Epinephrine Nebulization Research Articles

Unexpected and severe postintubation croup after a very short day surgery in a pediatric patient: a case report.

An 18 month-old boy underwent endoscopic foreign body removal under anesthesia on an outpatient basis and the operation took approximately 5 minutes. Stridor developed in both lung fields 6 hours after emergence from anesthesia, and severe croup developed, with cyanosis of the lips and aggravated stridor 20 hours after the end of the procedure. The croup resolved with oxygen therapy, intravenous dexamethasone, and epinephrine nebulization therapy. In this report, we suggest that thorough investigations of the patient's past history, including history of any airway problems, and careful monitoring after emergence from anesthesia be done in order to decide the proper discharge time of the patient. Further, proper prophylaxis following risk stratification is important, especially in patients at high risk of postoperative airway obstruction.

Heliox for croup in children

Croup is thought to be triggered by a viral infection and is characterised by respiratory distress due to upper airway inflammation and swelling of the subglottic mucosa in children. Mostly it is mild and transient and resolves with supportive care. In moderate to severe cases, treatment with corticosteroids and nebulised epinephrine (adrenaline) is required. Corticosteroids improve symptoms but it takes time for a full effect to be achieved. In the interim, the child is at risk of further deterioration. This may rarely result in respiratory failure necessitating emergency intubation and ventilation. Nebulised epinephrine may result in dose-related adverse effects including tachycardia, arrhythmias and hypertension and its benefit may be short-lived. Helium-oxygen (heliox) inhalation has shown therapeutic benefit in initial treatment of acute respiratory syncytial virus (RSV) bronchiolitis and may prevent morbidity and mortality in ventilated neonates. Heliox has been used during emergency transport of children with severe croup and anecdotal evidence suggests that heliox relieves respiratory distress. To examine the effect of heliox on relieving symptoms and signs of croup, as determined by a croup score (a tool for measuring the severity of croup).To examine the effect of croup on rates of admission or intubation (or both), through comparisons of heliox with placebo or any active intervention(s) in children with croup. We searched CENTRAL 2013, Issue 10, MEDLINE (1950 to October week 5, 2013), EMBASE (1974 to November 2013), CINAHL (1982 to November 2013), Web of Science (1955 to November 2013) and LILACS (1982 to November 2013). In addition, we searched two clinical trials registries: the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) and clinicaltrials.gov (searched 12 November 2013). Randomised controlled trials (RCTs) and quasi-RCTs comparing the effect of helium-oxygen mixtures with placebo or any active intervention(s) in children with croup. Two review authors independently identified and assessed citations for inclusion. A third review author resolved disagreements. We assessed included trials for allocation concealment, blinding of intervention, completeness of outcome data, selective outcome reporting and other potential sources of bias. We reported mean differences for continuous data and odds ratios for dichotomous data. We descriptively reported data not suitable for statistical analysis. We included three RCTs with a total of 91 participants. One study compared heliox 70%/30% with 30% humidified oxygen administered for 20 minutes in children with mild croup and found no statistically significant differences in the overall change in croup scores between heliox and the comparator. In another study, children with moderate to severe croup were administered intramuscular dexamethasone 0.6 mg/kg and either heliox 70%/30% with one to two doses of nebulised saline, or 100% oxygen with one to two doses of nebulised racaemic epinephrine for three hours. In this study, the heliox group's croup scores improved significantly more at all time points from 90 minutes onwards. However, overall there were no significant differences in croup scores between the groups after four hours using repeated measures analysis. In a third study, children with moderate croup all received one dose of oral dexamethasone 0.3 mg/kg with heliox 70%/30% for 60 minutes in the intervention group and no treatment in the comparator. There was a statistically significant difference in croup scores at 60 minutes in favour of heliox but no significant difference after 120 minutes. It was not possible to pool outcomes because the included studies compared different interventions and reported different outcomes. No adverse events were reported. There is some evidence to suggest a short-term benefit of heliox inhalation in children with moderate to severe croup who have been administered oral or intramuscular dexamethasone. In one study, the benefit appeared to be similar to a combination of 100% oxygen with nebulised epinephrine. In another study there was a slight change in croup scores between heliox and controls, with unclear clinical significance. In another study in mild croup, the benefit of humidified heliox was equivalent to that of 30% humidified oxygen, suggesting that heliox is not indicated in this group of patients provided that 30% oxygen is available. Adequately powered RCTs comparing heliox with standard treatments are needed to further assess the role of heliox in children with moderate to severe croup.

