Transcutaneous carbon dioxide pressure for monitoring patients with severe croup

doi:10.1016/S0022-3476(05)83324-4

The Journal of Pediatrics

Volume 117, Issue 5, November 1990, Pages 701-705

https://doi.org/10.1016/S0022-3476(05)83324-4 Get rights and content

In a prospective investigation of 17 children with severe croup, we analyzed the effect of epinephrine inhalations and mild sedation with chloral hydrate on transcutaneous carbon dioxide pressure (tcPco₂), pulse oximetry measurements, and croup scores. There was a highly significant reduction (p<0.001) in the tcPco₂ values and croup scores after inhalation of epinephrine. The changes in the tcPco₂ values correlated with the clinical findings. Mild sedation also significantly improved the croup scores but failed to influence the tcPco₂ values. There was not statistically significant difference in pulse oximetry saturation, fraction of administered oxygen, heart rate, or respiratory rate before and after inhalation of epinephrine or chloral hydrate adminstration. Monitoring tcPco₂ appears to be a reliable and objective tool for managing patients with upper airway obstruction, whereas croup scores may be misleading.

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Racemic epinephrine and humidified air can also be useful adjuncts [9,11]. For purposes of respiratory function testing, light sedation without intubation has been performed in patients with croup and has been shown to cause no clinical deterioration [4,12]; however, the therapeutic effects of light sedation in these patients have rarely been reported. Dexmedetomidine is a newer sedative drug that is a selective α2 agonist and acts as a central agent in the brain and spinal cord [13].
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Determination of disease severity relies on clinical assessment. Various proposed methods for objective assessment of respiratory distress in children with croup are either impractical or insensitive to change across the full range of disease severity.23,57–59 Consequently, in clinical trials of treatment effectiveness, outcome measures have mainly included clinical scores and health-care use.60,61
Most children who present with acute onset of barky cough, stridor, and chest-wall indrawing have croup. A careful history and physical examination is the best method to confirm the diagnosis and to rule out potentially serious alternative disorders such as bacterial tracheitis and other rare causes of upper-airway obstruction. Epinephrine delivered via a nebuliser is effective for temporary relief of symptoms of airway obstruction. Corticosteroids are the mainstay of treatment, and benefit is seen in children with all levels of severity of croup, including mild cases.
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The evaluation of infants and children with upper airway obstruction always involves a history and physical examination, which in many cases allow a diagnosis to be made. Assessment of severity and response to treatment relies on subjective parameters. Flow-volume loop analysis is a rapid, simple and effective method of evaluating patients with upper airway obstruction non-invasively. Imaging studies are complementary to endoscopy, and include plain radiography as well as computed tomography and magnetic resonance imaging, with the latter two being increasingly used in the evaluation of the paediatric airway. The ultimate diagnostic test for evaluation of upper airway obstruction, however, is flexible endoscopy.
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Acquired upper airway obstruction is a common cause of respiratory emergencies in children. Most pathologic processes that result in upper airway compromise are a consequence of infection, trauma or aspiration. Today, many of the infectious causes of upper airway obstruction have lost their threat as a result of the progress made in preventing and treating these infections. Prompt recognition and appropriate management of the child presenting with upper airway obstruction remains critical, because certain causes can progress rapidly from a mild to a potentially life-threatening disease state. A correct diagnosis can often be made by history and physical examination, but additional studies may be useful in selected cases. The child’s clinical appearance is the most reliable indicator of severity, and measurable signs are of less value. If respiratory failure is imminent, airway protection and endoscopy for definitive diagnosis may have priority over any other therapeutic or diagnostic procedure.
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2000, Archives de Pediatrie
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Upper airway obstruction is a frequent cause of admission to the emergency department and the intensive care unit. Symptoms are mainly represented by dyspnea and stridor. Severity must be rapide/y assessed to allow adapted treatment and avoid cardiac arrest and hypoxic encephalopathy. The possible etiologies are numerous, with acquired and congenital ones, but the majority is represented by laryngitis, lymphoid hypertophy and laryngotracheomalacia. In case of respiratory failure, treatment must first establish airway patency with bag and mask ventilation, and then intubation. If vital prognosis is not threatened, biologic, radiologic or endoscopic examination can be performed to identify the cause of the obstruction and treat it.

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Original articleTranscutaneous carbon dioxide pressure for monitoring patients with severe croup

Pediatr Clin North Am

J Pediatr

J Pediatr

J Pediatr

J Pediatr

Croup and epiglottitis in children: the anesthesiologist as diagnostician

Anesth Analg

Treatment of laryngotracheobronchitis (croup): Use of intermittent positive-pressure breathing and racemic epinephrine

Am J Dis Child

Continuous measurements of skin surface oxygen and CO2 tensions in obstructive sleep apnea

Laryngoscope

Nebulized racemic epinephrine by IPPB for the treatment of croup: a double-blind study

Am J Dis Child

Original article
Transcutaneous carbon dioxide pressure for monitoring patients with severe croup

Continuous measurements of skin surface oxygen and CO₂ tensions in obstructive sleep apnea