Asthma, Bronchiolitis and Croup (and some quickies) Pediatric ABC’s Asthma, Bronchiolitis and Croup (and some quickies) David Chaulk Pediatric EM Fellow January, 2004

Case 1 A seven year old boy presents to the Emergency Department with a 24 hour history of cough, wheeze and increasing shortness of breath which began shortly after the onset of a low grade fever and rhinorrhoea. He has had one previous episode of wheezing. The episode had followed an upper respiratory tract infection. He is not on any medications.

What treatment would you initiate? He is agitated and talking in short phrases only, with a respiratory rate of 40 per minute, heart rate of 130 and oxygen saturation in room air of 89%. Examination of the chest reveals moderate intercostal and subcostal retractions. On auscultation, you note reduced breath sounds throughout the lung fields with widespread expiratory wheeze. Other than a clear nasal discharge, the remainder of the physical examination is normal. What treatment would you initiate? We should discuss the predictive value of RR, presenting room air oxygen saturation for hospitalization.

Questions: Should you give him ipratropium bromide with the first mask? What about racemic epinephrine instead of salbutamol? Steroids? PO or IV? Inhaled? When? What about magnesium ? Spacer vs nebulizer ?

Question 1: Does the addition of a nebulized anticholinergic agent (ipratropium bromide) to nebulized beta-agonist decrease the risk of admission to hospital?

Should inhaled anticholinergics be added to ß2 agonists for treating acute childhood and adolescent asthma? A systematic review Plotnick et al, 1998 10 trials involving 836 children. Outcomes: respiratory function (FEV1) and rates of admission Addition of a single dose of anticholinergic : improvement in FEV1 at 60 minutes (mean difference 16.1%) but no reduction in hospital admission

Should inhaled anticholinergics be added to ß2 agonists for treating acute childhood and adolescent asthma? A systematic review Plotnick et al, 1998 In children with more severe asthma who received multiple doses of ipratropium: reduction in hospital admission by 30% Number of children needed to treat with ipratropium to prevent one hospital admission is 11 Important to emphasize effect is apparent only for moderate to severe asthmatics, not for mild. Ducharme J Pediatr~ 2000 or 2001

Moderate to severe asthma in ED Effect of nebulized ipratropium on the hospitalization rates of children with asthma Qureshi et al, 1998 Double blind RCT 434 pts, 2-18 yrs Moderate to severe asthma in ED All had salbutamol every 20 minutes and oral prednisone at 2mg/kg Received either ipratropium bromide (500 mcg) or placebo with the second and third inhalations of salbutamol Importance of this study is that it included children under six, different than many of the other studies examining this question.

Effect of nebulized ipratropium on the hospitalization rates of children with asthma Qureshi et al, 1998 Significant decrease in hospitalization, with an absolute reduction in hospitalization rate of 15.1% The number of children with severe asthma to be treated with ipratropium to prevent one admission was 6.6

Cochrane Review May 2001 8 studies - considerable heterogeneity Single dose does not work Multiple dose decreases admissions NNT 12 overall 95% CI ( 8, 32 ) NNT 7 severe subgroup 95% CI ( 5,20 )

Question 2: Is racemic epinephrine effective in children who have acute asthma ?

Salbutamol or racemic epinephrine at 0,20,40 min A randomized double blind study comparing the efficacy of racemic epinephrine to salbutamol in acute asthma. Plint et al, 2000 Double blind RCT 120 pts, 1-17 yrs Salbutamol or racemic epinephrine at 0,20,40 min All had PO dexamethasone. Outcomes: pulmonary index score (PIS), oxygen saturation, length of stay in ED, hospital admission and relapse rate. No significant difference between two treatments Mention IV salbutamol

Question 3: In children with acute asthma, do IV steroids decrease hospitalization and improve clinical symptoms as compared to oral steroids?

Intravenous versus oral corticosteroids in the management of asthma in children Barnett, 1997 Double blind RCT 49 pts, 18 mo-18 yr with severe asthma Given 2 mg/kg methylprednisolone either PO or IV 30 min after first albuterol Outcomes: Pulmonary index score, FEV1, hospital admission rates No difference in PIS, FEV1 at 4 hours. No difference in hospitalization rates.

Oral versus intravenous corticosteroids in children hospitalized with asthma Becker et al, 1999 Double blind RCT 66 pts, 2-18 yrs Prednisone 2 mg/kg/dose BID vs methylprednisolone 1 mg/kg/dose QID Outcomes: length of hospitalization, ß agonist use, duration of Oxygen tx and PFT’s Oxygen use significantly less in prednisone group (30 vs 59 hours). No other differences noted.

