Management of Croup

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Management of Croup

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Classification

• Mild
• Intermittent barky cough, stridor with agitation
  but not at rest, mild tachypnea and tachycardia
• Moderate
• Audible stridor at rest, worsening stridor with
  agitation, barky cough, increased work of
  breathing(retraction, tachypnea, tachycardia)
• Severe
• Stridor with evidence of respiratory failure,
  that is cyanosis and altered mental status
• From Rosens Emergency Medicine fifth Edition

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Mist

• Mist improved symptoms with 10-20 min, perhaps by
  moistening thickened secretion, making them
  easier to mobilize.
• It is often all that is required for mild croup.
• It does not reduce subglottic edema.

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Racemic Epinephrine

• Acts by stimulating ?-adrenergic receptors in the
  subglottic mucous membranes, producing
  vasoconstriction and decreased mucosal edema.
• RE is composed of equal amounts of D- and
  L-isomers of epinephrine.
• Majority of its activity is due to L-isomers.
  D-isomers is only 30 potency of L-isomers.

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Racemic Epinephrine

• Positive effects can be seen in 10min with
  maximal effects in 1h and goes about 2h.
• RE dose not change the nature course of disease
  but improve ventilation.
• Use RE decreases the number number of children
  with croup requiring intubation, ICU admission,
  and general admission to the hospital.

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L-epinephrine(Bosmin) vs RE

• Dose
• Bosmin(11000) 0.5mL/kg(max 5mL)
• RE(2.25) 0.05mL/kg(max 0.5mL)
• Patients in both groups showed significant
  transient reduction of the croup score and RR
  following the aerosol(Plt0.01),but there were no
  differences between treatment groups when croup
  score,HR , BP, and RR were assessed over time.
• Yeheskel el, Pediatrics 1992 89302-306

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Relapse vs Rebound phenomenon

• Relapse phenomenon is more correctly
• The relapse phenomenon 2h after treatment was
  seen in 35(6 of 17 patients who improved) and
  25(2 of 8 patients) in the placebo group. No
  child was clinically worse 2h after treatment
  than before treatment.
• S.Kristjansson el, Acta Padiatri 831156-60,1994

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The current standard

• Administer nebulized epinephrine with early
  steroid and monitor these patients in the ED for
  least 3h before considering discharge for
  moderate to severe croup.
• Contraindication severe left ventricular
  outflow obstruction(IHSS, subvalvular aortic
  stenosis), pulmonary stenosis, TOF, and
  HRgt180(unless tachycardia from respiratory
  failure)

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Corticosteroids

• Steroid demonstrates clinical benefits in
  moderate to severe croup as in mild croup.
• Most likely it is due to vasoconstriction of the
  edematous mucosa.There effect on immune
  modulation and protein synthesis occur later and
  may be responsible for the longer-term clinical
  benefits.

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Dexamethasone

• Its half life is about 2 days(range 36-72 h).
  Peak effects are seen in 2 h with persistent
  effects over the next few weeks.
• 0.6 mg/kg dexamethasone(max 10 mg) IM is the
  standard in the outpatient management.
• Minh N. Cruz el, Pediatrics 199596220-223

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IM vs oral dexamethasone

• No direct comparison of oral and parenteral
  dexamethasone has be made.
• Studies primarily from the adult asthma
  literature demonstrate near bioequivalence of
  intravenous and oral steroids.
• The greater problem is vomiting and the bitter
  taste.
• Oral 0.15 mg/kg was equivalent to 0.6 mg/kg.
• G.C.Geelhoed el, Pediatric Pul 20362-368, 1995

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Nebulized budesonide and oral dexamethasone

• Oral dexamethasone vs nebulized budesonide vs
  oralnebulized steroid have the similar
  outcomes.Oral dexamethasone is the preferred
  intervention because of it ease of administration
  , lower cost, and more widespread availabilty.
• JAMA, 19982791629-1632

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Nebulized budesonide and IM dexamethasone

• IM dexamethasone resulted in greatest improvement
  than nebulized budesonide.
• Overall rate of hospitalization were 23 vs
  38(P0.18) and decreased croup score were
  2.9?0.2 vs 2.0?0.2(P0.003)
• David W. el, N Engl J Med 1998 339 498-503

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Intubation

• A croup score above 8 without rapid improvement
• Two catecholamine nebulizations required within 1
  hr
• Houlry nebulizations s required beyond the second
  hour
• Acute mental status changes associated with
  respiratory failure
• Worsening respiratory failure despite ongoing
  treatment
• Severe croup in a child with neonatal lung
  disease
• Moderately severe to severe croup in a child who
  need transfer

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Fibroscopic laryngscopy

• Considered in atypical or recurrent presentation
  of a crouplike syndrome.
• Indicated in children who fail to respond to
  standard therapy and occasionally in the very
  young to rule out laryngomalacia and other
  congenital cause of strider.