Evidence based guideline for the management of croup

Transcription

1 Evidence based guideline fr the management f crup Mazza D, Wilkinsn F, Turner T, Harris C n behalf f the Health fr Kids Guideline Develpment Grup. Crup is a cmmn presentatin in bth the general practice and hspital emergency department setting. The relatively recent intrductin f sterid use in the management f crup has resulted in decreased hspital admissins and imprved utcmes fr children. This resurce prvides an evidence based guideline fr the management f crup in general practice which is endrsed by The Ryal Australian Cllege f General Practitiners. Crup, als knwn as laryngtrachebrnchitis, is a cmmn childhd respiratry illness caused by a range f viruses. Viral infectin causes inflammatin f the upper airway, which is characterised by barking cugh, inspiratry stridr, harseness and respiratry distress. Mst cases f crup are relatively mild and self limiting. Hwever, crup can ccasinally cause severe respiratry bstructin and rarely, death. Why was this guideline develped? Despite the fact that the use f crticsterids has revlutinised the management f crup, with fewer return visits and/r hspital (re)admissins required and a decrease in length f time spent in hspital, 1 crup remains a cmmn reasn fr children t present t hspital. In the 5 years frm 1 July 1999 t 30 June 2004, there were mre than presentatins by children with crup t Victrian hspital emergency departments. Apprximately 30% f these children (~1600 per year) were admitted t hspital, and less than 0.5% (~23 per year) were admitted t intensive care units. 2 Better management in the general practice setting and imprved knwledge f the cnditin may result in decreased hspital utilisatin. This guideline cvers diagnsis, natural histry and management, infectin cntrl issues, and indicatins fr hspital admissin and discharge. The full guideline can be fund at hfk/pdf/hfkbrnchilitisguideline.pdf. Recmmendatins Diagnsis The diagnsis f crup is clinical. There is very little research evidence n which t establish evidence based recmmendatins fr the diagnsis f crup. Hwever, there is a cnsensus f pinin in the medical literature that a child presenting with abrupt nset f barking cugh, inspiratry stridr and harseness is likely t have crup. The severity f these symptms varies ver time. Crup is usually preceded by symptms f a mild upper respiratry tract infectin, including lw grade fever, runny nse and cugh. A child presenting with abrupt nset f barking cugh, inspiratry stridr and harseness is likely t have viral crup Histrically there has been a distinctin made between viral crup and spasmdic r recurrent crup. Opinin in the medical literature is divided as t whether these are separate entities r represent ends f the spectrum f the crup syndrme. Differentiating between the tw cnditins is difficult and largely unnecessary as treatment in either case is determined by the patient s histry and severity f airway bstructin. D Cnsider ther diagnses in children with recurrent crup 14 Reprinted frm Vl. 37, N. 6, June 2008 SPECIAL ISSUE

2 Differential diagnses Crup-like symptms may be present in children with several ther cnditins including: inhaled freign bdy epiglttitis bacterial tracheitis cngenital abnrmality subglttic haemangima. D The fllwing clinical features shuld alert the clinician t lk fr cnditins ther than crup in a child with crup-like symptms: expiratry wheeze r lss f vice txic appearance r high grade fever drling, difficulty swallwing, anxiety prlnged, r recurrent stridr pr respnse t treatment age less than 3 mnths Investigatins The diagnsis f crup is clinical and ther investigatins are nly rarely f value. In particular, radigraphy is nt helpful in diagnsing crup. C Radigraphy shuld nt be used t diagnse crup C Radigraphy shuld nt be rutinely used t differentiate crup frm epiglttitis D Radigraphy may ccasinally be warranted in patients with stridr where the diagnsis is uncertain. If radigraphy is rdered, the patient shuld be mnitred during imaging by staff able t manage the patient s airway D Naspharyngeal aspiratin shuld nt be undertaken in children with suspected crup Patients at high risk Children with pre-existing cnditins causing narrwing f the upper respiratry tract, such as Dwn