eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease

Parainfluenza Virus Infections: Treatment & Medication

Author: Roy M Vega, MD, Assistant Professor of Pediatrics, Albert Einstein College of Medicine; Director, Pediatric Emergency Services, Department of Emergency Medicine, Bronx Lebanon Hospital Center, Bronx, NY
Contributor Information and Disclosures

Updated: Aug 28, 2009

Treatment

Medical Care

Management of croup caused by parainfluenza virus (PIV) infection depends on the severity of disease.

  • Prehospital care
    • Prehospital care includes fever control and attempts to alleviate respiratory symptoms and patient anxiety.
    • Respiratory symptoms commonly improve with benign measures such as sitting in a bathroom with a steaming shower and allowing vapor droplets to soothe inflamed airways. Another option includes exposing the child to the cool night air. Often, the patient's symptoms resolve en route to the hospital. Attempts at calming or distracting the child can be beneficial.
    • Antipyretics may assist with fever control. Moderate or severe croup requires medical evaluation in the office or emergency department.
  • Emergency department care
    • Mild croup: Management of mild croup consists of cool blow-by oxygen mist, fever control, and observation to determine whether the airway appears compromised.
    • Moderate croup
      • Cool oxygen mist and steroids are common therapies. Controlled trials for the palliation of croup symptoms have yielded conflicting results, and routine use of dexamethasone in this disease remains controversial. Dexamethasone was traditionally intramuscularly administered; however, recent studies have documented the use of oral steroids.
      • In patients who fail to improve, administration of racemic epinephrine with a nebulizer has been beneficial. If racemic epinephrine alleviates symptoms, observe the patient for a minimum of 3 hours to ensure the patient's condition does not worsen (eg, due to possible rebound laryngospasm as the racemic epinephrine dose wears off). If asymptomatic at this time, the patient can be discharged with proper follow-up care.
      • In patients with moderate croup, oral intake may be lacking; therefore, evaluate the patient's hydration status. Intravenous fluids may be required.
    • Severe croup
      • Perform the same measures as in moderate croup. Observe for signs of impending respiratory failure.
      • Repeat racemic epinephrine nebulization may be needed, in addition to intensive care monitoring. Racemic epinephrine nebulizations can be repeated at 1-hour to 2-hour intervals as needed. Fortunately, fewer than 5% of patients who are admitted require artificial airway support (endotracheal intubation).

Medication

No specific antiviral agents are available for treating parainfluenza virus (PIV) infections; however, medications are available to treat the respiratory symptoms associated with croup. The medications include corticosteroids and nebulized epinephrine to treat airway inflammation and edema.

Glucocorticoids

These agents have anti-inflammatory properties and cause profound and varied metabolic effects. They modify the body's immune response to diverse stimuli. Anti-inflammatory drugs (specifically dexamethasone) help reduce the inflammation and subglottic edema of croup. Despite delayed onset of action, the high potency and prolonged intramuscular half-life of dexamethasone make it the preferred corticosteroid for croup.


Dexamethasone (Decadron)

Criterion standard anti-inflammatory drug for reducing airway edema that occurs in croup. Other glucocorticoids have been used, including prednisone and prednisolone. Dexamethasone is thought to decrease inflammation by suppressing migration of polymorphonuclear leukocytes and reversing increased capillary permeability.

Adult

10 mg PO/IV/IM qd

Pediatric

0.6 mg/kg PO/IM qd prn; not to exceed 10 mg/d

Possible decreased effects with coadministration of barbiturates, phenytoin, or rifampin; decreases effect of salicylates and vaccines

Documented hypersensitivity; immunosuppressed patients receiving corticosteroids; varicella

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in hyperthyroidism, osteoporosis, cirrhosis, nonspecific ulcerative colitis, peptic ulcer, diabetes, and myasthenia gravis; tuberculosis; untreated systemic infections; ocular herpes simplex virus


Budesonide (Pulmicort Respules)

Nebulized budesonide has been found to be beneficial in treating croup.

