A randomized trial of a single dose of oral dexamethasone for mild croup

Potential therapeutic approaches for modulating expression and accumulation of defective lamin A in laminopathies and age-related diseases

Scientific understanding of the genetic components of aging has increased in recent years, with several genes being identified as playing roles in the aging process and, potentially, longevity. In particular, genes encoding components of the nuclear lamina in eukaryotes have been increasingly well characterized, owing in part to their clinical significance in age-related diseases. This review focuses on one such gene, which encodes lamin A, a key component of the nuclear lamina. Genetic variation in this gene can give rise to lethal, early-onset diseases known as laminopathies. Here, we analyze the literature and conduct computational analyses of lamin A signaling and intracellular interactions in order to examine potential mechanisms for altering or slowing down aberrant Lamin A expression and/or for restoring the ratio of normal to aberrant lamin A. The ultimate goal of such studies is to ameliorate or combat laminopathies and related diseases of aging, and we provide a discussion of current approaches in this review.

Understanding implementation processes of clinical pathways and clinical practice guidelines in pediatric contexts: a study protocol

Background

Canada is among the most prosperous nations in the world, yet the health and wellness outcomes of Canadian children are surprisingly poor. There is some evidence to suggest that these poor health outcomes are partly due to clinical practice variation, which can stem from failure to apply the best available research evidence in clinical practice, otherwise known as knowledge translation (KT). Surprisingly, clinical practice variation, even for common acute paediatric conditions, is pervasive. Clinical practice variation results in unnecessary medical treatments, increased suffering, and increased healthcare costs. This study focuses on improving health outcomes for common paediatric acute health concerns by evaluating strategies that improve KT and reduce clinical practice variation.

Design/Methods

Using a multiple case study design, qualitative and quantitative data will be collected from four emergency departments in western Canada. Data sources will include: pre- and post-implementation focus group data from multidisciplinary healthcare professionals; individual interviews with the local champions, KT intervention providers, and unit/site leaders/managers; Alberta Context Tool (ACT) survey data; and aggregated patient outcome data. Qualitative and quantitative data will be systematically triangulated, and matrices will be built to do cross-case comparison. Explanations will be built about the success or lack of success of the clinical practice guidelines (CPG) and clinical pathways (CPs) uptake based upon the cross-case comparisons.

Significance

This study will generate new knowledge about the potential causal mechanisms and factors which shape implementation. Future studies will track the impact of the CPG/CPs implementation on children's health outcome, and healthcare costs.

Scientific rationale for the use of alpha-adrenergic agonists and glucocorticoids in the therapy of pediatric stridor

Purpose. The most common pharmacological therapies used in the treatment of stridor in children are glucocorticosteroids (GC) and alpha-adrenergic (αAR) agonists. Despite the long-standing reported efficacy of these medications, there is a paucity of data relating to their actual mechanisms of action in the upper airway. Summary. There is compelling scientific evidence supporting the use of αAR-agonists and GCs in pediatric stridor. αAR signaling and GCs regulate the vasomotor tone in the upper airway mucosa. The latter translates into better airflow dynamics, as delineated by human and nonhuman upper airway physiological models. In turn, clinical trials have demonstrated that GCs and the nonselective αAR agonist, epinephrine, improve respiratory distress scores and reduce the need for further medical care in children with stridor. Future research is needed to investigate the role of selective αAR agonists and the potential synergism of GCs and αAR-signaling in the treatment of upper airway obstruction and stridor.

Pharmacokinetics, pharmacodynamics, and comparative bioavailability of single, oral 2-mg doses of dexamethasone liquid and tablet formulations: a randomized, controlled, crossover study in healthy adult volunteers

BACKGROUND

Dexamethasone is a glucocorticoid used widely worldwide for immunosuppressive treatment, allergies, bronchiolitis, and croup, among others. For children, liquid formulations are especially suitable because, compared with other dosage forms, both exact dosing and proper intake are facilitated.

OBJECTIVE

The objective was to evaluate the pharmacokinetics, pharmacodynamics, and comparative bioavailability of a commercial liquid oral dexamethasone formulation intended for pediatric use relative to those of a tablet.

