Jan 8, 2024
In this podcast, Dr. Gabi Hester, a pediatric hospitalist and Quality Improvement (QI) medical director for Children's Hospitals of Minnesota and St. Luke's Hospital in Duluth. Dr. Hester brings her knowledge and experience in everything related to croup and bronchiolitis (specifically pertaining to in-patients and to frontline healthcare providers).
*Dr. Gabi Hester, speaker for this educational event, has disclosed that she is a consultant who provides content recommendations to AvoMed. All relevant financial relationships for Dr. Hester have been mitigated.
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SHOW NOTES:
*See the attachment for additional
information.
PODCAST OVERVIEW
CROUP
(layngotracheitis)
Overview
- 400,000 approx. ER visits/year in U.S.
- Costly, approx. $53 million/year
- Scary disease due to airway obstruction
- Para-influenza most common
- Classically, kids are admitted after 2 racemic epinephrine
nebulizers
- Dr. Hester studied croup and
hospitalization (see resources below)
- Kids admitted, and no further
treatment or intervention (observed)
Presentation and
treatment
- Rhinorrhea, low grade fever, barky cough (seal
bark)
- Inspiratory stridor, usually worse when
agitated
- Rarely insp and exp stridor (if progressed disease state)
- Dexamethason 0.6 mg/kg (max dose of 12-16 mg)
- Nebulized racemic epinephrine (RA)
- bridge for steroid to
kick in
- reserved for
stridulous patient
- Think about croup mimics
- not responding to racemic epinephrine
- older kids (i.e. 7 yr old), think about
other diagnoses
- Epiglottitis
- cough is less barky
- respiratory distress and
tripoding
- thumb print sign
- Bacterial tracheitis
- can be complication of
viral croup
- can quickly
decompensate
- Foreign body, airway anomalies, etc.
TREATMENT:
- cool outdoor air can be soothing, no good studies to support
- humidified air
- imaging can be done (steeple sign on AP neck) but not routinely
required
- Worried about foreign body?
Epiglottitis?
- not responding to racemic epi
- CXR if hypoxia. Not typical of croup
to be hypoxia.
Research (links
below)
- Most kids don't need further treatment after ED course.
- <1% needed adanced airway, heliox, etc.
- 1:5 hospitalized kids needed further racemic epi
- Some limitations (included pre-ER racemic epi)
- Study was done at a Children's,
tertiary hospital, not a community or small hospital
- Follow-up QI study (2022) evaluating croup guidelines showed 60%
relative reduction in admissions to hospital (4-5% hospitalization
rate)
- 3 RA nebs before admission was found to be
safe
Croup Guidelines at Children's
Hospital
- '3 is the new 2' re: racemic epi nebs
- Good H&P, dexamethasone and up to 3 doses of RA, hen
admit
- 2 hour obsrervation after each dose of RA
- Repeating steroids is controversial. If repeated, give in 48
hours, but rarely needed
- Dexamethasone tastes terrible
COVID impact
- Seasonal presenation shift occurred
- Omicron related croup more common
- No difference in serverity with COVID-19, but increased
volumes
Resources:
Hester, G., Barnes, T., O'Neill, J.,
Swanson, G., McGuinn, T., & Nickel, A. (2019). Rate of Airway
Intervention for Croup at a Tertiary Children's Hospital
2015-2016. The Journal of emergency
medicine, 57(3), 314–321. https://doi.org/10.1016/j.jemermed.2019.06.005
Hester, G., Nickel, A. J., Watson,
D., Maalouli, W., & Bergmann, K. R. (2022). Use of a Clinical
Guideline and Orderset to Reduce Hospital Admissions for
Croup. Pediatrics, 150(3),
e2021053507. doi.org/10.1542/peds.2021-053507
https://publications.aap.org/pediatrics/article/150/3/e2021053507/188776/Use-of-a-Clinical-Guideline-and-Orderset-to-Reduce?autologincheck=redirected
Lefchak, B., Nickel, A., Lammers, S., Watson, D., Hester, G. Z., & Bergmann, K. R. (2022). Analysis of COVID-19-Related Croup and SARS-CoV-2 Variant Predominance in the US. JAMA network open, 5(7), e2220060. https://pubmed.ncbi.nlm.nih.gov/35796213/
BRONCHIOLITIS
Overview
- Leading cause of hospitalization in kids < 1 year old in
U.S.
- Cold sx, fever, runny nose at first
- Several days into URI, increased work of breathing, wheezing,
reatractions
- Typically at its worst on day 5
- Cough can persist up to 2 weeks
Diagnosis and treatment
- Most interventions and tests don't have a significant impact on
patient outcome
- Consider albuterol nebulizer trial after intial therapies
(suctioning, hydration)
- Nasal suctioning imperative
- consider socioeconomic factors
- Hydration staus important
- Respiratory therapy is a resource (consider this if albuterol is
not really working)
- Be mindful of exlusion criteria for the guideline (cardiac and
other underlying co-morbidities, etc.)
- Oxygen (low flow)
- High flow nasal cannula is helpful in respiratory distress
- no reduction in hospital length of
stay
- may increase PICU use (some
institutions only use this in the ICU)
- Scoring systems for bronchiolitis severity not very useful
- Respiratory rate, work of breathing (WOB), agitation, coloration,
heart rate - all factor into asssessment
- Infants may be tricky - be sure to examine well with baby
unclothed, watch carefully for retractions and nasal flaring
COVID impact
- Seasonal variation/timing and severity of illness changes were
seen
Testing and CXR
- Will testing change
treatment?
-
Routine RSV testing not needed
- Apnea and RSV: any respiratory virus can cause apnea in
susceptible and very young infants
- Routinely, CXR not required, unless worried about bacterial
pneumonia
- high fever late in illness
- When and who to admit?
- Significant WOB, hypoxia,
dehydration, very young infants, apnea
- Consider family resources and
barriers to care
Treatment and
Vaccines
- On the
way!
-
Vaccine gibven to mothers in 3rd trimester
- Nirsevimab given to infants
Research (links
below)
- Forthcoming treatment (Nirsevimab) specifically for
RSV
- Improved
outcomes, less hospitalizations
- Race, ethnicity and socioeconomics impact
outcomes
Resources:
Hammitt, L. L., Dagan, R., Yuan, Y., Baca Cots, M., Bosheva, M.,
Madhi, S. A., Muller, W. J., Zar, H. J., Brooks, D., Grenham, A.,
Wählby Hamrén, U., Mankad, V. S., Ren, P., Takas, T., Abram, M. E.,
Leach, A., Griffin, M. P., Villafana, T., & MELODY Study Group
(2022). Nirsevimab for Prevention of RSV in Healthy Late-Preterm
and Term Infants. The New England journal of
medicine, 386(9), 837–846.
https://doi.org/10.1056/NEJMoa2110275
chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.nejm.org/doi/pdf/10.1056/NEJMoa2110275?articleTools=true
Hester, G.,
Nickel, A. J., Watson, D., & Bergmann, K. R. (2021). Factors
Associated With Bronchiolitis Guideline Nonadherence at US
Children's Hospitals. Hospital
pediatrics, 11(10), 1102–1112.
https://doi.org/10.1542/hpeds.2020-005785
https://publications.aap.org/hospitalpediatrics/article/11/10/1102/181172/Factors-Associated-With-Bronchiolitis-Guideline
Thanks to Dr. Gabi Hester for her expert knowledge and contribution to this podcast.
Please check out the additional show notes for more information/resources.