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Introduction: Twenty-one-month old female with past medical history of egg allergy, presented to our hospital emergency room with perioral rash, emesis, cough, and generalized itching. One hour prior to admission she had meat loaf (containing milk, eggs). Child was given an antihistaminic medication and brought to emergency room. In the emergency room, patient received three doses of epinephrine 0.01mg/kg (1:1000 concentration; one dose IM and two doses IV) and racemic epinephrine nebulization over a period of twenty minutes for respiratory distress. Work of breathing continued to get worse and she became hypotensive. Three normal saline boluses of 20ml/kg each were given for hypotension and she was started on epinephrine drip at 1 mcg/kg/min in the emergency room before transferring the child to PICU. In PICU, the child had increased work of breathing, tachycardia (180-200 bpm) and poor peripheral perfusion. Child was intubated in the PICU and was placed on mechanical ventilator. She started developing pink frothy secretions. X-ray chest was consistent with pulmonary edema. EKG showed sinus tachycardia with nonspecific ST T wave changes and an echocardiogram revealed depressed left ventricular systolic function with an ejection fraction of 44%. Initial troponin (3.2 ng per ml), CPK-MB (11.5 ng per ml) and beta type natriuretic peptide (5000 pg per ml) levels were elevated. She was started on milrinone and lasix drips and epinephrine drip was weaned off. Over the next ten days, serial echocardiograms showed improvement in cardiac function with a final ejection fraction of 69% and normalization of cardiac enzymes. Child was discharged home fourteen days after admission. Discussion: Children with severe anaphylaxis may present with non-cardiogenic pulmonary edema and vasodilatory shock. However, in our patient clinical status worsened after starting epinephrine therapy and her cardiac enzymes were elevated along with cardiac dysfunction suggesting myocardial injury. As the child improved once the epinephrine was stopped catecholamine induced cardiomyopathy is a distinct possibility. Epinephrine is the cornerstone of anaphylaxis treatment. However, it has a narrow therapeutic index and can results in serious side effects. It is known that high dose of epinephrine administration can cause myocardial stunning and global myocardial hypokinesis. Diffuse myocardial injury was observed in experimental studies with excessive catecholamines. Such changes are also seen in patients with catecholamine excess states like, pheochromocytoma, stress induced cardiomyopathy (Tako-tsubo cardiomyopathy), and neurogenic myocardial stunning. This child was managed with ventilatory support, milrinone infusion and discontinuation of epinephrine. In refractory cases ECMO may be needed as a temporary support. Catecholamine induced cardiomyopathy is reversible within days to weeks. Caution should be exercised giving multiple doses of epinephrine for the management of anaphylaxis. Catecholamine induced cardiomyopathy should be considered in a child with poor cardiac function and high dose of epinephrine.