METHODS

In a randomized, controlled, crossover study in 24 healthy adult volunteers, we administered single doses of the liquid and tablet formulation, containing 2 mg of dexamethasone each. Blood samples were taken up to 24 hours postdose. Quantification was carried out using a validated specific and sensitive high-pressure liquid chromatography with UV detector method. Noncompartmental pharmacokinetic parameters were compared between treatments according to European Medicines Agency (EMA) bioequivalence guidelines. For AUC(0-t) and C(max), the 90% CI for the ratio of the test and reference products should be contained within the predetermined acceptance interval of 80% to 125%. As a pharmacodynamic variable, we measured suppression of endogenous cortisol (predose and postdose).

RESULTS

Both preparations showed similar pharmacokinetic and pharmacodynamic profiles but high between-subject variability of pharmacokinetic key parameters and endogenous cortisol concentrations (>30%). Mean AUC(0-t), AUC(0-∞), and C(max) were 37.8 ng/mL/h, 46.0 ng/mL/h, and 9.35 ng/mL, respectively, for the liquid and 41.3 ng/mL/h, 48.1 ng/mL/h, and 9.17 ng/mL, respectively, for the tablet formulation. T(max) was 0.89 hour (liquid) and 0.97 hour (tablet). The point estimates and 90% CIs for AUC(0-t), AUC(0-∞), and C(max) ratios (liquid vs tablet) were 91.42% (82.05%-101.86%), 95.72% (84.46%-108.5%), and 102.04% (86.94%-119.76%), respectively. Thus, point estimates and 90% CIs were within the bioequivalence range of 80% to 125% for all relevant parameters, including the pharmacodynamic parameter AUEC (area under the effect curve).

CONCLUSIONS

This single-dose study suggests that the test and reference products met the EMA regulatory criteria to assume bioequivalence in these fasting healthy male and female volunteers. German Register of Clinical Trials registration number: DRKS00000785.

How fast does oral dexamethasone work in mild to moderately severe croup? A randomized double-blinded clinical trial

OBJECTIVE

For children with croup controversy remains over dosage and time to onset of action of oral steroids. The Cochrane Collaboration and other reviews have suggested 0.6 mg/kg dexamethasone be used (despite some evidence that 0.15 mg/kg is effective) with no expectation of benefit before 4-6 h. This randomized double-blinded clinical trial examines whether 0.15 mg/kg dexamethasone works by 30 min.

METHODS

Children with croup aged above 6 months presenting to a tertiary paediatric ED with a Westley croup score of mild to moderate range (scores 1-6 out of 17) were randomized to receive either 0.15 mg/kg dexamethasone or oral placebo solution. Vital signs and croup score were recorded at study entry and every 10 min up to 1 h after administration of the study drug. The main outcome measure was croup score at 30 min.

RESULTS

Each group contained 35 children. Baseline characteristics were similar, except for respiratory rate, which was higher in the placebo group. There was a growing trend to a lower croup score in the dexamethasone group, evident from 10 min and statistically significant from 30 min.

CONCLUSION

For children with croup an oral dose of 0.15 mg/kg dexamethasone offers benefit by 30 min, much earlier than the 4 h suggested by the Cochrane Collaboration. This result might encourage doctors to treat more children with all severities of croup being less worried about potential side-effects and delayed benefit.

Glucocorticoids for croup

BACKGROUND

Since the initial publication of this systematic review in 1997, several randomized trials examining the benefit of glucocorticoids have been published. The objective of this review is to provide evidence to guide clinicians in their treatment of patients with croup by determining the effectiveness of glucocorticoids and to identify areas requiring future research.

OBJECTIVES

To determine the effect of glucocorticoids for children with croup.

SEARCH STRATEGY

We searched CENTRAL (2010, Issue 3), which contains the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE (1966 to July week 2, 2010) and EMBASE.com (1974 to July 2010). We also contacted authors of identified croup trials published in the last 10 years to inquire about additional published or unpublished trials.

SELECTION CRITERIA

Randomised controlled trials (RCTs) that examine children with croup and objectively measure the effectiveness of glucocorticoids.

DATA COLLECTION AND ANALYSIS

Two review authors identified studies for potential relevance based on the review of the title and abstract (when available). Two review authors independently reviewed studies for relevance using a priori inclusion criteria and assessed trial quality. Differences were resolved by consensus. One review author extracted data using a structured form and another review author checked the results for accuracy. We performed standard statistical analyses.