syndrme, are at higher risk f severe crup What bservatins shuld be taken? The Guideline Develpment Grup (GDG) agreed that the mst imprtant bservatins fr a child with crup (Table 2) are: mental state stridr accessry muscle use, tracheal tug r chest wall retractin heart rate respiratry rate. Crup is a disease f the upper airway and gas exchange in the alveli is usually unaffected. It is therefre lgical that decreased xygen saturatin is a late sign f severity in crup. There is n evidence t determine when xygen saturatin shuld be measured in children with crup. In the absence f evidence the GDG agreed that xygen saturatin (where available) shuld be measured at first presentatin and then nly in children with signs f severe r life threatening crup. D Measurements f xygen saturatin shuld be made at presentatin t hspital, and in children with signs f severe r life threatening crup Nnpharmaclgical management Children with crup shuld be kept calm, and distressing prcedures kept t a minimum as agitatin may wrsen airway bstructin. Humidified air Assessment Assessment f crup is fcused n classificatin f severity f airway bstructin as either: mild mderate severe, r life threatening. There is little high quality evidence n which t base recmmendatins fr the assessment f severity f airway bstructin in children with crup. The clinical signs and symptms in Table 1 are based n cnsensus pinin. Ludness f stridr is nt a gd indicatr f the severity f crup Our search identified tw randmised cntrlled trials 3,4 investigating the effectiveness f mist, steam r humidificatin in the treatment f crup, neither f which shwed any clinically significant difference with the use f humidified air. B Mist r humidified air has nt been demnstrated t be an effective treatment fr children with crup Cld air Sme parents als reprt that children with crup imprve when expsed t cl air. N research evidence was identified that investigated the effectiveness f cld r cl air in alleviating symptms f crup. Reprinted frm Vl. 37, N. 6, June 2008 SPECIAL ISSUE 15

3 Table 1. Algrithm fr the management f crup in general practice Assessment f degree f airway bstructin Mild Mderate Severe Life threatening Nrmal mental state Anxius, tired Agitated, exhausted Cnfused, drwsy N stridr r nly when distressed Stridr at rest N r subtle accessry muscle use, tracheal tug r chest wall retractin Minr accessry muscle use, tracheal tug r chest wall retractin Marked accessry muscle use, tracheal tug r chest wall retractin Maximal accessry muscle use, tracheal tug r chest wall retractin r exhaustin Nrmal heart rate Increased heart rate Markedly increased heart rate Able t talk and/r feed Sme limitatin f ability t talk and/r feed Increased respiratry rate T breathless t talk and/r feed Pr respiratry effrt Silent chest Extreme pallr Cyansis* Lw muscle tne Nte: If the patient has signs r symptms acrss categries, always treat accrding t the mst severe features Take special care with children wh have relevant cmrbidities r chrnic illnesses, and cnsult apprpriate specialist clinicians Initial treatment Send t hspital by ambulance Send t hspital by ambulance Prvide xygen Prvide xygen Nebulised adrenaline fur 1 ml vials (ttal 4 ml) f 1:1000 slutin Nebulised adrenaline fur 1 ml vials (ttal 4 ml) f 1:1000 slutin d nt dilute d nt dilute drive nebulisatin with xygen where pssible drive nebulisatin with xygen where pssible Cnsider ral prednislne 1.0 mg/kg Oral prednislne 1.0 mg/kg Oral prednislne 1.0 mg/kg OR IM dexamethasne 0.6 mg/kg Oral prednislne 1.0 mg/kg OR IM dexamethasne 0.6 mg/kg Allw the child t adpt the psitin that they find mst cmfrtable Allw the child t adpt the psitin that they find mst cmfrtable Allw the child t adpt the psitin that they find mst cmfrtable Allw the child t adpt the psitin that they find mst cmfrtable Prvide parent infrmatin Prvide parent infrmatin Send hme if stable r reassess after 1 hur if there is any cncern Observe if facilities available at the surgery, r send t hspital Reassess within 1 hur Respnse t treatment Gd respnse Send hme when child has n signs f mderate r severe airway bstructin and is clinically well Prvide patient infrmatin, including reasns t return Pr respnse Send t hspital by ambulance * Decreased xygen saturatin is a late sign f severity. Oxygenatin may be maintained even in severe crup SpO 2 <92% is an indicatr f increased severity. Hwever it is recgnised that this frm f assessment will nt be available t mst GPs 16 Reprinted frm Vl. 37, N. 6, June 2008 SPECIAL ISSUE

