Inhaled corticosteroids in croup: Time to go local?

The aim of treatment in croup is to control upper airway inflammation and consequent obstruction. Usually, corticosteroids are advised in all and epinephrine in moderate-to-severe cases. However, institutional practices vary significantly with regard to the preferred steroid and route of administration. We searched the MEDLINE database and the Cochrane Library for current evidence. We also performed a search for existing guidelines. We discuss a Cochrane Review published in April 2018, including 43 randomized controlled trials, which suggests that systemic dexamethasone might result in greater benefit compared to nebulized budesonide. Adverse effects are uncommon with both. As there are very few head-to-head trials, there is a need for more studies comparing clinical outcomes between inhaled and systemic corticosteroids. The current evidence supports the use of dexamethasone as the first-line agent but budesonide should be used if the former is not available or tolerated.