Nebulized epinephrine for croup in children

Croup is a common childhood illness characterized by barky cough, stridor, hoarseness and respiratory distress. Children with severe croup are at risk for intubation. Nebulized epinephrine may prevent intubation. To assess the efficacy (measured by croup scores, rate of intubation and health care utilization such as rate of hospitalization) and safety (frequency and severity of side effects) of nebulized epinephrine versus placebo in children with croup, evaluated in an emergency department (ED) or hospital setting. We searched CENTRAL 2013, Issue 6, MEDLINE (1966 to June week 3, 2013), EMBASE (1980 to July 2013), Web of Science (1974 to July 2013), CINAHL (1982 to July 2013) and Scopus (1996 to July 2013). Randomized controlled trials (RCTs) or quasi-RCTs of children with croup evaluated in an ED or admitted to hospital. Comparisons were: nebulized epinephrine versus placebo, racemic nebulized epinephrine versus L-epinephrine (an isomer) and nebulized epinephrine delivered by intermittent positive pressure breathing (IPPB) versus nebulized epinephrine without IPPB. Primary outcome was change in croup score post-treatment. Secondary outcomes were rate and duration of intubation and hospitalization, croup return visit, parental anxiety and side effects. Two authors independently identified potentially relevant studies by title and abstract (when available) and examined relevant studies using a priori inclusion criteria, followed by methodological quality assessment. One author extracted data while the second checked accuracy. We use the standard methodological procedures expected by the Cochrane Collaboration. Eight studies (225 participants) were included. In general, children included in the studies were young (average age less than two years in the majority of included studies). Severity of croup was described as moderate to severe in all included studies. Six studies took place in the inpatient setting, one in the ED and one setting was not specified. Six of the eight studies were deemed to have a low risk of bias and the risk of bias was unclear in the remaining two studies.Nebulized epinephrine was associated with croup score improvement 30 minutes post-treatment (three RCTs, standardized mean difference (SMD) -0.94; 95% confidence interval (CI) -1.37 to -0.51; I(2) statistic = 0%). This effect was not significant two and six hours post-treatment. Nebulized epinephrine was associated with significantly shorter hospital stay than placebo (one RCT, MD -32.0 hours; 95% CI -59.1 to -4.9). Comparing racemic and L-epinephrine, no difference in croup score was found after 30 minutes (SMD 0.33; 95% CI -0.42 to 1.08). After two hours, L-epinephrine showed significant reduction compared with racemic epinephrine (one RCT, SMD 0.87; 95% CI 0.09 to 1.65). There was no significant difference in croup score between administration of nebulized epinephrine via IPPB versus nebulization alone at 30 minutes (one RCT, SMD -0.14; 95% CI -1.24 to 0.95) or two hours (SMD -0.72; 95% CI -1.86 to 0.42). None of the studies sought or reported data on adverse effects. Nebulized epinephrine is associated with clinically and statistically significant transient reduction of symptoms of croup 30 minutes post-treatment. Evidence does not favor racemic epinephrine or L-epinephrine, or IPPB over simple nebulization.The authors note that data and analyses were limited by the small number of relevant studies and total number of participants and thus most outcomes contained data from very few or even single studies.

