A Randomized Comparison of Helium–Oxygen Mixture (Heliox) and Racemic Epinephrine for the Treatment of Moderate to Severe Croup

Abstract

ABSTRACT. Objective. To compare the additive effect of a helium-oxygen mixture (Heliox) or racemic epinephrine (RE) on croup scores (CSs) in children with moderate to severe croup treated with humidified oxygen and steroids.Design. A prospective, randomized, double-blind trial.Setting. Emergency department and pediatric intensive care unit of an urban level I trauma center.Participants. Randomly assigned, consecutive children ages 6 months to 3 years presenting with moderate to severe croup (CS: >5).Interventions. After cool humidified oxygen and 0.6 mg/kg of intramuscular dexamethasone, patients were randomized to receive either Heliox or RE. Vital signs, oxygen saturation, and CSs were recorded at regular intervals.Outcome/Analysis. Reductions in CSs were compared using repeated-measures analysis of variance.Results. Thirty-three patients were enrolled. Three were excluded because of protocol violations, and 1 was excluded because of lack of documentation, leaving 29 patients for final analysis. The average age was 24.2 months, 20 were male (68.8%). Both Heliox and RE were associated with improvement in CSs over time. There were no significant differences in mean CS, oxygen saturation, respiratory rate, or heart rate between groups at baseline or at the end of the treatment period.Conclusion. In patients with moderate to severe croup, the administration of Heliox resulted in similar improvements in CS compared with patients given RE. Pediatrics 2001;107(6). URL: http://www.pediatrics.org/ cgi/content/full/107/6/e96; helium-oxygen mixture, croup.ABBREVIATIONS. RE, racemic epinephrine; CS, croup score; ED, emergency department. L aryngotracheobronchitis, or croup, is a common respiratory illness in children. Most cases of croup are mild and require only supportive care with humidified oxygen. However, in moderate to severe cases, aggressive therapy may be necessary to avoid exhaustion and subsequent respiratory failure. Although steroids have gained widespread acceptance as a means of attenuating subglottic edema, racemic epinephrine (RE) has long been considered the mainstay of acute therapy for moderate to severe croup. 1 Helium is a biologically inert gas that possesses a very low specific gravity (density) and is one third the viscosity of air. 2 These properties result in a decreased resistance to airflow (lower Reynolds number), and suggest that a helium-oxygen mixture may be a useful adjunct to improve ventilation via enhanced laminar airflow in the face of moderate to severe croup. Recently, mixtures of helium and oxygen have been used successfully in the pediatric intensive care unit setting for treatment of both refractory viral and postextubation croup. [3][4][5] Although both Heliox (AGA Gas, Flint, MI) and RE have been independently shown to decrease the work of breathing and lower croup scores (CSs), 3,4,6 no study to date has compared these modalities in the management of moderate to severe croup. Therefore, the purpose of this study was to compare the relative effect of Heliox and RE on CSs in pe...

Medicines used in respiratory diseases only seen in children

“…Two RCTs, one comparing heliox to epinephrine in children who had already received i.m. dexamethasone [227], and another comparing heliox to oxygen-enriched air in children with mild croup [228], did not show significant differences in croup scores between the groups. Due to costs and practical limitations, the general use of heliox cannot be recommended.…”

Use of helium-oxygen mixtures in the treatment of croup: a systematic review

“…The initial screening excluded 34, and the remaining 10 were reviewed in full text for potential inclusion. After a full text review, two trials were identified that fulfilled the inclusion criteria (table 1)32 33 and eight were excluded (table 2). 26 – 29 34 – 37…”

Estudio descriptivo del uso de heliox en pacientes de la Unidad de Cuidado Intensivo Pediátrico del Instituto de Ortopedia Infantil Roosevelt

“…La literatura reporta pacientes con asma que presentan adecuada respuesta al tratamiento en el 73% de los casos, y en pacientes con estridor postextubación producidos por lesión suglótica, (trauma, lesiones ocupando espacio e infecciones), el heliox disminuyó la necesidad de intubación o reintubación en 71% de los casos 5 . En el crup se ha encontrado igual efectividad comparado con el uso de epinefrina racémica 14 .…”

“…Se ha utilizado en diferentes patologías de tipo obstructivo que comprometen la vía aérea superior, (crup, epiglotitis, estenosis subglótica), vía aérea inferior (bronquiolitis, crisis asmática) así como en el manejo del neumotórax y la hiperamonemia [7][8][9][10][11][12][13][14][15][16] . Las patologías en las que se ha utilizado con mayor frecuencia ha sido en asma (78%) y en crup postextubación (51%).…”