Safety and Efficacy of Nebulized Racemic Epinephrine in Conjunction With Oral Dexamethasone and Mist in the Outpatient Treatment of Croup

doi:10.1016/S0196-0644(95)70290-3

Annals of Emergency Medicine

Volume 25, Issue 3, March 1995, Pages 331-337

Presented at the American Academy of Pediatrics Section on Emergency Medicine, Washington, DC, October 1993.

https://doi.org/10.1016/S0196-0644(95)70290-3 Get rights and content

Abstract

Study objective: To identify patients with croup who after treatment with nebulized racemic epinephrine, oral dexamethasone, and mist may be safely discharged home after a period of observation.

Design: Prospective interventional. Setting: Urban children's hospital emergency department. Participants: Children with croup who received racemic epinephrine for the treatment of stridor at rest. Interventions: After treatment with .5 mL racemic epinephrine, .6 mg/kg dexamethasone PO, and mist, patients who were assessed as being safe for discharge after 3 hours of observation were discharged home and contacted for 48-hour follow-up. Results: Fifty-five patients with croup were treated with racemic epinephrine. Thirty patients (55%) had sustained responses and were discharged home after 3 hours of observation. No recurrence of respiratory distress and no return visits for medical care were reported (95% confidence interval, 0% to 8.0%). Conclusion: Patients with croup who are treated with racemic epinephrine, oral dexamethasone, and mist may be safely discharged home if the patient is assessed as ready for discharge after 3 hours of observation. [Ledwith CA, Shea LM, Mauro RD: Safety and efficacy of nebulized racemic epinephrine in conjunction with oral dexamethasone and mist in the outpatient treatment of croup. Ann Emerg Med March 1995;25:331-337.]

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)

JM Fogel et al.
Racemic epinephrine in the treatment of croup: Nebulization alone versus nebulization with intermittent positive pressure breathing
J Pediatr
(1982)
JL Goldhagen
Croup: Pathogenesis and management
J Emerg Med
(1983)
PB Kelley et al.
Racemic epinephrine use in croup and disposition
Am J Emerg Med
(1992)
DM Super et al.
A prospective randomized double-blind study to evaluate the effect of dexamethasone in acute laryngotracheitis
J Pediatr
(1989)
NS Skolnik
Treatment of croup. A critical review
Am J Dis Child
(1989)
FW Denny et al.
Croup: An 11-year study in a pediatric practice
Pediatrics
(1983)
B Fearon
The acute obstructed laryngitis in infants and children
Hosp Med
(1968)
JC Adair et al.
Ten-year experience with IPPB in the treatment of acute laryngotracheobronchitis
Anesth Analg
(1971)
A Melnick et al.
Spasmodic croup in children: Personal experiences with intermittent positive pressure breathing in therapy
Clin Pediatr
(1972)
LM Taussig et al.
Treatment of laryngotracheobronchitis (croup)
Am J Dis Child
(1975)

CR Westley et al.

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

Am J Dis Child

(1978)

JD Cherry

Croup (laryngitis, laryngotracheitis, spasmodic croup and laryngotracheobronchitis)

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Citation 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 (ED) discharge is safe when croup-related stridor has resolved after corticosteroids and a single dose of racemic epinephrine (RE). Little evidence supports the traditional practice of hospital admission after ≥ 2 doses of RE.
Our aim was to describe the frequency and timing of clinically important inpatient interventions after ≥ 2 ED RE doses.
We identified patients hospitalized for croup after ED treatment with corticosteroids and ≥2 doses of RE. We compared asymptomatic (admitted solely on the number of RE doses) and symptomatic (admitted due to disease severity) groups with regard to inpatient RE administration, supplemental oxygen, helium-oxygen mixture (heliox) therapy, intubation, or transfer to a higher level of care, time to hospital discharge, and revisit and readmission rates within 48 h of discharge.
Of 200 subjects admitted after ≥ 2 ED RE doses, 72 (36%) received clinically important inpatient interventions: RE (n = 68 [34%]), heliox (n = 9 [5%]), and supplemental oxygen (n = 4 [2%]). Of patients who received inpatient RE, 53% received only 1 dose. No patients underwent intubation or transfer to higher level of care. The 112 asymptomatic patients had fewer interventions (14% vs. 63%; p < 0.001) and shorter hospital durations (14.5 vs. 22 h; p < 0.001). Only 14% of the asymptomatic group received RE, with 75% receiving a single dose. There were no differences in revisit and readmission rates.
Inpatient interventions after ≥ 2 ED doses of RE for croup were infrequent, most commonly RE administration. Most patients asymptomatic upon admission require 0–1 inpatient RE doses and may be candidates for outpatient management.
Emergency department diagnosis and treatment of anaphylaxis: A practice parameter
2014, Annals of Allergy, Asthma and Immunology

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^☆: 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

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Safety and Efficacy of Nebulized Racemic Epinephrine in Conjunction With Oral Dexamethasone and Mist in the Outpatient Treatment of Croup☆,☆☆,★

Abstract

Section snippets

INTRODUCTION

MATERIALS AND METHODS

RESULTS

DISCUSSION

CONCLUSION

Acknowledgements

J Pediatr

J Emerg Med

Am J Emerg Med

J Pediatr

Treatment of croup. A critical review

Am J Dis Child

Croup: An 11-year study in a pediatric practice

Pediatrics

The acute obstructed laryngitis in infants and children

Hosp Med

Ten-year experience with IPPB in the treatment of acute laryngotracheobronchitis

Anesth Analg

Spasmodic croup in children: Personal experiences with intermittent positive pressure breathing in therapy

Clin Pediatr

Treatment of laryngotracheobronchitis (croup)

Am J Dis Child

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)