Nebulized L-epinephrine in Post -Bronchoscopy Croup

Nebulized L- epinephrin in Post -Bronchoscopy CroupSafety and Efficacy of Nebulized L- epinephrin in Post -Bronchoscopy Croup in Children, Anesthesia ConsiderationDr Asma Aref Idamat, PharmacistDr Hussein Khraysha, Senior Specialist AnesthetistDr Najeh Alomari, Consultant Pediatric SurgeonAmman-JordanABSTRACT accusatory To assess the value of bronchodilator effect of nebulized epinephrine target bronchoscopy in children and to compare the effectiveness and side effects of nebulized L-epinephrine (NLE) 1/1000 at a drug of 0.1 mL/kg versus 0.5 mL/kg in the discourse of post-bronchoscopy croup and upper air duct obstruction .MATERIAL AND METHOD Between April1998 and April 2002, 120 children, who actual signs and symptoms of upper airway obstruction (UAO) later bronchoscopy, were randomized to receive either 0.1 mL/kg or 0.5 mL/kg of nebulized L-epinephrine (NLE). Age gathering ranged from 4months to 14 years, mean of 4.6 years, male /female ratio 41. UAO scores, vital signs (VS) ,oxygen intensity level (O2 Sat)and side effects if evince were recorded before ,at 15 minutes , 35 minutes and 45 minutes after the treatment. The treatment was obliging in the recovery room under the care of the anesthetist and pediatric surgeon. All patients were reviewed guardedly prior to discharge from recovery room.RESULTS Sixty children were altogetherocated to the 0.1mL/kg (NLE) and sixty children to the 0.5 mL/kg (NLE).. The (NLE) was mixed with 2ml of normal saline. Both groups showed betterments in UAO scores and Oxygen saturation over time. There were no significant differences in UAO scores and VS between the groups at all time points. There were no side effects of epinephrine during the observation.CONCLUSION The administration of nebulized L-epinephrine is safe and effective in reliving croup and upper airway obstruction (UAO) post-bronchoscopy in children. NLE at the social disease of 0.1 mL/kg resultant roles in equivalent improvements in the UAO scores, compared with the point of 0.5 mL/kg. No complications were seen in either point and we commend the routine occasion of 0.1ml/kg (NLE) post bronchoscopy in children.Key words Bronchoscopy, Bronchodilators, L-adrenaline, croup, childrenIntroductionCroup or subglottic edema post bronchoscopy and post cannulisation is a well known entity. Children are much unprotected to develop croup after such procedures than adults due to well known differences in the anatomy of upper airway and tracheo-bronchial tree with narrower laryngeal and tracheal lumens with the result of obstruction more readily by to mucosal edema due to different causes, same viral and bacterial infections as well as hypersensitive manifestations. The narrowest part of upper airway is that at the level of cricoid cartil succession which makes the internal tracheal injury by endo tracheal tube or bronchoscope sheath more prone at the narrow subglottic area even after easily passage through the vocal cords. Broncho scopic removal of aspirated foreign bodies in children is a common procedure in Jordan and many other countries worldwide. The procedure is performed under general anesthesia using rigid bronchoscopic device through which the respiration is maintained. Foreign bodies are usually successfully removed using forceps, wash out with saline and suction tube. In many cases repeated bronchoscopic intubation may be necessary to assure complete removal of foreign bodies with the result of significant irritation and edema to the tracheo-bronchial tree with the sequel of croup, wheezy agency and features of upper airway obstruction (UAO) which may lead to significant morbidity and prolonged hospitalization. The incidence of post intubation croup in children was reported to be between 1 to 6 % (1,2). The medical treatment of postintubation croup is the aforementioned(prenominal) as that for infectious croup, including corticosteroids and nebulized epinephrine. The vasoconstrictive effect of