image by: Philippe Put

HWN Suggests

Briefs: All bark and no stridor

In many ways the management of sicker patients with suspected croup is more straightforward. Give them steroids early, let the patient protect their own airway and use inhaled racemic epinephrine. But what about the larger majority of kids that you might see in the ED (usually between 10PM and 4AM) who now have a barky cough and that’s it. Sure, maybe they had stridor at home, but not in the ED with you, where they are as happy as a clam watching Jake and the Neverland Pirates.

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 Acute Management of Croup

This PedsCases Note provides a one-page infographic on the acute management of croup, based on the CPS Practice Point guideline. It outlines common symptoms to look for in mild, moderate, and severe presentations of croup, and presents a treatment and management flowchart for each presentation. It was created by Sparsh Shah, a 4th year medical student at the University of Toronto.

 Croup: ED-focused Highlights

Croup is a spectrum of illness characterized by varying degrees of inflammation in the upper respiratory tract, with possible involvement of the lower respiratory tract. Patients may have laryngotracheitis, laryngotracheobronchitis, or laryngotracheobronchopneumonitis. In 75% of cases, parainfluenza virus is responsible. Otherwise, RSV, metapneumovirus, influenza, adenovirus, coronavirus, or even mycoplasma can cause a similar syndrome. Some patients have recurrent bouts of upper airway edema causing a croup-like syndrome, which is referred to as spasmodic croup. This is thought to be potentially related to hypersensitivity to viral antigens.

 Rebound stridor in children with croup after nebulised adrenaline: does it really exist?

So, in answer to the proposed question: “Do children with croup (patient group) when treated with nebulised adrenaline (intervention) develop re-emergence of stridor, worse than initial baseline presentation (comparison) as defined by changes in symptoms score (outcome)?” Or “Rebound stridor in children with croup after nebulised adrenaline: does it really exist?” The answer is no.

Articles of Interest

Efficacy of low-dose nebulized epinephrine as treatment for croup: A randomized, placebo-controlled, double-blind trial

We performed a randomized controlled double-blind non-inferiority trial in pediatric patients with moderate to severe croup and found that LD (0.1 mg/kg) 1:1000 nebulized L-epinephrine therapy was not inferior with regard to croup score reduction compared to CD (0.5 mg/kg) therapy. To our knowledge, this is the first study to explore the effects of different epinephrine doses in croup patients.

Management of severe croup

The first step is to provide nebulized epinephrine. The dose is either 5ml of standard L-epinephrine (1:1000 concentration) or 0.5ml of 2.25% racemic epinephrine. Use whichever your hospital stocks.

Alternative to Racemic Epinephrine in Croup

0.5 mg/kg up to 5 mg of 1:1000 (anaphylaxis formulation) can be placed in a nebulizer and has similar efficacy to racemic and is used in places where racemic is unavailable to too expensive.

Epinephrine nebulization

0.5 ml/kg/dose (using 1 mg/ml ampoule). Do not exceed 5 ml of nebulised epinephrine.- - -

Going with the Flow: Respiratory Care in the Pediatric Emergency Department

The first line of treatment for croup is glucocorticoids. Glucocorticoids have demonstrated improvement in croup scores at 6 and 12 hours, decreased return visits or readmissions, and decreased ED and hospital length of stay.

Lightning Learning: Croup

Moderate/Severe Croup (biphasic stridor, irritability or reduced conscious level) may require nebulised adrenaline (0.4 ml/kg 1:1000, max 5 mls) and management in the ER.

Nebulized Budesonide for Children with Mild-to-Moderate Croup

We conclude that nebulized budesonide leads to a prompt and important clinical improvement in children with mild-to-moderate croup who come to the emergency department.

Nebulized epinephrine for croup in children

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 IPPB over simple nebulization.

Nebulized Epinephrine Treatment in Pediatric Emergency Department

The recommended dose of nebulized epinephrine is 0.5 mg/kg (maximum 5 mg) of 1/1000 solution in patients with stridor at rest or severe respiratory distress. Some authors suggest the nebulized epinephrine dose should be 2.5 mg per dose diluted with 4-5 ml normal saline in patients less than 4 years. In four years and older patients 5mg dose is sufficient with no more dilution. The rasemic epinephrine dose is 0.5 ml of a 2.25% solution with 2.5 ml normal saline. Nevertheless, there is wide variation in terms of the epinephrine doses described in the literature.

Pediatric Approach to Croup

Croup, better known by its formal name of laryngotracheobronchitis, causes subglottic inflammation and edema resulting in laryngeal obstruction and narrowing of the airways. The swelling at the cricoid ring (narrowest part of the pediatric airway) results in symptoms of airflow obstruction (stridor). Croup is most frequently seen in children age 6 months – 3 years. The most common etiology is parainfluenza although influenza, RSV, or adenovirus can also cause it. The peak incidence of croup is in the fall and winter months.

What The Heck Is Racemic Epinephrine?

Racemic epinephrine, on the other hand (no pun intended) contains both L-Epinephrine, AND D-Epinephrine. The “D” stands for dextrorotary, which we can think of as “right-handed Epi”. The D-Epinephrine is simply a mirror image of the L-epinephrine.

Resources

5 Essential Steps to Managing Croup

Standard L-Epinephrine (1:1000) up to 5 mg nebulized, has been shown to be just as safe as, and possibly more effective than racemic epinephrine.

Life in the Fastlane

CLINICAL FEATURES autumn & early spring 6 months -> 2 years URTI -> barking cough, hoarseness, stridor secretions +++ mild fever dysphagia.

Pediatric EM Morsels

Admit: Stridor at rest despite racemic Epi, Persistent respiratory distress, Dehydration, Poor social situation.