Cochrane Review: Nebulized epinephrine for croup in children

AbstractBackgroundCroup is a common childhood illness characterized by barky cough, stridor, hoarseness and respiratory distress. Children with severe croup are at risk for intubation. Nebulized epinephrine (NE) may prevent intubation.ObjectivesTo evaluate the efficacy and safety of NE in children presenting to emergency department (ED) or admitted to hospital with croup.Search methodsWe searched CENTRAL (The Cochrane Library 2010, Issue 4), containing the Cochrane Acute Respiratory Infections Group's Specialized Register, MEDLINE (1966 to November Week 1, 2010), EMBASE (1980 to November 2010), Web of Science (1974 to November 2010), CINAHL (1982 to November 2010) and Scopus (1996 to November 2010).Selection criteriaRandomized controlled trials (RCTs) or quasi‐RCTs of children with croup evaluated in an ED or admitted to hospital. Comparisons were: NE versus placebo, racemic NE versus L‐epinephrine (an isomer), and NE delivered by intermittent positive pressure breathing (IPPB) versus NE without IPPB. Primary outcome was change in croup score post‐treatment. Secondary outcomes were rate and duration of intubation and hospitalization, croup return visit, parental anxiety and side effects.Data collection and analysisTwo authors independently identified potentially relevant studies by title and abstract (when available) and examined relevant studies using a priori inclusion criteria, followed by methodologic quality assessment. One author extracted data while the second checked accuracy. We performed standard statistical analyses.Main resultsEight studies (225 participants) were included. NE was associated with croup score improvement 30 minutes post‐treatment (three RCTs, standardized mean difference (SMD) ‐0.94; 95% confidence interval (CI) ‐1.37 to ‐0.51; I2 statistic = 0%). This effect was not significant two and six hours post‐treatment. NE was associated with significantly shorter hospital stay than placebo (one RCT, mean difference ‐32.0 hours; 95% CI ‐59.1 to ‐4.9). Comparing racemic and L‐epinephrine, no difference in croup score was found after 30 minutes (SMD 0.33; 95% CI ‐0.42 to 1.08). After two hours, L‐epinephrine showed significant reduction compared with racemic epinephrine (one RCT, SMD 0.87; 95% CI 0.09 to 1.65). There was no significant difference in croup score between administration of NE via IPPB versus nebulization alone at 30 minutes (one RCT, SMD ‐0.14; 95% CI ‐1.24 to 0.95) or two hours (SMD ‐0.72; 95% CI ‐1.86 to 0.42).Authors' conclusionsNE is associated with clinically and statistically significant transient reduction of symptoms of croup 30 minutes post‐treatment. Evidence does not favor racemic epinephrine or LE, or IPPB over simple nebulization.Plain Language SummaryNebulized epinephrine for croup in childrenCroup is a common childhood illness that is usually caused by a viral infection. Symptoms of croup include a hoarse voice, a 'barking' cough and noisy breathing. These symptoms are the result of swelling that occurs in the area of the windpipe (trachea) just below the voice box (larynx). Although most cases of croup are mild and resolve on their own, occasionally the swelling can be severe enough to cause difficulty in breathing. In these children, epinephrine (also called adrenaline) is a medication that is inhaled as a mist to temporarily shrink the swollen area in the trachea.This review looked at trials of inhaled epinephrine for the treatment of children with croup. Compared to no medication, inhaled epinephrine improved croup symptoms in children at 30 minutes following treatment (three studies, 94 children). This treatment effect disappeared two hours after treatment (one study, 20 children). However, children's symptoms did not become worse than prior to treatment. No study measured adverse events. This review is comprised of only eight studies and the number of included children was small (225). Few studies examined similar outcomes, therefore data could often not be pooled and conclusions are based on one or few studies.

Adverse effects during specific oral tolerance induction: in home phase

Specific oral tolerance induction (SOTI) is a promising approach for severe food allergies. There are little data in the literature regarding the home-phase of SOTI, not only with regard to type and frequency of adverse reactions but also regarding the most suitable treatment and protocol. To define the incidence and severity of adverse reactions, possible risk factors, and the safety and effectiveness of the home-phase of an original SOTI protocol in a large group of children with severe cow's milk (CM) allergy, after the hospital "rush" phase. The study was conducted by recording in-home phase adverse events, success and failure as reported by parents, and calling families. Adverse reactions were treated following the International Guidelines, arbitrarily modified by introducing nebulised epinephrine for respiratory reactions, oral beclomethasone for acute gastric pain and oral cromolyn for recurrent gastric pain. Out of 140 patients, 132 were contacted; eight were inaccessible (follow-up 2-84 months). The number of adverse reactions was 1 in every 100 doses. The reactions were treated with nebulised epinephrine (221 reactions), IM epinephrine (6 reactions), and other drugs. Patients with high specific IgE levels (greater than 100 kU(A)/L) and lower CM dose (less than 5 ml) at the end of in-hospital phase showed a higher risk both for number of reactions and use of nebulised epinephrine. The home phase of SOTI was characterised by a significant number of adverse reactions, mostly managed with an acceptable rate of side effects. Nebulised epinephrine played a pivotal role in respiratory reactions.

The significance of reduced airway hyperemia and enhanced oxygenation after epinephrine nebulization in a preclinical evaluation*

Department of Surgery, University of Iowa Burn Treatment Center, University of Iowa, Iowa City, IA The author has not disclosed any potential conflicts of interest.