epinephrine decreases the degree of subglottic edema, resulting in clinical improvement. Traditionally recemic epinephrine has been utilize as a non-selective adrenergic agonist of choice in children due to its supposedly someer side effects than the more active and more readily available natural laevorotatory form of epinephrine. However, there seems to be no pharmacological basis for this belief (3-5) and subsequent trials have shown the L-epinephrine which we use for resuscitation, to be safe and effective in twain infectious and postintubation croup(6,7). In addition, L-epinephrine is readily available in all countries while racemic epinephrine is not. Even in countries where both forms are available the racemic form is much more expensive(8 ).It was noted that the doses of L-epinephrine used in those trials were 2.5 and 5 mL of 11000 solution for all recruited children, regardless of weight. As a result, the dose of L-epinephrine in the treatment of croup has been suggested to be 0.5 mL/kg, with a maximum dose of 2.5 mL and 5 mL for children younger and older than 4 years, respectively (9). So far there have been very few reports that have studied the efficacy L- epinephrine in the management of post bronchoscpy croup and (UAO) in children. This study was designed for tow purposes of (a) ascertaining the effectiveness of L-epinephrine in the management of croup and weezy chest post bronchoscpy in children or not and (b) comparing the efficacy of a nebulized L-epinephrine at the dose of 0.1ml/kg versus 0.5ml/kg for the treatment of the above conditions and finally to recommend the routine use of L-epinephrine at the dose of 0.1ml/kg as protocole for the management croup and (UAO) post bronchoscopy in ChildrenMaterial and MethodsBetween April1998 and April 2002, 120 children, who developed signs and symptoms of upper airway obstruction (UAO) after bronchoscopy such as severe irritative cough, wheezy chest, stridor and hoarseness of voice were randomized to receive either 0.1 mL/kg or 0.5 mL/kg of nebulized L-epinephrine (NLE) with maximum of 2mL for patients below 5 years of age and 4mL for patients above 5 years of age. Two mL of normal saline were added to the dose of L-epinephrine. Age group ranged from 4months to 14 years, mean of 4.6 years, male /female ratio 41. We used L-epinephrine because racemic epinephrine in not available in our hospital and it is expensive. The treatment was accomplished in the recovery room under the care of the anesthetist and pediatric surgeon using facemask with 100% oxygen at 6 liters/minute. The main parametric quantity that evaluated was the change of the (UAO) scores (Table 1) and the other parameters that evaluated were changes in the respiratory rate, heart rate, note pressure and oxygen saturation observed by pulse oxymeter. All parameters were evaluated at 15 minutes, 35 minutes and 45 minutes after the treatment, side effects of nebulized epinephrine, if deport such as tremor, arrhythmi a, and pallor were recorded at the same time. The management was repeated after 2 hours whenever clinically indicated if the results were not satisfactory. All patients were reviewed carefully prior to discharge from recovery room.RESULTSOne hundred and twenty children post bronchoscopy for foreign body aspiration (FBA) were enrolled in this study. Sixty children were allocated to the 0.1mg/kg (NLE) and sixty children to the 0.5 mL/kg (NLE). The (NLE) was mixed with 2ml of normal saline. Both groups had the same baseline characteristics (Table 2) and both groups had initially moderate upper airway obstruction. Both groups showed clinically significant improvements and reduction in UAO scores and Oxygen saturation at 15, 35 and 45 minutes(Table 3) compared to that prior to (NLE) at time 0. There were no significant differences in UAO scores and VS between the groups at all time points and none required warm intubation or re-bronchoscopy. Side effects of epinephrine including pallor, arrhythmia and tremor were not