Adult

Not applicable

Pediatric

2-4 mg/d inhaled via nebulizer divided qd/bid

Ketoconazole may increase plasma levels of budesonide; cimetidine may increase bioavailability of budesonide

Documented hypersensitivity; immunosuppressed patients receiving corticosteroids; varicella; patients may develop PO thrush

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Tuberculosis, untreated systemic infections, ocular herpes simplex virus


Prednisolone (Delta-Cortef, Pediapred)

Many practitioners administer liquid prednisolone for patients with croup in lieu of dexamethasone. Prednisolone has not been proven superior to dexamethasone.

Adult

Not applicable

Pediatric

1-2 mg/kg/d PO qd or divided bid

Decreases effects of salicylates and toxoids (for immunizations); phenytoin, carbamazepine, barbiturates, and rifampin decrease effects of corticosteroids

Documented hypersensitivity; immunosuppressed patients receiving corticosteroids; varicella

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in hyperthyroidism, osteoporosis, cirrhosis, nonspecific ulcerative colitis, peptic ulcer, diabetes, and myasthenia gravis; tuberculosis; untreated systemic infections; ocular herpes simplex virus

Bronchodilators

When delivered by air or oxygen-powered devices, epinephrine is directly delivered to respiratory mucosal surfaces and smooth muscle. Because nebulizers deliver the medication directly to the target organ, fewer systemic adverse effects are encountered in comparison with oral or parenteral administration.


Epinephrine, racemic solution (Vaponefrin, microNefrin)

Very effective in reversing upper airway edema when administered with a nebulizer. Proposed mechanism of action is alpha-adrenergic receptor-mediated vasoconstriction of edematous tissues.

Adult

Mix 0.5 mL with 3 mL 0.9% NaCl (normal saline) and inhale via nebulizer q1-2h prn

Pediatric

Mix 0.05 mL/kg with 3 mL 0.9% NaCl (normal saline) and inhale via nebulizer q1-2h prn; not to exceed 0.5 mL/dose

Inhaled anesthetics may enhance cardiac irritability; nonselective beta-blockers block the beta effects of epinephrine leaving unopposed alpha effects (eg, hypertension)

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Tachycardia, especially with HR >200 BPM; consider cardiac monitoring if multiple doses required


L-epinephrine (Adrenalin)

In concentrations of 1:1000, may be substituted for racemic epinephrine for nebulized administration.

Adult

5 mL nebulized q1-2h prn; mix with 3 mL 0.9% NaCl

Pediatric

<4 years: Mix 2.5 mL with 3 mL 0.9% NaCl (normal saline) and inhale via nebulizer
>4 years: Administer as in adults

Inhaled anesthetics may enhance cardiac irritability; nonselective beta-blockers block the beta effects of epinephrine leaving unopposed alpha effects (eg, hypertension)

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Tachycardia, especially with HR >200 BPM, consider cardiac monitoring if multiple doses required

More on Parainfluenza Virus Infections

Overview: Parainfluenza Virus Infections
Differential Diagnoses & Workup: Parainfluenza Virus Infections
Treatment & Medication: Parainfluenza Virus Infections
Follow-up: Parainfluenza Virus Infections
Multimedia: Parainfluenza Virus Infections
References

References

  1. Kesebir D, Vazquez M, Weibel C, et al. Human bocavirus infection in young children in the United States: molecular epidemiological profile and clinical characteristics of a newly emerging respiratory virus. J Infect Dis. Nov 1 2006;194(9):1276-82. [Medline].

  2. Manning A, Russell V, Eastick K, et al. Epidemiological profile and clinical associations of human bocavirus and other human parvoviruses. J Infect Dis. Nov 1 2006;194(9):1283-90. [Medline].

  3. [Guideline] Standard precautions in hospitals. In: Betsy Lehman Center for Patient Safety and Medical Error Reduction, JSI Research and Training Institute, Inc. Prevention and control of healthcare-associated infections in Mass. Part 1: final recommendations of the Expert Panel. Massachusetts Department of Public Health; 2008 Jan 31. p. 42-9. [Full Text].

  4. Lopez Perez G, Morfín Maciel BM, Navarrete N, Aguirre A. Identification of influenza, parainfluenza, adenovirus and respiratory syncytial virus during rhinopharyngitis in a group of Mexican children with asthma and wheezing. Rev Alerg Mex. May-Jun 2009;56(3):86-91. [Medline].

  5. Stankova J, Carret AS, Moore D, et al. Long-term therapy with aerosolized ribavirin for parainfluenza 3 virus respiratory tract infection in an infant with severe combined immunodeficiency. Pediatr Transplant. Mar 2007;11(2):209-13. [Medline].

