Trust Guideline for Acute Stridor in Children

Transcription

1 A Clinical Guideline For Use in: By: For: Key words: Name of document author: Job title of document author: Name of document author s Line Manager: Job title of author s Line Manager: Supported by: Children s Assessment Unit (CAU), Children s Wards, Accident & Emergency (A&E) Medical and nursing staff in the above Children over a month of age with acute stridor or with suspected inhaled foreign body Stridor, Children, inhaled foreign body Chris Upton, updated by Anjay Pillai Consultant Paediatrics David Booth Clinical Director Paediatrics Dr Mark Dyke, Paediatric Consultant NNUH Assessed and approved by the: Date of approval: 16/10/2015 Ratified by or reported as approved to (if applicable): To be reviewed before: This document remains current after this date but will be under review To be reviewed by: Clinical Guidelines Assessment Panel (CGAP) If approved by committee or Governance Lead Chair s Action; tick here Clinical Standards Group and Effectiveness Sub-Board 16/10/2018 Chris Upton Reference and / or Trust Docs ID : CA1080 ID: 1162 Version : 6 Description of changes (for revised longer a joint guideline with James Paget versions): University Hospital Compliance links: e.g. NICE ne If - does the strategy/policy deviate from the recommendations of N/A NICE? If so why? This guideline has been approved by the Trust's Clinical Guidelines Assessment Panel as an aid to the diagnosis and management of relevant patients and clinical circumstances. t every patient or situation fits neatly into a standard guideline scenario and the guideline must be interpreted and applied in practice in the light of prevailing clinical circumstances, the diagnostic and treatment options available and the professional judgement, knowledge and expertise of relevant clinicians. It is advised that the rationale for any departure from relevant guidance should be documented in the patient's case notes. The Trust's guidelines are made publicly available as part of the collective endeavour to continuously improve the quality of healthcare through sharing medical experience and knowledge. The Trust accepts no responsibility for any misunderstanding or misapplication of this document. Available via Trust Docs Version: 6 Trust Docs ID: 1162 Page 1 of 7

2 Quick reference guideline/s A. Clinical algorithm for the management of acute stridor in children Acute Stridor Assess with ABC Ineffective respiratory effort or reduced consciousness - Give Oxygen - Contact SpR & Anaesthetist - Consider ENT Surgeon - Nebulised adrenaline 400 Micrograms/kg (0.4 ml/kg of 1:1000) maximum 5 mg (5ml of 1:1000) - drips or x-rays - Keep child and family calm - Measure Sa02 SaO2 <92% Any improvement? Give Oxygen Assess recession in-drawing and air entry Severe Moderate Mild Intubation preferably in theatre Epiglottitis? Pus in Trachea - Nebulised budesonide 2mg stat and/or - Oral prednisolone 2mg/kg for 1-3 days - Admit till stridor settled or mild - Reassurance - Observe 1-2 hours - PAU Improving? - Croup - IV Dexamethasone 150 Micrograms/kg repeated after 12 hours if necessary - IV Ceftiaxone 80mg/kg/day - Supportive care Extubation Recovery, Home Available via Trust Docs Version: 6 Trust Docs ID: 1162 Page 2 of 7

3 B. Clinical algorithm for the management of suspected inhaled foreign body Inhaled foreign body Is history definite? Are there localised chest signs or strider Inspiratory and expiratory CXR's if co-operative Chest screening if not Are there any chest signs? Contact thoracic surgical teams for same day rigid bronchoscopy Suggestiv e of foreign body? Plain CXR rmal? Foreign body to remove? Treat alternative diagnosis e.g. - wheeze with bronchodilator - pneumonia with antibiotics Recovery Home Available via Trust Docs Version: 6 Trust Docs ID: 1162 Page 3 of 7

