decreases in additional treatments were found in the primary analysis. Publication bias does not impact results importantly. No between-trial significant differences were found between populations with mild and moderate croup. Oral dexamethasone may be superior to intramuscular dexamethasone.

REVIEWER'S CONCLUSIONS

Dexamethasone and budesonide are effective in relieving the symptoms of croup as early as six hours after treatment. Fewer return visits and/or (re)admissions are required and the length of time spent in hospital is decreased in inpatients. Dexamethasone is also effective in mild croup populations. Research is required to examine the most beneficial method for disseminating croup practice guidelines and to increase the uptake of evidence to improve outcomes.

Management of croup

Croup, or laryngotracheobronchitis, is a common childhood illness most often caused by viral infections. It is usually a benign, self-limiting disease, but can result in life-threatening upper airway obstruction. Until recently, it was not uncommon for children with severe croup to be admitted to intensive care for intubation. Management used to be limited to supportive measures, including mist therapy. The use of corticosteroids in patients with croup was controversial for many years but has, in the last decade, transformed the management of this disorder. Although corticosteroids do not alter the history of the viral infection, an adequate dose of oral or parenteral dexamethasone or nebulized budesonide has been shown to have a beneficial effect on the symptoms of croup.

Effect of Dexamethasone in Acute Laryngotracheitis

Fifty eight patients between the ages of six months and five years were studied in a randomized double-blind trial to determine whether dexamethasone has a role in the outpatient management of patients with acute viral croup of moderate severity. For various reasons, twelve were excluded from the final results. In the 46 patients who completed the study (32 males, 14 females) the only significant differences detected between the treatment groups were that the duration ofrhinorrhea was longer in the dexamethasone group compared with placebo (median 2,5 days vs 1,5 day) and the pre-discharge croup score was higher in the dexamethasone group compared with placebo (2 vs 0).

Conclusion: The use of dexamethasone in the outpatient management of viral croup is associated with a reduction in the severity of illness within 24 hours of treatment. Patients with viral croup of moderate severity should be considered candidates for the use of dexamethasone before discharge from the paediatric emergency clinic.

The use of dexamethasone in the prevention of postextubation stridor in pediatric patients in PICU/NICU settings: an analytical review

ISSUES AND PURPOSE

Dexamethasone has been used to prevent postextubation stridor in children, but its use is controversial. Five randomized, controlled clinical trials were reviewed to analyze the effectiveness of prophylactic dexamethasone on postextubation stridor in pediatric patients.

CONCLUSIONS

Previous studies had inconsistent results. Several factors may contribute to postextubation stridor in pediatric patients. Postextubation stridor and extubation failure do not always result from airway edema.

PRACTICE IMPLICATIONS

In addition to prophylactic dexamethasone, other approaches should be used to prevent postextubation stridor, such as preparing the patient, following established guidelines, and providing appropriate postextubation care.

Glucocorticoids for croup

BACKGROUND

Since the last meta-analysis in 1989, a number of randomised trials on the benefit of glucocorticoids have been published, resulting in an increasing interest in the use of glucocorticoids to treat outpatients with croup. The objective of this review was to provide evidence to guide clinicians in their treatment of patients with croup, to examine the effectiveness of glucocorticoids in these patients, and to identify areas of uncertainty for future research.

OBJECTIVES

To determine the effect of glucocorticoids for children with croup.

SEARCH STRATEGY

We searched The Cochrane Controlled Trials Register, MEDLINE (January 1966 to August 1997) and Excerpta Medica/EMBASE (January 1974 to August 1997). We also contacted (by mail) authors of identified croup trials published in the last five years to inquire about other trials, published or unpublished.

SELECTION CRITERIA

Meta-analysis of randomised controlled trials that examine the effectiveness of glucocorticoid treatment in children with croup.

DATA COLLECTION AND ANALYSIS

Data were extracted using a structured form, which captured patient status (inpatient or outpatient), intervention and control, with the name of the drug, route of administration and dose. Data were also collected on the primary outcome measures comprised of a clinical croup score at baseline (as well as any other subsequent assessment times), length of stay (hours), patients status improved (yes/no), and use of co-interventions. The quality of the trials was assessed using empirically derived items that involved scales and components. Two researchers (TPK, MA) then selected studies as being potentially relevant based on a review of the titles and abstracts, if available. The complete text of these studies was then retrieved. All studies that had been retrieved were reviewed independently by two reviewers (AS, TPK). Data were extracted by one reviewer (MA) and checked for accuracy by a second reviewer (TPK). Two observers independently assessed quality (MA, JK), and inter rater agreement was measured by the intra class correlation. Differences were resolved by consensus.