  6. Barkin RM. Respiratory disorders. In: Pediatric Emergency Medicine Concepts Clinical Practice. 1993.

  7. Cressman WR, Myer CM 3rd. Diagnosis and management of croup and epiglottitis. Pediatr Clin North Am. Apr 1994;41(2):265-76. [Medline].

  8. Cruz MN, Stewart G, Rosenberg N. Use of dexamethasone in the outpatient management of acute laryngotracheitis. Pediatrics. Aug 1995;96(2 Pt 1):220-3. [Medline].

  9. Custer JR. Croup and related disorders. Pediatr Rev. Jan 1993;14(1):19-29. [Medline].

  10. Donaldson D, Poleski D, Knipple E, et al. Intramuscular versus oral dexamethasone for the treatment of moderate-to-severe croup: a randomized, double-blind trial. Acad Emerg Med. Jan 2003;10(1):16-21. [Medline].

  11. Kairys SW, Olmstead EM, O'Connor GT. Steroid treatment of laryngotracheitis: a meta-analysis of the evidence from randomized trials. Pediatrics. May 1989;83(5):683-93. [Medline].

  12. Klassen TP, Watters LK, Feldman ME, et al. The efficacy of nebulized budesonide in dexamethasone-treated outpatients with croup. Pediatrics. Apr 1996;97(4):463-6. [Medline].

  13. Prendergast M, Jones JS, Hartman D. Racemic epinephrine in the treatment of laryngotracheitis: can we identify children for outpatient therapy?. Am J Emerg Med. Nov 1994;12(6):613-6. [Medline].

  14. Rittichier KK, Ledwith CA. Outpatient treatment of moderate croup with dexamethasone: intramuscular versus oral dosing. Pediatrics. Dec 2000;106(6):1344-8. [Medline].

  15. Rudy. Croup: Has management changed?. Contemp Pediatr. 1993;10:21-32.

  16. Vega R. Rapid viral testing in the evaluation of the febrile infant and child. Curr Opin Pediatr. Jun 2005;17(3):363-7. [Medline].

  17. Wendt CH, Weisdorf DJ, Jordan MC, Balfour HH Jr, Hertz MI. Parainfluenza virus respiratory infection after bone marrow transplantation. N Engl J Med. Apr 2 1992;326(14):921-6. [Medline].

  18. Williams JV. The clinical presentation and outcomes of children infected with newly identified respiratory tract viruses. Infect Dis Clin North Am. Sep 2005;19(3):569-84. [Medline].

Further Reading

Keywords

parainfluenza virus infection, PVI, croup, upper respiratory tract infection, laryngotracheobronchitis, URTI, severe acute respiratory syndrome, SARS, pneumonia, parainfluenza virus, coryza, cough, bronchiolitis, paramyxovirus, human bocavirus, treatment, diagnosis

Contributor Information and Disclosures

Author

Roy M Vega, MD, Assistant Professor of Pediatrics, Albert Einstein College of Medicine; Director, Pediatric Emergency Services, Department of Emergency Medicine, Bronx Lebanon Hospital Center, Bronx, NY
Roy M Vega, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Medical Editor

Ashir Kumar, MBBS, MD, FAAP, Professor, Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University; Consulting Staff, Department of Pediatrics, EW Sparrow Hospital
Ashir Kumar, MBBS, MD, FAAP is a member of the following medical societies: American Academy of Pediatrics, American Association of Physicians of Indian Origin, American Federation for Clinical Research, American Society for Microbiology, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Joseph Domachowske, MD, Professor of Pediatrics, Microbiology and Immunology, Department of Pediatrics, Division of Infectious Diseases, State University of New York-Upstate Medical University
Joseph Domachowske, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Society for Microbiology, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and Phi Beta Kappa
Disclosure: Nothing to disclose.

CME Editor

Robert W Tolan Jr, MD, Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine
Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility
Disclosure: GlaxoSmithKline Honoraria Speaking and teaching; MedImmune Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; sanofi pasteur Honoraria Speaking and teaching; Baxter Healthcare Honoraria Speaking and teaching

Chief Editor

Russell W Steele, MD, Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine
Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association
Disclosure: None None None

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.