In a child 6 months to 3 years old with mild viral laryngotracheobronchitis (croup), does inhalation of cool (cold) air provide therapeutic benefit?

Cold Air for Croup: Not Recommended Based on Current Guidelines

Current evidence does not support the use of cold air or humidified air for treating croup in children, and this intervention should not be relied upon as a therapeutic measure. 1

Guideline Recommendations

The most authoritative guidelines explicitly state that cold or humidified air provides no therapeutic benefit:

• Cold or humidified air is not supported by published evidence as an effective treatment intervention for viral croup, according to consensus recommendations. 2

• Humidification therapy has not been proven beneficial in the management of croup. 3

• Mist/humidified air provides no additional symptom improvement and does not alter the disease process. 4

• The American Academy of Pediatrics and other major guideline bodies do not include cold air exposure in their treatment algorithms for croup, focusing instead on corticosteroids and nebulized epinephrine for moderate-to-severe cases. 1, 5

Recent Contradictory Research Evidence

A 2023 randomized controlled trial published in Pediatrics found that 30-minute exposure to outdoor cold air (<10°C) as an adjunct to oral dexamethasone resulted in greater symptom improvement compared to room temperature exposure (49.2% vs 23.7% achieving ≥2-point decrease in Westley Croup Score at 30 minutes, P=.007). 6 Children with moderate croup showed the most benefit (risk difference 46.1%, P<.001). 6

However, this single study has not yet been incorporated into clinical practice guidelines, and the established consensus remains that cold air is not a recommended intervention. 1, 2, 3, 4

Evidence-Based Treatment Algorithm

Instead of cold air, the following approach should be used:

For All Severity Levels:

• Administer oral dexamethasone 0.15-0.60 mg/kg (maximum 10 mg) immediately to all children with croup, regardless of severity. 1, 2, 3

For Moderate-to-Severe Croup (stridor at rest, respiratory distress):

• Add nebulized epinephrine 0.5 ml/kg of 1:1000 solution (maximum 5 ml) for rapid but temporary relief lasting 1-2 hours. 1, 5
• Observe for at least 2 hours after the last epinephrine dose to monitor for rebound symptoms. 1, 5

Supportive Care:

• Provide supplemental oxygen to maintain SpO₂ ≥94% using nasal cannula, head box, or face mask. 1
• Minimize handling to reduce metabolic demands in severely ill children. 1
• Avoid chest physiotherapy, which offers no benefit and may cause harm. 1

Clinical Pitfalls to Avoid

• Do not rely on cold air or humidified air as a primary or adjunctive treatment based on current guidelines. 1, 2, 3, 4

• Do not discharge patients within 2 hours of nebulized epinephrine due to risk of rebound symptoms. 1, 5

• Do not use nebulized epinephrine in outpatient settings where immediate return is not feasible. 1, 5

• Do not withhold corticosteroids in mild cases, as they are recommended for all severity levels. 1, 2, 3

Hospitalization Criteria

Consider admission when:

• Three or more doses of nebulized epinephrine are required. 1, 5
• Age <18 months with severe symptoms. 1
• Oxygen saturation <92% on room air. 1
• Family unable to provide appropriate observation at home. 1