Clinical Director for Women s and Children s Division

UPPER AIRWAY OBSTRUCTION (UAO) (INCLUDING CROUP) CHILDREN & YOUNG PEOPLE 0-16 CLINICAL GUIDELINES Register No: 10097 Status: Public Developed in response to: Guideline Review CQC Fundamental Standard: 11, 12 Consulted With: Post/Committee/Group: Date: Alison Cuthbertson/ Miss Rao Mahesh Babu Manas Datta Aloke Agrawal Muhammed Ottayil Sharmila Nambiar Sharon Lim Ahmed Hassan Mel Chambers Mel Hodge Mary Stebbins Sarah Moon Clinical Director for Women s and Children s Division Matron CYP Senior Sister, Phoenix Ward Clinical Facilitator CYP Specialist Midwife Guidelines and Audit November 2017 Professionally Approved By Dr Datta Clinical Director Children s Services 21 st June 2018 Version Number 3.0 Issuing Directorate Women s and Children s Ratified by: DRAG Chairman s Action Ratified on: 29 th June 2018 Executive Management Board Sign Off Date July 2018 Implementation Date 9 th July 2018 Next Review Date May 2021 Author/Contact for Information Dr Ottayil, Policy to be followed by (target staff) All Clinicians Distribution Method Hard copies on ward Intranet & website Related Trust Policies (to be read in conjunction with) 04072 Hand hygiene 04064 Safeguarding Children 05111 Paediatric Resuscitation Policy Children s Early Warning Tool (CEWT) Document Review History: Version Number: Reviewed by: Issue Date: 1.0 Caroline Fox 23.09.2010 2.0 Victoria Machell 20th November 2011 3.0 Dr Ottayil 9 th July 2018 1

Index 1. Purpose 2. Equality and Diversity 3. Scope 4. Assessment 5. General Management 6. Specific Management of Viral Croup 7. Epiglottitis 8. Foreign Body Obstruction 9. Bacterial Tracteitis 10. Inhalation Injury 11. Indications for intubation 12. Staff Training 13. Infection Prevention 14. Audit and Monitoring 15. Communication 16. References 17. Appendices A. Appendix A - Viral Croup Flowchart B. Appendix B - Algorithm for Paediatric Foreign Body Obstruction 2

1.0 Purpose 1.1 To guide medical and nursing staff in the management of children and young persons attending hospital with acute onset of stridor caused by upper airway obstruction (UAO) 2.0 Equality and Diversity 2.1 Mid Essex Hospital Services NHS Trust is committed to the provision of a service that is fair, accessible and meets the needs of all individuals. 3.0 Scope 3.1 For all staff treating Children and Young people with Upper airway obstruction 3.2 These guidelines list causes of stridor and the management of children admitted with upper away obstruction concerns. 4.0 Assessment 4.1 The most pertinent clinical sign of upper airway obstruction is stridor, which is usually an inspiratory noise, but sometimes can be both inspiratory and expiratory. 4.2 Not to be confused with: Wheeze: a sign of lower airway obstruction and narrowing. Persisent stridor signifies upper airway collapse in children with decreased conscious state, pharyngeal hypotonia or swallowing problems. 4.3 Causes of stridor Common Uncommon Rare Viral Epiglottitis Diphtheria laryngotracheobronchitis Bacterial tracheitis Retropharyngeal abscess (croup) Laryngeal foreign body Angioneuroticoedema Superimposed infection Inhalational injury (burns) on subglottic stenosis or laryngomalacia Anaphylaxis Severe bilateral tonsillar enlargement 4.4 It is important to identify and treat serious upper airway obstruction. Once the airway is secure, time can be spent on identifying the specific cause for upper airway obstruction (UAO). 4.5 Specific points in history taking Is this the first presentation? Is there a history of previous intubation or difficulty with intubation? Is the airway stable? 3

4.6 Danger signs and useful pointers to the cause of UAO: Sudden or rapid onset foreign body, epiglottitis, tracheitis, anaphylaxis Soft or low pitched stridor epiglottitis, tracheitis Toxic appearance and high fever - epiglottitis, tracheitis, retropharyngeal abscess Drooling, open mouth, sitting forward - epiglottitis, retropharyngeal abscess, severe tonsillar obstruction. 5.0 General Management 5.1 Avoid upsetting the child 5.2 Leave child with parent in a comfortable position 5.3 Do not insert tongue depressor 5.4 Do not attempt intravenous access or blood tests, unless required for emergency treatment. Consider applying ametop / emla and use distraction techniques to obtain intravenous access. 5.5 Do not ask for a Chest or lateral neck X-ray 5.6 Do not force an oxygen mask over face. Oxygen can mask symptoms of airway obstruction. Only use oxygen if clinically indicted by low oxygen saturations. 5.7 Adrenaline nebulisers may temporarily relieve severe airway obstruction, usually in a dose of 0.4ml/kg of 1:1000 solution, up to a maximum of 5 ml. The effect of adrenaline is temporary. 5.8 Pulse oximetry is a poor guide to severity of UAO when oxygen is delivered 6.0 Specific Management of Viral Croup 6.1 The term croup refers to a clinical syndrome characterised by barking cough, inspiratory stridor and hoarseness of voice. It results from viral inflammation of the upper airway, including larynx, trachea and bronchi; hence the term laryngotracheobronchitis. The symptoms are typically worse at night and peak on about the second or third night. Differentiating spasmodic croup from viral croup is difficult and often not useful. 6.2 The loudness of the stridor is not a good guide to the severity of obstruction. 6.3 Children with pre-existing narrowing of the upper airways (e.g. Subglottic stenosis congenital or secondary to prolonged neonatal ventilation) or children with generalized hypotonia, e.g. Down Syndrome are prone to more severe croup and admission should be considered even with mild symptoms. 6.4 Viral croup can be mild, moderate or severe and is summarized in flowchart appendix A. 4

