Croup (Laryngo-tracheo-bronchitis)

Transcription

1 Croup (Laryngo-tracheo-bronchitis) 1a 2a 2b Title of Guideline (must include the word Guideline (not protocol, policy, procedure etc) Contact Name and Job Title (author) Directorate & Speciality Date of submission September 2015 Date when guideline reviewed September 2018 Guideline Number 2014 Explicit definition of patient group to which it applies (e.g. inclusion and exclusion criteria, diagnosis) Abstract Key Words Guideline for the assessment and management of croup (laryngo-tracheo-bronchitis) in children and young people Dr Jayesh Bhatt, Paediatric Respiratory Consultant Directorate: Family Health Children Speciality: Respiratory Children and young people under the age of 18 years with croup (laryngo tracheobronchitis) This guideline describes the assessment and management of croup (laryngotrachoebronchitis) in children and young people under 18 years of age Paediatrics. Children. Croup, Laryngotracheobronchitis, Statement of the evidence base of the guideline has the guideline been peer reviewed by colleagues? meta analysis of randomised controlled X trials at least one well-designed controlled study without randomisation at least one other type of well-designed quasi-experimental study 3 well designed non-experimental descriptive studies (ie comparative / correlation and case studies) 4 expert committee reports or opinions and / or clinical experiences of respected authorities 5 recommended best practise based on the clinical experience of the guideline developer Consultation Process Staff at Nottingham Children s Hospital via the Guidelines process. Target audience Staff at the Nottingham Children s Hospital This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date. JM Bhatt Page 1 of 6 September 2015

2 Document Control Document Amendment Record Version Issue Date Author V1 V2 General Notes: Summary of changes for new version: (delete all red text before submitting final version) THIS IS IMPORTANT: Please BRIEFLY summarise the update (if any) eg Use of magnesium in acute presentation Added investigations Required investigations reduced JM Bhatt Page 2 of 6 September 2015

3 Croup (Laryngotracheobronchitis) Croup (laryngotracheobronchitis) is a common cause of upper airway obstruction in children and is characterised by hoarseness, barking cough, inspiratory stridor and variable respiratory distress. These symptoms occur as a result of oedema of the larynx and trachea, which has been triggered by a recent viral infection. Para influenza virus type 1 is the agent most commonly identified in cases of croup. It most commonly occurs in children aged from 6 months to 6 years. The annual incidence of croup in children younger than six years ranges from 1.5 to 6%. Symptoms are typically worse at night. Most croup will be dealt with in primary care but up to 30% of cases will require hospitalisation, of these less than 2% need intubation. Differential Diagnosis The main differential diagnosis of upper airway obstruction include: 1. Epiglottitis - this is now rare due to Hib vaccination but does still occur (check immunisation history). Consider the diagnosis in a child who is drooling, agitated and who does not have a cough. If you are unsure call for senior help. 2. Bacterial tracheitis - consider in a child with a croup like illness (barking cough and stridor) who has a high fever and has not responded to treatment for croup. Tracheitis is usually caused by Staphylococcus aureus (Treat with flucloxacillin). 3. Inhaled foreign body - ask for history specifically if there is sudden onset of stridor in a well child. 4. Angioedema - associated swelling of the face and tongue, often with urticaria and wheeze. For management see anaphylaxis protocol. Remember croup may present with other coincidental diagnosis e.g. asthma, pneumonia, otitis media. Assessment The child should be assessed where they are most settled (e.g. on parents lap). Assess the clinical severity of the airway obstruction (not the loudness of the stridor). Avoid upsetting the child unnecessarily. DO NOT EXAMINE THE THROAT. DO NOT ATTEMPT IV ACCESS OR SEND THE CHILD TO X-RAY. Call for senior assistance if you are concerned Initial assessment should follow primary survey ABCD approach. A B C D - Inspiratory or biphasic stridor, drooling, dysphonia, dysphagia are all concerning signs Assess work of breathing and effectiveness of respiration (air entry and SaO2) Assess for shock consider hypovolaemic shock of child with epiglottitis or cardiovascular effects of potential respiratory failure Deteriorating/altered conscious level is a sign of severe upper airways obstruction JM Bhatt Page 3 of 6 September 2015