Question 4: When should you give systemic steroids to the patient ?

Cochrane Review May 2001 Early emergency department treatment of acute asthma with systemic corticosteroids 12 Studies : 863 Patients 409 Pediatric Steroids within 1 hr of arrival in the ED Main outcome: need for admission Number needed to treat with steroids in the first hour to prevent one admission = 6

Question 5 What is the role of inhaled steroids in acute asthma?

6 trials ( 4 adult, 2 pediatric) The effectiveness of inhaled corticosteroids in the emergency department treatment of acute asthma: a meta-analysis Edmonds, 2002 6 trials ( 4 adult, 2 pediatric) 2 compared inhaled steroids in addition to systemic steroids, 4 comparison to placebo 352 pts Less likely to be admitted (OR 0.3) Small improvement in peak exp flows ( 8%) Unable to determine if as effective as systemic steroids There are broadly two timing issues with inhaled. Early use in ED vs. use on discharge. The is a SR for each topic. Let’s talk more about this when we meet.

Question 5 Is magnesium sulfate effective in improving symptoms in children with moderate to severe acute asthma?

After receiving B agonist and methylprednisolone A randomized trial of magnesium in the emergency department treatment of children with asthma. Scarfone, 2000 54 pts 1-18 yrs After receiving B agonist and methylprednisolone 75 mg/kg of MgSO4 or placebo Outcomes: pulmonary index score, admissions No significant differences between groups David, I think it is important to mention the other RCT published since the SR by Ciarillo. My view on the issue is outlined below – it’s a comment I wrote a couple years ago. ‘Though the use of magnesium to treat acute asthma was first proposed in the 1930’s, controlled trials examining the effectiveness of magnesium have only been published in the last 15 years. The majority of studies have been in adults; until now only two controlled trials have been published in children (J Pediatr 1996;129:809-14 & Indian Pediatr 1997;34:389-97). Though neither Ciarallo et al. nor Scarfone et al. fully described how they carried out randomization or allocation (as advocated by the CONSORT Statement, JAMA 1996:226:637-9), in general both studies are well designed. Scarfone’s study design included a strict management protocol for co-treatments such as albuterol and methylprednisolone and general guidelines for hospital admission, whereas Ciarallo’s study allowed ED physicians much greater autonomy in terms of whether or not to use co-treatments or to admit patients to hospital. This is unlikely, however, to be the reason for the difference in their findings. That is because, on average, fixed management protocols dampen patient-to-patient variability not due to the study treatment. Therefore this difference in study design should have predisposed Ciarallo to finding no difference and Scarfone to finding a difference between the treatment groups - the opposite of their actual findings. The likely explanation for why Ciarallo found magnesium to be effective and Scarfone did not, is in how they selected their respective patient populations. Though it is somewhat difficult to compare overall clinical severity between the two studies because they used very different methods (a Peak Expiratory Flow Rate less than 70% predicted following three nebulized bronchodiator treatments versus a Pulmonary Index between 8 and 13 prior to treatment with any bronchodilator), the rate of admission in the control group – 100% versus 53% - suggests Ciarallo’s patients were a lot sicker. This speculation is consistent with the findings of Rowe et al. (Ann Emerg Med 2000;36:181-189) who have recently published a well designed meta-analysis of randomized controlled trials examining the benefit of magnesium in both adults and children with acute asthma. They found, after analyzing seven controlled trials involving 668 patients, that patients treated with magnesium had somewhat greater improvements in pulmonary function and fewer hospitalizations, but that neither were statistically significant. However, when they performed a subgroup analysis, patients with severe asthma treated with magnesium had significantly greater improvement in pulmonary function and fewer hospitalizations. Their findings were the same when they considered only the two previously published pediatric trials. Consequently it is my opinion that - when viewed in the context of Rowe’s meta-analysis - the results of Ciarallo and Scarfone are consistent and provide a reasonably strong argument for the selective use of intravenous magnesium in those children with acute severe asthma who do not adequately respond to bronchodilators.’

