From the Guidelines
The best treatment for a three-year-old patient with barky cough, audible stridor, mild intercostal retractions, and normal oxygen saturation is propranolol, as it has been shown to be effective in managing airway infantile hemangiomas (IHs) with low complication rates 1. This clinical presentation is consistent with airway IH, which can cause biphasic stridor and barky cough, often mistaken as croup 1. The diagnosis of airway IH is usually made by endoscopy in the operating room, and in most cases, IHs of the airway may be managed medically 1. Key factors to consider in the management of airway IH include the degree of airway obstruction, the extent of extralaryngeal IH, and the location of the patient at the time of diagnosis 1. Some important points to note in the management of airway IH include:
- The need for operative endoscopy to confirm the diagnosis and define the extent of the airway lesion 1
- The potential for associated vascular, brain, or chest anomalies that could affect treatment 1
- The importance of considering the experience of the treating physician and the preferences of the parents/caregivers in determining the need for and type of intervention 1
- The role of propranolol in the management of airway IH, which has been shown to be effective with low complication rates 1. It is also important to note that referral to a pediatric surgical specialist, such as a pediatric otolaryngologist, may be necessary for the management of complicated infections or congenital malformations of the head and neck structures, including the airway 1. In terms of specific treatment, propranolol is the recommended treatment for airway IH, with the optimal dose and duration of therapy remaining uncertain, but most clinicians dosing the drug as they would for cutaneous IH 1. For immediate symptom relief, exposure to cool mist or humidified air may help, and if stridor persists at rest or respiratory distress worsens, nebulized epinephrine may be administered 1. However, the primary treatment for airway IH is propranolol, and the use of propranolol has been shown to be effective in reducing the symptoms of airway IH, including biphasic stridor and barky cough 1.
From the FDA Drug Label
Purpose Bronchodilator Warnings Asthma alert Because asthma may be life threatening, see a doctor if you: Are not better in 20 minutes Get worse Need more than 12 inhalations in 24 hours The patient's symptoms of barky cough, audible strider, and mild intercostal retraction with normal O2 saturation may indicate a respiratory condition such as croup.
- The use of epinephrine (INH) 2 or 2 may be considered as a bronchodilator to help relieve symptoms.
- However, it is essential to consult a doctor before administering any medication, especially in a three-year-old patient.
- Dexamethasone (PO) 3 is not directly indicated for the treatment of acute respiratory symptoms in this scenario.
From the Research
Treatment Options for Croup
The patient's symptoms, including a barky cough, audible stridor, and mild intercostal retraction with normal O2 saturation, are consistent with croup. The following treatment options are supported by the evidence:
- Corticosteroids, such as dexamethasone, are the mainstay of treatment for croup, regardless of severity 4, 5, 6
- A single dose of orally administered dexamethasone (0.15-0.6 mg/kg) is recommended for mild croup 4
- Nebulized epinephrine may be added for moderate-to-severe croup, but its effect is less remarkable in patients treated with dexamethasone 5, 6, 7, 8
- Maintaining at least 50% relative humidity in the child's room is recommended, and a mist tent with supplemental oxygen may be helpful if there is evidence of hypoxemia 5
Discharge Criteria
Patients with croup who are treated with racemic epinephrine, oral dexamethasone, and mist may be safely discharged home if they are assessed as ready for discharge after 3-4 hours of observation 7, 8
Medication Dosage
The correct dosage of dexamethasone is important, as lower steroid dosages have proven to be ineffective in treating croup 5