acute croup management in children · croup (acute laryngotracheobronchitis) is a clinical syndrome...

CHS Document ID 00702 Acute Croup Management in Children Children’s Health Services

Custodian/Review Officer: Chair, GBMA Clinical Procedures Editorial Group Version no: 1.0 Applicable To: Medical and Nursing staff working in Children�’s Health Services Approval Date: 14/08/2011 Effective Date: 15/08/2011 Next Review Date: August, 2013 Authority: GBMA Clinical Procedures Editorial Group Approving Officer: CEO Children�’s Heath Services Name: Dr Peter Steer �…�…�…�…�…�…�…�…�…�…�…�…�…�… Signature Supersedes: N/A Key Words: Children; acute croup; emergency management; admission, discharge criteria; and Accreditation References: EQuIP 5 criteria 1.3.1, 1.4.1, 1.5.1

1. Purpose This procedure provides clinical practice guidelines for the treatment of children (0-14 years of age) with acute croup.

2. Scope This procedure relates to all Children�’s Health Services (CHS) and Metro Children�’s Health Services staff involved with the care and management of children with acute croup.

3. Introduction Croup (acute laryngotracheobronchitis) is a clinical syndrome characterised by barking cough, inspiratory stridor and hoarseness of voice with or without respiratory distress.1,2 It is a common cause of upper airway obstruction in young children (between 1 and 2 years of age), accounting for approximately 2.3% of emergency presentations in Australia and New Zealand.3,4 Although croup is usually a mild and self-limited illness, significant upper airway obstruction, respiratory distress and rarely death, can occur.4

Croup results from inflammation of the upper airway, including the larynx, trachea, and bronchi. Viral invasion of the laryngeal mucosa leads to inflammation, hyperaemia, and oedema. This may then result in narrowing of the subglottic region.5 Children compensate for this narrowing by breathing more quickly and deeply.

In children with severe croup, as the narrowing progresses their increased work of breathing becomes counter-productive. Airflow through the upper airway becomes turbulent (producing stridor) and their compliant chest wall begins to cave in during inspiration.6,7,8 This results in paradoxical breathing, and consequently the child becomes fatigued. If untreated, these events may lead to hypoxia and hypercapnoea, which may eventually result in respiratory failure and arrest.6,7,8

Typical viral croup develops over a few days with a concurrent coryzal illness. A number of viruses may cause croup, the most common of which are Parainfluenza and RSV.1,2,9,4,10 The airway obstruction symptoms of croup are classically worse at night and peak on the second or third night of the illness. Symptoms usually resolve within 48 hours but occasionally persist for up to a week.1,2,11,12 Croup mostly affects children between 6 and 36 months, although it may occur in older children or infants as young as 3 months.10 It is rare beyond 6 years of age.5,13

General consensus is that children with croup should be made as comfortable as possible, and clinicians should take special care during

Version No.: 1.0; Effective From: 15/08/2011 of 10

CHS Proc 00702: Acute Croup Management in Children

Printed copies are uncontrolled





assessment and treatment not to frighten or upset the child because agitation may cause substantial worsening of symptoms.13

4. Assessment Children with croup may present with a range of symptoms and varying levels of severity (mild, moderate, severe and life-threatening). Accurate assessment of the severity of croup is important for initial management. Croup severity scores have been used in hospital-based clinical research studies to assess the suitability of patients for treatment in a standardised manner.14 However, they are of limited value in clinical practice.14 It is also important to always consider differential diagnosis of an acute episode of stridor (Table 1).