MAIN RESULTS

Thirty-eight studies were included (n = 4299). Glucocorticoids were associated with an improved Westley score (maximum 17 points) at six hours with a mean difference of -1.2 (95% confidence interval (CI) -1.6 to -0.8) and at 12 hours -1.9 (95% CI -2.4 to -1.3); at 24 hours this improvement was no longer significant (-1.3, 95% CI -2.7 to 0.2). Fewer return visits and/or (re)admissions occurred in participants treated with glucocorticoids (risk ratio (RR) 0.5; 95% CI 0.3 to 0.7). Length of time spent in accident and emergency or hospital (mean difference 12 hours, five to 19 hours) was significantly decreased for participants treated with glucocorticoids. Use of epinephrine decreased for children treated with a glucocorticoid (risk difference 10%; 95% CI 1 to 20).

AUTHORS' CONCLUSIONS

Dexamethasone and budesonide are effective in relieving the symptoms of croup as early as six hours after treatment. Fewer return visits and/or (re)admissions are required and the length of time spent in hospital is decreased. Research is required to examine the most beneficial method for disseminating croup practice guidelines and to increase the uptake of evidence.

Pediatric emergency research networks: a global initiative in pediatric emergency medicine

OBJECTIVES

Objectives of the Pediatric Emergency Research Network's (PERN's) meeting included (1) learn about each of the participating network's missions, goals, and infrastructure; (2) share important contributions each network has made to the creation of new knowledge; (3) discuss "best practices" to improve each network's effectiveness; and (4) explore the potential for a collaborative research project as proof of concept that would help us promote quality of care of the acutely ill and injured child/youth globally.

METHODS

In October 2009, a multiday meeting was attended by 18 delegates representing the following pediatric emergency medicine research networks: Pediatric Emergency Medicine Collaborative Research Committee (United States), Pediatric Emergency Care Applied Research Network (United States), Pediatric Emergency Research of Canada (Canada), Paediatric Research in Emergency Departments International Collaborative (Australia and New Zealand), and Research in European Pediatric Emergency Medicine (15 countries in Europe and the Middle East).

RESULTS

The inaugural meeting of PERN demonstrated that there is a common desire for high-quality research and the dissemination of this research to improve health and outcomes of acutely ill and injured children and youths throughout the world. Presently, the PERN group is in the final stages of developing a protocol to assess H1N1 risk factors with the collection of retrospective data.

CONCLUSIONS

Several members of PERN will be gathering at the International Conference on Emergency Medicine in Singapore, where the group will be presenting information about the H1N1 initiative. The PERN group is planning to bring together all 5 networks later in 2010 to discuss future global collaborations.

The relationship between characteristics of context and research utilization in a pediatric setting

Background

Research utilization investigators have called for more focused examination of the influence of context on research utilization behaviors. Yet, up until recently, lack of instrumentation to identify and quantify aspects of organizational context that are integral to research use has significantly hampered these efforts. The Alberta Context Tool (ACT) was developed to assess the relationships between organizational factors and research utilization by a variety of healthcare professional groups. The purpose of this paper is to present findings from a pilot study using the ACT to elicit pediatric and neonatal healthcare professionals' perceptions of the organizational context in which they work and their use of research to inform practice. Specifically, we report on the relationship between dimensions of context, founded on the Promoting Action on Research Implementation in Health Services (PARIHS) framework, and self-reported research use behavior.

Methods

A cross-sectional survey approach was employed using a version of the ACT, modified specifically for pediatric settings. The survey was administered to nurses working in three pediatric units in Alberta, Canada. Scores for three dimensions of context (culture, leadership and evaluation) were used to categorize respondent data into one of four context groups (high, moderately high, moderately low and low). We then examined the relationships between nurses' self-reported research use and their perceived context.

Results

A 69% response rate was achieved. Statistically significant differences in nurses' perceptions of culture, leadership and evaluation, and self-reported conceptual research use were found across the three units. Differences in instrumental research use across the three groups of nurses by unit were not significant. Higher self-reported instrumental and conceptual research use by all nurses in the sample was associated with more positive perceptions of their context.

Conclusions

Overall, the results of this study lend support to the view that more positive contexts are associated with higher reports of research use in practice. These findings have implications for organizational endeavors to promote evidence-informed practice and maximize the quality of care. Importantly, these findings can be used to guide the development of interventions to target modifiable characteristics of organizational context that are influential in shaping research use behavior.

