Croup, tratamiento actual / Croup management

Croup is a frequent cause of outpatient and emergency consultation. It is frequently triggered by a viral respiratory infection and characterized by an abrupt onset. We describe current studies about the treatment of croup. The use of systemic corticosteroids stands out as choice treatment, and nebulized epinephrine as short term therapy while waiting for the anti-inflammatory effect of steroids.

El Croup (laringitis aguda) es motivo frecuente de consulta en servicios de urgencia y policlínicos pediátricos. Generalmente es gatillado por una infección respiratoria viral y se caracteriza por un inicio abrupto. En el presente texto se describen los estudios vigentes acerca de su tratamiento. Destacan los corticoides sistémicos como terapia de elección y la adrenalina nebulizada como terapia de acción corta en espera de la acción antinflamatoria esteroidal.

Impacted button-battery masquerading as croup.

BACKGROUND: Foreign body ingestion is a frequent complaint in the Pediatric Emergency Department. OBJECTIVE: Button-battery ingestion is discussed, with particular attention being given to its management. CASE REPORT: Here is an interesting case of a button-battery ingestion by a 1-year-old boy with known asthma who presented to our Emergency Department. He presented in acute respiratory distress with signs of upper airway obstruction. Failing conventional therapy, a chest radiograph was obtained, which led to the diagnosis and subsequent removal. CONCLUSION: The management of a button-battery ingestion depends on the patient's age, the presence or absence of symptoms, the size of the object, and location of the object within the gastrointestinal tract. In years past, every esophageal button battery required emergent endoscopic removal. But revised guidelines from the National Battery Ingestion Hotline at the National Capital Poison Center have adjusted this management, which is discussed.

Acute obstructive respiratory tract diseases in a pediatric emergency unit: evidence-based evaluation.

OBJECTIVES: The objective of this study was to determine the evidence-based performance of the pediatric emergency unit in the diagnosis of and treatment approach to the patients with asthma, bronchiolitis, and croup. METHODS: In this study conducted in a retrospective cross-sectional way, emergency cards and computer data have been used. In the performance evaluation, the National Hospital Ambulatory Medical Care Survey criteria were considered. In the evaluation of performance in diagnosis, the rates of chest x-ray studies and use of corticosteroids and antibiotics were examined. Use of antibiotics in the cases not having a fever or any symptoms of bacterial infection and failure in prescribing steroids to the cases with moderate-to-severe symptoms were considered as bad performance criteria. χ(2) test was used for the data, which can be classified; Mann-Whitney U and Student t tests were used for the data with normal distribution and for the continuous variables. RESULTS: Study groups were composed of 2795 patients (1742 cases with asthma, 115 cases with croup, 938 cases with bronchiolitis) aged between 3 and 140 months (mean [SD], 41.2 [31] months). Chest x-ray study was requested significantly more often in the cases of bronchiolitis and croup with severe symptoms. In asthma cases, chest x-ray study was requested in those with severe clinical symptoms. In all 3 groups, a significant difference between the severity levels of the cases, from whom hemogram was requested, was determined. Biochemical tests were requested more often in those with severe bronchiolitis or asthma. Antibiotics were prescribed to none of the mild bronchiolitis cases. However, steroids were recommended more often to patients with moderate and severe bronchiolitis. They were administered to all patients with croup. Systemic steroids were prescribed more often to those with moderate or severe asthma. CONCLUSIONS: In our unit, both antibiotics administration and chest x-ray studies requested in patients with bronchiolitis, croup, and asthma were in low rates. Steroids in asthma attacks were found to be high in severe cases and in croup cases as well.

Corticosteroids in respiratory diseases in children.

We review recent advances in the use of corticosteroids (CS) in pediatric lung disease. CS are frequently used, systemically or by inhalation. Their mechanisms of action in pulmonary diseases are ill defined. CS exert direct inhibitory effects on many inflammatory cells through genomic mechanisms. There is a time lag before clinical response, and the washout of effects is also prolonged. Prompt relief in some conditions, such as croup, may be related to airway mucosal vasoconstriction through a nongenomic mechanism. CS have proven beneficial roles in the treatment of asthma, croup, allergic bronchopulmonary aspergillosis, and subglottic hemangioma. In some conditions, such as bronchiolitis, cystic fibrosis, and bronchopulmonary dysplasia, their use is controversial and is not recommended routinely. In other conditions, such as tuberculosis, interstitial lung disease, acute lung aspiration, and acute respiratory distress syndrome, CS are often used empirically despite the lack of clear evidence of their benefit. New drug regimens, including the more flexible use of inhaled corticosteroids and long-acting ß-agonists in asthma, the lack of efficacy of oral corticosteroids in preschool children with acute wheeze, the severe complications of systemic dexamethasone used to prevent bronchopulmonary dysplasia and thus more restricted use, and the beneficial effect of pulse high-dose intravenous methylprednisolone in patients with allergic bronchopulmonary aspergillosis or cystic fibrosis are among the major recent developments. There is concern about adverse effects, especially growth and adrenal suppression, induced by systemic CS in children. These have been reduced, but not eliminated, with the use of the inhaled route. The benefits must be weighed against the potential detrimental effects.

