Chennupati, Sri Kiran, MD

Shi, Harry

Yaeger, Susan K, MD

English

Lehigh Valley Health Network: LVHN Scholarly Works

Lehigh Valley Health Network LVHN Scholarly Works USF-LVHN SELECT A Clinical Guideline for the Endoscopic and Medical Management in Children with Recurrent Croup Harry Shi Susan K. Yaeger MD Sri Kiran Chennupati MD Follow this and additional works at: https://scholarlyworks.lvhn.org/select-program  Part of the Medical Education Commons This Poster is brought to you for free and open access by LVHN Scholarly Works. It has been accepted for inclusion in LVHN Scholarly Works by an authorized administrator. For more information, please contact LibraryServices@lvhn.org. © 2018 Lehigh Valley Health NetworkLehigh Valley Health Network, Allentown, PennsylvaniaThe chance of any significant finding during an endoscopic exam for recurrent croup is low. Most often, bronchoscopy or laryngoscopy is performed just for the purpose to facilitate a parent’s ease of mind. There should be a higher threshold before considering performing an invasive procedure on a child. Those children with risk factors associated significant endoscopic findings, such as a history prematurity, previous intubation, inpatient consult for croup, and age <1, should be strong candidates for endoscopic procedures. Physicians should utilize these indicators to assist in their clinical decision making when selecting patients for bronchoscopy or laryngoscopy. An inherent weakness for this study is that all data were originated from outside sources and may not accurately reflect the patient population seen at LVHN. We hope to address this shortcoming with an internal chart review of LVHN pediatric patients with croup and recurrent croup once there has been IRB approval. A Clinical Guideline for the Endoscopic and Medical Management in Children with Recurrent CroupREFERENCESBased on these new findings and recommendations from LVHN’s own pediatric emergency medicinephysician Dr. Susan Yaeger, a clinical management pathway for croup and recurrent croup is proposed(Figure 9). Those patients who have the clinical diagnosis of croup should be assessed for severityaccording to the Westley scoring system. Mild cases can be managed with outpatient treatment byfamily medicine, pediatrics, and pediatric ENT, but these patients should be followed up regularly.Those who are scored as moderate or severe croup should be advised to go to the EmergencyDepartment for further assessment. Standard treatment should be given to these patients, who shouldbe checked on once an hour for 2 hours. If patients’ symptoms have been clinically improved and meetdischarge criteria, they can be discharged and followed up as outpatients. If patients’ symptoms arenot improved and/or meet admission criteria, they should be hospitalized and receive 3 doses ofepinephrine treatment. If patients’ conditions are still not improved after treatment with 3 or moredoses of epinephrine, or if it is a case of recurrent croup, a pediatric ENT should be consulted. Fromthis point, the pediatric ENT physician can choose to proceed with invasive procedure or reassure theparents depending on whether the patient has certain risk factors with significant associations withendoscopic findings. This clinical pathway is proposed to assist in physician’s clinical decision making.Each patient’s history is unique and then should be considered when making decisions on the bestmanagement plan.The data shows that 182 out of 1258 patients had significant findings on invasive diagnostic studies.This means over 85% of patients underwent unnecessary invasive procedure. In order to better alignthe current approach to recurrent croup to the SELECT teachings, this report by a multi-disciplinaryteam of pediatric hospitalist, pediatric otolaryngologist, and pediatric emergency medicine physicianled by Dr. Chennupati aims to aid physicians in their decision-making process. With a focus on values-centered patient care, by identifying significant patient risk factors, invasive diagnostic procedures canbecome targeted towards patients with a higher chance of positive findings, thus sparring pediatricpatients from potential unnecessary iatrogenic trauma. By recommending a simple chart review onpediatric recurrent croup patients to identify significant risk factors, the hope is for this process toreduce the number of endoscopic procedures. In the long run, this will not only reduce generalhealthcare cost for patients, but also improve the overall patient care experience for both the child andtheir patients.This project was a designed quality improvement project by Dr. Sri Chennupati of the pediatricENT department. PubMed database searches were conducted using MeSH terms “recurrent croup”AND “bronchoscopy” OR “endoscopy”. All prospective or retrospective studies on the pediatricpopulation published between 1990 and 2019 were included. Only fully accessibly publications wereincluded in this study. Recurrent croup was defined as two or more episodes of croup. Abronchoscopic or endoscopic finding of significance was either deemed significant by the