Table 1: Differential diagnosis of acute onset stridor and respiratory distress

Toxic appearance Non-toxic appearance Bacterial tracheitis Epiglottitis Retropharyngeal abscess Peritonsillar abscess (quinsy)

Spasmodic croup Angioneurotic oedema Laryngeal foreign body Subglottic haemangioma

Note: Toxic appearance is defined as a child who looks unwell and has reduced interaction with their environment13

Adapted from: Sydney West Area Health Service15 and Royal Children�’s Hospital, Melbourne16 Due to the lack of strong evidence for reliable croup severity scores CHS consensus opinion is that the initial assessment of a child presenting with croup should be based on the Nurse Practitioner Clinical Practice Guideline for the Management of Croup developed by Sydney west area health service.15 When performing the clinical assessment, the following clinical features should be considered to inform treatment (Table 2): Table 2: Assessment of severity

MILD MODERATE SEVERE LIFE THREATENING occasional barking cough

mild or no respiratory distress at rest

no audible stridor at rest

no cyanosis normal SaO2

frequent barking cough audible stridor at rest respiratory distress including increased work of breathing (WOB), increased respiratory rate and use of accessory muscles

no cyanosis normal SaO2 little or no agitation

persistent stridor at rest (may be expiratory)

severe respiratory distress including increased effort, marked decreased air entry, hypotonia and pallor

fatigue or altered mental state

hypoxia (cyanosis or SaO2 93%)

audible stridor may be quieter

cyanosis lethargy or decreased level of consciousness

no response to pharmacotherapy

Adapted from: Sydney West Area Health Service15 and Cherry17 Blood tests and a CXR are rarely indicated in the assessment of croup. Lateral x-ray of the neck is not routinely required and seldom provides information that affects management.14 Although subglottic narrowing, radio-opaque foreign bodies and supraglottic swelling may be apparent on radiographic imaging of the airway, the risk of the procedure generally outweighs any benefits, as neck extension required for the procedure may precipitate sudden severe obstruction.14

5. Management The most important steps in the management of croup include the appropriate use of systemic (or nebulised) corticosteroids and nebulised adrenaline.18-23 These interventions have led to a demonstrated reduction in the need for, and duration of, endotracheal intubation, length of stay, and representation to emergency services.18,19,21,24-26





Given there is no definitive treatment for the viruses that cause croup, therapy should be directed toward decreasing airway oedema and providing supportive care (respiratory support and maintenance of hydration). Recommendations for the management of croup include:

avoid distressing procedures (e.g. examining throat) as anxiety may exacerbate croup nurse the child sitting upright on carer's lap blood tests, SaO2 monitoring and oxygen mask are rarely indicated a routine NPA is not required for children with a typical clinical picture of croup.

5.1 Corticosteroids The precise mechanism by which corticosteroids exert their effect is not fully known. It is presumed to be on the basis of rapidly acting anti-inflammatory properties and/or vasoconstrictive actions in the upper airway.

The method of delivery of corticosteroid has been compared in a number of trials with oral (liquid form), IV, IM and inhaled (nebulised) routes all being shown to be superior to placebo.1,2,20 Oral administration is recommended, whenever possible, to reduce pain and distress to the child, and lessen the risk of further airway swelling and compromise.

Oral corticosteroids have the advantage of being inexpensive and therefore readily available and easy to administer.2,20,27 Studies have demonstrated oral dexamethasone at doses between 0.15 to 0.6 mg/kg/dose to be equivocal.1,2,20 It is therefore suggested that the smallest dose (0.15 mg/kg orally) be administered to achieve the desired outcome. Prednisolone (at a dose of 1 mg/kg/dose) is a commonly used alternative to dexamethasone.28

Dexamethasone and prednisolone have been shown to provide equivalent initial clinical response, but prednisolone use is associated with a higher representation rate.28,29 Current therapeutic guidelines therefore suggest that, if prednisolone is used, a second dose be prescribed, to be taken on the evening following the initial presentation.30 Note that oral dexamethasone may not be as readily available at community pharmacies or all hospitals, while oral prednisolone is now available commercially and is manufactured in a palatable liquid solution.30

5.2 Nebulised budesonide Nebulised budesonide may have a faster onset of action (within 30 minutes) compared to systemically administered corticosteroids (1-2 hours).1,2,20,31 Oral corticosteroids however are the preferred option (unless the child repeatedly vomits the oral medication), due to the availability and cost of the medication, equipment required, the time needed for administration and the potential for the child to become distressed when nebulised preparations are used.1,2,20

