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Three Part Question

In [children with croup], is [nebulised budesonide as effective as oral/IM dexamethasone] at [reducing symptoms as measured using a croup score].

Clinical Scenario

A 3 year old boy was admitted to A&E via ambulance following a few hours history of being unwell with a barking ‘croupy’ cough, inspiratory stridor and a brief history of cyanosis. Due to the short history, alternative diagnoses such as epiglottitis could not be fully and safely excluded so nebulised budesonide was given instead of oral dexamethasone. The patient intially improved but the stridor returned rapidly after the nebuliser was stopped. The patient required nebulised adrenaline and a brief inpatient stay.

Search Strategy

Ovid Medline 1950-2008
Search terms: “croup” AND “budesonide” AND “dexamethasone”
Limited to English language papers

Search Outcome

21 papers found of which 15 were irrelevant or of insufficient quality. The remaining 6 papers are shown in the table below.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Geelhoed et al 1995 Australia	80 children aged 5-158 months hospitalised with croup Groups: oral dexamethasone, nebulised budesonide, placebo	3-way randomised double-blind placebo controlled trial	Time to achieve a croup score ≤1	Dexamethasone 2 hours, budesonide 3 hours, placebo 8 hours (no significant difference between steroid groups)
Klassen et al 1996 Canada	50 children aged 3 months-5 years with a croup score ≥ 3 after 15 minutes mist therapy Groups: Nebulised budesonide, nebulised placebo	Randomised double-blind placebo controlled trial	Change of 2 points in croup score 4 hours post-treatment	Budesonide 84%, placebo 56%	All patients received oral dexamethasone in addition to their nebuliser
Klassen et al 1998 Canada	197 children aged 3 months-5 years with a croup score ≥2 after 15 minutes mist therapy. Groups: oral dexamethasone + nebulised placebo, oral placebo + nebulised budesonide, oral dexamethasone + nebulised budesonide	Randomised controlled trial	Mean change in Westley croup score	Budesonide -2.3, dexamethasone -2.4, both -2.4.
Johnson et al 1998 Canada	144 patients aged 24 ± 18 months with a croup score of 3-6 after 30 mins humidified oxygen Groups: nebulised budesonide, IM dexamethasone, placebo	Randomised double blind placebo controlled trial	Change in (Westley) croup score	Change in croup score was significantly greater with IM dexamethasone than nebulised budesonide.	All patients treated simultaneously with nebulised adrenaline.
Cetinkaya et al 2004 Turkey	60 patients aged 6 - 36 months diagnosed with croup Groups: nebulised budesonide, oral dexamethasone, IM dexamethasone, placebo	Randomised controlled trial	Westley croup score measured at 0, 24, 48 and 72 hours	No significant difference between steroid administration methods.
Geelhoed 2005 Australia	72 children aged 3 - 126 months hospitalised with croup Groups: nebulised budesonide, nebulised placebo	Randomised controlled trial	Change in croup scores from 0-12 hours	No significant difference between the two groups	All children received oral dexamethasone in addition to their nebuliser

Comment(s)

No studies show that budesonide is superior to dexamethasone in the treatment of croup. 4 studies show that there is no difference between the methods of steroid administration. One study shows that dexamethasone is superior to budesonide. One study suggests that the combination of nebulised and oral/IM steroid is better than dexamethasone in isolation. Other arguments for using dexamethasone include the fact that children tolerate nebulisers poorly and this may reduce the concentration of budesonide inhaled. In addition, dexamethasone is cheaper than budesonide and should therefore be used first wherever possible.

Clinical Bottom Line

Children presenting to the emergency department with croup should be given oral or IM dexamethasone as a first line method of steroid administration. However, nebulised budesonide is a safe and effective alternative in children who are not distressed by wearing a facemask.

References

1. Geelhoed GC, Macdonald WB. Oral and inhaled steroids in croup: a randomized, placebo-controlled trial. Pediatr Pulmonol 1995; 20(6):355-61
2. Klassen TP, Watters LK, Feldman ME, Sutcliffe T, Rowe PC. The efficacy of nebulized budesonide in dexamethasone-treated outpatients with croup. Pediatrics 1996;97(4):463-6
3. Klassen TP, Craig WR, Moher D, Osmond MH, Pasterkamp H, Sutcliffe T, et al. Nebulized budesonide and oral dexamethasone for treatment of croup: a randomized controlled trial. JAMA 1998;279(20):1629-32.
4. Johnson DW, Jacobson S, Edney PC, Hadfield P, Mundy ME, Schuh S A comparison of nebulized budesonide, intramuscular dexamethasone, and placebo for moderately severe croup. N Engl J Med 1998;339(8):498-503.
5. Cetinkaya F, Tufekci BS, Kutluk G. A comparison of nebulized budesonide, and intramuscular, and oral dexamethasone for treatment of croup. Int J Pediatr Otorhinolaryngol 2004;68(4):453-6.
6. Geelhoed GC Budesonide offers no advantage when added to oral dexamethasone in the treatment of croup. Pediatr Emerg Care 2005;21(6):359-62