Higher Dose Intravenous Magnesium Therapy For Children with Moderate to Severe Acute Asthma Ciarallo, 2003 Double Blind, Placebo controlled trial 30 pts aged 6-18 At 20 minutes Mg group improved in all aspects of PFT (PF, FEV1, FVC) Still greater improvement at 110 mins More likely to be discharged (8/16 compared to 0/14) Compare this study with Scarfone, Ciarallo had sicker pateints

Cochrane Review Magnesium sulfate for treating exacerbations of acute asthma in the emergency department Sep 2000 7 trials 5 adult, 2 pediatric 665 pts ( 78 pediatric) Outcome = Admission Rate No benefit when all patients treated Severe sub-group showed significant benefit (90% --> 48% adm)

Question 6 Does the Salbutamol need to be given by nebulization or can a spacer device be used?

Cochrane Review July 2001 16 studies: 686 children 375 adults No difference in admission rate 95% CI ( OR: 0.4 to 2.1 ) Children’s LOS in the ED shorter mean diff: -0.62 hours 95% CI ( -0.84 to -0.40 )

Metered-dose inhalers with spacers vs nebulizers for pediatric asthma Chou, 1995 152 patients > 2 years old Unblinded 3 puffs q20 minutes via aerochamber vs. 0.15mg/kg Ventolin via nebulizer

Time in ED Vomiting HR Spacer 66 9% +5% Nebulizer 103 20% +15% Metered-dose inhalers with spacers vs nebulizers for pediatric asthma Chou, 1995 Time in ED Vomiting HR Spacer 66 9% +5% Nebulizer 103 20% +15%

Single dose does not appear to be of any benefit Case 1- Summary: Multiple doses of ipratropium bromide added to nebulized ßagonist reduce the rate of hospital admission Single dose does not appear to be of any benefit Racemic epinephrine is equivalent to salbutamol in children with asthma, with no increased adverse effects Let’s discuss this.

Case 1- Summary: Oral steroids given in equipotent doses are equivalent to intravenous steroids Steroids should be given early in the emergency course Inhaled steroids may have an adjunctive role Magnesium may be beneficial in severe cases Spacers may be effective for acute asthma

Pediatric Asthma Guidelines MILD Treatment Nocturnal cough Exertional SOB Increased Ventolin use Good response to Ventolin O2 sat > 95% Ventolin Consider po Steroids

Pediatric Asthma Guidelines Normal mental status Abbreviated speech SOB at rest Ventolin > q4h O2 sat 92%-95% O2 100% Ventolin Systemic corticosteroids Consider anticholinergic MODERATE Treatment

Pediatric Asthma Guidelines Altered mental status Difficulty speaking Laboured respirations Persistent tachycardia No prehospital relief with Ventolin O2 saturation <92% 100% O2 Continuous Ventolin Systemic corticosteroids Anticholinergic Consider Magnesium sulfate SEVERE Treatment

Case 2 A four month old infant is seen in your emergency department with a history of fever and difficulty breathing. He has had nasal congestion and cough for several days and today developed increased respiratory difficulties.

Case 2 He was born at 32 weeks gestation and had an uncomplicated neonatal course, requiring no oxygen or ventilatory support. He has been well since discharge from the neonatal unit and is on no regular medications. There is no history of atopy.

Case 2 On examination, he is in moderate respiratory distress. Vital signs are as follows: HR 180, RR 60, T 38.9o C. Oxygen saturation 91%. He has widespread wheeze and fine crackles on auscultation. Remainder of exam is normal. The chest x-ray shows evidence of hyperinflation (air-trapping) and some infiltrates in the lower lobes. A diagnosis of viral bronchiolitis is made.

Questions: Does treatment with bronchodilators reduce symptoms or the need for hospital admission? Is epinephrine more effective than beta-agonists? Does treatment with steroids reduce symptoms or the need for hospital admission? Does treatment with antibiotics reduce bacterial complications?

Question 1: In infants with clinical features of bronchiolitis, does treatment with bronchodilators improve symptoms and reduce the need for hospital admission?

Efficacy of Bronchodilator Therapy in Bronchiolitis: A meta-analysis Kellner et al, 1996 RCTs of bronchodilator use in bronchiolitis 15 of 89 publications met selection criteria 8 trials had first time wheezers only Total of 734 pts included 3 outcomes: clinical score, O2 saturation, and hospitalization

Efficacy of Bronchodilator Therapy in Bronchiolitis: A meta-analysis Kellner et al, 1996 ß2 agonist most commonly used was albuterol. Some studies also included ipratropium bromide and epinephrine. With pooled results, only improvement in clinical sxs was statistically significant. No effect on hospital admission rates. Conclusion: There is a only a modest short-term effect of bronchodilators on bronchiolitis

Efficacy of ß2 agonists in Bronchiolitis: A reappraisal and meta-analysis Flores and Horowitz, 1997 ß2 agonists had no impact on hospitalization rates. No significant effect on respiratory rate. Statistically significant improvement in oxygen saturation (2.8%) and heart rate (15 bpm) but not clinically significant. Short term outpatient studies do not support the use of ß2 agonists in bronchiolitis.