[Acute group A beta-hemolytic streptococcus membranous laryngotracheobronchitis in an adult]. / Laryngotrachéobronchite aiguë membraneuse à streptocoque bêta-hémolytique du groupe A de l'adulte.

OBJECTIVE: To describe the first case of a group A beta-hemolytic streptococcus laryngotracheobronchitis as well as the other possible etiologies in a case of acute dyspnea. METHODS: We report the case of a 46-year-old woman with a doubtful vaccination status who presented clinical features of croup (laryngotracheobronchitis). She developed respiratory distress and required endotracheal intubation. RESULTS: The endoscopy demonstrated a great deal of crust and pseudomembrane detachment. Bacterial culture grew group A beta-hemolytic streptococcus. Progression was good with antibiotics and corticosteroid treatment. CONCLUSION: Bacterial acute pseudomembranous croup (laryngotracheobronchitis) is rare. We must search for the most frequent diagnoses such as diphtheria and epiglottitis. This is the first case to be reported in the literature.

Los corticoides orales, son más o menos eficaces que el budesonide inhalado, para tratar la laringitis subglótica, leve a moderada, en niños? / Are oral corticosteroids more or less effective than inhaled budesonide in treating mild to moderate croup in children?

El tratamiento de la laringitis aguda en los niños, sigue siendo muy controvertido. Mientras que algunos sugieren no tratar las laringitis leves argumentando que se trata de un proceso benigno y autolimitado, otros están a favor de brindar tratamiento farmacológico, ya que éste puede ofrecer beneficios. Tanto el budesonide nebulizado como los corticoides orales, han demostrado mejorar la sintomatología inicial de la laringitis leve a moderada, disminuir el tiempo de estadía en el área de observación de urgencias, disminuir los ingresos hospitalarios y la necesidad de intubacíón. La revisión de la literatura mostró que el budesonide y la dexametasona oral, en monodosis, son igualmente eficaces. A la hora de elegir una vía de administración de los corticoides, debe tenerse en cuenta la disponibilidad de la droga, la edad y la colaboración del paciente y de sus padres. Considerando estos parámetros, parecería que la dexametasona oral se convierte en el tratamiento de elección para niños con laringitis leve a moderada, ya que es más económica, está más disponible que el budesonide, y su administración es más sencilla que la nebulización.

Laringotraqueobronquitis en niños hospitalizados: características clínicas / Laryngotracheobronchitis in hospitalized children: clinical features

Introducción: Laringotraqueobronquitis (LTB) es una condición frecuente en niños, con escasos estudios publicados en la literatura nacional. Objetivo: Caracterizar los episodios de LTB en nuestra institución. Método: Estudio retrospectivo descriptivo del 2001 al 2003. Resultados: 68 pacientes sufrieron 72 episodios de LTB. La edad promedio fue 16,5 meses, 62 por ciento eran varones. La mayoría de los ingresos ocurrieron en otoño (65 por ciento). El número de días promedio de síntomas previo al ingreso fue 2, siendo los más frecuentes estridor (85 por ciento), tos seca (78 por ciento) y fiebre (72 por ciento). La estadía promedio duró 1 día. Se identificó virus Parainfluenza en 12 de 23 inmunofluorescencias. La terapia incluyó adrenalina (100 por ciento), corticoides (96 por ciento), oxígeno (15 por ciento), salbutamol (11 por ciento) y antibióticos (11 por ciento). Las complicaciones fueron neumonía (3 por ciento) y traqueitis bacteriana (2 por ciento). Conclusión: En nuestra serie, LTB fue más frecuente en varones y menores de 2 años, con clara estacionalidad, estadías hospitalarias cortas y un bajo riesgo de complicaciones.

