Progress has been made in the treatment for patients with
croup and
bronchiolitis in the past decade. By intervening with pharmacologic agents, a better outcome has been documented in children with these diseases. A lower probability of hospital admission means that fewer health care dollars need to be expended in this area. The present state of evidence substantiates the following.
Bronchiolitis . Nebulized
albuterol causes significant short-term improvement in clinical scores in bronchiolitic children, but there is no evidence that it reduces admission rates or decreases length of hospitalization. . Nebulized
epinephrine results in significant improvement in clinical scores and airway resistance in children hospitalized with
bronchiolitis and in the emergency department causes acute improvement in oxygenation, decreases length of time in the emergency department and admission rate to hospital. . There is no evidence to support the use of
dexamethasone or other glucocorticosteroids for infants hospitalized with
bronchiolitis.
Croup . Nebulized
budesonide or oral
dexamethasone results in acute clinical improvement in outpatients with mild to moderate
croup, reducing the need for hospitalization. . A combination of nebulized
budesonide and oral
dexamethasone may provide the best clinical outcome, although further evidence is needed to substantiate this . The required dose of oral
dexamethasone may range from 0.15 mg/kg to 0.6 mg/kg for best clinical outcome. . Use of
racemic epinephrine or L-
epinephrine in the emergency department, especially when used concomitantly with
glucocorticoids, does not require automatic hospital admission; a 3-hour observation period in the emergency department may suffice. . Use of intramuscular
dexamethasone is difficult to justify in patients with
croup who are able to ingest oral medications. Future studies need to examine dosing of
glucocorticoids for inpatients with
croup. In addition, an important question remains as to whether very mild
croup patients (those with no evidence of respiratory distress) might benefit from
glucocorticoids administered in the physician's office or the emergency department.