Question 2: Does epinephrine, which has both alpha and beta-adrenergic properties, have an advantage over salbutamol and other beta-agonists?

A Meta Analysis of Randomized Controlled Trials Evaluating The Efficacy of Epinephrine For the Treatment of Acute Viral Bronchiolitis Hartling, et al., Oct 2003 14 studies, 7 inpt, 6 outp, 1 unk Outpatients Epinephrine more effective than placebo in clinical score (60 minutes) Oxygen saturation (30 mins) RR at 30 mins Epinephrine more effective than salbutamol in: Oxygen saturation at 60 mins RR at 60 mins HR at 90 mins Small number of studies of varying quality Inpatient results not as impressive difference b/w r/e and ventolin

Question 3: In infants with clinical features of bronchiolitis, does treatment with dexamethasone reduce symptoms?

Dexamethasone in salbutamol-treated patients with acute bronchiolitis: a randomized controlled trial. Klassen et al, 1997 Randomized, double blind study. 67 pts, 6 wks-15 mos. Hospitalized infants. Oral dexamethasone (0.5 mg/kg first dose, followed by two daily doses of 0.3mg/kg) or placebo. Outcomes: readmission rate, length of stay and improvement in clinical score. No statistically significant difference between treatment and placebo groups.

Systemic Corticosteroids in infant bronchiolitis: a meta-analysis Systemic Corticosteroids in infant bronchiolitis: a meta-analysis. Garrison, 2000 6 trials 347 hospitalized pts < 24 months Outcomes: Length of stay, duration of symptoms, clinical scores LOS or DOS: .43 days less in steroid group Clinical score : - 1.60 (favoring treatment) Steroids beneficial?

Efficacy of oral dexamethasone in outpatients with acute bronchiolitis Efficacy of oral dexamethasone in outpatients with acute bronchiolitis. Schuh 2002 Double blind RCT 70 children <24 mos Dexamethasone 1 mg/kg vs placebo Outcomes: Clinical score and admissions Admission rate in Dex group 19% vs 44% in placebo group

Question 4: Is oral salbutamol effective for the outpatient management of bronchiolitis?

Randomized, Double-blind, Placebo-controlled Trial of Oral Salbutamol in Outpatient Infants with Acute Viral Bronchiolitis Patel 2002 Randomized, double-blind trial Infants with first-time wheezing At discharge ED received either salbutamol (0.1 mg/kg/ dose) TID or placebo for 7 days Daily telephone interviews inquiring about symptom frequency and severity were conducted with caregivers for 14 days Outcome: time to resolution of symptoms

Randomized, Double-blind, Placebo-controlled Trial of Oral Salbutamol in Outpatient Infants with Acute Viral Bronchiolitis Patel 2002 Secondary outcomes included time to: normal feeding and sleeping resolved cough resolved coryza, and quiet breathing Re-visit and hospital admission rates were also measured 127 infants were enrolled SAL = 63, PLAC = 64 mean age 4.9 mos, 60% male 76% positive for RSV

Randomized, Double-blind, Placebo-controlled Trial of Oral Salbutamol in Outpatient Infants with Acute Viral Bronchiolitis Patel 2002 Mean times to resolution of symptoms (days) were similar: SAL = 8.9 PLAC = 8.4 (p = 0.5) No significant group differences in the secondary outcomes No significant group differences in the symptom resolution in infants treated with oral salbutamol versus placebo

Question 5: In infants with RSV bronchiolitis, does treatment with antibiotics reduce bacterial complications or the need for readmission?

