Inhaled Corticosteroids Offer Promising Option for Managing Recurrent Croup

Research study background

A multidisciplinary team of researchers at Children’s Hospital Colorado published promising findings on the development of novel preventive treatment for children suffering from recurrent croup.  

Acute croup and recurrent croup are triggered by viruses, resulting in a tell-tale barky cough accompanied by a high-pitched stridor, hoarseness and breathing difficulties. Despite these shared symptoms, their underlying disease processes differ. Recurrent croup tends to occur more often in children with a family history of croup, asthma, or atopy, as opposed to healthy children. It has also been linked to gastroesophageal reflux disease (GERD) and eosinophilic esophagitis (EoE).

Historically, recurrent croup has been considered an anatomical issue related to airway abnormalities, prompting evaluations with laryngoscopy or bronchoscopy procedures under anesthesia. However, our experts theorize it resembles airway reactivity similar to asthma.

Previously, inhaled corticosteroids (ICS) have been used for acute croup episodes, with suggested benefits as a preventative therapy. In the largest known cohort study of its kind, the team hypothesized prophylactic ICS could potentially decrease both the frequency and severity of recurrent croup episodes in patients without fixed airway lesions.

Study authors retrospectively reviewed charts of children referred to outpatient pulmonology, otolaryngology, allergy or gastroenterology clinics at Children’s Colorado for recurrent croup between June 2019 and January 2021. In this study, recurrent croup was defined as three or more episodes occurring within a lifetime. Patients with asthma and inducible laryngeal obstruction diagnoses were excluded.

Among the patients who underwent imaging or diagnostic laryngoscopy/bronchoscopy, there were few airway abnormalities, and none required surgical intervention. Most patients treated with medical therapy used fluticasone propionate inhalers twice daily upon the onset of an upper respiratory infection. Nearly 90% of parents reported improvement in symptoms.

There were no significant differences in past medical history or comorbidities between patients who improved on ICS and those who did not, and no reported adverse drug reactions. ICS treatment seemed to be particularly effective in patients with more than five episodes of croup. In addition, some patients with GERD or EoE also reported improvements with ICS therapy.

Clinical implications

The initiation of ICS at the first sign of a viral upper respiratory infection to reduce episodes of recurrent croup is a novel preventative treatment developed by our experts. The team is planning to conduct randomized control trials in the future to validate its effectiveness.