Preclinical evaluation of epinephrine nebulization to reduce airway hyperemia and improve oxygenation after smoke inhalation injury*

Acute lung injury secondary to smoke inhalation is a major source of morbidity and mortality in burn patients. We tested the hypothesis that nebulized epinephrine would ameliorate pulmonary dysfunction secondary to acute lung injury by reducing airway hyperemia and edema formation and mediating bronchodilatation in an established, large animal model of inhalation injury. Prospective, controlled, randomized trial. University research laboratory. Twenty-four chronically instrumented, adult, female sheep. Following baseline measurements, the animals were allocated to a sham-injured group (n = 5), an injured and saline-treated group (n = 6), or an injured group treated with 4 mg of nebulized epinephrine every 4 hrs (n = 6). Inhalation injury was induced by 48 breaths of cotton smoke. The dose of epinephrine was derived from dose finding experiments (n = 7 sheep). The injury induced significant increases in airway blood flows, bronchial wet/dry weight ratio, airway obstruction scores, ventilatory pressures, and lung malondialdehyde content, and contributed to severe pulmonary dysfunction as evidenced by a significant decline in Pao₂/Fio₂ ratio and increase in pulmonary shunt fraction. Nebulization of epinephrine significantly reduced tracheal and main bronchial blood flows, ventilatory pressures, and lung malondialdehyde content. The treatment was further associated with significant improvements of Pao₂/FIO₂ ratio and pulmonary shunting. Nebulization of epinephrine reduces airway blood flow and attenuates pulmonary dysfunction in sheep subjected to severe smoke inhalation injury. Future studies will have to improve the understanding of the underlying pathomechanisms and identify the optimal dosing for the treatment of patients with this injury.

Puffiness of the eyelids and lips with multiple subcutaneous masses in 2-month-old infant

Hematol Oncol Stem Cell Ther 3(4) Fourth Quarter 2010 hemoncstem.edmgr.com 196 Skin involvement can be the initial sympf tom of hematologic diseases in children.1 Lymphoblastic leukemia/ lymphoma (LBL) is a neoplasm of the precursor Iymphoid cells considered to be the lymphomatotis variant of acute lymphoblastic leukemia (ALL). Distinction between LBL and ALL relies on the massive presence in the latter of blast cells in the bone marrow (>25% blasts) and in the blood. According to the Revised EuropeanfAmerican Classification of Lymphoid Neoplasms (REAL clasf silication), ALL and LBL account for 80% and 20% of neoplastic proliferation of lymphoblasts, respectively.2 LBL affects predominantly children and young adults with occasional older patients have been reported.3,4 A 2fmonthfold female presented with multiple subf cutaneous swellings on the scalp, shoulders and upper and lower limbs for the previous week. The swelling prof gressed to the eyelids and lips with intermittent stridor after receiving treatment for a common cold (Figure 1). Angioneurotic edema was suspected. She received stef roids treatment and frequent adrenaline nebulization, but the condition progressed. On examination, she apf Puffiness of the eyelids and lips with multiple subcutaneous masses in 2-month-old infant

Management of Post-Intubation Croup in a Down Syndrome Infant with Dexamethasone and Low Dose Nebulized Epinephrine- A Case Report

I describe my experience with the management of postintubation croup in a 10-month-old infant with Down syndrome (DS). While it has been recognized that children with DS tend to develop obstruction of the upper airway postoperatively, debate remains concerning the appropriate management in this situation. Although there is no evidence either supporting or refuting the use of nebulized epinephrine in infants, postintubation croup was successfully treated by inhaled nebulized epinephrine in addition to intravenous dexamethasone in an infant with DS.

