Delivery of Epinephrine by Metered-Dose Inhaler for the Treatment of Croup in Children

Study Objective: Croup, also known as laryngotracheobronchitis, is a common pediatric presentation in the emergency department. When children present with moderate or severe croup, epinephrine, either racemic or L-isomer, given by nebulization is considered standard of care. Since the beginning of the SARS-CoV-2 pandemic, many medical institutions have moved away from the delivery of medications by nebulization whenever possible in order to prevent aerosolization of the SARS-CoV-2 virus and infecting others in close proximity. Delivery of respiratory medication by metered-dose inhaler (MDI) was the most commonly adopted method to replace nebulization. Primatene MIST (Armstrong Pharmaceuticals) is an over-the-counter, L-epinephrine MDI. In February 2021, the Pediatric Service Line Pharmacy and Therapeutics Committee of the Northwell Health system approved the use of Primatene MIST in children >= 1 years old presenting to the emergency department with croup as an alternative to nebulized epinephrine. We aim to demonstrate that L-epinephrine administered by MDI is safe and effective in children presenting with moderate croup. Study Design/Methods: We conducted a single-center retrospective chart review study of children 1 to 17 years of age who presented to the emergency department at Cohen Children's Medical Center and were evaluated for suspected croup from March 2021 until May 2022. As part of a surveillance and later reapproval process by the Pediatric Service Line Pharmacy and Therapeutics Committee of the Northwell Health system for Primatene MIST, data was prospectively collected and entered into a REDCap database. This included Westley Croup Score, requirement of additional doses of epinephrine, adverse events, disposition, and return within 48 hours. During the initial rollout, eligible patients were administered 4 puffs through an attached spacer. Following safety review, dosing was increased to 6 puffs. Result(s): A total of 24 pediatric patients with croup received Primatene MIST. The mean age was 3.3 years (SD:2.3 years) and 75% were male. Of the 16 patients who had respiratory viral testing, 19% tested positive for SARS-CoV-2 virus. The median Westley Croup Scores at presentation was 3 (IQR:2,3;Range:2-5), 0 (IQR:0,1;Range:0-4) at 30 minutes and 0 (IQR:0,1;Range:0-3) at 120 minutes following Primatene MIST administration. A second dose of epinephrine (nebulized or MDI) was administered to 7 patients (29.2%;CI:14.9%-49.2%). Only 1 patient (4.2%) was admitted and 1 (4.2%) returned within 48 hours. There were no reported adverse events. Conclusion(s): Epinephrine administered by MDI is a safe and effective treatment for moderate croup. It should be considered as an alternative to nebulized epinephrine when there are concerns for infectious aerosolization. No, authors do not have interests to disclose Copyright © 2022

Pediatric emergency department utilization during the COVID-19 pandemic in New York City

OBJECTIVES: This study describes the utilization of a pediatric emergency department (ED) during the early months of the COVID-19 pandemic in the initial U.S. epicenter, including the impact on visit acuity and incidences of common diagnoses. STUDY DESIGN: We performed an observational retrospective review of patients younger than 18 years old seen in a New York City pediatric ED from March 7th to May 6th 2020, and during the same time period in 2018 and 2019. Demographics, visit details, diagnoses, and dispositions were compared. Validated algorithms were utilized to create practical diagnosis groupings and to determine the probability of a visit requiring emergent evaluation. RESULTS: ED visits during the pandemic decreased by 56% to an average daily census of 67 patients, from an anticipated 152. Admission rates rose from 13.3% to 17.4% (p<0.001), and the proportion of triage Emergency Severity Index level 1 and 2 patients increased by 23.7% (p<0.001). Non-emergent visits dropped from 32.3% to 27.5% (p<0.001). Several common, often low-acuity diagnoses saw disproportionate reductions in visits including headache, chest pain, and minor injuries. Concerningly, visits for suicidal ideation, suicide attempt, or self-harm increased by 100% (p<0.001) and visits for evaluating abuse or neglect decreased by 89% (p=0.01). CONCLUSIONS: Pediatric ED utilization substantially deceased during the early months of the COVID-19 pandemic in New York City, but left relatively higher patient acuity. Healthcare systems in early epicenters must also prepare for the disproportionate impact a pandemic has on the most vulnerable pediatric patients, particularly those at risk for self-harm or abuse.