Nebulized L-epinephrine in Post -Bronchoscopy Croup

Nebulized L- epinephrin in Post -Bronchoscopy CroupSafety and qualification of Nebulized L- epinephrin in Post -Bronchoscopy Croup in minorren, Anesthesia Con trademarkrationDr Asma Aref Idamat, druggistDr Hussein Khraysha, Senior Specialist AnesthetistDr Najeh Alomari, Consultant Pediatric surgeonAmman-JordanABSTRACTOBJECTIVE To assess the value of bronchodilator effect of nebulized epinephrine send off bronchoscopy in children and to compare the intensity level and military position set up of nebulized L-epinephrine (NLE) 1/ guanine at a dosage of 0.1 mL/kg versus 0.5 mL/kg in the intervention of stakes-bronchoscopy derriere and focal ratio air lane bulwark . temporal AND METHOD Between April1998 and April 2002, 120 children, who developed signs and symptoms of upper flight path stop (UAO) by and by bronchoscopy, were randomized to receive either 0.1 mL/kg or 0.5 mL/kg of nebulized L-epinephrine (NLE). Age group ranged from 4months to 14 years, mean of 4.6 years , mannish /fe virile ratio 41. UAO lashings, vital signs (VS) ,oxygen saturation (O2 Sat)and side make if expose were recorded before ,at 15 legal proceeding , 35 proceedings and 45 minutes after the treatment. The treatment was accomplished in the retrieval room under the care of the anesthetist and pediatric surgeon. All patients were freshened guardedly prior to discharge from recoin truth room.RESULTS lux children were allocated to the 0.1mL/kg (NLE) and sixty children to the 0.5 mL/kg (NLE).. The (NLE) was mixed with 2ml of conventionalism saline. two groups showed improvements in UAO scores and oxygen saturation over date. There were no significant differences in UAO scores and VS betwixt the groups at all time points. There were no side cause of epinephrine during the observation.CONCLUSION The administration of nebulized L-epinephrine is safe and effective in reliving croup and upper flight path obstacle (UAO) post-bronchoscopy in children. NLE at the panel ing of 0.1 mL/kg results in similar improvements in the UAO scores, compared with the venereal infection of 0.5 mL/kg. No complications were seen in either drug and we preach the spell single-valued function of 0.1ml/kg (NLE) post bronchoscopy in children.Key words Bronchoscopy, Bronchodilators, L-adrenaline, croup, children displayCroup or subglottic edema post bronchoscopy and post intubation is a well go to bedn entity. Children are more vulnerable to develop croup after much(prenominal) procedures than adults due to well known differences in the manakin 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 variant causes, like viral and bacterial infections as well as supersensitized manifestations. The narrowest part of upper airway is that at the level of cricoid cartilage which makes the familiar tracheal injury by endo tracheal tube or bronchoscope pillow slip more prone at the narrow subglottic area even after easily passage through the vocal cords. Bronchoscopic removal of aspirated unlike bodies in children is a common procedure in Jordan and many other countries worldwide. The procedure is per human bodyed under general anesthesia utilize rigid bronchoscopic device through which the ventilation is maintained. Foreign bodies are usually successfully removed using forceps, rinse off out with saline and suction tube. In many cases repeated bronchoscopic intubation may be demand to assure complete removal of foreign bodies with the result of significant headache and edema to the tracheo-bronchial tree with the sequel of croup, reedy chest 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 same as that for pathogenic cro up, 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 used as a non-selective adrenergic supporter of choice in children due to its supposedly fewer side set up than the more active and more readily available natural laevorotatory jump of epinephrine. However, there seems to be no pharmacological basis for this belief (3-5) and consequent trials have shown the L-epinephrine which we use for resuscitation, to be safe and effective in some(prenominal) infectious and postintubation croup(6,7). In addition, L-epinephrine is readily available in all countries sequence 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 dots of L-epinephrine used in those trials were 2.5 and 5 mL of 1 cubic yard solution for all recruited children , heedless of weight. As a result, the do drugs 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 ripened than 4 years, respectively (9). So far there have been truly few reports that have studied the efficacy L- epinephrine in the counsel of post bronchoscpy croup and (UAO) in children. This plain 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 inexorable 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 parameter that evaluated was the change of the (UAO) scores ( add-in 1) and the other parameters that evaluated were changes in the respiratory rate, heart rate, relationship thrust 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 fall in such as tremor, arrhythmia, 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 coke 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 ( circuit card 2) and both groups had initially moderate upper airway obstruction. Both groups showed clinically significant improvements and decrement in UAO scores and oxygen saturation at 15, 35 and 45 minutes( delay 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 immediate intubation or re-bronchoscopy. Side effects of epinephrine including pallor, arrhythmia and tremor were not observed.Table 1 Upper airway obstruction score (15)**Score012CoughStridorRetractioninspiratory breath soundsCyanosis* no(prenominal)NoneNoneNormalNoneHoarse cryInspiratorySuprasternalHarsh with rhonchiIn room airBarkInspiratory +expiratorySuprasternal+ substernal +intercostalDelayedIn 40% oxygen*Cyanosis was modified and specify as oxygen saturation ** Downes JJ, Raphaely RC. Pediatric intensifier care. Anesthesiology 1975 43 238-50.Table 2 Patient characteristics of our study groups0.1mL/kg0.5mL/kgNumber of patients6060Mean age (years)3.45.8Gender (M/F ratio)4141UAO score immediately after bronchoscopy( Mild ( conquer 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 Minutes35 MinutesNebulized L-epinephrine / DoseNumber of pati ents0.1mL/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 command 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 seek to verify the safety and efficacy of bronchodilator effect of (NLE) and to prove that a dose of 0.1mL/kg is at least(prenominal) as effective as the dose of 0.5mL/kg in the treatment of croup and (UAO) post bronchoscopy in children. many an(prenominal) 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 keep and expensive, making 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 (UA O) scores at 24 and 48 hours after admission, even in the placebo group without dexamethasone treatment .The present study found similar results at average 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 requ ired 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 and 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 palliate 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 in any case efficacious in the treatment of children with post-bronchoscopy croup. This dose may be adapted to diminish mucosal edema of the upper airway by touch 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 air way 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. 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