Croup vs Epiglottitis: Which One is a Medical Emergency?

Stridor is the high-pitched sound made by turbulent flow of respiratory gases through a narrowing in the airway.  It can be biphasic, inspiratory or expiratory depending on the anatomic location.

Croup is a respiratory infection with a characteristic cough, inspiratory stridor (laryngeal or supraglottic obstruction) and possible respiratory distress.  Usually caused by the Hemophilus parainfluenzae virus type 1, it affects children between 1 and 3 years of age.  Manifestations include cold symptoms, low fever, barking cough and hoarseness.  Treatment includes oxygen, steroids (dexamethasone 0.6 mg/kg PO/IM) and racemic epinephrine (to relieve airway edema and decrease airway resistance due to swelling).  Avoid racemic epi in children with glaucoma and ventricular outflow obstruction.

Steeple sign seen in xrays of children with croup.

Epiglottitis is an inflammation of the epiglottis due to an infectious process.  It can involve other structures such as the arytenoid, false cords and posterior tongue leading to airway obstruction.  Most often bacterial in origin due to Hemophilus influenzae type B, it affects children between 2 and 5, however the median age is increasing over the past decade.  It presents acutely in otherwise healthy children with a fever as high as 104F (40C).  Epiglottic inflammation occurs quickly with the child sitting forward to use the accessory muscles of respiration and pain in the throat.  Salivation is prominent with difficulty swallowing.  Treatment includes keeping a parent in attendance at all times to keep the child calm, oxygen, sitting position, immediate intubation.  Diagnosis is confirmed through radiologic studies showing the steeple sign representing a uniform narrowing of the subglottic airway by inflammation.

Angioedema seen in children with epiglottits. Note involvement of arytenoids and false cords.

Etiology Parainfluenza virus Hemophilus influenza
Age 4 mo to 2 yrs 2-5 yrs
Onset Subacute exacerbation of preexistent URI Acute
Temperature Low-grade fever High fever
Course Usually mild, stridor may worsen at night Rapid progress of symptoms
Symptoms Barky cough, stridor Dysphagia, sore throat, dysphonia, respiratory distress
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Bronchial Thermoplasty: Anesthetic Considerations

Bronchial thermoplasty is a new procedure, approved by the FDA in 2010, for the treatment of severe asthma.  It is a procedure where heat is applied to the bronchial wall to reduce the amount of smooth muscle and reduce its’ ability to contract.  Bronchial thermoplasty is a non-drug procedure for severe persistent asthma in patients 18 years and older whose asthma is not well controlled with inhaled corticosteroids and long-acting beta-agonists.  It is contraindicated in patients with AICD, pacemaker, and other implanted devices or who have had it done previously.

This minimally invasive bronchoscopic procedure is performed in three outpatient procedure visits, each treating a different area of the lungs and scheduled approximately three weeks apart.  The lobes of the lungs are completed in the following order: right lower lobe, left lower lobe and upper lobes.  The right middle lobe is NOT treated.  After all three procedures are performed, the bronchial thermoplasty treatment is complete. No clinical data are available studying the safety and/or effectiveness of repeat treatments.

Bronchial thermoplasty is routinely performed under moderate sedation or light anesthesia, and the patient typically goes home the same day.  The pulmonologist performs the procedure using a standard bronchoscope with the thermal catheter inserted via the side port.  The radiofrequency energy is delivered with low power in a temperature controlled (65 degrees C) environment.  It is considered to be a low fire risk with a maximum time per burn of 10 seconds.

Anesthetic considerations include:

  • Outpatient
  • Should be on prophylactic prednisone or equivalent for 3 days prior to procedure
  • General with OETT or sedation
  • Nebulizer and pulmonary function tests done immediately before procedure
  • Consider using Glycopyrrolate to dry up secretions and performing a deep extubation
  • Avoid histamine releasing medications
  • The procedure lasts approximately 1 hour long
  • The patient is moved to the PACU for post-op monitoring for 2 to 4 hours
  • It is recommended that  spirometry assessment be done pre-procedure and in PACU before discharge

How to Ace the Anesthesia Interview

How to Ace the Anesthesia School Interview

Applying to Nurse Anesthesia school and completing your years of ICU nursing are just the beginning.  As most all CRNAs know, the interview counts for 80% of your admission evaluation.  Each school wants the most talented students who will complete the program successfully and pass the certification exam on the first try.  The interview is your opportunity to shine!  The importance of this moment cannot be understated.  Be prepared and practice, practice, practice!