authors ordefined as grade II and great subglottic stenosis, requiring surgical intervention, or repeatbronchoscopy for surveillance as established by Jabbour et al14. All relevant published studies werechecked for references and citations to ensure all notable studies were included. Any publicationsthat are case reports and/or of non-English language were excluded. The meta-analysis only includedstudies in which patient risk factors were able to be linked to individual patients (Figure 1). Casereports were excluded from the meta-analysis.Review Manager 5.4 was used to determine the overall odds ratio and its 95% confidence intervalfor each risk factor associated with recurrent croup. Sample data was added under dichotomousdata type. The inverse variance statistical method was used, with a fixed effect analysis model. Studyconfidence intervals and total confidence intervals were set to 95%. The studies were sorted by yearof study on the forest plots.Harry Shi, B.S., Susan K. Yaegar, M.D., Sri K. Chennupati, M.D.1. LEUNG A, KELLNER J, JOHNSON D. Viral croup: a current perspective. Journal of Pediatric Health Care. 2004;18(6):297-301. doi:10.1016/s0891-5245(04)00268-82. Denny FW, Murphy TF, Clyde WA Jr, Collier AM, Henderson FW. Croup: an 11-year study in a pediatric practice. Pediatrics. 1983 Jun;71(6):871-6. PMID: 6304611.3. Segal AO, Crighton EJ, Moineddin R, Mamdani M, Upshur RE. Croup hospitalizations in Ontario: a 14-year time-series analysis. Pediatrics. 2005 Jul;116(1):51-5. doi: 10.1542/peds.2004-1892. PMID: 15995030.4. Hide DW, Guyer BM. Recurrent croup. Arch Dis Child. 1985;60(6):585-586. doi:10.1136/adc.60.6.5855. Van Bever HP, Wieringa MH, Weyler JJ, Nelen VJ, Fortuin M, Vermeire PA. Croup and recurrent croup: their association with asthma and allergy. An epidemiological study on 5-8-year-old children. Eur J Pediatr. 1999 Mar;158(3):253-7. doi: 10.1007/s004310051062. PMID: 10094451.6. Waki EY, Madgy DN, Belenky WM, Gower VC. The incidence of gastroesophageal reflux in recurrent croup. Int J Pediatr Otorhinolaryngol. 1995 Jul;32(3):223-32. doi: 10.1016/0165-5876(95)01168-b. PMID: 7665269.7. Bjornson CL, Johnson DW. Croup in children. CMAJ. 2013;185(15):1317-1323. doi:10.1503/cmaj.1216458. Goldhagen JL. Croup: pathogenesis and management. J Emerg Med. 1983;1(1):3-11. doi: 10.1016/0736-4679(83)90003-3. PMID: 6386967.9. Moore M, Little P. Humidified air inhalation for treating croup. Cochrane Database Syst Rev. 2006 Jul 19;(3):CD002870. doi: 10.1002/14651858.CD002870.pub2. Update in: Cochrane Database Syst Rev. 2011;(6):CD002870. PMID: 16855994.10. Moore M, Little P. WITHDRAWN: Humidified air inhalation for treating croup. Cochrane Database Syst Rev. 2011 Jun 15;(6):CD002870. doi: 10.1002/14651858.CD002870.pub3. PMID: 21678339.11. Eghbali A, Sabbagh A, Bagheri B, Taherahmadi H, Kahbazi M. Efficacy of nebulized L-epinephrine for treatment of croup: a randomized, double-blind study. Fundam Clin Pharmacol. 2016 Feb;30(1):70-5. doi: 10.1111/fcp.12158. Epub 2015 Nov 12. PMID: 26463007.12. Waisman Y, Klein BL, Boenning DA, Young GM, Chamberlain JM, O'Donnell R, Ochsenschlager DW. Prospective randomized double-blind study comparing L-epinephrine and racemic epinephrine aerosols in the treatment of laryngotracheitis (croup). Pediatrics. 1992 Feb;89(2):302-6. PMID: 1734400.13. Hiebert JC, Zhao YD, Willis EB. Bronchoscopy findings in recurrent croup: A systematic review and meta-analysis. Int J Pediatr Otorhinolaryngol. 2016 Nov;90:86-90. doi: 10.1016/j.ijporl.2016.09.003. Epub 2016 Sep 5. PMID: 27729160.14. Jabbour N, Parker NP, Finkelstein M, Lander TA, Sidman JD. Incidence of operative endoscopy findings in recurrent croup. Otolaryngol Head Neck Surg. 2011 Apr;144(4):596-601. doi: 10.1177/0194599810393883. Epub 2011 Feb 24. PMID: 21493242.15. Zoorob R, Sidani M, Murray J. Croup: an overview. Am Fam Physician. 2011 May 1;83(9):1067-73. PMID: 21534520.16. Bjornson CL, Johnson DW. Croup in the paediatric emergency department. Paediatr Child Health. 2007;12(6):473-477. doi:10.1093/pch/12.6.473Problem StatementCroup is a common respiratory condition seen in the pediatric population that can occur in up to 15% of children typically between the ages of 6 months and 6 years old1. Croup has a 1.5 times higher incidence seen in boys than girls, with peak incidence seen between 7 months to 36 months2,3. It is frequently caused by a viral infection and manifests as “seal-like” barking cough and respiratory distress. Less commonly, roughly 5% but as high as 6.4% of children experience recurrent coup which is defined as at least 2 episodes of croup or croup-like symptoms4,1. Currently there is not a strict guideline as to when endoscopic procedures like bronchoscopy and laryngoscopy should be pursued in the setting of recurrent croup. Previous studies have linked a history of asthma, gastroesophageal reflux disease (GERD), and intubation among other risk factors in children to recurrent croup and identified those risk factors as possible indications5,6. The objectives of this project are to extend the current understanding of risk factors for recurrent croup