Respiratory viral infections in infants: causes, clinical symptoms, virology, and immunology

In global terms, respiratory viral infection is a major cause of morbidity and mortality. Infancy, in particular, is a time of increased disease susceptibility and severity. Early-life viral infection causes acute illness and can be associated with the development of wheezing and asthma in later life. The most commonly detected viruses are respiratory syncytial virus (RSV), rhinovirus (RV), and influenza virus. In this review we explore the complete picture from epidemiology and virology to clinical impact and immunology. Three striking aspects emerge. The first is the degree of similarity: although the infecting viruses are all different, the clinical outcome, viral evasion strategies, immune response, and long-term sequelae share many common features. The second is the interplay between the infant immune system and viral infection: the immaturity of the infant immune system alters the outcome of viral infection, but at the same time, viral infection shapes the development of the infant immune system and its future responses. Finally, both the virus and the immune response contribute to damage to the lungs and subsequent disease, and therefore, any prevention or treatment needs to address both of these factors.

27 years of croup: an update highlighting the effectiveness of 0.15 mg/kg of dexamethasone

OBJECTIVE

To update an earlier observational study (1980-1995) documenting dramatic improvements in the management of croup with the mandatory use of a single oral dose of dexamethasone and to ascertain whether a reduction from a dose of 0.6 to 0.15 mg/kg in 1995 maintained these improved outcomes over the next 11 years.

METHODS

We evaluated retrospectively the experience of children with croup in Princess Margaret Hospital for Children, the only tertiary paediatric hospital in Western Australia, over the subsequent 11 year period from 1996 to 2006 inclusive. Data were updated from ED, general hospital and the intensive care unit records to show the numbers of children presenting to the hospital, admitted, transferred to intensive care and intubated. We also recorded the length of hospital stay and representation rate of all cases within 7 days.

RESULTS

The dramatic improvements in outcomes for croup, including reduced admission rates, length of stay, transfers to the intensive care unit, intensive care unit days and number of intubations as reported in our earlier paper, were maintained using 0.15 mg/kg dexamethasone. Admission rates for croup have fallen from 30% in the early 1990s to less than 15% in recent years, whereas the representation rate has risen slightly.

CONCLUSION

The improved outcomes for children with croup presenting to our paediatric ED have been maintained with a reduced, single oral dose of 0.15 mg/kg of dexamethasone.

Dealing with heterogeneity of treatment effects: is the literature up to the challenge?

Background

Some patients will experience more or less benefit from treatment than the averages reported from clinical trials; such variation in therapeutic outcome is termed heterogeneity of treatment effects (HTE). Identifying HTE is necessary to individualize treatment. The degree to which heterogeneity is sought and analyzed correctly in the general medical literature is unknown. We undertook this literature sample to track the use of HTE analyses over time, examine the appropriateness of the statistical methods used, and explore the predictors of such analyses.

Methods

Articles were selected through a probability sample of randomized controlled trials (RCTs) published in Annals of Internal Medicine, BMJ, JAMA, The Lancet, and NEJM during odd numbered months of 1994, 1999, and 2004. RCTs were independently reviewed and coded by two abstractors, with adjudication by a third. Studies were classified as reporting: (1) HTE analysis, utilizing a formal test for heterogeneity or treatment-by-covariate interaction, (2) subgroup analysis only, involving no formal test for heterogeneity or interaction; or (3) neither. Chi-square tests and multiple logistic regression were used to identify variables associated with HTE reporting.

Results

319 studies were included. Ninety-two (29%) reported HTE analysis; another 88 (28%) reported subgroup analysis only, without examining HTE formally. Major covariates examined included individual risk factors associated with prognosis, responsiveness to treatment, or vulnerability to adverse effects of treatment (56%); gender (30%); age (29%); study site or center (29%); and race/ethnicity (7%). Journal of publication and sample size were significant independent predictors of HTE analysis (p < 0.05 and p < 0.001, respectively).

Conclusion

HTE is frequently ignored or incorrectly analyzed. An iterative process of exploratory analysis followed by confirmatory HTE analysis will generate the data needed to facilitate an individualized approach to evidence-based medicine.

Epiglottitis and croup

Infections of the upper airways are a frequent cause of morbidity in children. Viral laryngotracheobronchitis (croup) is the most common cause of stridor in children and usually has a self-limited course with occasional relapses in early childhood. Epiglottitis has become rare in developed countries with the advent of universal vaccinations against Haemophilus influenzae. It can be rapidly fatal, however, if not promptly recognized and appropriately managed. This article reviews the pathogenesis, epidemiology, clinical presentation, diagnosis, and management of these pediatric upper airway infections.

Croup management in Australia and New Zealand: a PREDICT study of physician practice and clinical practice guidelines

OBJECTIVE

Comparison of clinical practice guideline (CPG) recommendations and reported physician management of croup at PREDICT (Paediatric Research in Emergency Departments International Collaborative) sites as baseline for planned randomized controlled trials.

