Out-of-hospital cardiopulmonary arrest in children with croup

Predictors of disease severity and outcomes in pediatric patients with croup and COVID-19 in the pediatric emergency department

BACKGROUND

Croup caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is an emerging disease, and data on the risk factors associated with disease severity are still limited. The Westley croup score (WS) is widely used to assess croup severity. The current study aimed to analyze biomarkers associated with the WS and clinical outcomes in patients with croup and coronavirus disease 2019 in the pediatric emergency department (PED).

POPULATION AND METHOD

Patients diagnosed with croup caused by SARS-CoV-2 were admitted at two PEDs. Clinical data including age, WS, length of hospital stay, initial laboratory data, and treatment were analyzed. Clinical parameters were evaluated via multivariate logistic regression analysis. The best cutoff values for predicting croup severity and outcomes were identified using the receiver operating characteristic curve.

RESULT

In total, 250 patients were assessed. Moreover, 128 (51.2%) patients were discharged from the PED, and 122 (48.8%) were admitted to the hospital. Mild, moderate, and severe croup accounted for 63.6% (n = 159), 32% (n = 80), and 4.4% (n = 11) of all cases, respectively. A high mean age (years), neutrophil count (%), neutrophil-to-lymphocyte ratio (NLR), ALT (U/L), procalcitonin (ng/mL), and hemoglobin (g/dL) level, and length of hospital stay (days), and a low lymphocyte count (%) and blood pH were associated with croup severity and need for intensive care. Based on the multivariate logistic regression model, the NLR remained independent factors associated with croup severity and prognosis. Further, NLR was significantly correlated with WS. The area under the receiver operating characteristic curve of NLR for predicting a WS of ≥3 was 0.895 (0.842-0.948, p < 0.001), and that for predicting ICU admission was 0.795 (0.711-0.879, p < 0.001). The best cutoff values for a WS of ≥3 and ICU admission were 1.65 and 2.06, respectively.

CONCLUSION

NLR is correlated with WS and is a reliable, easy-to-use, and cheap biomarker for the early screening and prognosis of croup severity in the PED. A higher NLR may indicate severe croup and the need for further treatment. And the WS score remains reliable for estimating the severity of croup caused by SARS-CoV-2 and the risk of intensive care.

Global burden of out-of-hospital cardiac arrest in children: a systematic review, meta-analysis, and meta-regression

The incidence of out-of-hospital cardiac arrest (OHCA) and its mortality among children decreased globally over the years. However, the incidence, mortality, and its determinants are heterogeneous globally. The current study was designed to investigate the incidence of OHCA, mortality, and its determinants based on a systematic review of published literature. A comprehensive search was conducted in PubMed/Medline; Science Direct, Cochrane Library, Hinari, and LILACS without language and date restrictions. The data were extracted with two independent authors in a customized format. The methodological quality of the included studies was evaluated using the Newcastle-Ottawa appraisal tool. A total of 2526 articles were identified from different databases with an initial search. Forty-eight articles with 138.3 million participants were included in the systematic review. The meta-analysis showed that the pooled rate of mortality was found to be 70% (95% CI: 57-81%, 42 studies, 28,345 participants). The incidence of OHCA and mortality among children was very high among children with significant regional disparity. Those children with cardiovascular causes of arrest, and initial nonshockable rhythm were independent predictors of OHCA-related mortality. This systematic review and meta-analysis is registered in Prospero (CRD42022316602). IMPACT: This systematic review addresses a significant health problem in a global context from 1995 to 2022. The meta-regression revealed that the incidence of OHCA and mortality of children decline over the years in high-income countries despite regional dispraises among individual studies. Body of evidence on the incidence of OHCA and mortality is lacking in low- and middle-income countries.