There are usually three segments to the interview, allowing the interviewers to see you in varying situations.  First, there is the personal interview.  Some schools will have 6-8 staff and students waiting in a room to review your CV, ask about your clinical experience and determine your potential for success in their program.  This can be the most nerve wracking for the interviewee.  Practice answering interview questions with anyone who will stand still long enough to listen to your response.  While the list below is not an exhaustive list of questions, they will get you started as you prepare.

1. Why do you want to become a CRNA?

This is probably the most challenging question for most of us.  While the expected answer might be the financial stability offered by a career in Nurse Anesthesia, most school directors want to hear a deeper, more considered answer that shows your commitment to the profession and your integrity.  Nurse Anesthesia is a wonderful profession, but it is such because so many of those who have gone before you have remained committed to building the foundation for a strong, safe and autonomous profession.  Dig deep and formulate an answer that reflects your commitment to the practice and art of anesthesia in an autonomous setting.

2. What makes you a great applicant?

This is your time to shine.  No one knows you better than you and this is your opportunity to let the interviewers know why you’ll be a fabulous SRNA.  Discuss your passions, commitment to patient care, and give examples of when you went above and beyond all others for the betterment of a patient or a department.  Keep it direct and brief, but definitely toot your own horn.

3. Why do you want to go to a particular program / why this school?

Research, research, research!  Know the details of your chosen program inside and out.

Find out passing rates, costs, student satisfaction, instructor qualifications, whether or not their leadership has doctoral degrees and even how many clinical sites they offer the anesthesia students.  Each school is different and you should know yours!

4. What was your most challenging clinical day at work?

We all have days where we wonder if we did enough or if we did everything right.  Review such a day with the interview team but present it in such a way as to show your skills.  How did you handle it when your patient coded?  Did you participate when the code team arrived or did you step aside and let them run the code?  Challenging patients develop our clinical skills.  Use this time to highlight your clinical skills in a real-world situation.

5. How do you maintain your own moral compass?

Unlike many other professions, Nurse Anesthesia is wonderfully autonomous.  While this provides a very stimulating clinical environment for practice, it can offer opportunities for missed documentation, medication errors or worse.  The interviewers want to know where your personal integrity comes from.  How do you maintain your own moral compass in your practice?

6. They may ask you a scenario question where you are the clinical nurse preceptor and you are working with a brand new graduate nurse on your unit.  The graduate nurse hangs an insulin drip instead of a labetalol drip and opens it wide, giving the patient a 100 unit bolus of insulin.  When the GN figures out what he did, he stands in the corner, unsure of what to do.  What do you do?

In your answer, they want you to put the patient first.  Do you talk the graduate nurse through the mistake, taking time to write up the error or do you address the patient and their care? Fairly straight-forward, however you would be surprised how many interviewees focus on reprimanding the graduate nurse!

7. How do you handle stress in your life?

Anesthesia school is stressful.  You’ll push yourself to limits you never thought you could reach.  You should have tried and true ways to relieve that stress and maintain your sanity.  The interview committee wants to hear that you are capable of handling stressful situations in healthy ways.

In addition to the interview, many schools are also having the applicants complete a written test covering such topics as drug calculations, medication regimens and ICU scenarios.  Know dosing, use and common adverse effects of all drugs used on your unit such as antiarrhythmics, pressors and vasodilators.

Finally, as if all of this wasn’t enough, there are a number of schools who will place students into a simulation lab, where ACLS-like clinical scenarios are presented and the applicants work through the clinical presentation and treat the ‘patient’.  This can be nerve wracking and really push the applicant over the edge.  They want to see how you handle a ‘real-life’ stressful situation in the operating room.  Remember to know your ACLS algorhythms very well and apply them to the patient.  Stay focused on patient care and you will do fine.

Getting accepted into anesthesia school is a wonderful accomplishment and the beginning of an intense journey for you.  Be yourself, be knowledgeable and practice, practice, practice!