4 Table 2. Nrmal parameters fr paediatric vital signs Heart rate (awake) (beats/min) Nenate Infant (6 mnths) Tddler (2 years) Pre-schl Schl age (7 years) Adlescent (15 years) Heart rate (asleep) (beats/min) Respiratry rate (breaths/min) Systlic BP (5 95%) (mmhg) Diastlic BP (5 95%) (mmhg) Temperature ( C) D Cld air has nt been established as an effective treatment fr crup in hspital emergency departments. The reviewers established that crticsterids were as effective in children with mild crup as they were in children with mderate crup. Oxygen There is little research investigating the effectiveness f xygen in children with crup. Hwever, the clinical ratinale fr its use is clear. In the absence f clear evidence the GDG made the fllwing cnsensus recmmendatin: D Give xygen t any child with severe r life threatening crup A Cnsider giving crticsterids t children with mild crup A Children with mderate r severe crup shuld be given crticsterids With an awareness that dexamethasne is nt readily available in an ral frmulatin and ral prednislne is widely available, the GDG agreed that until further evidence is available, either dexamethasne r prednislne can be used. Psitin N research evidence was identified which examined the effectiveness f different bdy psitins fr children with crup. In the absence f evidence the GDG nted that children with crup tend t find their wn mst cmfrtable psitin and develped the fllwing cnsensus recmmendatin: D Children with crup shuld be allwed t adpt the psitin that they find mst cmfrtable Pharmaclgical management Crticsterids There is gd evidence t supprt the use f crticsterids in crup. A Cchrane systematic review by Russell et al 1 including 31 studies and 3736 children, fund that crticsterids imprved crup symptm scres after 6 and 12 hurs, but that the difference was n lnger significant at 24 hurs. Crticsterids als reduced re-presentatin rates, reduced the need fr adrenaline and decreased the time spent B In children with crup, dexamethasne r prednislne can be used There is inadequate evidence t determine the mst apprpriate dse, the mst apprpriate number f dses, r methd f administratin f crticsterids fr children with crup. In the absence f evidence the GDG agreed t recmmend a dse f 0.60 mg/kg ral dexamethasne r 1.0 mg/kg prednislne in line with ther lcal guidelines and the systematic reviewers suggestin. The GDG acknwledges that 0.60 mg/kg dexamethasne is nt a pharmaclgically equivalent dse t 1.0 mg/kg prednislne. Hwever, there is nt enugh evidence t establish best practice, and in the absence f evidence it is difficult t justify changes t current practice. D Children with crup receiving crticsterids shuld be given a dse f 0.60 mg/kg dexamethasne r 1.0 mg/kg ral prednislne; preferably rally, r intramuscularly if the child is vmiting There is nt enugh evidence t determine whether multiple dses f crticsterids are mre effective than single dses. In the absence Reprinted frm Vl. 37, N. 6, June 2008 SPECIAL ISSUE 17

5 f evidence the GDG was unable t make a recmmendatin abut the value f repeat dses. Adrenaline A systematic review 5 was identified which examined the effectiveness f nebulised adrenaline in children with crup. The review included three small, randmised cntrlled tirals which fund that, cmpared with placeb, adrenaline imprved crup scre as sn as 10, and within 30, minutes. One f these studies reprted that there was n significant difference between treatment and placeb grups at 120 minutes. All these studies examined the effectiveness f nebulised adrenaline given in a hspital emergency department rather than by the GP. Hwever, the GDG agreed that the evidence was applicable t the general practice setting as well as the hspital setting. A Children with severe r life threatening crup shuld be given adrenaline as a first line treatment There is n evidence as t the mst effective dse f adrenaline. In the absence f evidence, the GDG agreed t make a cnsensus recmmendatin in line with lcal practice guidelines. D Nebulise fur 1 ml ampules (ttal 4 