4 The Modified Westley Clinical Scoring System for Croup Points Inspiratory Stridor Not present When agitated/ active At rest Intercostal Recession No recession Mild recessions moderate Severe Air entry Normal Mildly decreased Severely decreased Cyanosis None With agitation/ activity At rest Conscious level Normal Altered This gives a possible croup score of 0-17 Mild 2 Moderate 3-5 Severe 6 Remember hypoxaemia is a feature of severe/critical upper airways obstruction. DO NOT be falsely reassured by normal SaO2 Management of Laryngotracheobronchitis Provide a calm reassuring atmosphere, keeping the child with parents if possible. Treatment with glucocorticoids is effective in improving symptoms of croup in children as early as six hours and for up to at least 12 hours after treatment ; a recent study however suggests that dexamethasone offers benefit by 30 min. A single oral dose of dexamethasone, probably 0.6 mg/kg, should be preferred because of its safety, efficacy and cost-effectiveness but in a child who is vomiting, nebulized budesonide or intramuscular dexamethasone might be preferable. Mild to moderate croup Give one dose of 0.6mg/kg dexamethasone orally. Steroid treatment reduces the severity and duration of symptoms. Nebulised budesonide 2 mg as a single dose should be given in a vomiting child who cannot tolerate oral dexamethasone. Assess the child hourly. Reassess at 4 hours, if improving consider discharge (see criteria for discharge). Moderate to severe croup JM Bhatt Page 4 of 6 September 2015

5 Give humidified oxygen to keep the oxygen saturations >93%. Give oral dexamethasone 0.6mg/kg (or nebulised budesonide 2mg if child is vomiting or too unwell to take oral medication) Reassess in 1 hour if improving admit to ward and continue hourly assessment. If poor response to steroid child should have a senior review. Review diagnosis. Consider nebulised L-epinephrine see management of severe croup. Severe/ life threatening croup Assess ABCD Give 100% oxygen with continuous cardiac and oxygen saturation monitoring. Call anaesthetic and senior paediatric help urgently. Give nebulised L-epinephrine 1 in 1000 solution. (1mg/ml) o <1 yr 2.5 ml epinephrine diluted with 2.5 ml normal saline o >1 yr 5ml epinephrine undiluted. L-epinepherine can be repeated after 30 minutes if necessary. It can cause rebound with worsening obstruction as effect wears off after minutes Give nebulised budesonide 2mg if this will not delay airway management. Transfer to high dependency/ PICU. Nebulised epinephrine should be given on general paediatric wards only as a holding measure in a child being transferred to PICU. Intubation. o Ideally by a senior paediatric anaesthetist with gas induction, in a controlled o environment. If child is in extremis, intubation by the most experienced person present. The cords will be swollen, an ETT several sizes smaller than predicted may be necessary. Do not cut the tube. Give dexamethasone 0.6 mg/kg IV. Do not attempt to gain IV access until airway is secure. Give antibiotics only if bacterial tracheitis suspected. Criteria for Discharge Parents confident they can manage child s symptoms and are able to bring the child back if necessary. Absent or mild intermittent stridor with SpO2 in air> 93%. Dexamethasone given (in all cases even if child only has barking cough). Other diagnosis i.e. foreign body, epiglottits etc excluded. Children with pre-existing narrowing of the upper airways (e.g. subglottic stenosis) and children with Down s syndrome are prone to more severe croup. Admission should be considered even with mild symptoms. Never discharge within 3 hours of giving epinephrine. Child with recurrent croup should be referred to ENT department. JM Bhatt Page 5 of 6 September 2015

6 References Russell KF, Liang Y, O'Gorman K, Johnson DW, Klassen TP. Glucocorticoids for croup. Cochrane Database Syst Rev Jan 19;(1):CD Dobrovoljac M, Geelhoed GC.How fast does oral dexamethasone work in mild to moderately severe croup? A randomized double-blinded clinical trial. Emerg Med Australas Feb;24(1): Oral dexamethasone in the treatment of croup, 0.15 vs 0.3 vs 0.6mg/kg Paediatric pulmonolgy Dec; 20(6): Geelhoed GC, Macdonald WB Nebulised steroid in the treatment of croup: a systematic review of randomised controlled trials. Griffin S, Ellis S, Fitzgerald-Barron A, Rose J, Egger M. Br J Gen Prac Feb 2000, 50(451): The effectiveness of glucocorticoids in treating croup: meta analysis. Ausejo M, Saenz A, Pham B, Kellner JD, Johnson DW, Moher D, Klassen TP. BMJ 1999 Sep 4; 319(7210): (Cochrane library) Nebulised budesonide vs oral dexamethasone for the treatment of croup. Klassen T, Craig W, Moher D, et al JAMA 279: , 1998 A comparison of nebulised budesonide, im dexamethasone and placebo in moderately severe croup. Johnson et al New Engl J Med 1998 Aug 20; 339(8): The disposition of children with croup treated with racemic epinephrine and dexamethasone in the emergency dept J Emerg Med Jul-Aug; 16(4):535-9 A randomised trial of a single dose of oral dexamethasone for mild croup. Bjorsen CL et al. N Engl J Med 2004;351: Breathing difficulties: An evidence based guideline for the management of children presenting with acute breathing difficulty (Children Nationwide January 2002) Glucocorticoid Treatment In Croup.(guideline review) J.Harry Baumer,Arch Dis Child Educ Pract Ed 2006;91:ep58-ep60. JM Bhatt Page 6 of 6 September 2015