The recommended dose of budesonide is 2 mg/dose (independent of age and weight) to be nebulised with high flow oxygen.32 The child's eyes should be covered and their face washed afterwards to prevent facial irritation.32 5.3 Nebulised adrenaline Immediate treatment with nebulised adrenaline should be considered in any child with persisting inspiratory stridor (at rest) and marked chest wall retractions (moderate to severe croup). Adrenaline is thought to reduce bronchial and tracheal epithelial vascular permeability thereby decreasing airway oedema, resulting in an increase in the airway radius and improved airflow.2,18

The recommended dose for adrenaline is independent of age and weight (5 mL of undiluted 1:1000 adrenaline nebulised with oxygen).30 The child should be reassessed regularly following administration (clinical observations every 15 minutes for the first hour) and the dose may be repeated if there is inadequate response.30 If a child requires more than one dose of nebulised adrenaline the paediatric team and/or PICU should be notified.30

Adrenaline has a rapid onset of action with an improvement in croup symptom scores within 30 minutes.18,33 The duration of effect is approximately 2 hours.1,2,34 Historically, children were admitted for 24 hours after an initial dose of nebulised adrenaline. However, combined data from 5 prospective clinical trials in patients treated with adrenaline and dexamethasone (or budesonide) and observed for 2-4 hours found that fewer than 5% of children discharged home returned within 72 hours (with only 6/253 requiring admission).23,35-38 There were no reported adverse outcomes. This prospectively derived data along with 2 retrospective cohort studies provides good evidence that children treated with nebulised adrenaline may be safely discharged home,





provided their symptoms have not recurred within 2-4 hours of the nebulised adrenaline dose.22,34 General consensus is that children who require nebulised adrenaline be observed for 4 hours after administration before discharge. 5.4 Other Treatments Supplemental oxygen therapy may be required for children with severe viral croup who have significant oxygen de-saturation (SaO2 < 93%). Oxygen may be administered without causing the child to be agitated via a plastic hose with the opening held within a few centimetres of the nose and mouth (blow-by oxygen).13

The use of steam inhalations has not been shown to be of significant benefit in acute croup treatment.39 It is also contraindicated as the use of steam inhalers has been associated with scalds and burns in young children.40

Heliox has no proven advantage over nebulised adrenaline.39-42

See the flow chart emergency management of children with acute croup�—Appendix 1.

6. Disposition The decision to admit a child with acute croup is made after initial treatment and observation. The presence of ongoing stridor at rest after treatment necessitates admission.

When a decision is made to transfer a child to a higher level facility (Level 6), referral must be made through RSQ.43

Activation of the QLD emergency medical system coordination centre (QCC)

Further information on the preparation of a infant prior to transport can be obtained through RSQ Clinical Guidelines paediatric section (pages 31-35).43

Statewide RSQ clinical guidelines�—Paediatrics

7. Definition of terms / Abbreviations Term Definition

Children 0-14 years of age

CHS Children�’s Health Services

CXR Chest X-ray

IM Intramuscular

IV Intravenous

NPA Nasopharyngeal aspirate

PICU Paediatric Intensive Care Unit

RSQ Retrieval Services Queensland

RSV Respiratory syncytial virus

SaO2 Oxygen saturations

Toxic Looks unwell and have reduced interaction with environment13

WOB Work of breathing

http://qheps.health.qld.gov.au/rts/docs/rsq_activation.pdf

http://qheps.health.qld.gov.au/rts/docs/clin_guide_pt2.pdf





8. References and Suggested Reading 1. Fitzgerald DA., Mellis C.M. Management of acute upper airways obstruction in children. Modern

Medicine of Australia. 1995; 38: 80-88. 2. Klassen TP. Croup: A current perspective in emergency medicine. Pediatric Clinics of North