observed.Table 1 focal ratio airway obstruction score (15)** marking012CoughStridorRetractioninspiratory breath soundsCyanosis*NoneNoneNoneNormalNoneHoarse cryInspiratorySuprasternalHarsh with rhonchiIn room airBarkInspiratory +expiratorySuprasternal+ substernal +intercostalDelayedIn 40% oxygen*Cyanosis was modified and defined as oxygen saturation ** Downes JJ, Raphaely RC. Pediatric intensive care. Anesthesiology 1975 43 238-50.Table 2 Patient characteristics of our study groups0.1mL/kg0.5mL/kgNumber of patients6060 stand for age (years)3.45.8Gender (M/F ratio)4141UAO score immediately after bronchoscopy( Mild ( Moderate 4-7) n, %(Severe 7) n, %12 (20%)42 (70%)6 (10%)15 (25%)38 (63.33%)7 (11.66%)Table 3 The outcome variables in our study groupsTimeTime 015 proceeding35 MinutesNebulized L-epinephrine / DoseNumber of patients0.1mL/kg 0.5mL/kg60 600.1mL/kg 0.5mL/kg60 600.1mL/kg 0.5mL/kg60 60Upper airway obstruction score(Mean)5 (1-8) 5 (1-7)3 (1-6) 2 (0-5)2 (0-5) 1.4 (0-5)Respiratory rate/minute (Mean)28 3032 3329 28Heart rate /minute (Mean)126 128130 128125 123Systolic blood pressure mmHg (Mean)95 100102 10697 103Diastolic blood pressure mmHg(Mean)55 6158 6356 62Oxygen saturation % (Mean)93 9496 9798 98DiscussionPost bronchoscopy croup and respiratory distress is know entity in pediatric age group, especially when there is a need for repeated bronchoscopic trials for retrieval of long standing foreign bodies. In such conditions, severe inflammatory process of tracheo-bronchial tree is almost present from certain foreign bodies like peanut and other seeds that elaborate severe irritative substances leading to infection and granulation of bronchial tree that aggravate the respiratory distress, bronchospasm and croup post bronchoscopy. The main aim of the clinician in such conditions is to provide relief of respiratory distress by decreasing upper airway irritation and improving air entry. The present study has attempted to verif y the safety and efficacy of bronchodilator effect of (NLE) and to prove that a dose of 0.1mL/kg is at least as effective as the dose of 0.5mL/kg in the treatment of croup and (UAO) post bronchoscopy in children. Many studies have tested the value of racemic epinephrine compared to placebo (10) and to nebulized salbutamol (11-13) and the results showed superior value of racemic epinephrine in the treatment of bronchiolitis. It seems no pharmacological basis for the belief that racemic epinephrine is safer than L-epinephrine (3-5) and racemic epinephrine is not available in Jordan and is thus difficult to obtain and expensive, devising L-epinephrine a more viable option. Sumboonnanonda (14) used (NLE) at the dose 0.05mL/kg (maximum 0.5mL) in the treatment of infectious croup. They found a clinically significant improvement in (UAO) scores at 24 and 48 hours after admission, even in the placebo group without dexamethasone treatment .The present study found standardised results at av erage 30 minutes in children with post-bronchoscopy croup and wheezy chest. The maximum dose of (NLE) in this study was 2mL for patients less than 5 years of age and 4mL for patients more than 5 years. In our study we confirmed the safety and efficacy of (NLE) in the treatment of post intubation croup (6) and infectious croup (7), when Nutman (6) used 0.25mL of 1% L-epinephrine (2.5mg) regardless the weight, for children post-intubation croup and found significant reduction of stridor score within 20 minutes, the same we observed in our study which continued at least over the next 4 hours post bronchoscopy. Waisman (7) used 5mL of 1/1000 L-epinephrine (5mg), regardless the weight, in children with infectious croup when he found a significant reduction of croup score, reaching its maximum at 30 minutes. The majority of our patients required one section of (NLE) to achieve these results and in very few of them who had long standing foreign bodies and repeated trials of bronchoscopy an d bronchial wash out, another session of (NLE) required over 24 