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Nebulized budesonide for children with mild-to-moderate croup
Abstracts
together with age may serve to define patients at increased risk for thrombolytic related hemorrhagic CVAs. [ Paulo Berger, MD] Editor’s Comment: If validated in a larger study, this observation may prove useful. However, the wide variation in blood pressures due to interobserver technique differencesmay be difficult to overcome.
0 NEBULIZED BUDESONIDE FOR CHILDREN WITH MILD-TO-MODERATE CROUP. Klassen TP, Feldman ME, Watters LK, et al. NEJM. 1994;331(5):28590. The objective of this randomized, placebo-controlled trial was to determine if emergency department treatment with nebulized budesonide, a synthetic glucocorticoid, results in significant clinical improvement in outpatients with mild-to-moderate croup. Patients were recruited from a childrens’ hospital emergency department. Eligibility criteria were: age 3 months to 5 years, syndrome consistent with croup, and a croup score of at least 2 after breathing humidified oxygen for at least 15 min. Patients were excluded if they had severecroup (croup score > 8 or requiring immediate racemic epinephrine), history of recent steroid use, or chronic airway disease. Subjects were randomized to double-blinded treatment with nebulized budesonide or saline. They were assessedat baseline, then hourly for 4 h, until the croup score was 1 or less, or the physician discharged the patient. Physicians were able to use other medications at their discretion. Outcome variables included croup scores; global assessmentof change as assessedby physicians, parents, and research assistants; and number of patients requiring observation or treatment for more than 4 h. Three hundred ninety patients were diagnosed with croup during the study period. However, only 54 patients who met eligibility criteria and presented at times when the study team was available were included. In comparison to the placebo-treated group, the group treated with budesonide had a significantly lower median croup score, more favorable global assessments,and discharge from the emergency department occurred earlier. There was no significant difference in use of adjunctive treatment. The authors conclude that nebulized budesonide is effective in the initial therapy of mild-to-moderate croup. [Marc David Taub, MD] Editor’s Comment: This is a relatively small study of a convenience population, but Budesonide performed impressively with no adverse effects noted.
0 CARDIOPULMONARY RESUSCITATION AND RIB FRACTURES IN INFANTS. Spevak MR, Kleinman, PK, Belanger PL, et al. JAMA. 1994;272:617-8. Numerous studies have demonstrated association between cardiopulmonary resuscitation (CPR) and resultant rib fractures in adults. Despite a lack of comparable stud-
425 ies, a similar association is often assumed in infants. In a retrospective review, the medical records and autopsy results of 91 infants less than 1 year of age who received CPR over an 8-year period were reviewed. All infants also received skeletal surveys that were reviewed by two pediatric radiologists. Although CPR was administered by emergency department technicians in 82% of cases, parents, other family members, and police were also identified as the person giving CPR. Seventy-five of the 91 infants died of sudden infant death syndrome. Sixteen died of other natural or accidental causes. No infants were found to have rib fractures. The authors concluded that any identified rib fractures in an otherwise normal infant should raise a suspicion of abuse, even if the infant required resuscitation. [Scott J. Jones, MD] Editor’s Comment: The presence of rib fractures in this age group should cause the diagnosis of nonaccidental trauma to be considered.
0 INCREASED CEREBRAL AND DECREASED FEMORAL ARTERY BLOOD FLOW VELOCITIES DURING DIRECT LARYNGOSCOPY AND TRACHEAL INTUBATION. Moorthy SS, Greenspan CD, Dierdorf SF, et al. Anesth Analg. 1994;78:1144-8. As demonstrated in previous studies, both direct laryngoscopy and tracheal intubation cause an increase in heart rate and arterial blood pressure due to sympathoadrenal stimulation. This study of 13 adults demonstrates the distribution of blood flow to various organs during intubation by measuring changes in blood flow velocity, which has been shown to correlate with changes in blood flow. The authors prospectively studied blood flow velocity in the common carotid, middle cerebral, and femoral arteries before and after laryngoscopy and intubation. The authors report an increase in both common carotid and middle cerebral artery blood flow velocity as well as a decrease in femoral artery blood flow velocity. These findings of increased cerebral blood flow and decreased peripheral blood flow further support the need to consider the effect of direct laryngoscopy and tracheal intubation in patients with suspected increased intracranial pressure or vascular malformations. [Melissa McClure, MD] Editor’s Comment: Rapid sequenceinduction should be performed with adjuncts to reduce intracranial pressure in all cases, and not just in patients with signs of such abnormalities.
0 CUFFED ENDOTRACHEAL TUBES IN PEDLQTRIC INTENSIVE CARE. Deakers TW, Reynolds G, Stretton M, et al. J Pediatr. 1994;125(1):57-62. The use of uncuffed endotracheal tubes (ETTs) in children under 8 is the current standard of care. Concern regarding postextubation laryngeal edema and tracheal ste-
together with age may serve to define patients at increased risk for thrombolytic related hemorrhagic CVAs. [ Paulo Berger, MD] Editor’s Comment: If validated in a larger study, this observation may prove useful. However, the wide variation in blood pressures due to interobserver technique differencesmay be difficult to overcome.