ml) f 1 mg in 1 ml (1:1000) adrenaline slutin undiluted. D nt dilute the adrenaline slutin r give a mre dilute slutin as this will decrease the effectiveness D Where pssible nebulisatin shuld be driven by xygen Level f care Mst children with signs f mild t mderate crup can be adequately managed by a GP. When crticsterids are administered, the child shuld be mnitred either by the GP r in the hspital setting fr 2 4 hurs. D Children with mild crup (Table 2) can be managed by a GP and sent hme fr bservatin if the GP is cnfident the parent/carer can adequately manage the child s illness D Children with mderate crup (Table 2) shuld be given crticsterids and bserved ver a 2 4 hur perid. These children can be managed by a GP if they can prvide this level f care, therwise the child shuld be sent t a hspital When shuld an ambulance be called? There is n evidence t determine when a child shuld be taken t hspital by ambulance. The main reasn t call an ambulance t take a child t hspital rather than t take the child by car is cncern that the degree f airway bstructin may suddenly increase and the child s cnditin may rapidly deterirate. In the absence f evidence, and in cnsultatin with the Victrian Metrplitan Ambulance Service, the GDG agreed t the fllwing cnsensus recmmendatins: D An ambulance shuld be called fr any child with severe r life threatening crup D If at any time there is cncern abut a child s ability t breathe, an ambulance shuld be called t take the child t a hspital A number f extended case series 6 8 have investigated the safety f discharging children with crup wh have received adrenaline in a hspital emergency department. While these studies are f relatively pr methdlgical quality, they prvide enugh evidence t determine that it is reasnable t discharge a child with crup 2 3 hurs after adrenaline is administered, if they are free f stridr and intercstal retractins at rest and clinically well. D Nt all children wh receive adrenaline will require admissin t hspital. A child with crup wh receives adrenaline and crticsterids may be discharged after 3 hurs bservatin if they are free f stridr and intercstal retractins at rest and clinically well Analgesics and antipyretics N research evidence was identified t determine when it is apprpriate t give simple analgesics r antipyretics (eg. ibuprfen r paracetaml) t children with crup. Analgesics and antipyretics are nt essential t the treatment f crup, but may be useful in addressing assciated symptms such as a sre thrat. Children with severe r life threatening crup, r children with mderate crup wh d nt respnd t crticsterids, shuld be taken t a hspital emergency department. Case study 1 mild crup Yur receptinist slts in Suzy, 3 years f age, at 9.30 am. Suzy has previusly been well. Her mther says she has had symptms f a cld fr the past 48 hurs and then last night at 2 am wke with a barking cugh and a harse vice. Frm time t time thrughut the night when she was running arund, she had funny, nisy breathing but it settled by this mrning. Her mther thinks she might have crup as Suzy s lder brther had it when he was her age. On examinatin Suzy is happy, alert and playing with the tys in yur cnsulting rm. She has a seal like cugh frm time t time, there is n temperature, n accessry muscle use, n inspiratry stridr and her chest is clear. Her heart rate is nrmal and she is able t talk, albeit with a harse vice. A prvisinal diagnsis f mild crup is made. Yu explain the diagnsis t Suzy s mther and prvide her with infrmatin n the cnditin, asking her t call r t return if Suzy s symptms wrsen. 18 Reprinted frm Vl. 37, N. 6, June 2008 SPECIAL ISSUE