MAIN RESULTS

Twenty-four studies were deemed relevant for inclusion (N=2221). Glucocorticoid treatment was associated with an improvement in the croup severity score at 6 hours with an effect size of -1.0 (95% confidence interval -1.5 to -0.6) and at 12 hours -1.0 (-1.6 to -0. 4); at 24 hours this improvement was no longer significant (-1.0, -2. 0 to 0.1). There was a decrease in the number of adrenaline treatments needed in children treated with glucocorticoids: a decrease of 9% (95% confidence interval 2 to 16%) among those treated with budesonide and of 12% (4 to 20%) among those treated with dexamethasone. There was also a decrease in the length of time spent in accident and emergency (-11 hours, 95% confidence interval -18 to 4 hours), and for inpatients hospital stay was reduced by 16 hours (-31 to 1 hour). Publication bias seems to play a part in these results.

REVIEWER'S CONCLUSIONS

Dexamethasone and budesonide are effective in relieving the symptoms of croup as early as 6 hours after treatment. Fewer co-interventions are used and the length of time spent in hospital is decreased in patients treated with glucocorticoids.

Do steroids prevent reintubation in children with laryngotracheobronchitis?

BACKGROUND

Classic laryngotrachoebronchitis (LTB) is an inflammatory process, with oedema and secretions that involve the entire laryngotracheobronchial tree. The severity of lower airway disease in African children with LTB has previously been documented. The aim of the present study was to determine whether steroids prevent reintubation in African children with classic LTB.

METHOD AND RESULTS

The study was a retrospective analysis from January 1993 to December 1996. Eighty-two black children with LTB were mechanically ventilated in the intensive care unit (ICU). By univariate regression, the estimated B coefficients for variables such as age, pneumonia, days of intubation, arterial partial oxygen tension (PaO2) : fractional inspired oxygen (FIO2) ratio, atelectasis and antibiotic use were not statistically significant (P > 0.05) as predictors for reintubation. Using multiple regression (all independent variables in combination), none of the variables acted as predictors of reintubation (P = 0.25). Steroids were shown to have no effect alone or in association with other variables in altering reintubation rates. An increase in the days of intubation showed a tendency towards reintubation (P = 0.06) in the univariate analysis (odds ratio 1.00-1.14), but showed no statistically significant difference in multivariate analysis. Of the variables used as predictors of reintubation, none acted either as a preventive factor or as a risk factor.

CONCLUSION

The present results suggest that steroids should not be recommended at any stage in treatment of intubated patients with classic LTB. Prospective studies should evaluate the major risk factors for reintubation: duration of intubation, trauma to the airway at intubation and during ICU stay, and dose and timing of steroids. They should also evaluate whether upper airway disease is present alone or in association with lower airway disease.

A comparison of nebulized budesonide, intramuscular dexamethasone, and placebo for moderately severe croup

BACKGROUND

In children with croup, treatment with nebulized budesonide decreases symptoms, but it is uncertain how budesonide compares with dexamethasone, the conventional therapy for croup, and whether either reduces the rate of hospitalization.

METHODS

We performed a double-blind, randomized trial involving 144 children with moderately severe croup. The children were treated with racepinephrine and a single dose of 4 mg of nebulized budesonide (48 children), 0.6 mg of intramuscular dexamethasone per kilogram of body weight (47 children), or placebo (49 children). The children were assessed before treatment and then hourly for five hours after treatment. Physicians who were unaware of the treatment assignments determined the children's need for further treatment and hospitalization.

RESULTS

The characteristics of the groups were similar at base line, including the types of viruses identified, the types of croup, and the clinical severity of the illness. The overall rates of hospitalization were 71 percent in the placebo group (35 of 49 children), 38 percent in the budesonide group (18 of 48 children), and 23 percent in the dexamethasone group (11 of 47 children) (unadjusted P=0.001 for the comparison of budesonide with placebo, P<0.001 for the comparison of dexamethasone with placebo, and P=0.18 for the comparison of budesonide with dexamethasone). Children treated with budesonide or dexamethasone had a greater improvement in croup scores than those given placebo (P=0.03 and P<0.001, respectively), and those treated with dexamethasone had a greater improvement than those treated with budesonide (P=0.003).

