Outpatient treatment of croup with nebulized dexamethasone
D. W. Johnson, S. Schuh, G. Koren and D. M. Jaffee
Division of Emergency Medicine, Department of Paediatrics, Hospital for Sick Children, University of Toronto, Ontario, Canada.
PURPOSE: To determine if treating children who have acute, moderate croup
with nebulized dexamethasone sodium phosphate in the emergency department
results in clinical improvement by 4 hours and a decrease in the
hospitalization rate. DESIGN: Randomized, double-blind, placebo controlled
trial. SETTING: Emergency department, children's hospital. PATIENTS:
Fifty-five children with croup who were in moderate respiratory distress
after treatment with mist for 30 minutes who met inclusion and exclusion
criteria. MEASUREMENTS: Croup score, respiratory rate, heart rate, and
oxygen saturation were assessed by one of us (D.W.J. or S.S.) before
treatment and 2 and 4 hours after treatment. A staff pediatrician or senior
pediatric resident, also "blind" to treatment, decided on admission to or
discharge from the hospital. The differences between groups for change in
croup score and hospitalization rate after treatment were analyzed.
RESULTS: Evaluation of the croup scores disclosed a significant improvement
in the dexamethasone-treated group compared with the placebo group at 4
hours (P=.005, Mann-Whitney U). However, the hospitalization rate was not
statistically different at the end of treatment (33% vs 52%, P=.28) or
after 24 hours (48% vs 60%, P=.56, Yates corrected chi(2)). Our study has
80% power to detect a two-thirds reduction in hospitalization rate. Two
patients with neutropenia treated with dexamethasone had a clinical course
consistent with bacterial tracheitis. CONCLUSIONS: Treatment of moderate
croup with nebulized dexamethasone results in clinical improvement within 4
hours. We did not show a decrease in hospitalization rates, although our
sample size was only large enough to detect a 67% reduction in the rate of
hospitalization. Given the infectious complications and the absence of
evidence for a sustained clinical effect, we do not recommend that patients
with croup be treated with nebulized dexamethasone.