METHODS

Review of CPGs for croup from PREDICT sites and survey of specialist pediatric emergency physicians regarding croup management. PREDICT sites included 8 tertiary pediatric hospitals and 3 large mixed emergency departments in Australia and New Zealand.

RESULTS

Nine of the 11 sites had a CPG for croup. Response rate was 94% (78/83). Adrenaline was recommended for moderate croup (3%), severe croup (52%), and life-threatening croup by (100%). Steroid therapy was recommended for mild croup (45%), for moderate croup (97%), for severe croup (97%), and for life-threatening croup (96%). Steroid choice was oral dexamethasone (60%) and oral prednisolone (38%). In severe croup, 77% used intravenous/intramuscular dexamethasone, 10% used intravenous/intramuscular methylprednisolone, and 8% used nebulized budesonide. Commonest dosage regimens were 0.15 mg/kg dexamethasone or 1 mg/kg prednisolone. A standard volume dosage regimen for nebulized adrenaline was used by 54%, whereas 39% used a weight-based formula. Clinical practice guidelines recommended 5 mg (11%) or 10 mg (33%) for standard volume dosing, and all CPGs using weight-based dosing recommend 0.5 mg/kg with maximum doses ranging from 5 to 15 mg.

CONCLUSIONS

Croup management at PREDICT emergency departments is similar, based on oral steroids and nebulized adrenaline. The steroid and adrenaline regimens used by respondents and their CPGs were not consistent. This reflects limitations of available evidence for management of this common disease, highlighting the need for definitive trials, particularly in the management of mild croup.

Respiratory viruses other than influenza virus: impact and therapeutic advances

Though several antivirals have been developed and marketed to treat influenza virus infections, the development of antiviral agents with clinical activity against other respiratory viruses has been more problematic. Here we review the epidemiology of respiratory viral infections in immunocompetent and immunocompromised hosts, examine the evidence surrounding the currently available antivirals for respiratory viral infections other than influenza, highlight those that are in the pipeline, and discuss the hurdles for development of such agents.

Serum interferon-gamma, interleukin-4, and interleukin-6 in infants with adenovirus and respiratory syncytial virus infection

BACKGROUND

To characterize adenoviral (ADV) infection, the clinical symptoms, laboratory findings and serum cytokine concentrations were evaluated in ADV patients and compared with those in patients with respiratory syncytial virus (RSV) infections.

METHODS

A total of 63 patients who had been diagnosed with ADV infections or RSV on an antigen detection test were enrolled in the present study between December 2002 and March 2004. Forty patients had RSV infection and 23 patients had ADV infection. Serum cytokine (interleukin [IL]-4,6 and interferon [IFN]-gamma) concentrations were analyzed. Concentration of IL-6 in both infection groups was analyzed regardless of whether the patients had been given steroids (dexamethaxone or prednisolone). In addition, IL-6 levels were measured on day 1 and 4 of hospitalization.

RESULTS

A strong inflammatory response was observed in patients with ADV infection. Serum IL-6 levels in patients with ADV infection on day 4 of hospitalization were significantly higher than those in patients without steroids treatment or in patients with RSV infection. IL-4, and IFN-gamma were not significantly different.

CONCLUSION

Patients with ADV infections who were given steroids had a temporary increase of IL-6, which might have indicated the development of a severe clinical course if not been administered.

Croup

Most children who present with acute onset of barky cough, stridor, and chest-wall indrawing have croup. A careful history and physical examination is the best method to confirm the diagnosis and to rule out potentially serious alternative disorders such as bacterial tracheitis and other rare causes of upper-airway obstruction. Epinephrine delivered via a nebuliser is effective for temporary relief of symptoms of airway obstruction. Corticosteroids are the mainstay of treatment, and benefit is seen in children with all levels of severity of croup, including mild cases.

Croup in the paediatric emergency department

Croup is a common childhood illness. The majority of children presenting with an acute onset of barky cough, stridor and indrawing have croup. A careful history and physical examination is necessary to confirm the diagnosis of croup, and to rule out potentially serious alternative causes of upper airway obstruction. Nebulized adrenaline is effective for the temporary relief of airway obstruction. Corticosteroids are the mainstay of treatment in children with croup of all levels of severity.

