Posts Tagged ‘corticosteroids’

Croup treatment has and hasn’t changed

December 21, 2017

With a cough like the bark of a seal
And the kiddy so good doesn’t feel
There’s no way to avoid
A dose of steroid
Croup must be treated with zeal.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. A month in the Arctic followed a month in Iowa followed 3 months in British Columbia, to which we have returned. Any identifiable patient information has been included with permission.
I had cause to contemplate how things do and don’t change in medicine. Consider, for example, croup. If a virus swells a child’s narrow airway, a barking cough, much like a seal asking for a fish, follows. Death can ensue if the airway narrows to the point of closing, or if the child stops breathing out of exhaustion.
The pediatric ward in the hospital where I did my residency had two outdated features for treating croup when I arrived.
One consisted of a tiled room that could be filled with water vapor; a large cloud chamber that could sleep 8. During my tenure its only use was storage.
But the spacious balcony on the other side of the nurses’ station told a different story. It had sliding glass doors and space for 6 cribs. In a bad croup year, the nurses bundled the children up, to sleep with their faces uncovered in the cold, dry Wyoming air.
It worked for most of the kids, and I still recommend that strategy, saying, “Now if the spasm of croup doesn’t clear in 3 breaths you’re already headed to the ER.”
Treatments have come and gone and come back. Antibiotics, we found, did no good. Theophylline (a close cousin of caffeine, and found in pharmacologic amounts in chocolate) helped, but not much, and had a lot of side effects so has since been completely displaced by the albuterol (in Canada, salbutamol) updraft.
Every winter, during the peak croup season, I’d ask my pediatrician friends if we’d gotten anything new for croup, and every winter they’d shake their heads.
We used to use inhaled adrenaline (also called epinephrine). It has come and gone in five year cycles. A year and a half ago I thought for sure that I’d never use it again when I heard a study showed it did no better than inhaling saline (salt water).
We used steroids a lot and stopped for a while in the 90s, started again just before the millennium, and continue to this day. Controversy remains regarding dose, and method of administration.
But croup has changed. The really, really bad version, where the epiglottis (the flap valve between the airway and the swallow tube) swells has disappeared with modern immunizations for diphtheria and Hemophilus influenza. And with the decreasing smoking rates we don’t see nearly as much as we used to.
I had cause to research croup treatment recently, finding, to my surprise, that all my internet sources recommend inhaled epinephrine and steroids. Just like 1982.


Death, unconditional love, and a really bad case of enlightenment

October 10, 2010

You know, it’s not that I pried,

 But Bob said, “Last night I died,

    It wasn’t a frightenment

    But a bad case of enlightenment

I was willing to take it in stride.”

My friend Bob almost died last night

Bob controlled his diabetes well for the last ten years, before a disc in his mid back exploded and necessitated surgery about ten days ago.  He faces a very real possibility of paraplegia. Standard of care in these cases includes steroids.  I’ve been in California for the last few days visiting him in the rehab hospital.

Doctors throw the term steroids around more carelessly than two-year-olds throw rice at a Chinese restaurant.  The word refers to any molecule built on a cholesterol skeleton, including testosterone (the main male hormone) and estrogen (the main female hormone).  In this case, “steroids” mean things like cortisol or cortisone or prednisone, properly called corticosteroids.  They’re widely used in dermatology, asthma, emphysema, and cancer chemotherapy.

They are the body’s main stress hormone; we use cortisol levels to measure the stress of an episode.

My personal experience with the class of drugs goes back twenty years, when my rheumatologist decided to treat my flaring ankylosing spondylitis (spinal arthritis related to rheumatoid arthritis) with prednisone.  My back felt great, I felt even better: creative, energetic, and invulnerable.  I talked so fast that my wife and daughters had to tell me to slow down.  I slept four hours a night and awakened rested.  I wrote another novel.  But steroids exact a price, I started to get irritable, I could hear repetition in my speech, and I lost so much strength in my shoulders I couldn’t string my bow.  My rheumatologist tapered the dose down and started methotrexate (a very nasty drug); I’ve not been on prednisone since—I found it too seductive.  In retrospect, it put me into hypomania (a state near mania, part of bipolar disorder), a known side effect of the drug. 

Steroids like prednisone powerfully inhibit the body’s inflammatory response.  Post-surgical swelling in the area of the spine can put enough pressure on the spinal cord to strangle it; thus the corticosteroid therapy.  Predictably, they wreak havoc with blood sugars, but not in a linear fashion, and physicians play a balancing act trying to avoid the adverse consequences of sugars too high or too low. 

Bob has been on Decadron or dexamethasone; compared to prednisone it’s a steroid, well, on steroids.  The doctors on the case have been appropriately prescribing insulin, but corticosteroids bring chaos to diabetes.  His sugar crashed last night.  His blood pressure, blood sugar, and oxygenation fell below levels that sustain life.

He doesn’t remember seeing white light or darkness, and he calls the experience “a really bad case of enlightenment.”  He no longer fears the pain of death.  He loves his freedom.

But he’s alive today and better than he was yesterday.  He has minimal movement in the left leg and a trace on the right.  Between the steroids, motion in his legs, and his new-found freedom, his spirits are soaring, his thoughts are racing, and he relishes the feeling of unconditional love he has for the people around him.