America. 1999; 46 (6): 1167-1178. 3. Acworth J., Babl F., Borland M., et al. Patterns of presentations to the Australian and New Zealand

paediatric emergency research network. Emergency Medicine Australasia. 2009; 21 (1): 59-66. 4. Segal AO., Crighton EJ., Moineddin R., et al. Croup hospitalizations in Ontario: A 14-year time-series

analysis. Pediatrics. 2005; 116 (1): 51-55. 5. Cherry JD., Feigin RD. Textbook of paediatric infectious diseases. 3rd ed. Philadelphia (USA): WB

Saunders Company; 2006. 6. Johnson D. Clinical evidence: Croup [internet]. Clinical Evidence website; 2009 [cited 2011 May 10].

Available from: http://clinicalevidence.bmj.com/ceweb/conditions/chd/0321/0321-get.pdf 7. Davis G. An examination of the physiological consequences of chest wall distortion in infants with

croup. Calgary (CA): University of Calgary; 1985. 8. Davis G., Cooper D., Mitchell I. The measurement of thoraco-abdominal asynchrony in infants with

severe laryngotracheobronchitis. Chest. 1993; 103 (6): 1842�–1848. 9. Peltola V., Heikkinen T., Ruuskanen O. Clinical courses of croup caused by influenza and

parainfluenza viruses. Pediatric Infectious Diseases Journal. 2002; 21(1): 76-78. 10. Denny FW., Murphy TF., Clyde WA., et al. Croup: an 11-year study in a pediatric practice.

Pediatrics. 1983; 71 (6); 871-876. 11. Skolnik NS. Treatment of Croup: a critical review. American Journal of Diseases of Children. 1989;

143 (9): 1045-1049. 12. Johnson DW., Williamson J. Croup: duration of symptoms and impact on family functioning. Pediatric

Research. 2001; 49: 83A. 13. Bjornson CL., Johnson DW. Croup. The Lancet. 2008; 371 (9609): 329-339. 14. Fitzgerald DA., Kilham HA. Croup: Assessment and evidence-based management. Medical Journal

of Australia. 2003; 179 (7): 372 - 377. 15. Sydney West Area Health Service. Nurse Practitioner Clinical Practice Guideline for the

Management of Croup [internet]. NSW Health website; 2004 [cited 2011 May 11]. Available from: http://www.health.nsw.gov.au/resources/nursing/practitioner/pdf/ab_croup_np_guidelines.pdf

16. Royal Children�’s Hospital, Melbourne. Croup (Laryngotracheobronchitis) [internet]. Royal Children�’s Hospital, Melbourne website; 2009 [cited 2011 May 11]. Available from: http://www.rch.org.au/clinicalguide/cpg.cfm?doc_id=5141

17. Cherry JD. Croup. The New England Journal of Medicine. 2008; 358 (4): 384-91. 18. Fitzgerald DA., Mellis CM., Johnson M., et al. Nebulised budesonide as effective as nebulised

adrenaline in moderately severe croup. Pediatrics. 1996; 97 (5): 722-725. 19. Tibbals J., Shann FA., Landau LI. Placebo-controlled trial of prednisolone in children intubated for

croup. Lancet. 1992; 340 (8822): 745-748. 20. Geelhoed GC., Macdonald WB. Oral dexamethasone in the treatment of croup: 0.15 mg/kg versus

0.3 mg/kg versus 0.6 mg/kg. Pediatric Pulmonology. 1995; 20 (6): 362-368. 21. Klassen TP., Craig WR., Moher D., et al. Nebulized budesonide and oral dexamethasone for

treatment of croup. Journal of the American Medical Association. 1998; 279 (20): 1629-1632. 22. Kelley PB., Simon JE. Racemic epinephrine use in croup and disposition. American Journal of

Emergency Medicine. 1992; 10 (3): 181-183. 23. Prendergast M., Jones JS., Hartman D. Racemic adrenaline in the treatment of laryngotracheitis:

Can we identify children for outpatient therapy. American Journal of Emergency Medicine. 1994; 12 (6): 613-616.