6 Myths dispelled We dn t knw Facts cnfirmed The use f mist r humidified air is NOT Questin whether a secnd dse f Sterid use has markedly decreased the effective in the treatment f crup sterid after 24 hurs is helpful when number f children needing hspital a child has cntinuing symptms admissin with crup Ludness f stridr is NOT a gd indicatr f the severity f crup Either prednislne r dexamethasne can be used t treat crup Case study 2 mderate crup Yur receptinist calls yu t see Mei Ling, 4 years f age, wh she has placed in the treatment rm as she lks unwell. As yu walk in the dr yu ntice that the child lks anxius and is sitting quietly n her father s knee. She has inspiratry stridr at rest and when yu examine her chest yu nte that there is sme tracheal tug and chest wall retractin. Her pulse rate is 130. Mei Ling s father says she was unable t eat r drink that mrning. Yu diagnse mderate crup and administer 17.0 mg f prednislne (her weight is 17 kg). Yu explain the diagnsis t her father, prvide him with infrmatin n the cnditin, and then ring the lcal hspital emergency department. Yu explain t the father that the child will require bservatin in hspital t ensure she imprves. Case study 3 severe crup Yu hear a frantic knck n yur dr... Please cme quickly, this child lks very sick. An anxius lking mther is clutching her 3 year ld sn wh appears very pale, agitated and exhausted. He has marked chest wall retractin and tracheal tug and is t breathless t respnd t yur questins. His mther says he develped nisy breathing during the night and has deterirated rapidly this mrning. On examinatin he has an increased pulse and respiratry rate and pr air entry. Yu diagnse severe crup and administer xygen while asking yur receptinist t call an ambulance. Yu nebulise 4 x 1.0 ml vials f 1:1000 adrenaline using the xygen tank t drive it. Because the by is unable t tlerate any ral intake, yu draw up and administer dexamethasne intramuscularly at a rate f 0.60 mg/kg. By the time yu d all that, the ambulance has arrived and transprts the child t hspital. Summary f imprtant pints A child is likely t have crup if they present with abrupt nset f barking cugh, inspiratry stridr and harseness. Ludness f stridr is NOT a gd indicatr f the severity f crup. Distressing prcedures shuld be kept t a minimum as agitatin may wrsen airway bstructin. Cnsider ther diagnses in children with recurrent crup. Radigraphy shuld nt be used t diagnse crup r differentiate it frm epiglttitis. Any child with crup wh als has a pre-existing upper airway abnrmality, r a significant relevant cmrbidity r chrnic illness, shuld be sent by ambulance t a hspital emergency department. Sterid use shuld be cnsidered in mild crup and given in mderate-severe crup. Sterids shuld preferably be given rally, r intramuscularly if the child is vmiting. Use either: 0.60 mg/kg dexamethasne r 1 mg/kg ral prednislne. Unlike asthma, there is insufficient evidence t determine whether multiple dses f crticsterids are mre effective than single dses. Use f mist r humidified air is NOT an effective treatment fr crup. Cld air has NOT been established as an effective treatment fr crup. Children with crup shuld be allwed t adpt the psitin they find mst cmfrtable. If at any time there is cncern abut a child s ability t breathe, an ambulance shuld be called t take the child t a hspital. References 1. Russell K, Wiebe N, Saenz A, et al. Cchrane Acute Respiratry Infectins Grup. Gluccrticids fr crup. Cchrane Database Syst Rev 2006; Issue Department Human Services Data available n request. 3. Net GM, Kentab O, Klassen TP, Osmnd MH. A randmized cntrlled trial f mist in the acute treatment f mderate crup. Academic Emerg Med 2002;9: Burchier D, Dawsn KP, Fergussn DM. Humidificatin in viral crup: a cntrlled trial. Aust Paediatr J 1984;20: Jhnsn D. Crup. Clinical Evidence 2004;12: Kelley PB, Simn JE. Racemic epinephrine use in crup and dispsitin. Am J Emerg Med 1992;10: Prendergast M, Jnes JS, Hartman D. Racemic epinephrine in the treatment f laryngtracheitis: can we identify children fr utpatient therapy? Am J Emerg Med 1994;12: Rizs JD, DiGravi BE, Sehl MJ, Talln JM. The dispsitin f children with crup treated with racemic epinephrine and dexamethasne in the emergency department. J Emerg Med 1998;16: crrespndence afp@racgp.rg.au Reprinted frm Vl. 37, N. 6, June 2008 SPECIAL ISSUE 19