4 Objectives To optimise the management of children presenting with acute stridor or with an inhaled foreign body. Rationale Acute stridor is a common and potentially serious condition in childhood. Prompt recognition to distinguish it from the more common wheeze is important, as treatment is different and has effectively reduced morbidity. The guideline is strongly evidence based see references below. There is irrefutable evidence suggesting all children with acute stridor admitted to hospital should receive steroids (1). The one area of controversy is whether this should be given initially via a nebuliser or orally. The guideline recognizes that either route is acceptable but that pragmatically it is often easier to give a nebuliser in the distressed child. An inhaled foreign body, which may or may not be present with stridor, requires urgent assessment and management to reduce morbidity. In the past investigation has been haphazard at times and the guideline suggests a rational system of investigation based on best practice. Broad recommendations C. tes for use with the clinical algorithms 1. Stridor is an inspiratory noise. Wheeze is expiratory but the two may co-exist in the same child. It is important to distinguish between them, as the management is different. 2. Children often wake in the night with stridor and panic in both the child and parents can make the situation worse. Unless the child has ineffective respiratory effort or reduced consciousness do not immediately confront them with facemasks, drips and ECG leads as this may make panic worse. A calm approach maintaining parental involvement is preferred. 3. Severe stridor presents with marked supra-clavicular indrawing, subcostal and intercostal recession and reduced air entry. The stridulous noise may not be loud if the airway is compromised. Hypoxaemia is a sign of extremely severe disease if due to upper airway obstruction. 4. Moderate stridor presents with sub and intercostal recession but supraclavicular indrawing is usually mild. The stridulous noise is often loud as air entry is maintained and there may be a barking cough (like a seal). SaO2 is normal unless there is co-existent lower airway pathology. 5. Mild stridor presents with minimal recession and the cough is often the most distressing aspect for the child. The child drinks and eats normally. SaO2 is always normal. 6. Nebulised adrenaline is a useful treatment but its effects are short-lived (2). It is now recognised as being of similar efficacy to steroid treatment, which has a longer duration (3). Adrenaline is therefore reserved for those with severe stridor, either to try to prevent the need for intubation or as an adjunct to steroids. Available via Trust Docs Version: 6 Trust Docs ID: 1162 Page 4 of 7

5 7. Steroids are the mainstays of management. Meta-analysis of many trials has confirmed their efficacy and it is mandatory that any child with stridor severe enough to need hospital admission should receive steroids (1). Mild croup can become more severe, however, and some would advocate that all children with suspected croup should receive steroids (4). Although this is an option, at present we do not consider the evidence strong enough, particularly in terms of numbers needed to treat, to recommend steroids in mild croup. 8. Steroids may be given either as nebulised Budesonide or orally. Most studies suggest these to be of equal efficacy (1). One potential advantage of nebulised delivery is speed of action (5), which may be important in severe stridor. One study, however, suggests that steroids via either route can work within two hours (6). This has not been confirmed in other studies and seems to contradict the existing evidence about the speed of action of steroids in other diseases, such as asthma. Pragmatically it is also often easier to give a nebuliser to a distressed child than to give them oral medication. If nebulised treatment is used a single dose suffices as systemic steroids can be given soon after. 9. By convention most studies have used Dexamethasone as the systemic steroid. However, Prednisolone works and is readily available in a soluble form (7). It is also simpler to use the same steroid as we use in asthma. Prednisolone at a dose of 2mg/kg/day is therefore the preferred oral steroid. A single dose is often sufficient but 3 to 5 days treatment may be needed in more severe croup. There is some evidence that a single dose of Dexamethasone 150micrograms/kg gives a longer lasting effect than a single dose of Prednisolone 1 mg/kg (8), so Dexamethasone could be considered if sending home with a single dose. 10. Mist (9) and Humidity (10) are outdated and ineffective treatments for stridor. Unfortunately they are still used in the community on occasions. Their use should be discouraged; both because children have received scalds if boiling kettles have been used and the alternatives above have proven efficacy. 11. Intubation has become rarer as the use of steroids has increased. If necessary it is ideally performed in theatre by an experienced Paediatric Anaesthetist. If intubation seems likely the 4 th on call, post fellowship Registrar in Anaesthetics should be called in the first instance, who should see as priority and call the Consultant Paediatric Anaesthetist. Oxygen should be given in a non-threatening way in severe stridor and the child kept nil by mouth at first. If the airway is compromised, however, intubation may be essential in less than ideal circumstances to save life, particularly in A&E. Tracheotomy is extremely rarely needed in these circumstances but ENT involvement is necessary if intubation is difficult. Intubated patients with croup should receive intravenous steroids initially with Dexamethasone 150micrograms/kg repeated after 12 hours if necessary. Following intubation the child should be stabilised on the main Intensive Care Unit, usually followed by transfer to a Paediatric Intensive Care Unit. 12. Epiglottitis has become very rare following the introduction of Haemophilus influenzae b immunisation. However, immunisation rates have dropped Available via Trust Docs Version: 6 Trust Docs ID: 1162 Page 5 of 7