Epinephrine and Dexamethasone in Children with Bronchiolitis

Although numerous studies have explored the benefit of using nebulized epinephrine or corticosteroids alone to treat infants with bronchiolitis, the effectiveness of combining these medications is not well established. We conducted a multicenter, double-blind, placebo-controlled trial in which 800 infants (6 weeks to 12 months of age) with bronchiolitis who were seen in the pediatric emergency department were randomly assigned to one of four study groups. One group received two treatments of nebulized epinephrine (3 ml of epinephrine in a 1:1000 solution per treatment) and a total of six oral doses of dexamethasone (1.0 mg per kilogram of body weight in the emergency department and 0.6 mg per kilogram for an additional 5 days) (the epinephrine-dexamethasone group), the second group received nebulized epinephrine and oral placebo (the epinephrine group), the third received nebulized placebo and oral dexamethasone (the dexamethasone group), and the fourth received nebulized placebo and oral placebo (the placebo group). The primary outcome was hospital admission within 7 days after the day of enrollment (the initial visit to the emergency department). Baseline clinical characteristics were similar among the four groups. By the seventh day, 34 infants (17.1%) in the epinephrine-dexamethasone group, 47 (23.7%) in the epinephrine group, 51 (25.6%) in the dexamethasone group, and 53 (26.4%) in the placebo group had been admitted to the hospital. In the unadjusted analysis, only the infants in the epinephrine-dexamethasone group were significantly less likely than those in the placebo group to be admitted by day 7 (relative risk, 0.65; 95% confidence interval, 0.45 to 0.95, P=0.02). However, with adjustment for multiple comparisons, this result was rendered insignificant (P=0.07). There were no serious adverse events. Among infants with bronchiolitis treated in the emergency department, combined therapy with dexamethasone and epinephrine may significantly reduce hospital admissions. (Current Controlled Trials number, ISRCTN56745572.)

Clinical review: Post-extubation laryngeal edema and extubation failure in critically ill adult patients

Laryngeal edema is a frequent complication of intubation. It often presents shortly after extubation as post-extubation stridor and results from damage to the mucosa of the larynx. Mucosal damage is caused by pressure and ischemia resulting in an inflammatory response. Laryngeal edema may compromise the airway necessitating reintubation. Several studies show that a positive cuff leak test combined with the presence of risk factors can identify patients with increased risk for laryngeal edema. Meta-analyses show that pre-emptive administration of a multiple-dose regimen of glucocorticosteroids can reduce the incidence of laryngeal edema and subsequent reintubation. If post-extubation edema occurs this may necessitate medical intervention. Parenteral administration of corticosteroids, epinephrine nebulization and inhalation of a helium/oxygen mixture are potentially effective, although this has not been confirmed by randomized controlled trials. The use of non-invasive positive pressure ventilation is not indicated since this will delay reintubation. Reintubation should be considered early after onset of laryngeal edema to adequately secure an airway. Reintubation leads to increased cost, morbidity and mortality.

Heliox como fuente de nebulización del tratamiento broncodilatador en lactantes con bronquiolitis

Introduction Heliox is a helium-oxygen mixture which improves laminar flow and decreases airway resistance and the work of breathing. The aim of this study was to assess the effects of salbutamol or epinephrine nebulization driven by heliox in infants with moderate-to-severe bronchiolitis. Materials and methods This prospective, observational, interventional, controlled and randomized study included ninety-six children who came to our pediatric emergency department with first episode of moderate-to-severe bronchiolitis. The patients were randomized to receive salbutamol or epinephrine nebulized with either oxygen (control group) or heliox (70% helium and 30% oxygen) as the driving gas. Heart rate, respiratory rate, pulse oximetry oxygen saturation and clinical score were measured before and after the treatment period. We also reported hospitalization rates and the number of patients who returned to the emergency department in the following seventy two hours. Results There were no significant differences between both groups. The only statistically significant difference was that, in the heliox group, patients with severe bronchiolitis needed a lower number of nebulizations than infants in the control group. Conclusions According to our study, heliox-driven salbutamol or epinephrine is not an effective therapy in patients with acute bronchiolitis.

