JRCALC does not recommend the use of nebulised adrenaline at home for the management of croup
Question and answer: JRCALC does not recommend the use of nebulised adrenaline at home for the management of croup (laryngotracheobronchitis). This is a decision taken by JRCALC's Clinical Guidelines Subcommittee and supported by AACE. It has been discussed on a number of occasions since at least 2013. In reaching this conclusion, the following considerations were discussed: 1) dexamethasone often produces significant clinical improvements, within a short-time scale, when administered to children with croup. Dexamethasone for Croup was "new" to the 2013 JRCALC Guidelines. 2) while demonstrating a clinical effect in children with severe, life-threatening airway obstruction, adrenaline nebulisation is rarely required, even in hospital practice, where steroids are the mainstay of therapeutic interventions. In an audit of 50 children with acute upper airway obstruction/croup requiring hospital admission (to Poole Hospital), only 3 children (6%) required adrenaline nebulisation and these were patients that had critical airway obstruction that were closely monitored in either HDU, ITU or Resus and subsequently required intubation. 3) Adrenaline has a very short plasma half-life (2-3 minutes). In croup, it is thought to vasoconstrict the larynx's vascular bed, reducing swelling and oedema but, due to it's short period of efficacy, it's effects can and do wear off, with the possibility of rebound hyperaemia and subsequent deterioration. This short lived "improvement" might falsely assure the prehospital responder into thinking that the child is "much better" whereas subsequent deterioration may shortly occur, once the adrenaline has been metabolised, and it's effects wear off. When used in a hospital setting, adrenaline is thought to "buy time" while senior staff with advanced airway skills are assembled, should intubation (or further, surgical airway) be needed - a situation very different from those encountered by a paramedic crew working perhaps 20 minutes from the hospital, without Anaesthetic/Critical Care/ENT support.
Date posted: November 14, 2018
Date resolved: November 14, 2018