6 recently and it remains important to be aware of it. Epiglottitis is a septicaemic illness and good supportive care as for any septic child is needed. Ceftriaxone is the preferred intravenous antibiotic, at a dose of 80mg/kg/day. The important differences between croup and epiglottitis are: CROUP EPIGLOTTITIS Organism Parainfluenza virus Haemophilus influenzae b Age 6 months - 3 years 3-7 years Prodrome URTI Usual Uncommon Onset Days Hours Cough Present Often absent Dysphagia Absent Severe with dribbling Systemic Mildly unwell Toxic and ill Posture preference Sitting/leaning forward 13. Bacterial tracheitis is a rare cause of stridor. The child is usually extremely ill with coexistent septicaemia and pneumonia. The cardinal sign is pus in the trachea at intubation. Staphylococcus aureus is the most likely organism, but other types of Haemophilus, Moraxella or Streptococcus may be responsible (11). Intravenous Ceftriaxone at a dose of 80mg/kg/day is the initial antibiotic choice, pending culture and sensitivities. 14. Inhaled foreign bodies may present with stridor. Other presentations include the asymptomatic child following a choking episode, cough, wheeze or hoarseness. The history may not be definite but the diagnosis should always be considered in such children. Prompt recognition and removal is essential, as they can be fatal. Delay in removal may also cause long term morbidity, such as bronchiectasis. 95% of inhaled foreign bodies in children are organic, most commonly peanuts, and are not radio-opaque (12). Never accept a single plain Chest X-ray in a child with a definite history of inhaled foreign body. Clinical audit standards % of children presenting with moderate or severe stridor should receive steroids in some form. 2. Children presenting with mild stridor should not be given steroids. 3. Children with acute severe stridor not improving with adrenaline and steroids should be intubated in theatre. 4. Children with a good history of inhaled foreign body should be assessed by screening, inspiratory and expiratory films or a bronchoscopy and never by a single chest X-Ray. Summary of development and consultation process undertaken before registration and dissemination The guideline was drafted by Dr Chris Upton on behalf of the guideline development group of the Paediatric Directorate, which has agreed the final content. During its development it has been circulated for comment to: colleagues in Paediatric Nursing, Accident & Emergency, Paediatric Radiology, Thoracic Surgery, ENT, Microbiology, Available via Trust Docs Version: 6 Trust Docs ID: 1162 Page 6 of 7

7 Intensive Care and Paediatric Anaesthesia. Comments received were largely positive. Changes made included which specific anaesthetist to call and antibiotics appropriate for bacterial tracheitis. This version endorsed by the above. Dr C Upton reviewed the guideline in September 2013 and no clinical changes were necessary. Distribution list/ dissemination method To CAU, Paediatric Wards, A&E and the above Departments, and on the Intranet. References/ source documents 1) The effectiveness of glucocorticoids in treating croup: meta-analysis. Ausejo M, Saenz A et al BMJ 1999;319: ) Inhalation of racemic adrenaline in the treatment of mild and moderately severe croup. Clinical symptom score and oxygen saturation measurements for evaluation of treatment effects. Kristjansson S, Berg-Kelly K & Winso E Acta Paediatr 1994;83: ) Nebulized budesonide is as effective as nebulized adrenaline in moderately severe croup. Fitzgerald D, Mellis C et al Pediatrics 1996;97: ) Efficacy of a small single dose of oral dexamethasone for outpatient croup: a double blind placebo controlled trial. Geelhoed GC, Turner J & Macdonald WBG BMJ 1996;313: ) The efficacy of nebulized budesonide in dexamethasone-treated outpatients with croup. Klassen TP, Watters LK et al Pediatrics 1996;97: ) Oral and inhaled steroids in croup: a randomized, placebo-controlled trial. Geelhoed GC & Macdonald WB Pediatr Pulmonol 1995;20: ) Placebo-controlled trial of prednisolone in children intubated for croup. Tibballs J, Shann FA & Landau LI Lancet 1992;340: ) Humidification in viral croup: a controlled trial. Bourchier D, Dawson KP & Fergusson DM Aust Paediatr J 1984;20: ) Controlled delivery of high vs low humidity vs mist therapy for croup in emergency departments: a randomized controlled trial. Scolnik D, Coates AL et al JAMA 2006; 295: )Prednisolone versus dexamethasone in croup: a randomised equivalence trial. Sparrow A, Geelhoed G Arch Dis Child 2006; 91: )Bacterial tracheitis in children. Kasian GF, Bingham WT et al CMAJ 1989;140: )Inhalation of foreign bodies in Chinese children: a review of 400 cases. Mu L, He P & Sun D Laryngoscope 1991;101: Available via Trust Docs Version: 6 Trust Docs ID: 1162 Page 7 of 7