The effect of epinephrine by nebulization on measures of airway obstruction in patients with acute severe croup

To demonstrate that tests of pulmonary function applicable to sick infants and small children with acute severe viral croup would provide clear, objective evidence of responsiveness to therapy with nebulized epinephrine. Oesophageal pressure changes and airflows at the mouth were measured in 17 patients with acute severe croup, before and after nebulization with epinephrine. In 12 of the 17 patients there was a significant improvement in respiratory mechanics following epinephrine nebulization. Six of the 12 patients who responded to adrenaline also received 0.9% saline by nebulization, without improvement. No measures derived from combined flow and volume data showed any statistically significant change following epinephrine nebulization. Measures combining flow and pressure data, specifically inspiratory airway resistance, expiratory airway resistance, work of breathing, rate of work of breathing and volume for effort, showed changes of 26%, 33%, 16%, 16% and 46% respectively. The most statistically significant measures were pressure-rate product, pressure-time integral, oesophageal pressure alone and expiratory resistance. These changes persisted for at least 10 min after inhalation although there was some evidence of decline in pharmacologic effect at that time. Nebulized epinephrine results in a short-lived improvement in some but not all patients with croup. This reduction in respiratory effort occurs secondary to a decline in inspiratory and expiratory airway resistance. Oesophageal pressures measured via a feeding tube are satisfactory for quantification of the acute response and may be a useful continuous monitoring device. Flow measurements are unhelpful, and continuous administration of nebulized epinephrine should be investigated.

Idiopathic hemoptysis in pregnant women: A distinct entity?

In pregnant women, the reported cases of hemoptysis were most often mild and had an identified cause. Between November 2003 and January 2006, three pregnant women at 16-20 weeks gestation were admitted to our respiratory intensive care unit for massive hemoptysis. One of the women had experienced mild hemoptysis, considered as idiopathic, during her first pregnancy, with no recurrence until her second pregnancy. In all three cases, hemoptysis was massive. CT scan after iodine injection did not reveal any cause. Opacification of the bronchial artery showed hyperemia from abnormally dilated and tortuous bronchial arteries. Bronchial artery embolization (BAE) was performed in all three patients, successfully in two. Intravenous vasopressin was used as second-line treatment for recurrent bleeding after BAE in one patient. The women carried the pregnancy to term with delivery of healthy infants. Further complete investigation after the births did not identify any possible local (pulmonary) or general cause of bleeding in these three patients. Although these cases could be considered idiopathic, the close association with duration of pregnancy suggests the hemoptysis may be related to hormonal changes.

Treatment of Supraglottic Airway Edema by Local Hyaluronidase

Treatment of Supraglottic Airway Edema by Local Hyaluronidase

A randomized comparison of dexamethasone 0.15 mg/kg versus 0.6 mg/kg for the treatment of moderate to severe croup

Although previous studies have shown that dexamethasone is useful in croup, the optimal dosage has not been clarified yet. The aim of this study was to investigate the effectiveness of dexamethasone 0.15 mg/kg single dose compared with the recommended dose of 0.6 mg/kg for treatment of hospitalized children with moderate to severe croup. Forty-one children aged 6 months to 5 years admitted from March 2001 to October 2003 at the pediatric ward of Hatyai Hospital with moderate to severe croup were recruited for the study. After random allocation, each child received a single intravenous injection of either dexamethasone 0.6 mg/kg (maximum dose 12 mg) or 0.15 mg/kg (maximum dose 3 mg). All children were given a single dose of epinephrine nebulization at the beginning of the study. The croup scores were measured at 0, 1, 2, 3, 4, 6, 8, 10 and 12 h after the dexamethasone injection. One hour following the injection, the mean croup scores were significantly reduced from baseline values in both groups (p<0.01). There was no difference in the mean croup scores between the two groups at any time. Median times to croup scores equal or less than two in both high- and low-dose groups were 8 and 7.9 h, respectively. No patient required intubation or was removed from the study because of a rising croup score after enrollment. There was no significant adverse reaction from dexamethasone treatment in either group. Dexamethasone 0.15 and 0.6 mg/kg are equally effective in the treatment of moderate to severe croup.