24. Jaffe D. The treatment of croup with glucosteroids. New England Journal of Medicine. 1998; 339 (8): 553-555.

25. Cruz MN., Stewart G., Rosenberg N. Use of dexamethasone in the outpatient management of acute laryngotracheitis. Pediatrics. 1995; 96 (2 Pt 1): 220-223.

26. Super DM., Cartelli NA., Brooks JG., et al. A prospective randomised doubleblind study to evaluate the effect of dexamethasone in acute laryngotracheitis. Journal of Pediatrics. 1989; 115 (2): 323-329.

27. Ausejo M., Sanez A., Pham B., et al. The effectiveness of glucosteroids in treating croup: meta-analysis. British Medical Journal. 1999; 319 (7210): 595-600.

28. Sparrow A., Geelhoed G. Prednisolone vs. dexamethasone in croup: A randomised equivalence trial. Archives of Disease in Childhood. 2006; 91 (7): 580-583.

http://clinicalevidence.bmj.com/ceweb/conditions/chd/0321/0321-get.pdf

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Denny%20FW%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Murphy%20TF%22%5BAuthor%5D

http://www.health.nsw.gov.au/resources/nursing/practitioner/pdf/ab_croup_np_guidelines.pdf

http://www.rch.org.au/clinicalguide/cpg.cfm?doc_id=5141





29. Fifoot AA., Ting JY. Comparison between single-dose oral prednisolone and oral dexamethasone in the treatment of croup: a randomized, double-blinded clinical trial. Emergency Medicine Australasia. 2007; 19 (1): 51-58.

30. Therapeutic Guidelines Ltd. Croup [internet]. Therapeutic Guidelines website; 2009 [cited 2011 May 12]. Available from: http://online.tg.org.au.cknservices.dotosec.com/ip/tgc/rsg/3807.htm

31. Husby S., Agertoft L., Mortensen S., et al. Treatment of croup with nebulized steroid (budesonide): a double-blind placebo controlled study. Archives of Disease in Childhood. 1993; 68 (3): 352-355.

32. Australian Medicines Handbook Pty Ltd. Australian Medicines Handbook 2010. Australia: Australian Medicines Handbook Pty Ltd; 2010.

33. Waiisman Y., Klein BL., Boenning DA., et al. Prospective randomised double-blind study compairing L-epinephrine aerosols in the treatment of laryngotracheitis (croup). Pediatrics. 1992; 89 92): 302-306.

34. Corneli H., Bolte R. Outpatient use of racemix epinephrine in croup. American Family Physician. 1992; 46 (3): 683�–684.

35. Johnson D., Jacobson S., Edney P., et al. A comparison of nebulized budesonide, intramuscular dexamethasone, and placebo for moderately severe croup. New England Journal of Medicine. 1998; 339 (8): 498:503.

36. Rizos J., DiGravio B., Sehl M., et al. The disposition of children with croup treated with racemic epinephrine and dexamethasone in the emergency department. The Journal of Emergency Medicine. 1998; 16 (4): 535�–539.

37. Ledwith C., Shea L., Mauro R. Safety and efficacy of nebulized racemic epinephrine in conjunction with oral dexamethasone and mist in the outpatient treatment of croup. Annals of Emergency Medicine. 1995; 25 (3): 331-337.

38. Kunkel N., Baker M. Use of racemic epinephrine, dexamethasone and mist in the outpatient management of croup. Pediatric Emergency Care. 1996; 12 (3): 156-159.

39. Moore M., Little P. Humidified air inhalation for treating croup. Cochrane Database of Systematic Reviews. 2006; Issue 3, Art. No.: CD002870.

40. Greally P., Cheng K., Tanner M., et al. Children with croup presenting with scalds. British Medical Journal. 1990; 301 (6743): 113.