0 NEBULIZED BUDESONIDE FOR CHILDREN WITH MILD-TO-MODERATE CROUP. Klassen TP, Feldman ME, Watters LK, et al. NEJM. 1994;331(5):28590. The objective of this randomized, placebo-controlled trial was to determine if emergency department treatment with nebulized budesonide, a synthetic glucocorticoid, results in significant clinical improvement in outpatients with mild-to-moderate croup. Patients were recruited from a childrens’ hospital emergency department. Eligibility criteria were: age 3 months to 5 years, syndrome consistent with croup, and a croup score of at least 2 after breathing humidified oxygen for at least 15 min. Patients were excluded if they had severecroup (croup score > 8 or requiring immediate racemic epinephrine), history of recent steroid use, or chronic airway disease. Subjects were randomized to double-blinded treatment with nebulized budesonide or saline. They were assessedat baseline, then hourly for 4 h, until the croup score was 1 or less, or the physician discharged the patient. Physicians were able to use other medications at their discretion. Outcome variables included croup scores; global assessmentof change as assessedby physicians, parents, and research assistants; and number of patients requiring observation or treatment for more than 4 h. Three hundred ninety patients were diagnosed with croup during the study period. However, only 54 patients who met eligibility criteria and presented at times when the study team was available were included. In comparison to the placebo-treated group, the group treated with budesonide had a significantly lower median croup score, more favorable global assessments,and discharge from the emergency department occurred earlier. There was no significant difference in use of adjunctive treatment. The authors conclude that nebulized budesonide is effective in the initial therapy of mild-to-moderate croup. [Marc David Taub, MD] Editor’s Comment: This is a relatively small study of a convenience population, but Budesonide performed impressively with no adverse effects noted.
0 CARDIOPULMONARY RESUSCITATION AND RIB FRACTURES IN INFANTS. Spevak MR, Kleinman, PK, Belanger PL, et al. JAMA. 1994;272:617-8. Numerous studies have demonstrated association between cardiopulmonary resuscitation (CPR) and resultant rib fractures in adults. Despite a lack of comparable stud-
425 ies, a similar association is often assumed in infants. In a retrospective review, the medical records and autopsy results of 91 infants less than 1 year of age who received CPR over an 8-year period were reviewed. All infants also received skeletal surveys that were reviewed by two pediatric radiologists. Although CPR was administered by emergency department technicians in 82% of cases, parents, other family members, and police were also identified as the person giving CPR. Seventy-five of the 91 infants died of sudden infant death syndrome. Sixteen died of other natural or accidental causes. No infants were found to have rib fractures. The authors concluded that any identified rib fractures in an otherwise normal infant should raise a suspicion of abuse, even if the infant required resuscitation. [Scott J. Jones, MD] Editor’s Comment: The presence of rib fractures in this age group should cause the diagnosis of nonaccidental trauma to be considered.
0 INCREASED CEREBRAL AND DECREASED FEMORAL ARTERY BLOOD FLOW VELOCITIES DURING DIRECT LARYNGOSCOPY AND TRACHEAL INTUBATION. Moorthy SS, Greenspan CD, Dierdorf SF, et al. Anesth Analg. 1994;78:1144-8. As demonstrated in previous studies, both direct laryngoscopy and tracheal intubation cause an increase in heart rate and arterial blood pressure due to sympathoadrenal stimulation. This study of 13 adults demonstrates the distribution of blood flow to various organs during intubation by measuring changes in blood flow velocity, which has been shown to correlate with changes in blood flow. The authors prospectively studied blood flow velocity in the common carotid, middle cerebral, and femoral arteries before and after laryngoscopy and intubation. The authors report an increase in both common carotid and middle cerebral artery blood flow velocity as well as a decrease in femoral artery blood flow velocity. These findings of increased cerebral blood flow and decreased peripheral blood flow further support the need to consider the effect of direct laryngoscopy and tracheal intubation in patients with suspected increased intracranial pressure or vascular malformations. [Melissa McClure, MD] Editor’s Comment: Rapid sequenceinduction should be performed with adjuncts to reduce intracranial pressure in all cases, and not just in patients with signs of such abnormalities.
0 CUFFED ENDOTRACHEAL TUBES IN PEDLQTRIC INTENSIVE CARE. Deakers TW, Reynolds G, Stretton M, et al. J Pediatr. 1994;125(1):57-62. The use of uncuffed endotracheal tubes (ETTs) in children under 8 is the current standard of care. Concern regarding postextubation laryngeal edema and tracheal ste-