[Steroids in the critical care children with septic shock and other conditions]

Steroids are indicated in paediatric intensive care as anti-inflammatory drugs or for substitutive treatment. During septic shock, the incidence of adrenal insufficiency (AI) varies between 18 à 52%, depending on the relative or absolute nature of the AI. Contrary to adults, for whom long courses of low doses of corticosteroids were shown to reduce mortality and increased shock reversibility, particularly in those with a negative synacthene test, no study provided sufficient evidence to show a benefit of steroids in terms of outcome in children with septic shock. In neonates, AI occurs frequently after cardiac surgery and the administration of steroids can improve haemodynamic condition. The recommended dose of hydrocortisone during septic shock or after cardiac surgery is 30 to 100 mg/m(2)/d. Dexamethasone is efficient to reduce postextubation stridor in children and neonate and the rate of reintubations in neonate. During croup, oral or parenteral steroids reduce clinical symptoms. Dexamethasone also reduces the incidence of severe chronic lung disease and the duration of tracheal intubation in premature infants. However the high incidence of side effects, particularly on the central nervous system, makes steroids currently not recommended for bronchopulmonary dysplasia. At last, steroids are indicated for severe asthma and for bacterial meningitis. In this latter indication, dexamethasone was shown to improve neurological outcome, indeed mortality in Haemophilus influenzae and Streptococcus pneumoniae meningitis.

Comparison between single-dose oral prednisolone and oral dexamethasone in the treatment of croup: a randomized, double-blinded clinical trial

OBJECTIVE

To compare the effectiveness of three corticosteroid regimens in children with mild to moderate croup.

METHODS

Double-blinded, randomized comparative trial with parallel design, conducted in the ED of a paediatric tertiary care hospital. Children aged 6 months to 6 years presenting to the ED with croup were eligible for inclusion if their Westley croup score was 2 or more. They were randomized to receive a single oral dose of either prednisolone 1 mg/kg, dexamethasone 0.15 mg/kg or dexamethasone 0.6 mg/kg. Primary outcome measures were the magnitude and rate of reduction in Westley croup score, rate of return for medical care with ongoing croup, and further treatment with steroids in the week following index presentation. Secondary outcome measures were the proportion of subjects requiring admission or salvage therapy, such as nebulized adrenaline, during index presentation.

RESULTS

A total of 99 children, aged 6-79 months, were enrolled (mean age: 1.7 years). Thirty-four patients were randomized to receive prednisolone 1 mg/kg, 34 to receive dexamethasone 0.15 mg/kg, and 31 to receive dexamethasone 0.6 mg/kg. Baseline characteristics of the three groups were similar. The parents of 86 patients (87%) were available for follow-up telephone interview at 1 week. There were no significant differences in primary or secondary outcome measures between the three treatment groups.

CONCLUSIONS

Both prednisolone 1 mg/kg and low-dose dexamethasone (0.15 mg/kg) were found not to differ in efficacy from the currently recommended 0.6 mg/kg dexamethasone. The use of these corticosteroid regimens in treating patients with mild to moderate croup is thus supported.

A Single Dose of Dexamethasone To Prevent Postbronchoscopy Fever in Children

STUDY OBJECTIVE

To assess the effectiveness of one dose of dexamethasone (0.5 mg/kg; maximum, 10 mg) to prevent fever after bronchoscopy with BAL.

DESIGN

Randomized, placebo-controlled study.

PATIENTS

Immunocompetent nonfebrile children undergoing fiberoptic bronchoscopy with BAL.

MEASUREMENTS AND RESULTS

Sixty-nine children were included in the study. Thirty-eight children received saline solution, and 31 children received dexamethasone. The two groups were similar regarding the number of children < 2 years old, the percentage of abnormal bronchoscopic findings, the number of positive BAL culture findings, and the index of lipid-laden macrophages. Twenty-six children (68%) in the saline solution group (SG) had fever, compared to 3 children (9.6%) in the dexamethasone group (DG) [p < 0.001]. Fever after the procedure appeared later (12.3 +/- 5.5 h) in the DG compared to 5.4 +/- 2.7 h in the SG.

CONCLUSIONS

One dose of dexamethasone administered prior to performing bronchoscopy with BAL may prevent fever subsequent to the procedure. Further studies are necessary in order to determine the optimal dosing regimen for dexamethasone when used for this purpose.

The availability and accessibility of basic paediatric resuscitation equipment in primary healthcare centres: cause for concern?

BACKGROUND

Paediatric emergencies in primary healthcare centres are serious events that occur more commonly than envisaged. However, at present, these centres appear to lack the training and equipment to manage common paediatric emergencies.