Myth: Cool mist is an effective therapy in the management of croup

Croup is the most common infectious cause of acute airway obstruction in children between 1 and 6 years of age, accounting for 90% of cases of stridor. The majority of cases of croup are caused by parainfluenza and occur during the late fall and winter. Mist has been a mainstay for croup since the 19th century and, even today, many emergency departments (EDs) routinely begin cool mist therapy for patients with croup. Further therapy of croup typically includes nebulized racemic epinephrine and corticosteroids.

Comparison of nebulized epinephrine and terbutaline in patients with acute severe asthma: a controlled trial

Purpose: To compare the efficacy and tolerability of nebulized adrenaline and terbutaline in acute severe asthma. Methods: Design: Prospective pilot randomized double-blind cross-over trial. Setting: Emergency department of a university hospital. Patients: Thirty-eight patients admitted with severe acute asthma. Each patient received adrenaline (3 mg) and terbutaline (5 mg) nebulizations over 20 min in randomized order. Additional treatment comprised methylprednisolone, intravenous hydration, and oxygen. The efficacy and tolerability of the two drugs were evaluated at the end of each nebulization as well as potential synergistic effects. Results: Eighteen patients received adrenaline first, and 20 received terbutaline first. Peak expiratory flow (PEF) improved significantly in both groups after the first nebulization (from 157 L/min ± 111 L/min to 199 L/min ± 134 L/min with adrenaline, P < .01; and from 142 L/min ± 65 L/min to 193 L/min ± 181 L/min with terbutaline, P < .01). Both drugs induced a significant decrease in respiratory frequency. The improvement in PaO2 was only significant with terbutaline. Respiratory frequency, PEF and PaO2 were not improved by the second nebulization. No adverse effects were observed. Conclusions: Adrenaline nebulization was as effective and as well tolerated as terbutaline in acute severe asthma. No synergistic effect between terbutaline and adrenaline was observed.

Nebulized racemic epinephrine for extubation of newborn infants.

Following a period of mechanical ventilation, post-extubation upper airway obstruction can occur in newborn infants, especially after prolonged, traumatic or multiple intubations. The subsequent increase in upper airway resistance may lead to respiratory insufficiency and failure of extubation. The vasoconstrictive properties of epinephrine, and its proven efficacy in the treatment of croup in infants, has led to the routine use of inhaled nebulised epinephrine immediately post-extubation in some neonatal units. It is also recommended for neonates with post-extubation tracheal obstruction and stridor in neonatal and respiratory textbooks and reviews. The primary objective was to assess whether nebulised epinephrine administered immediately after extubation in neonates weaned from IPPV decreases the need for subsequent additional respiratory support. Searches were made of Medline (MeSH search terms 'epinephrine' and 'exp infant, newborn'), the Oxford Database of Perinatal trials, expert informants and journal hand searching mainly in the English language, expert informant searches in the Japanese language by Prof. Ogawa, previous reviews including cross references, abstracts, and conference and symposia proceedings. All randomised and quasi-randomised control trials in which nebulised epinephrine was compared with placebo immediately post-extubation in newborn infants who have been weaned from IPPV and extubated, with regard to clinically important outcomes (i.e. need for additional respiratory support, increase in oxygen requirement, respiratory distress, stridor or the occurrence of side effects). No studies met our criteria for inclusion in this review. No studies were identified which looked at the effect of inhaled nebulised epinephrine on clinically important outcomes in infants being extubated. There is no evidence either supporting or refuting the use of inhaled nebulised racemic epinephrine in newborn infants. randomised controlled trials are needed comparing inhaled nebulised racemic epinephrine with placebo in neonates post-extubation. This should be looked at both as a routine treatment post-extubation and as specific treatment for post-extubation upper airway obstruction. Study populations should include the group of infants at highest risk for upper airway obstruction from mucosal swelling because of their small glottic and sub-glottic diameters (ie those infants with birthweights less than 1000 grams).