Best Evidence Topics
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No difference was shown between nebulized epinephrine and nebulized budesonide in moderately severe croup.

Three Part Question

In a [child with croup] is [nebulised epinephrine or nebulised budesonide] more effective at [reducing croup score and length of stay]?

Clinical Scenario

A 4 year old girl attends the emergency department with moderately severe croup. You have heard that croup responds to steroid therapy, but wonder whether it is more effective than nebulised epinephrine.

Search Strategy

Medline 1966-11/00 using the OVID interface.
[(exp croup OR OR exp tracheitis OR OR OR AND (exp epinephrine OR OR exp budesonide OR] LIMIT to human AND english.

Search Outcome

119 papers found of which 118 were irrelevant or of insufficient quality. The remaining paper is shown in the table.

Relevant Paper(s)

Author, date and country Patient group Study type (level of evidence) Outcomes Key results Study Weaknesses
Fitzgerald D et al,
66 hospitalised children with viral or spasmodic croup. Budesonide 2mg vs epinephrine 4mgPRCTDuration of croup attack in hours31[21] vs 26[21] (not significant)Sample size calculated to be 66 but only 53 completed the 24 hr study. No follow up
Change in total croup symptom score7.1[1.2] vs 7.7[1.1] (not significant)
Side effectsNo significant difference


This study shows that there are no significant clinical differences between the two treatments. In such a case the relative cost of the treatment is an important factor in deciding which should be prescribed. [Web Editor comments] The small size of this study means that no conclusion can be drawn regarding the difference between these treatments.

Clinical Bottom Line

Nebulized epinephrine and nebulized budesonide are as effective as each other in moderately severe croup.

Level of Evidence

Level 3 - Small numbers of small studies or great heterogeneity or very different population.


  1. Fitzgerald D, Mellis C, Johnson M et al. Nebulized budesonide is as effective as nebulized adrenaline in moderately severe croup. Pediatr 1996;97:722-5.