CONCLUSIONS

In children with moderately severe croup, treatment with intramuscular dexamethasone or nebulized budesonide resulted in more rapid clinical improvement than did the administration of placebo, with dexamethasone offering the greatest improvement. Treatment with either glucocorticoid resulted in fewer hospitalizations.

Postextubation laryngeal edema: a review with consideration for home discharge

Respiratory complications occurring in the immediate postoperative period are well known to the seasoned postanesthesia care unit nurse. The most common adverse respiratory events originating in this setting are airway obstruction, hypoventilation, hypoxemia, and pulmonary aspiration of gastric contents. The focus of this article details airway compromise secondary to edema of the larynx and adjacent structures as a consequence of translaryngeal intubation. Postextubation laryngeal edema is a relatively rare problem; however, severe episodes may have life-threatening ramifications. A review of pertinent airway anatomy and airflow dynamics as they relate to this compromised airway condition is presented. Risk factors for the development of postextubation laryngeal edema plus contemporary patient treatment strategies will be reinforced. Patient management issues are addressed, with emphasis placed on the ambulatory patient in which discharge to a remote location is anticipated.

Croup

The management of mild to severe croup has undergone dramatic changes in the last 5 years, primarily due to the increased understanding of the benefits of treating it with steroids. Steroids have been used in the treatment of croup for many years, but, until recently, their use has remained controversial. Earlier studies were often not blinded or used inappropriate outcome measures, such as respiratory rate, which have not proven appropriate. Two attempts to review the literature in 1980 and 1989 cautiously supported the use of steroids. Despite these recommendations many practitioners continued to view croup in most cases as a benign self-limited condition, and since steroids have potential side-effects, their use was not considered justified. More recently, however, a number of developments such as the successful use of the inhaled steroid budesonide and oral dexamethasone have reinforced the argument for using steroids. Recent work has also shown that both inhaled and systemic steroids work by 1 hour and dramatically reduce morbidity and hospitalization time. The demonstration that an oral dose of 0.15 mg/kg dexamethasone is as effective as larger doses has made the use of systemic steroids more acceptable to many practitioners. All children with croup severe enough to be admitted to hospital should receive steroids. Two recent studies have shown that steroids also benefitted children who presented to emergency departments for treatment, but whose croup was not considered severe enough for admission. The type of steroid, the dose, and the mode of administration will need to be decided by the attending clinician.

Sixteen years of croup in a Western Australian teaching hospital: effects of routine steroid treatment

STUDY OBJECTIVE

To describe the experience of croup at Princess Margaret Hospital for Children (PMH), the only tertiary pediatric hospital in Western Australia, from 1980 through 1995 with reference to the introduction of routine steroid treatment in the ICU in 1989, in the general hospital wards from 1989 through 1993, and in the emergency department observation ward in 1993.

METHODS

Information on the numbers of children with croup presenting to PMH from 1980 through 1985 who were admitted to the general wards, the ICU, and the observation ward; intubation rate; and length of stay was obtained from a combination of state health records, hospital statistics, logbooks, and computer records.

RESULTS

The numbers of children who presented to and were admitted to PMH with croup were similar for all years of the study period. Since 1989, the annual number of children intubated (1980-1989 average, 8; 1990-1995 average, 4) and total ICU days for croup (1980-1989 average, 129; 1990-1995 average, 24) has decreased dramatically. The annual percentage of children transferred to the ICU (1980-1989 average, 11.6%; 1994-1995 average, 2.6%) and the average length of stay for PMH (1980-1989 average, 2.03 days; 1994-1995 average, 1.1 days) decreased every year from 1989 through 1994, coincident with increasing use of steroids for croup in the general wards. The change of policy from no steroids to compulsory use of steroids in the observation ward coincided with an increase in the percentage of children discharged home directly from the observation ward (to 97% from 80%).

CONCLUSION

The introduction of steroids at PMH coincided with a dramatic decrease in measures of severity for children admitted to hospital with mild to severe croup. All children hospitalized with croup should receive steroid therapy.

Infraglottic and bronchial infections

Concerns over infraglottic and bronchial infections have been a source of anxiety and lost sleep for many children, parents, and physicians. The annual incidence of lower respiratory tract infections in children younger than 6 years old exceeds 5 million in the United States. Despite the frequency of these infections, the often common and nonspecific clinical symptomatology, variable severity, and changing epidemiology over time all have contributed to our understanding and misunderstanding of these disorders.

The role of corticosteroids in respiratory diseases of children

Glucocorticosteroids are potent anti-inflammatory agents and have an important role in a variety of respiratory diseases. Although their exact mode of action is unknown, it is thought that they exert their effects by binding to cytoplasmic glucocorticoid receptors. In certain conditions, such as asthma, the value of steroids cannot be questioned, and inhaled steroids have revolutionized management. In other situations, such as interstitial lung disease, the true role of steroids is still to be defined. In the management of diseases such as tuberculosis, the use of steroids is solely based on anecdotal experience.

Safety and efficacy of nebulized racemic epinephrine in conjunction with oral dexamethasone and mist in the outpatient treatment of croup

STUDY OBJECTIVE

To identify patients with croup who after treatment with nebulized racemic epinephrine, oral dexamethasone, and mist may be safely discharged home after a period of observation.

DESIGN

Prospective interventional.

SETTING

Urban children's hospital emergency department.

PARTICIPANTS

Children with croup who received racemic epinephrine for the treatment of stridor at rest.

INTERVENTIONS

After treatment with .5 mL racemic epinephrine, .6 mg/kg dexamethasone PO, and mist, patients who were assessed as being safe for discharge after 3 hours of observation were discharged home and contacted for 48-hour follow-up.

RESULTS

Fifty-five patients with croup were treated with racemic epinephrine. Thirty patients (55%) had sustained responses and were discharged home after 3 hours of observation. No recurrence of respiratory distress and no return visits for medical care were reported (95% confidence interval, 0% to 8.0%).

CONCLUSION

Patients with croup who are treated with racemic epinephrine, oral dexamethasone, and mist may be safely discharged home if the patient is assessed as ready for discharge after 3 hours of observation.

Diagnosis and management of croup and epiglottitis

Viral croup and epiglottitis are two major inflammatory causes of airway obstruction in children. Two conditions, spasmodic croup and membranous laryngotracheobronchitis, are also frequent causes of obstruction on an inflammatory basis. Rapid diagnosis and effective management are required to ensure an uncomplicated outcome. The pharmacologic treatment, role and timing of endoscopy, and airway management principles are discussed.

The night after surgery. Postoperative management of the pediatric outpatient--surgical and anesthetic aspects

Outpatient or "ambulatory" anesthesia and surgery has revolutionized the way surgery is practiced in the United States. Safe, reliable, inexpensive, and convenient outpatient surgery is an attractive option for parents, children, health care providers, and insurers.

Placebo-controlled trial of prednisolone in children intubated for croup

Many studies have attempted to find out whether steroid treatment is beneficial in children with croup, but the results have been inconclusive. We have done a prospective placebo-controlled study of the effect of prednisolone on two clinical endpoints--the duration of intubation and the need for reintubation. Reasons for exclusion were age under 6 months, congenital airway anomalies, and previous intubation. 70 eligible children were randomly assigned treatment with prednisolone 1 mg/kg (n = 38) or placebo (n = 32) every 12 h given by nasogastric tube until 24 h after extubation. 11 (34%) placebo-treated and only 2 (5%) prednisolone-treated patients required reintubation after accidental or elective extubation (p = 0.004, Fisher's exact test; odds ratio 8.9, 95% confidence interval 1.7-59.3). Survival analysis with log-normal regression showed that the duration of intubation was shorter with steroid therapy (p less than 0.003) and increasing age (p less than 0.02), but was not influenced by endotracheal tube size or abnormality on chest radiograph. The median duration of intubation was 138 (95% CI 118-160) h in children who received placebo and 98 (85-113) h in the prednisolone group. Steroid therapy reduces the duration of intubation and the need for reintubation in children intubated for croup.

A prospective randomized double-blind study to evaluate the effect of dexamethasone in acute laryngotracheitis

To determine whether a single dose of dexamethasone (0.6 mg/kg) is useful in the treatment of acute laryngotracheitis (croup), 29 hospitalized patients with acute laryngotracheitis were randomly assigned in a double-blind fashion to receive either parenterally administered dexamethasone (n = 16) or a saline placebo (n = 13). Severity of the illness was assessed by a clinical croup score based on retractions, stridor, air entry, cyanosis, and level of consciousness. Twelve hours from the time of injection, the patients receiving the dexamethasone had a statistically significant decline in median croup score from 4.5 to 1.0 (p less than 0.001), whereas the patients receiving the placebo did not. By 24 hours, a decline of two or more points in the total croup score was noted in 85% of the patients in the dexamethasone group compared with 33% of the patients in the placebo group (p = 0.027). During this same period, only 19% of patients receiving dexamethasone required two or more racemic epinephrine treatments in comparison with 62% of patients who received the placebo (p less than 0.05). There was no statistical difference between the two groups in improvement in oxygen saturation, respiratory rates, or duration of hospitalization. We conclude that dexamethasone is beneficial in reducing the overall severity of moderate to severe acute laryngotracheitis during the first 24 hours after injection.

A randomized double-blind, placebo-controlled trial of dexamethasone and racemic epinephrine in the treatment of croup

Seventy-two children hospitalized for croup received on admission a single dose of either 0.6 mg/kg dexamethasone or an equivalent placebo intramuscularly from randomized ampules; subsequently the same patients were randomized to receive either nebulized racemic epinephrine or saline by intermittent positive pressure breathing. Of the four treatment groups those receiving a placebo injection and nebulized saline had the slowest recovery by all criteria. Dexamethasone and nebulized epinephrine reduced the symptoms and hastened recovery, but dexamethasone was more effective by clinical evaluation at 6 and 12 hours post admission. The patients given dexamethasone had a significantly shorter hospital stay than those receiving placebo. We conclude that a single injection of a potent corticosteroid is beneficial in acute spasmodic croup. Nebulized racemic epinephrine given with an appropriate device is also effective, but the effect of epinephrine is less remarkable in patients treated with dexamethasone.

Severe upper airway obstruction

This article describes management of newborn and older children with severe upper airway obstruction, that is, those needing or likely to need airway support for their intact survival. These children have more to gain from optimal care, and more to lose from any error than most other children requiring admission to a pediatric intensive care unit.

Infectious croup: a critical review

Infectious croup is a viral or bacterial syndrome characterized by a barking cough, hoarseness, and stridor. Three separate conditions will be discussed: laryngotracheobronchitis, spasmotic croup, and bacterial tracheitis. Each clinical entity will be defined and its treatment reviewed. Current treatment regimens for infectious croup involve various combinations of mist therapy, racemic epinephrine, corticosteroids, and syrup of ipecac. Tradition, rather than science, appears to be the basis of many of these treatments. Despite the frequent occurrence of infectious croup, no treatment has proved consistently successful. Prevention and better treatment methods are the keys for reducing the high cost of infectious croup to the medical care system.

Corticosteroids in airway management

Adrenal corticosteroids exert a strong suppressive influence on the basic inflammatory response that leads to tissue swelling. The corticosteroid effect is nonspecific. In upper airway obstruction caused by edema from infection, allergy, or trauma, corticosteroids will exert some degree of suppressive effect. The steroid effect is local and directly proportional to the concentration of steroids in the inflamed tissue. In upper airway obstruction steroids should be delivered to the inflamed tissue in high concentration with the least delay. Dexamethasone and methylprednisolone produce high blood levels within 15 to 30 minutes of intramuscular injection. Recommended initial doses for acute airway obstruction are dexamethasone, 1.0 to 1.5 mg/kg, or methylprednisolone, 5 to 7 mg/kg. The risk of harm from steroid therapy of 24 hours or less is negligible.

Croup: pathogenesis and management

Croup syndromes are common in children, most frequently being infectious in origin. Children present with a slow progression of inspiratory and expiratory stridor and a croupy, "barking seal" cough. Children are variably febrile and with progression of disease, exhaustion, agitation, cyanosis and air hunger may develop. The evaluation of the patient must focus on the degree of respiratory distress and associated findings. Epiglottitis and foreign body aspiration must be excluded. Management is primarily dependent upon administration of humidified air. Children with moderate to severe croup benefit from racemic epinephrine and steroids. Admission is indicated in children with stridor at rest, evidence of exhaustion, toxicity or respiratory distress. Active airway intervention is rarely required but may be life saving if obstruction develops.