Paediatric Ambulatory Care 1

1. Paediatric Ambulatory Care 1 Management of Croup By Robin Hyde Produced 2010

2. Croup (Laryngotracheobronchitis) • Common childhood illness • Peak incidence 2yrs of age m:f ratio 1.5 : 1 • Cause= Parainfluenza • Result upper airway obstruction • S/S Cough (Barking),Stridor,Hoarse,Fever • 1 in 10 children require hospitalisation • Estimated costs $56 million in the US • Mortality rate low 1 in 10,000 • Can be epidemic in the winter months • Wide classification Mild Moderate or Severe • Tools: Westley Croup Score or Modified Taussig Score Bjornson et al (2004) Knutson and Aring (2004) Patient UK (2009)

3. Clinical Question RATIONALE • No UK Based Guidelines • Sporadic and Variable practice • Formulation of Question PICO format • P= infant,child, paed/paediatrics', croup, Laryngotracheobronchitis, mild, moderate • I = single oral dose dexamethasone • C= single oral dose prednisolone • O= efficacy of treatment, symptom relief, re-admission rate reduced • “In the infant over 3 months of age, presenting to the acute admission unit with mild-moderate croup, does a single dose of dexamethasone match in efficacy of treatment i.e. re-admission rate and symptom relief, compared to a single dose of prednisolone”?

4. SEARCH STRATEGY • INCLUSION criteria: - RCTs, articles in English, post 2000, infant/child >3 months, solely presenting croup with mild to moderate classification, A&E/AAU • EXCLUSION criteria: - non-English articles, pre 2000, infant/child with predisposing respiratory complication (asthma, CF), severe croup/PICU setting, recent systematic reviews (i.e. In the last 5 years), meta-analysis’ • DATABASE use: - • TRIP database, Clinical evidence, Pubmed, Cochrane Library, Google Scholar • Medline , hits 8 • Cinahl, hits 6 • Embase, hits 6 • BNI, Hits 0 • 2 Articles chosen to use

5. ARTICLES... • Prednisolone versus dexamethasone in croup: a randomised equivalence trial • Sparrow and Geelhoed (2006) • Comparison between single-dose oral Prednisolone and oral dexamethasone in the treatment of croup: a randomised, double blinded clinical trial • Fifoot and Ting (2007)

6. Appraisal? CASP tool format ( PHRU 2006) • 10 questions to make sense of Randomised Controlled Studies • QUESTION 1 • Did the study ask a clearly-focused question?

7. 10 questions to make sense of Randomised Controlled Studies • QUESTION 2 • Was this a randomised controlled trial and was it appropriately so?

8. 10 questions to make sense of Randomised Controlled Studies • QUESTION 3 • Were participants appropriately allocated to intervention and control groups? • *please see Appendix 1

9. 10 questions to make sense of Randomised Controlled Studies • QUESTION 4 • Were participants, staff and study personnel ‘blind’ to participants study group?

10. 10 questions to make sense of Randomised Controlled Studies • QUESTION 5 • Were all of the participants who entered the trial accounted for at its conclusion?

11. 10 questions to make sense of Randomised Controlled Studies • QUESTION 6 • Were the participants in all groups followed up and data collected in the same way?

12. 10 questions to make sense of Randomised Controlled Studies • QUESTION 7 • Did the study have enough participants to minimise the play of chance?

13. 10 questions to make sense of Randomised Controlled Studies • QUESTION 8 • How are the results presented and what is the main result?

14. 10 questions to make sense of Randomised Controlled Studies • QUESTION 9 • How precise are these results? • QUESTION 10 • Were all important outcomes considered so the results can be applied?

15. DISCUSSION and CONCLUSION • Can I answer my clinical question from this appraisal? • Inconclusive-there is some evidence to support that dexamethasone provides more efficient treatment than prednisolone but not enough to say conclusively • More research required • Primary care • Over a longer period • ? Does multiple doses of corticosteroids provide improved efficacy in treatment than single doses? • APNP will be guided by local policy • Possibility of change locally • ?NEED FOR SOME UK GUIDELINES

16. References • Appraisal tool for randomised controlled trials studies NHS Critical Appraisal Skills Programme (2006) http://www.phru.nhs.uk/casp/appraisa.htm (accessed 20/08/2009) • Bjornson, C L Klassen, T P Williamson, J Brant , R Mitton C, Plint , A Bulloch, B Evered, L and Johnson, D (2004) A randomised trial of a single dose of oral dexamethasone for mild croup The New England Journal of Medicine 13 : 351 1306-1313 • Fifoot, A and Ting, Y S (2007) Comparison between single-dose oral prednisolone and oral dexamethasone in the treatment of croup: a randomised double blinded clinical trial Emergency Medicine Australasia 19 51-58 • Knutson, D and Aring, A (2004) Viral Croup American Family Physician 69 535-542 • Johnston, D (2008) Croup Clinical Evidence http://clinicalevidence.bmj.com/ceweb/conditions/chd/0321/0321-get.pdf(accessed 04/12/09) • Patient Uk-Croup http://www.patient.co.uk/health/Croup.htm accessed 17/11/09 • Sparrow, A and Geelhoed, G (2006) Prednisolone versus dexamethasone in croup: a randomised equivalence trial Archives of Disease in Childhood 91 580-583 • Westley CR, Ross EK, and Brooks JG. Nebulised racemic epinephrine by IPPB for the treatment of croup American Journal of Disease in the Child 1978;132:484–487 • Westley Croup Score http://www.welshem.org.uk/index.php?option=com_content&view=article&)id=92:westley-croup-score&catid=47:scoring&Itemid=73 (accessed 17/11/09)

17. Appendix 1 • Westley Croup Score • Total score ranging from 0–17 points. Five component items make up the score: • • Stridor (0 = none, 1 = with agitation only, 2 = at rest) • • Retractions (0 = none, 1 = mild, 2 = moderate, 3 = severe) • • Cyanosis (0 = none, 4 = cyanosis with agitation, 5 = cyanosis at rest) • • Level of consciousness (0 = normal [including asleep], 5 = disorientated) • Mild= score 0-2 • Moderate= score 3-5 • Severe= score 6-11 • Impending respiratory failure= score > 11 • Modified Taussig Croup Score • Stridor • None 0 • Only on crying, exertion 1 • At rest 2 • Severe (biphasic) 3 • Retractions • None 0 • Only on crying, exertion 1 • At rest 2 • Severe (biphasic) 3 • *1-2 mild, 3-4 moderate, 5-6 severe Westley et al (1978) Johnston (2008)