41. Weber JE., Chudnofsky CR., Younger JG., et al. A randomised comparison of helium-oxygen mixture (heliox) and racemix epinephrine for the treatment of moderate to severe croup. Pediatrics. 2001; 107(6): e96.

42. Vorwerk C., Coats T. Heliox for croup in children. Cochrane Database for Systematic Reviews. 2010; Issue 2, Art. No.: CD006822.

43. Statewide Clinical Coordination and Retrieval Services. Clinical guidelines: Section two [intranet]. Brisbane (AU): Queensland Government (Queensland Health); 2008 [cited July 25]. Available from: http://qheps.health.qld.gov.au/rts/docs/clin_guide_pt2.pdf

9. Supporting Documents Acute croup flow chart Croup fact sheet

10. Consultation Key stakeholders who reviewed this version are:

Staff Specialist �– Emergency Department, Royal Children�’s Hospital Clinical Nurse Consultant Emergency Department, Mater Children�’s Hospital Staff Specialist �– Emergency Department, Mater Children�’s Hospital Director of Paediatrics, Ipswich Hospital Clinical Nurse Consultant Emergency Department, Logan Hospital Nurse Practitioner �– Paediatrics, Logan Hospital Manager �– Clinical Standards, Queensland Ambulance Service Director of Paediatric Emergency Medicine, Children�’s Health Services Clinicians (medical, nursing, allied health) working within Level 4, Level 5 and Level 6 Children�’s

Health and Metro Children's Health Services in emergency, inpatient and ambulatory services Children�’s Health Services District clinical leaders �— medical, nursing and allied health

http://online.tg.org.au.cknservices.dotosec.com/ip/tgc/rsg/3807.htm

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Vorwerk%20C%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Coats%20T%22%5BAuthor%5D

http://qheps.health.qld.gov.au/rts/docs/clin_guide_pt2.pdf

http://qheps.health.qld.gov.au/ed/docs/child_croup.pdf





District Chief Executive Officers �— Children�’s Health Services, Metro South, Metro North and West-Moreton Health Service Districts

Queensland Ambulance Services �— Manager Clinical Standards. Acknowledgements: Children�’s Health Services would like to acknowledge the contribution made by:

Dr Jason Acworth�—Director of Paediatric Emergency Medicine, Children's Health Services Donna Franklin�—Project Manager SEQ PP, Children's Health Services Dr John Gavranich�—Director of Paediatrics, Ipswich Hospital Dr Sharon Anne McAuley �—Staff Specialist (ED), Mater Children's Hospital Dr Michelle Davison�—Staff Specialist (ED), The Prince Charles Hospital Dr Geoff Pearce�—Medical Officer, Royal Children�’s Hospital Shahn Horrocks�—Nurse Practitioner (ED), Gold Coast and Logan Hospitals Andrea Hetherington�—Clinical Nurse Consultant (Paediatrics) (ED), Logan Hospital Elizabeth Ruddy�—Clinical Nurse Consultant (ED), Mater Children's Hospital.

11. Procedure Revision and Approval History Version No Modified by Amendments authorised by Approved by

1.0 New document GBMA clinical procedures editorial group

CEO Children�’s Health Services

12. Audit / Evaluation Strategy Level of risk High

Audit strategy 1. Staff survey to evaluate awareness of procedure and emergency management practices

2. Observe practice

Review documentation, i.e. chart audit, to evaluate compliance with procedure

Audit tool attached Nil

Audit date Annual snapshot review (August)

Audit responsibility Individual Greater Brisbane Metropolitan hospitals, i.e. Ipswich, Logan, Redland, MCH, RCH, TPCH, Redcliffe, Caboolture

Key Elements / Indicators / Outcomes

KPI 1 �— greater than 80% staff awareness of procedure

KPI 2 �— greater than 80% compliance with procedure


13. Appendix 1 – Emergency Management of Children with Acute Croup





14. Appendix 2 – Admission/Discharge Criteria for Children with Acute Croup




CHS Proc:


