Nebulized Epinephrine for Croup in Children

This week, as part of the Child Health Emergency Medicine Social Media Campaign, we are highlighting a Cochrane summary on nebulized epinephrine for croup in children. This review was selected for the TREKK Evidence Repository on croup.

Key Messages:


Related TREKK Resources:

Cochrane Summary:

Croup is a common childhood illness which primarily affects those between the ages of six months and three years, with a peak annual incidence in the second year of life of nearly five per cent. Males and females are affected equally. Croup is most often caused by a viral infection. Symptoms of croup include a hoarse voice, a ‘barking’ cough and noisy breathing. These symptoms are the result of swelling that occurs in the area of the windpipe (trachea) just below the voice box (larynx). Although most cases of croup are mild and resolve on their own, occasionally the swelling can be severe enough to cause difficulty in breathing. In these children, epinephrine (also called adrenaline) is a medication that is inhaled as a mist to temporarily shrink the swollen area in the trachea.

This review looked at trials of inhaled epinephrine for the treatment of children with croup and is comprised of only eight studies with 225 participants. Of the eight included studies, six were assessed as having low risk of bias and two as unclear risk of bias (based upon assessment of adequate random sequence generation, allocations concealment, blinding of participants and personnel, blinding of outcome assessment, completeness of outcome data, and selective reporting). Studies assessed a variety of outcome measures and few studies examined the same outcomes; therefore, most outcomes contained data from a maximum of three studies, and in some cases only single studies.

Compared to no medication, inhaled epinephrine improved croup symptoms in children at 30 minutes following treatment (three studies, 94 children). This treatment effect disappeared two hours after treatment (one study, 20 children). However, children’s symptoms did not become worse than prior to treatment. No study measured adverse events.

The evidence is current to July 2013.

Authors’ Conclusions:

Nebulized epinephrine is associated with clinically and statistically significant transient reduction of symptoms of croup 30 minutes post-treatment. Evidence does not favor racemic epinephrine or L-epinephrine, or intermittent positive pressure breathing over simple nebulization. The authors note that data and analyses were limited by the small number of relevant studies and total number of participants and thus most outcomes contained data from very few or even single studies.

Check Out the Full Cochrane Systematic Review Below:

Bjornson, C., Russell, K., Vandermeer, B., Klassen, T.P., Johnson, D.W. (2013). Nebulized epinephrine for croup in children. Cochrane Database Syst Rev, 10, CD006619. doi: 10.1002/14651858.CD006619.pub3


This post is part of a weekly blog series highlighting pediatric emergency medicine (PEM) focused Cochrane summaries and other key resources selected by TREKK.

Published by arrangement with John Wiley & Sons.