Mild-to-Moderate Croup Presentations in Patients With COVID-19 Infection

This case series will describe two pediatric patients, aged nine months and two years, who presented to the emergency department with symptoms of croup. However, they were later found to have coronavirus disease 2019 (COVID-19). The two patients had no pre-existing medical conditions, and they were treated with steroids and nebulized epinephrine as required. They were discharged home with instructions to follow up with their primary care provider and to follow isolation guidelines. This report will illustrate how upper respiratory symptoms, including those consistent with croup, can be associated with or caused by an existing COVID-19 infection. More research is needed to determine if this association can lead to more long-term complications of COVID-19. Additionally, testing for COVID-19 should be incorporated into the assessment and management of this presentation. By recognizing this, clinicians can identify the cause of the illness sooner and initiate targeted treatment more effectively.

Fatal Anaphylactic Shock Ceftriaxone-Induced in a 4-Year-Old Child

One of the most used cephalosporin in clinical practice is ceftriaxone. Anaphylaxis due to the administration of ceftriaxone is considered a rare event. Here, we report a case of fatal anaphylactic shock after the administration of ceftriaxone in a child who had tolerated the drug in past exposures. The allergic pathogenesis is sustained by the clinical data (short time between the inoculation of the drug and the onset of the symptoms; past exposure to the same molecule and probable sensitization) and the postmortem examination findings (polivisceral congestion and intense eosinophilia found in the histological examination).

WITHDRAWN: Humidified air inhalation for treating croup

BACKGROUND

Croup (laryngotracheobronchitis) is a common cause of upper airway obstruction in children with a peak incidence of 60 per 1000 child years in those aged between one and two years. It is characterised by hoarseness, a barking cough, and inspiratory stridor. These symptoms are thought to occur as a result of oedema of the larynx and trachea, which have been triggered by a recent viral infection. Para influenza virus type 1 is the agent most commonly identified in cases of croup. Severe cases are admitted to hospital and steroid treatment is established to reduce disease severity. Treatment with humidified air was previously widely used and is still commonly recommended as home treatment.

OBJECTIVES

To assess the efficacy of humidified air in the treatment of croup.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 4, 2005), MEDLINE (1966 to January 2006) and EMBASE (1990 to January 2006).

SELECTION CRITERIA

Randomised controlled trials (RCTs) involving children suffering from croup treated with humidified air.

DATA COLLECTION AND ANALYSIS

Two authors independently identified potentially relevant abstracts identified from the search and then assessed the full papers for inclusion and methodological quality. Outcome measures included mortality, ventilation, admission to hospital, re-contact with medical services, number of days off school and relief of symptoms; these were separately analysed for the week following treatment. Data extraction was performed by the two authors then entered by one and checked by the second author. Missing data were obtained from trial authors where possible. Data were analysed using Review Manager version 4.2. Sensitivity and sub-group analysis were not possible due to the paucity of trials.

MAIN RESULTS

Three studies in emergency settings provided data on 135 patients with moderate croup for the main outcome (croup score). The combined results from 20 to 60 minutes in the three studies marginally favoured the treatment group with a weighted standardised mean difference of -0.14 (95% confidence interval (CI) -0.75 to 0.47). No other outcomes were significantly different between the groups.

AUTHORS' CONCLUSIONS

The croup score of children managed in an emergency setting with mild to moderate croup probably does not improve greatly with inhalation of humidified air. Further research is needed in primary care settings, using a wider range of more sensitive outcome measures.

Sudden death in a toddler with laryngotracheitis caused by human parainfluenza virus-1

Laryngotracheitis caused by human parainfluenza virus (HPIV) and not complicated by bacterial superinfection rarely causes sudden unexpected death in infants and toddlers, especially in the absence of stridor and a barking cough. We therefore describe a 15-month-old white male who died suddenly and unexpectedly with clinical and pathological features of laryngotracheitis caused by culture-proven HPIV-1 infection. Given the presence of mucosal inflammation extending into the vocalis muscle of the larynx without associated significant narrowing of the laryngotracheal airway lumen, we propose his death was a result of a laryngospasm, perhaps mediated by immune responses.