7 Resurce. Parent infrmatin Medical & nursing care fr yur child Imprtant pints t remember: Care fr children with crup fcuses n helping them t breathe easily. Yur child will be assessed t see hw hard they are finding it t breathe. Sme children with crup will be given a medicatin called prednislne. This helps reduce the swelling in the windpipe, making it easier fr the child t breathe. Children with severe crup may be given adrenaline. Adrenaline is breathed in thrugh a mask attached t xgyen. It relieves the tightness and swelling in the vicebx and windpipe. Crup is a cmmn childhd illness. Children with symptms f crup shuld be taken t see their General Practitiner (GP) if yu are at all cncerned. The symptms f crup smetimes last fr up t a week, and ften they get wrse at night. Call 000 fr an ambulance if yu are cncerned abut yur child s ability t breathe If yu are cncerned that yur child s breathing is wrsening nce yu get hme, then yu shuld g back t yur GP r the Emergency Department. Infrmatin fr Parents f Children with Crup Mst children respnd well and can g hme after a few hurs f bservatin. Sme children need t be treated fr several hurs in the Emergency Department, and a few children with crup will spend ne r tw nights in hspital. Yur child will be able t g hme when his / her breathing is imprved, and dctrs are happy with their cnditin. Maternal Child and Health Supprt Line: These websites have mre infrmatin n crup and ther illnesses: Did yu knw If yu dn t already have a GP yu can find a child friendly GP n the web: Disclaimer: This health infrmatin is fr general educatin purpses nly. It shuld nt be used in place f medical advice. Please cnsult with yur dctr and r ther health care prfessinals t ensure individualised and apprpriate health care is tailred fr yur child. What is crup? Crup is a cmmn childhd illness. It is smetimes called laryngtrachebrnchitis. Crup is caused by a viral infectin that causes the lining f the vicebx and windpipe t swell. This swelling may make it difficult fr a child t breathe. Crup usually affects children less than five years ld because they have a smaller and sfter vicebx and windpipe. There is n way t prevent a child frm getting crup. Because it is a viral disease, antibitics are nt effective in treating crup. Did yu knw Crup is mre cmmn in yung children, but lder children and teenagers can get crup t. What are the symptms f crup? Children with crup nrmally have sme f these symptms: A harsh, barking cugh (which sunds like a seal) Harse vice A nise when breathing in knwn as stridr (a harsh r high pitched breathing sund) Befre develping crup, children ften have ther symptms f a viral infectin such as a temperature, runny nse and sre thrat. The symptms f crup smetimes last fr up t a week, and ften the symptms get wrse at night. What care shuld I give at hme? After seeing a dctr, mst children with crup can be managed at hme. Stay calm, reassure yur child Sit with yur child in a psitin they find cmfrtable Try reading a favurite bk r watching TV r a vide with yur child Rest is imprtant as activity may make the symptms wrse Give yur child small amunts f drink at regular intervals. If a child is breastfed then d nt stp, give smaller feeds mre frequently. Mist, steam r humidified air are unlikely t be effective in treating crup. Be very careful with any f these as there is a danger the child might be burned. Did yu knw Mist, steam r humidified air have nt been shwn t help symptms f crup. When shuld I take my child t a dctr? If yur child has symptms f crup and yu are cncerned at all, take them t see yur General Practitiner (GP). Yur GP will assess yur child and plan apprpriate medical care. If yur child has symptms f crup and they have an existing upper airway abnrmality r chrnic illness, cnsult yur GP immediately. Take yur child t the Emergency Department, if yur child: Has stridr (high/harsh sunds when they breathe in) while they are sleeping r sitting quietly Lks unwell, pale, anxius, tired Has a high temperature Is drling Has cnsiderable decrease in intake f fluids / drink ver a hur perid Or if yur GP is nt available and yu are wrried abut yur child s cnditin Did yu knw Keeping yur child relaxed and cmfrtable can help ease the symptms f crup When shuld I call an ambulance? If yu are cncerned abut yur child s ability t breathe, call 000 fr an ambulance. Call 000 fr an ambulance if: If yur child has difficulty in breathing If yur child becmes flppy, agitated r cnfused Their lips r face becme blue r very pale When calling an ambulance yu will be asked sme questins, these may include: What is the exact address f the emergency? What phne number can they call yu back n? What is the prblem? Hw ld is the child? Is the child cnscius? Is the child breathing? 20 Reprinted frm Vl. 37, N. 6, June 2008 SPECIAL ISSUE