AIM

To determine the availability and accessibility of basic resuscitation equipment in primary healthcare centres.

METHODS

A questionnaire survey of 27 primary healthcare centres within the Nottingham City region determined the availability and accessibility of basic paediatric resuscitation equipment and algorithms.

RESULTS

No practice had all 21 basic resuscitation items, with 59% of practices having < or =10 of these items. Only 11% of practices had all seven basic airway and breathing resuscitation items, with 52% of practices having < or =4 items. No practice had all eight basic items for circulation management, with 82% of practices having < or =4 of these items. Only two practices had all six basic drug items, with 85% of practices having < or =3 of these items. Only 26% of practices had algorithms for paediatric basic life support and common emergencies, and only 30% of practices kept their resuscitation equipment together. In the last 5 y, less than a fifth of general practitioners were trained in paediatric resuscitation.

CONCLUSION

Primary healthcare centres appear to lack the training and equipment to manage common paediatric emergencies. We recommend standardization of equipment and algorithms, training and assessment of key personnel, and critical incident reporting within primary healthcare centres.

Changing epidemiology of life-threatening upper airway infections: the reemergence of bacterial tracheitis

OBJECTIVE

As a consequence of evolving medical practice, the epidemiology of potentially life-threatening upper airway infections is changing. We report our experience over 9 years with viral croup, epiglottitis, and bacterial tracheitis.

PATIENTS AND METHODS

We studied a retrospective case series of patients admitted to Vermont Children's Hospital with potentially life-threatening upper airway infections viral croup, epiglottitis, or bacterial tracheitis between 1997 and 2006.

MEASUREMENT AND MAIN RESULTS

There were 107 patients with viral croup admitted to Vermont Children's Hospital, with 16 (15%) admitted to the pediatric intensive care unit. Three patients with croup (17% of pediatric intensive care unit admissions, 3% of total admissions) required intubation. There were no serious complications. Eighteen patients were admitted with bacterial tracheitis. Ninety-four percent (n = 17) were admitted to the pediatric intensive care unit. Eighty-three percent (n = 15) were intubated. Twenty-eight percent of patients (n = 5) developed serious complications. Two adolescent patients were admitted with epiglottitis. Both were intubated and recovered without complications. Of 35 patients admitted to the pediatric intensive care unit with these potentially life-threatening upper airway infections, 20 patients (57%) developed respiratory failure. Fifteen patients (75%) had bacterial tracheitis, 3 patients (15%) had viral croup, and 2 patients (10%) had nonclassic epiglottitis.

CONCLUSIONS

Immunization against Haemophilus influenza type b and widespread use of corticosteroids for the treatment of viral croup have changed the epidemiology of acute infectious upper airway disease. As potentially life-threatening infections, viral croup and epiglottitis have been eclipsed by bacterial tracheitis. In this series, bacterial tracheitis was 3 times more likely to have caused respiratory failure than viral croup and epiglottitis combined. Bacterial tracheitis should be considered in children who present with acute life-threatening upper airway infection.

Oral betamethasone versus intramuscular dexamethasone for the treatment of mild to moderate viral croup: a prospective, randomized trial

OBJECTIVE

Intramuscular dexamethasone is an effective, but painful, treatment for croup. The effectiveness of betamethasone, an oral, palatable, and equally potent glucocorticoid has not been studied. The purpose of this study was to compare the effectiveness of a single oral dose of betamethasone with intramuscular dexamethasone in the outpatient treatment of mild to moderate croup.

METHODS

Children aged 6 months to 6 years presenting to a tertiary care pediatric emergency department (ED) with a modified Westley croup score of 0 to 11 were randomized to receive either 0.6 mg/kg IM dexamethasone or 0.4 mg/kg PO betamethasone. Croup score, heart rate, respiratory rate, pulse oximetry, and need for supplemental treatments were recorded at study entry and at 1, 2, and 4 hours after treatment. Follow-up data were collected by daily telephone follow-up on persistence of symptoms and the need for additional treatment or physician visits up to 7 days after the ED visit.

RESULTS

Each study group contained 26 patients. Despite randomization, the mean baseline croup score was higher in the dexamethasone group (3.6 +/- 2.6 vs. 2.0 +/- 2.4, P = 0.03). Patients in both groups showed a significant reduction in the croup score after treatment, and there were no significant differences between croup scores at 4 hours (P = 0.18). Similarly, there were no differences between groups in the hospital admission rate, time to resolution of symptoms, need for additional treatments, or number of return ED visits.