Risk of secondary bacterial infection in infants hospitalized with respiratory syncytial viral infection Hall et al, 1988 1706 pts, 565 of these RSV positive. < 3 yrs Prospective 7 of 565 had subsequent bacterial infection: 5 pneumonia (4 Strep. pneumoniae, 1 H.influenzae), 1 meningitis, 1 Salmonella sepsis prior antibiotic use in 5 of 7 overall 62% of RSV patients did not receive antibiotics Overall rate of bacterial infection is 1.2%

ßagonists not effective for bronchiolitis Case 2 - Summary: Bronchodilators have a only a modest short term effect on bronchiolitis ßagonists not effective for bronchiolitis Racemic epinephrine may improve clinical symptoms, reduces hospital admission rates - superior to salbutamol in some studies Bonchodilators and bronchioloitis…the jury is still out

Case 2 - Summary: Dexamethasone may be effective in bronchiolitis Oral salbutamol is not effective Antibiotic use in bronchiolitis does not improve outcome or reduce bacterial complications - overall risk of bacterial infection is low

Case 3 A two-year-old previously healthy, immunized boy is brought to the ED in acute respiratory distress. He has a 2 day history of runny nose, cough and low-grade fever. Today he has developed a hoarse voice and barky cough.

Case 3 On arrival, vital signs: RR 40, T 38.5, P 140, BP 90/60, O2 sat 95%. He is sitting upright in his mother's lap with stridulous, labored breathing. He is not drooling. He has diminished breath sounds, no crackles or wheezes. His extremities are pink and warm with brisk capillary refill. The remainder of his examination is normal. You diagnose croup and order racemic epinephrine.

Questions: Is steroid therapy effective in reducing acute symptoms? Do inhaled steroids give any additional benefit? Is dexamethasone 0.15 mg/kg as effective as 0.6 mg/kg?

Is mist therapy effective in reducing acute symptoms? Questions: Is mist therapy effective in reducing acute symptoms? Is L-epinephrine as effective as racemic epinephrine? Following nebulized epinephrine, what period of observation is needed Is epi beneficial, what’s its duration? How long must you observe? Should you hospitalize? RE vs LE? Mist Steroids – rate of intubation, duration of hospitalization, rate of admission, rate of return Type of steroid – Inhaled vs. IM/PO, additive benefit from inhaled, PO vs IM, dex vs other Heliox? Anything else? Beta agonists, AB, decongestants

Question 1: In children with croup, is steroid therapy effective in reducing acute symptoms?

The effectiveness of glucocorticoids in treating croup: meta-analysis Ausejo, 1999 Meta-analysis of RCTs of glucocorticoid treatment in croup 24 studies met inclusion criteria. 4 mos to 12 yrs (mean ages 13 to 45 mos) Trials included: 17 assessed dexamethasone 9 assessed budesonide 3 assessed methylprednisolone

The effectiveness of glucocorticoids in treating croup: meta-analysis Ausejo, 1999 Fourteen trials involved inpatients and 10 trials outpatients. The studies were small with a median of 40 participants. Overall, significant improvement in croup score at 6 and 12 hrs. By 24 hrs this improvement was not statistically significant.

The effectiveness of glucocorticoids in treating croup: meta-analysis Ausejo, 1999 Significant decrease in the number of epinephrine tx needed - decrease was 9% in the budesonide group and 12% in the dexamethasone group. Significant decrease in the length of hospital stay both in the ED (stay reduced by 11 hours) and for inpatients (stay reduced by 16 hours). NNT for significant improvement in outcome is 5-7 patients.

The effectiveness of glucocorticoids in treating croup: meta-analysis Ausejo, 1999 Conclusions: Glucocorticoids bring clinical improvement within 6 hours Nebulized budesonide, PO and IM Dexamethasone are equally effective in treating croup Use of glucocorticoids associated with lower rate of cointerventions and shorten hospital stay

Question 2: Do inhaled steroids give any additional benefit in children with croup?

Nebulized budesonide and oral dexamethasone for treatment of croup: A randomized controlled trial Klassen, 1998 Double blind RCT Three arms: oral dexamethasone 0.6 mg/kg and nebulized placebo oral placebo and nebulized budesonide 2 m - oral dexamethasone and nebulized budesonide Outcomes: croup score, hospitalization rates, time in ED, return visits, symptoms>1 week

Nebulized budesonide and oral dexamethasone for treatment of croup: A randomized controlled trial Klassen, 1998 Change in croup score was: -2.3 for Budesonide -2.4 for Dex -2.4 for combined group No differences between treatment groups. Conclusion: Based on decreased cost and ease of administration, dexamethasone alone is preferred treatment.

A comparison of nebulized budesonide, IM dexamethasone and placebo for moderately severe croup Johnson et al, 1998 Double blind RCT 144 pts, 6 mos-4 yr Treated with: nebulized budesonide IM dexamethasone placebo

A comparison of nebulized budesonide, IM dexamethasone and placebo for moderately severe croup Johnson et al, 1998 Hospitalization rates: 71% placebo 38% budesonide 23% dexamethasone Statistically significant difference steroids vs placebo No difference between bud and dex Croup scores: significant improvement with dex or bud better than placebo and dex better than budesonide

Question 3: In children with croup, is single-dose decadron 0.15 mg/kg PO as effective as 0.6 mg/kg PO in reducing acute symptoms?