hours on 6 hourly interval. The present results suggest that nebulized L-epinephrine, at a minimal dose of 0.1 mL/kg, is at least as effective as the dose of 0.5 mL/kg in the treatment of post-bronchoscopy croup. Both doses temporarily alleviated airway obstruction without undesirable side effects. The dose of 0.1 mL/kg is much less expensive. We would suggest that the dose of 0.1 mL/kg is also efficacious in the treatment of children with post-bronchoscopy croup. This dose may be adequate to diminish mucosal edema of the upper airway by stimulating alpha-adrenergic receptors and producing vasoconstriction (4).In conclusion, the presented data suggest that administration (NLE), at the dose of 0.1 mL/kg is safe and effective and results in a similar reduction in upper airway obstruction scores, compared with the dose of 0.5 mL/kg, in children with post-bronchoscopy croup. Neither dose was associated with any adverse side effects and we recommend the routine use of 0.1mL/kg (NLE) post bronchoscopy in children. Taking in consideration the comparable efficacy of both doses, the use of a small dose in clinical practice would save the medication expense and, theoretically, have a lower risk of developing side effects that are mostly dose dependent. Future studies should consider the use of (NLE) at the dose of 0.1 mL/kg in children with post bronchoscopy croup, which has a pathophysiology resembling infectious croup. Further studies examining the optimal dose and frequency of (NLE) in children with croup due to different pathologies including post-bronchoscopy croup seem warranted.Acknowledgment to DR Mohamad Al-Sukar, Chair of Anesthesia Department Royal Medical Services,Dr Kassem Khamaeseh,MD, Anesthesia intense care for their support and review of this manuscript.References1. Borland LM, Colligan J, Brandom B.W. J Clin AnesthesiaKoba BV, Jeon IS, Andre JM, MacKay I, Smith RM. Postintubation croup in children. Anesth Analg 1977 56501-5Holbrook PR, Issues in airway management -1988. Critical Care Clin 19884789-802Remington S, Meakin G. Nebulized adrenaline 1/1000 in the treatment of croup. Anesthesia 198641923-946Tabachilk E, Livensopn H. Clinical application of aerosols in pediatrics. Am Rev Respir Dis 198812297-103Waisman Y, Klein BL, Boeinning DA, Young GM, Chamberlain JM, ODonnell R, et al . Prospective randomized double-blind study comparing L-epinephrine and racemic epinephrine aerosol in the treatment of laryngotracheitis (croup). Pediatrics 199289302-6Nutman J, Brooks LJ, Deakin KM, Baldesare KK, Witte MK, Reed MD. Racemic versus L-epinephrine aerosol in the treatment of postextubation laryngeal edema Results from a prospective ,randomized double-blind study .Crit Care Med 1994221591-4Menon K, Sutcliffe T, Klassen TP. A randomized trial comparing the efficacy of epinephrine with salbutamol in the treatment of acute bronchiolitis. J Pediatr 19951261004-1007Siberry GK, Lannone R. The Harriet Lane Handbook 15th Edition .St Louis Mosby-Year book,2000705-6Kristjansson S, Lodrup KC, Wennegren G, Strannegard I-L, Carlsen KH. Nebulized racemic adrenaline in the treatment of acute bronchiolitis in infants and toddlers. condescending Dis Child 199369650-54Wennegren G, Holmgren D, Engstrom I, Sten G, Bjure J. utilise transcutaneous blood gases to evaluate treatment effects on acute asthma in young children. Scand J Clin Lab Invest 198848(supp 18941-44Sanchez I, Dekoster J, Powell RE, Walstein R, Chernik V, Effect of racemic epinephrine and salbutamol on clinical score and pulmonary mechanics in infant with bronchiolitis . J Pediatr 1993122145-151Reijonen T, Korpi M, Pitkakangas S, Tehhola S, Kyllikki R. The clinical efficacy of nebulized racemic epinephrine and albuterol in acute bronchiolitis. Arch Pediatr Adolosc Med 1995149686-692Sumboonnanonda A, Suwanjutha S, Sirinavin S. Randomized controlled trial of dexamethasone in infectious croup. J Med Assoc Thai 199780262-5Downes JJ, Raphaely RC. Pediatric intensive care. Anesthesiology 1975 43 238-50.