[Laryngitis revealing bacterial tracheitis in a five-year-old child]. / Laryngite révélatrice d'une trachéite bactérienne chez un enfant âgé de cinq ans.

CASE REPORT: We report the case of a five-year-old boy with clinical features of croup and left lower lobe pneumonia. Response to inhaled adrenaline and dexamethasone was incomplete and he developed respiratory distress. Direct laryngoscopy performed in the operating room showed mild glottic and subglottic inflammation. On bronchoscopy, there was thick pus coming from the left lower lobe. He was intubated for three days and regular toilet brought back thick pus. Tracheal fluid culture grew Haemophilius influenzae. COMMENTS: We suggest that he had bacterial tracheitis but that the tracheal involvement was not prominent at the time of diagnosis. CONCLUSION: Laryngoscopy and bronchoscopy in specialized surroundings should be considered for each child with croup unresponsive to conventional treatment, especially in case of lower respiratory tract involvement.

Common (but not always considered) viral infections of the lower respiratory tract.

Viral lower respiratory tract infections continue to cause a great deal of morbidity and mortality in the United States and worldwide, despite advances in treatment options, chemoprophylaxis, and vaccine development. The availability of ribavirin has improved the outlook in high-risk patients who develop respiratory syncytial virus bronchiolitis while intensive efforts are continued to develop an efficacious and safe vaccine. Respiratory syncytial virus immunoglobulin may prove to be a useful tool in the armamentarium of the pediatrician to prevent or modify respiratory syncytial virus disease in individual patients. Influenza vaccination and chemoprophylaxis remain mainstays in the prevention of influenza disease in high-risk individuals. The availability of a vaccine for varicella and a wider dissemination of measles vaccine, particularly in developing nations, may well limit the adverse outcomes associated with pneumonias caused by these two viruses. The transplant patient and other immunocompromised patients will continue to challenge clinicians and scientists to provide innovative and effective therapies for viral infections. The exciting advances in clinical and research virology over the last decade offer much hope to practicing pediatricians who struggle with offering prevention strategies and treatment options for their patients. Viral lower respiratory tract infections will never be eliminated as a clinical problem, although the morbidity and mortality associated with them will continue to improve.

Steroids for intubated croup masking airway haemangioma.

Recently, the beneficial role of steroids for acute laryngotracheobronchitis has been more clearly defined for both intubated and unintubated patients. However, corticosteroids also improve the clinical signs of airway haemangiomata. Two patients are described who illustrate how this can be a source of diagnostic confusion.

Hospitalized croup (bacterial and viral): the role of rigid endoscopy.

This is a retrospective study of 500 cases of hospitalized patients with the diagnosis of croup (laryngotrachitis), admitted between January 1986 and August 1988, at the Montreal Children's Hospital. The patient's age, sex, clinical history, physical examination, number of admissions, season of admission, method of diagnosis, treatment and management were reviewed. Two per cent of these patients were diagnosed as bacterial croup. All of them required intubation and endoscopic evaluation in their management. Of all the viral croup patients, less than one-third were severe enough to require an intensive care setting for their management. In these patients, 6% required endotracheal intubation, and on endoscopy, a significant number of these patients had an endoscopic airway abnormality in addition to croup (subglottic edema). According to our findings, we suggest diagnostic micro-laryngoscopy and bronchoscopy be performed on certain groups of croup patients because of their higher yield of airway abnormality on endoscopy.

Use of steroids and a long-acting vasoconstrictor in the treatment of postintubation croup. A ferret model.

There is little in the literature to support recommendations for the use of steroids and vasoconstrictors in the treatment of postintubation croup. We developed a ferret model to study this condition. Ninety-eight ferrets were used in these experiments, which were undertaken to evaluate the efficacy of steroids and/or a long-acting vasoconstrictor, to develop dose-response curves for dexamethasone sodium phosphate if it proved efficacious, and to evaluate the possible synergistic effects of combination therapy. With this animal model, we were able to document a statistically significant early effect of dexamethasone sodium phosphate, but only when administered in large doses (greater than 0.5 mg/kg). Our data also support the tapering of these large doses within a 20-hour period. The long-acting vasoconstrictor oxymetazoline hydrochloride has a clear and statistically significant beneficial effect that is apparent by 20 hours and continues through 40 hours. We did not find any additive or synergistic effect of the combination of dexamethasone and oxymetazoline. Further studies are underway in our laboratory to elucidate other aspects of this interesting syndrome.