Oral dexamethasone in the treatment of croup: 0. 15 mg/kg versus 0 Oral dexamethasone in the treatment of croup: 0.15 mg/kg versus 0.3 mg/kg versus 0.6 mg/kg. Geelhoed, 1995 RCT 164 pts >3mos No differences in croup score at 1-8 hours, hospitalization rate, length of stay or need for racemic epinephrine. Meta-analysis by Kairy – dose-response curve. Is a study focusing on milder disease applicable to those with most severe disease? Is the study adequately powered to detect equivalence?

Question 4: Is mist therapy effective in reducing acute symptoms?

Humidification in viral croup: a controlled trial Bourchier,1984 RCT. Not blinded 16 pts Humidified air delivered in croup tent for 12 hours vs room air. No difference in croup score, RR, HR, oxygen saturation at one hour intervals.

Randomized to receive humidified oxygen via mist stick vs. no mist A randomized controlled trial assessing the effectiveness of mist in the acute treatment of croup. Neto, 2002 71 pts Randomized to receive humidified oxygen via mist stick vs. no mist All received Dexamethasone 0.6 mg/kg Outcome measures: croup score, oxygen saturation, HR, RR, length of stay, admission rate. Assessed at 0,30,60,90,120 min. No significant difference in any of the outcome measures between the two groups. Important to note that delivery of humidity was not measured, and quite likely 100% was rarely achieved.

Question 5: In children with croup, is a comparable dose of L-epinephrine as effective in reducing acute symptoms as racemic epinephrine?

Prospective randomized double-blind study comparing L-epinephrine and racemic epinephrine in the treatment of laryngotracheitis Waisman, 1995 Double blind RCT 31 pts, 6 mos-6 yrs Racemic epinephrine 0.5 ml in 4.5 ml saline vs L-epinephrine 5 ml of 1:1000 solution. Both had reduction in croup score with no difference seen at 5,15,30,60,120 min. No differences in HR, RR, BP, Oxygen saturation.

Question 6: In children with croup who improve following nebulized racemic epinephrine, how long should they be observed to demonstrate no 'rebound' worsening of symptoms?

The disposition of children with croup treated with racemic epinephrine and dexamethasone in the emergency department Rizos et al, 1998 Prospective, cohort study 82 pts All received IM dexamethasone and racemic epinephrine. Discharged home if free of retractions and stridor at 2 hours. Telephone follow up. 6 required follow up within 48 hours. 2 were admitted No adverse outcomes.

Case 3 - Summary: Steroid therapy: improves clinical symptoms within 6 hours shortens hospital stay decreases need for epinephrine treatments Oral dexamethasone equivalent to nebulized budesonide no increased benefit of adding inhaled steroids Dexamethasone at 0.15 mg/kg as effective as 0.6 mg/kg

Case 3 - Summary: No proven benefit of mist therapy L-epinephrine as effective as racemic epinephrine with no increased adverse effects If patient is symptom free, may be discharged at 2 hrs post racemic epinephrine

Quickies

Epiglottitis RARE now with Hib gone Pneumococcus, Staph, Strep now more common as cause 3 – 7 years of age Rapid onset Medical emergency Don’t bug the kid but don’t let him out of your sight Call anesthesia; intubate in OR

Quickies

Retropharyngeal abscess 1-6 years Retropharyngeal LN’s gone after this GAS, anaerobes, S. aureus Need good film for diagnosis Neck extended in inspiration Width of prevertebral soft tissue > ½ C3 vertebral body Loss of cervical lordosis IV abx, ENT consult

Quickies 4 year old fully immunized girl Febrile, croupy cough, drooling, stridor Looks unwell, but no acute distress Coryza and sore throat for one day No rashes; no choking episodes You give racemic epi… no response You order lateral neck XR… no FB, no steeple sign, epiglottis normal, upper airway has irregular margins

Bacterial tracheitis Uncommon Can mimic croup quite closely; may be a complication of croup sicker, high fever, gradual onset of illness S. aureus usual cause “Shaggy trachea” on XR secondary to pseudomembrane formation Admit to ICU for iv antibiotics and observation “not all croup is viral croup”