title: Nebulised L-epinephrine and steroid combination in the treatment of moderate to severe croup.
abstract: OBJECTIVE
  To compare the effectiveness of nebulised L-epinephrine in combination with systemic or nebulised corticosteroid with that of cool mist and systemic corticosteroids in the treatment of moderate to severe croup.
  
  
  METHODS
  Children were eligible for study if they presented to the emergency department with a moderate to severe croup. Patients were randomly assigned to three groups: group 1, cool mist and intramuscular dexamethasone (n = 26); group 2, nebulised L-epinephrine and intramuscular dexamethasone (n = 31); group 3, nebulised L-epinephrine and nebulised budesonide (n = 19). The croup score, vital signs and oxygen saturation were assessed before and after medication. Adverse events, additional L-epinephrine and hospitalisation were recorded.
  
  
  RESULTS
  Age, sex, initial croup score and vital signs were similar in all groups. Croup scores were significantly decreased over time in all treatment groups and this decrease was very evident at 30 minutes (p < 0.05). Croup scores of groups 2 and 3 were significantly lower than those of group 1 at 30 and 60 minutes but no difference was observed between groups 2 and 3 at these timepoints. The numbers of patients who had croup scores <2 at 30 and 60 minutes were higher in groups 2 and 3 than group 1 (p = 0.004 and p = 0.032, respectively). More patients in group 1 received additional L-epinephrine treatments (p = 0.014). Changes in vital signs were not different among groups when assessed over time (p > 0.05).
  
  
  CONCLUSIONS
  This study demonstrated that with early combination treatment, croup scores improved rapidly and hospitalisation rates were low. Patients with moderate to severe croup presenting to the emergency department should receive nebulised L-epinephrine in combination with intramuscular dexamethasone or nebulised budesonide. No significant adverse effects were observed with L-epinephrine. The use of L-epinephrine has been proposed instead of racemic epinephrine in patients with moderate to severe croup because it is efficacious, well tolerated, less expensive and more readily available in many countries.
authors.affiliation: Department of Paediatrics, Dokuz Eylül University Faculty of Medicine, Izmir, Turkey.
authors.forename: Murat
authors.initials: M
authors.lastname: Duman
authors.forename: Durgül
authors.initials: D
authors.lastname: Ozdemir
authors.forename: Seçkin
authors.initials: S
authors.lastname: Atasever