Acute bronchiolitis and croup

Croup and acute bronchiolitis are common forms of virally induced respiratory disease in infancy and early childhood. There is good evidence that corticosteroids can ameliorate disease severity and alter the natural history of symptoms in patients who have croup and that temporary symptomatic benefit can be obtained from the use of nebulized adrenaline. The principle weakness when reviewing therapeutic interventions for acute bronchiolitis is the lack of a clear diagnostic test or definition. Current evidence suggests that oxygen is the only useful pharmacologic agent for correcting hypoxia.

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.

Humidified air inhalation for treating croup

BACKGROUND

Croup (laryngotracheobronchitis) is a common cause of upper airway obstruction in children with a peak incidence of 60 per 1000 child years in those aged between one and two years. It is characterised by hoarseness, a barking cough, and inspiratory stridor. These symptoms are thought to occur as a result of oedema of the larynx and trachea, which have been triggered by a recent viral infection. Para influenza virus type 1 is the agent most commonly identified in cases of croup. Severe cases are admitted to hospital and steroid treatment is established to reduce disease severity. Treatment with humidified air was previously widely used and is still commonly recommended as home treatment.

OBJECTIVES

To assess the efficacy of humidified air in the treatment of croup.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 4, 2005), MEDLINE (1966 to January 2006) and EMBASE (1990 to January 2006).

SELECTION CRITERIA

Randomised controlled trials (RCTs) involving children suffering from croup treated with humidified air.

DATA COLLECTION AND ANALYSIS

Two authors independently identified potentially relevant abstracts identified from the search and then assessed the full papers for inclusion and methodological quality. Outcome measures included mortality, ventilation, admission to hospital, re-contact with medical services, number of days off school and relief of symptoms; these were separately analysed for the week following treatment. Data extraction was performed by the two authors then entered by one and checked by the second author. Missing data were obtained from trails authors where possible. Data were analysed using Review Manager version 4.2. Sensitivity and sub-group analysis were not possible due to the paucity of trials.

MAIN RESULTS

Three studies in emergency settings provided data on 135 patients with moderate croup for the main outcome (croup score). The combined results from 20 to 60 minutes in the three studies marginally favoured the treatment group with a weighted standardised mean difference of -0.14 (95% confidence interval (CI) -0.75 to 0.47). No other outcomes were significantly different between the groups.

AUTHORS' CONCLUSIONS

The croup score of children managed in an emergency setting with mild to moderate croup probably does not improve greatly with inhalation of humidified air. Further research is needed in primary care settings, using a wider range of more sensitive outcome measures.

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.

[Bacterial tracheitis: an infectious cause of upper airway obstruction to be considered in children]

INTRODUCTION

Bacterial tracheitis is a cause of severe upper respiratory airway obstruction. It has been considered a rare entity whose clinical and epidemiological features are not well known.

PATIENTS AND METHODS

The medical records of children diagnosed with bacterial tracheitis and admitted to our pediatric intensive care unit (PICU) from June 1992 to May 2004 (12 years) were analyzed. The following variables were recorded: age, sex, personal history, need for endotracheal intubation, duration of intubation, isolated bacteria, antibiotic treatment, steroid administration, and length of stay in the PICU.

RESULTS

Twelve patients (six girls and six boys) were included in this study. Age ranged from 1 month to 13 years (median 24 months). Four children had a history of acute laryngotracheitis, one had Down syndrome and another had interauricular communication. All patients needed orotracheal intubation for 2 to 72 hours (median 48 hours). All patients received empirical antibiotic therapy: cephalosporins in 11 children (91 %) (in association with vancomycin or teicoplanin in four of them) and erythromycin in one (9 %). Corticosteroids were administered in nine patients (75 %). Bacterial pathogens were isolated from tracheal secretion culture in seven children (58 %) and the most common was Staphylococcus aureus (42 %). Three children (25 %) developed lobar pneumonia and one developed congestive cardiac insufficiency as a complication of bacterial tracheitis. In all patients, clinical outcome was satisfactory.

CONCLUSIONS

Although the absolute frequency of bacterial tracheitis is low, in our environment this entity represents a considerable cause of severe upper respiratory airway obstruction secondary to an infectious process. Therefore, it should be considered in patients who present with stridor and fever. If the correct treatment is provided, the prognosis is generally good.