CONCLUSION

There is no difference between oral betamethasone and intramuscular dexamethasonein the management of mild to moderate viral croup. It is palatable and does not require a nurse for administration, making it a good alternative for ambulatory management.

Airway infectious disease emergencies

Upper and lower respiratory infections are encountered commonly in the emergency department. Visits resulting from occurrences of respiratory disease account for 10% of all pediatric emergency department visits and 20% of all pediatric hospital admissions. Causes of upper airway infections include croup, epiglottitis, retropharyngeal abscess, cellulitis, pharyngitis, and peritonsillar abscesses. Lower airway viral and bacterial infections cause illnesses such as pneumonia and bronchiolitis. Signs and symptoms of upper and lower airway infections overlap, but the differentiation is important for appropriate treatment of these conditions. This article reviews the varied clinical characteristics of upper and lower airway infections.

The assessment and management of croup

The treatment of croup has changed considerably over the last 25 years with the liberalisation of the use of systemic corticosteroids for mild to moderate croup. The administration of corticosteroids in croup has reduced the severity of the condition, dramatically reduced the need for endotracheal intubation, shortened the duration of intubation, reduced the length of hospital stay, reduced the need for hospital admission and reduced daycare/preschool absenteeism and improved sleep in milder cases. Despite studies showing the efficacy of nebulised and intramuscular corticosteroids, the use of oral corticosteroids remains the recommended option in most, if not all, cases of croup presenting for medical assessment.

State of the evidence for standard-of-care treatments for croup: are we where we need to be?

BACKGROUND

Croup is a term that groups several different clinical syndromes with inspiratory stridor. The failure to delineate the specific syndromes has led to suboptimal treatment in many instances.

METHODS

A literature review and personal experience have been analyzed.

RESULTS

Specific croup syndromes have been identified. Most croup steroid-treatment studies have failed to adequately identify the specific illness being treated. With 2 exceptions, all studies done to date have been too small to sufficiently evaluate risks of steroids if the risk is 1% or less.

CONCLUSIONS

Three conclusions were reached: (1) no steroid treatment studies of moderate or severe laryngotracheitis have been of adequate size to determine the risk of progressive viral infection or secondary bacterial infection; (2) single dose steroid treatment or limited nebulized use is probably safe; and (3) we should encourage better clinical diagnosis of croup illnesses.

Croup hospitalizations in Ontario: a 14-year time-series analysis

OBJECTIVE

Croup is the most common form of airway obstruction in children. Known to be primarily viral, the seasonality of croup has been examined largely through its association with the human parainfluenza viruses. This study examined the seasonal pattern of croup hospitalizations in relation to age and gender for the province of Ontario during a 14-year period.

METHODS

A retrospective, population-based study design was used to examine seasonal and temporal patterns of croup hospitalizations from April 1, 1988, to March 31, 2002. All residents of Ontario who were aged 0 to 4 years and eligible for universal health coverage during the study period were included for analysis. Time-series analyses then were conducted on monthly aggregations of hospitalizations.

RESULTS

This study found strong evidence of croup hospitalization seasonality, with a biennial midautumn peak and annual summer trough, evident throughout the 14-year study period (Fisher's kappa = 51.11; Bartlett Kolmogorov Smirnov = 0.552). The pattern was observed in all children aged 0 to 4, although boys were hospitalized 2 times more often than girls of the same age. Rates of croup hospitalization were lower for children aged 1 to 4 years than for children aged 0 to <1. A marked decrease in croup hospitalizations was observed after the winter of 1993/1994 and continued to decrease in a step-wise manner for the remainder of the study period.

CONCLUSIONS

This study delineates a clear biennial pattern of seasonal croup hospitalizations, varying by age and gender, with a large decrease in hospitalizations after the winter of 1993/1994. It is expected that these findings will have important implications for the treatment and management of childhood croup.

Advances in the treatment and prevention of severe viral bronchiolitis

Viral bronchiolitis continues to be a major public health problem. Prevention of severe RSV-associated bronchiolitis has been achieved in high-risk infants by passive administration of the humanized monoclonal anti-RSV-F antibody, palivizumab. Development of more potent anti-RSV neutralizing antibodies is underway, and vaccine development continues to progress. Supportive therapy is the mainstay for the treatment of established infection while new antiviral and anti-inflammatory strategies are being explored in preclinical trials.