Safety and Efficacy of Nebulized Racemic Epinephrine in Conjunction With Oral Dexamethasone and Mist in the Outpatient Treatment of Croup☆,☆☆,★
Section snippets
INTRODUCTION
Croup is a clinical syndrome of hoarseness and barking cough, often associated with stridor, that results from a variable degree of subglottic obstruction. Croup is the most common cause of airway obstruction in children 6 months to 6 years old,1 with a peak incidence between the ages of 7 and 36 months.2, 3 In the second year of life, the annual incidence of croup has been reported as 4.7 per 100 children.2 Despite the frequency with which pediatric care providers encounter croup, debate
MATERIALS AND METHODS
Children seen in the emergency department at The Children's Hospital, Denver, Colorado, between December 1991 and March 1993 with the clinical diagnosis of croup (hoarseness and barking cough with stridor at rest) were eligible for inclusion in the study and an RE treatment, which required the clinical criterion of the presence of stridor at rest. Patients were excluded if (1) the stridor resolved within 20 minutes of mist therapy alone; (2) the patient did not exhibit signs of respiratory
RESULTS
Fifty-six children with croup who required RE were enrolled in the study. One child was lost to follow-up and deleted from statistical analysis, so 55 patients between the ages of 2 months and 13 years remained. Frequency distributions of age, sex, past medical history, and history of symptoms are shown in Table 2.Thirty patients (55%) were responders; 13 patients (24%) were relapsers; and 12 patients (22%) were nonresponders. All relapsers and nonresponders were hospitalized. Distinguishing
DISCUSSION
The assessment and management of croup have undergone a slow evolution during the past 30 years.14 Endotracheal intubations and tracheostomies to relieve airway obstruction in patients with severe croup were gradually replaced in the 1960s and 1970s by RE treatments delivered by intermittent positive pressure breathing (IPPB).4 In 1975, Taussig et al7 studied 7 patients who were treated with IPPB RE and concluded that relapse commonly occurs within 2 hours. Only 1 patient had a posttreatment
CONCLUSION
The management of croup suggested by our data avoids unnecessary and costly hospitalizations. We conclude, on the basis of our prospective results, that success with this strategy requires a full 3-hour observation period after the completion of the RE treatment, serial clinical evaluations, administration of dexamethasone and mist, and explicit home care instructions. Outpatient management of selected patients with croup who require treatment with RE is safe, cost-effective, and easily
Acknowledgements
Special thanks to Michael Shannon, MD, for originally planting this idea; Dennis Luckey, PhD, for his help with the data and statistics; and Roger Gunter for his help with the graphics.
References (25)
- et al.
Racemic epinephrine in the treatment of croup: Nebulization alone versus nebulization with intermittent positive pressure breathing
J Pediatr
(1982) Croup: Pathogenesis and management
J Emerg Med
(1983)- et al.
Racemic epinephrine use in croup and disposition
Am J Emerg Med
(1992) - et al.
A prospective randomized double-blind study to evaluate the effect of dexamethasone in acute laryngotracheitis
J Pediatr
(1989) Treatment of croup. A critical review
Am J Dis Child
(1989)- et al.
Croup: An 11-year study in a pediatric practice
Pediatrics
(1983) The acute obstructed laryngitis in infants and children
Hosp Med
(1968)- et al.
Ten-year experience with IPPB in the treatment of acute laryngotracheobronchitis
Anesth Analg
(1971) - et al.
Spasmodic croup in children: Personal experiences with intermittent positive pressure breathing in therapy
Clin Pediatr
(1972) - et al.
Treatment of laryngotracheobronchitis (croup)
Am J Dis Child
(1975)
Nebulized racemic epinephrine by IPPB for the treatment of croup: A double-blind study
Am J Dis Child
Croup (laryngitis, laryngotracheitis, spasmodic croup and laryngotracheobronchitis)
Cited by (82)
The Pediatric Airway
2019, A Practice of Anesthesia for Infants and ChildrenThe Pediatric Airway
2018, A Practice of Anesthesia for Infants and ChildrenInfections of the Upper and Middle Airways
2017, Principles and Practice of Pediatric Infectious DiseasesParamedic assessment and treatment of upper airway obstruction in pediatric patients: An exploratory analysis by the Children's Safety Initiative-Emergency Medical Services
2016, American Journal of Emergency MedicineInpatient Treatment after Multi-Dose Racemic Epinephrine for Croup in the Emergency Department
2015, Journal of Emergency MedicineCitation Excerpt :Although rebound stridor is the feared complication, patients relapse, at worst, to pretreatment levels of severity (2,5,6). After administration of corticosteroids and a single dose of RE, safe discharge from the emergency department (ED) is possible after an observation period of 2–4 h (7–11). Except for a single study describing the implementation of a clinical pathway that dictated disposition based on clinical response to treatment, little published evidence addresses hospital admission criteria (12–14).
Emergency department diagnosis and treatment of anaphylaxis: A practice parameter
2014, Annals of Allergy, Asthma and Immunology
- ☆
From the Section of General and Emergency Pediatrics, The Children's Hospital and University of Colorado Health Sciences Center, Denver, Colorado.
- ☆☆
Address for reprints: Carol A Ledwith, MD, The Children's Hospital B251, 1056 East 19th Avenue, Denver, Colorado 80218, 303-837-2868, Fax 303-837-2990
- ★
Reprint no. 47/1/62707