6.5 Oral steroids doses and steroids via nebulizer doses are: Oral dexamethasone 150 micrograms / kg, can also be repeated 12 hrs later Nebulised budesonide 2mg can be given on its own and with dexamethasone. 7.0 Epiglottitis Call for senior help Do PaediatricSpR/Consultant AnaestheticSpR/Consultant ENT SpR/Consultant Allow the child to remain in its favoured position The child should be constantly supervised by someone skilled in intubation Give humidified oxygen as tolerated. Do not Attempt oropharyngeal examination, since this may precipitate complete obstruction Attempt insertion of an iv cannula or take blood Send the child for neck x-ray or other x-ray Upset the child e.g. removing parents Leave the child unsupervised Rely only on pulse oximetry 8.0 Foreign Body Obstruction 8.1 The management depends on the site and severity of airway obstruction, the algorithm for paediatric foreign body airway obstruction should be followed (appendix B). Intubation may result in further impaction of the foreign body, and should be considered ONLY when there is impending/actual respiratory failure and/or cardio-respiratory arrest. The anaesthetist will then try to visualize/clear the foreign body under direct laryngoscopy. Otherwise, examination under anaesthetic with rigid bronchoscopy by ENT team is the best option. 9.0 Bacterial Tracheitis 9.1 Stridor may be soft or absent even in severe airway obstruction. Consider early intubation by anaesthetist. 10.0 Inhalational Injury 10.1 Along with the history, other pointers may include soot in sputum, singed nasal hair, soot around mouth and face, and facial burns involving mouth and nose. The airway must be secured at the earliest opportunity. Delay can lead to progressive airway obstruction due to oedema and a situation where intubation becomes impossible. Call anaesthetic team and intubate electively. 5

11.0 Indication for Intubation 11.1 Consider contacting the anaesthetic team for any of the following: Suspected epiglottitis Inhalational injury Fall in conscious level Increasing respiratory failure Rising pco 2 Exhaustion Hypoxia (SpO 2 <92% despite high-flow O 2 by mask >5 L/min) 11.2 Continued Monitoring The child requires close continual monitoring. Recording of pulse rate, respiratory rate and pattern, pulse oximetry and CEWT score. Supportive nursing care with adequate hydration 12.0 Staff Training 12.1 All medical and nursing staff are to ensure that their knowledge, competencies and skills are up-to-date in order to complete their portfolio for appraisal. 12.2 During induction process junior medical staff will receive instruction on current policies and guidelines. 12.3 At case presentation and junior doctor teaching will discuss upper airway obstruction cases and learn from the outcomes. 13.0 Infection Prevention 13.1 All staff should follow Trust guidelines on infection prevention ensuring that they effectively decontaminate their hands before and after each procedure. 14.0 Audit and Monitoring 14.1 Where a patient s notes have demonstrated that the appropriate action has not been taken a risk event form is to be completed. This will address any further training needs for staff that require updating. 14.2 As an integral part of the knowledge, skills framework, staff are appraised annually to ensure competency in computer skills and the ability to access the current approved guidelines via the trust s intranet site. 6

15.0 Communication 15.1 Ratified guidelines will be disseminated to appropriate staff quarterly via email and uploaded to the intranet and website. 15.2 Regular memos are posted on the Risk Management notice boards in each clinical area to notify staff of the latest revised guidelines and how to access guidelines via the intranet or clinical guideline folders. 15.3 A paper copy of this guideline will also be available to staff for reference. 16.0 References Bjornson CL, Johnson DW 2008 Croup The Lancet Vol 371. pg 329. Moore M, Little P, 2007 Humidified air inhalations for treating croup. Family Practice Vol 24. issue, 1 pg 295 NHS Children s Acute Transport Service (CATS) 7

Appendix A Viral Croup Flowchart Leave child in comfortable position Do not insert tongue depressor Do not insert IV line or take blood Do not x-ray Mild Croup Score = 0-1 Normal RR No recession Normal pulse rate Normal O2 sats Normal conscious level Moderate Croup Score =2-7 Normal or raised RR Mild recession AE decreased but easily audible O2 sats>93% Normal conscious level Severe Croup Score =/> 8 Increased RR Moderate/marked recession Decreased AE and nor easily audible Increased pulse rate O2 sats> 93% Reassure Follow local guidelines for discharge Consider dexamethasone 0.15mg/kg po Dexamethasone 150 mcg/kg po (max 2mg) or nebulised budesonide 2mg if po not possible Observation for 2-3 hours If no improvement or worsening, rescore and act accordingly Call for senior help Senior Paediatrician Senior Anaesthetist Stay with child Give nebulised adrenaline 0.5ml/kg of 1:1000 solution up to maximum of 5mls. This dose can be repeated. Stridor 0 = none 1 = at rest, audible with stethoscope 2 = at rest, audible without stethoscope Recession 0 = none 1 = mild recession 2 = moderate recession 3 = severe recession Cyanosis (O2 sats<92%in air) 0 = none 4 = with agitation 5 = at rest Level of consciousness 0 = normal 5 = altered mental state Child might require urgent intubation and transfer to PICU. Call CATS Acknowledgements to CAT guidelines 2006