and to develop a medical treatment pathway which will utilize risk factors as indicators for the use of endoscopic procedures to identify underlying airway pathologies for recurrent croup in the pediatric population at Lehigh Valley Health Network (LVHN).The treatment for croup and recurrent croup has evolved over last few decades. The primary management had once been the recommendation of inhalation of humidified air8. Since then, multiple studies, including a Cochrane Collaboration review, have shown that children with mild to moderate croup did not improve with inhalation of humidified air9,10. Currently, the use of corticosteroids, mainly the use of oral corticosteroids, has become the new standard management of croup11. Other treatment options include the use of racemic epinephrine and nebulized L-epinephrine7,11,12. Currently within the LVHN there is no established pathway indicating when invasive procedures should be consulted in the management of recurrent croup between the pediatricians, pediatric otolaryngologists (ENT), and family medicine physicians. This study builds upon the work of JC Hiebert et al13. by incorporating new study data published since their report and aims to use the findings to build LVHN’s own clinical pathway for the management of croup patients.Figure 2 - History of intubation vs No intubation, outcome: Significant findings on bronchoscopy.Figure 3 - History of Prematurity vs No prematurity, outcome: Significant findings on bronchoscopy.Figure 4 - History of GERD vs No GERD, outcome: Significant findings on bronchoscopy.Figure 5 - History of Asthma/Allergy vs No Asthma/Allergy, outcome: Significant findings on bronchoscopy.Figure 6 - History of Inpatient Consult vs No Inpatient Consult, outcome: Significant findings on bronchoscopy.Figure 7 - Age <1 vs Age >1, outcome: Significant findings on bronchoscopy.Figure 8 - Forest plot of comparison: Age <3 vs Age >3, outcome: Significant findings on bronchoscopy.After going through the Pubmed data base using the searchparameters as described above, a total of 135 articles were found thatwas published between 1990 and 2019. Articles were then screenedand only those that dealt with pediatric patient population with ahistory of recurrent croup and have undergone bronchoscopy orlaryngoscopy were reviewed. Articles to which there was limited accesswere excluded. One article published in Russian was excluded.Meanwhile, the article on meta-analysis of croup published by JCHiebert et al.13 in 2016 was excluded as this study aims to update thenew findings since that publication.A total of 15 articles was reviewed including 1258 pediatric patientswho were diagnosed with recurrent croup and underwent some sort ofinvasive diagnostic study. Of those 1258 patients, 182 had shownsignificant finding(s). Meta-analysis was done to study the associationbetween certain pre-procedural risk factors and significant intra-procedural findings. Our data showed that risk factors, includingprevious intubation [OR = 5.47, 95% CI = 2.81-10.63], history ofprematurity [OR = 2.22, 95% CI = 1.26-3.91], history of inpatient consultfor croup [OR = 3.19, 95% CI = 1.65-6.19], and patient age <1 [OR = 2.92,95% CI = 1.25-6.82], are associated with significant procedural findings.A previous history of GERD [OR = 1.54, 95% CI = 0.97-2.45] andAsthma/Allergies [OR = 0.90, 95% CI = 0.55-1.46] did not showstatistically significant association. In addition, patient age <3 [OR =1.28, 95% CI = 0.77-2.14] also did not display statistically significantassociation to procedural findings.Croup Diagnosis/Severity AssessmentModerate/Severe distressDexamethasone 0.15-0.6mg/kg15ED for assessment and workupStridor at rest AND one or more: intercostal/suprasternal retractions; tachypnea; agitation/restlessness/tired; difficulty with talking or feedingFollow up for dosage and/or increased work of breathingRacemic Epinephrine 30 2.25% inhalation solution (0.5 mL nebulized diluted in 3mL NS)+Dexamethasone 0.6mg/kgObserve for 2 hr, Q1 hour assessment (racepinephrine effect lasts only 2 hrs)Discharge criteria with outpatient ENT follow-up:•Minimal stridor at rest•Minimal retractions•Able to talk or feed•Has been 2 hours since last dose of racemic epiInpatient Admit criteria•3 or more doses of racepinephrine OR•Continued stridor at rest•Not meeting discharge criteria•Consult ENT(Recurrent croup with history of 2 or more previous episodes  should also consult ENT)Risk Factors for Bronchoscopy/Endoscopy:•History of prematurity•History of previous intubation•Previous inpatient consult•Age <1No Risk Factors for Bronchoscopy/Endoscopy:•Reassure parents•Continue treatmentOutpatient/Primary care settingNo improvementFigure 9 – Outpatient dexamethasone dose based on 2011 review15. ED assessment based on 2007 study by Bjornson and Johnson16.

A Clinical Guideline for the Endoscopic and Medical Management in Children with Recurrent Croup

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A Clinical Guideline for the Endoscopic and Medical Management in Children with Recurrent Croup

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