
Croup - management in the intensive care setting
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(Laryngotracheobronchitis)
PICU review considerations
- Diagnostic doubt e.g. foreign body, tracheitis, epiglottitis
- SpO2 < 90% on air
- Sternal or suprasternal retraction at rest
- Restlessness or pallor
- Decreased level of consciousness/exhaustion
- Known pre-existing airway pathology or admission to PICU with croup
- Requiring more than 1 dose nebulised adrenaline (0.5 mg/kg, max 5 mg)
Those patients who have had 1 dose nebulised adrenaline (+/- dexamethazone 0.6 mg/kg PO, IV or IM) in CED and after 3 h observation are asymptomatic may be sent home.
PICU management
- Minimise distress/ adequate fluids/ observation
- Do not routinely give oxygen (a SpO2 < 90% is a possible indication for intubation)
- Do not give antibiotics
- No investigations - CXR if SpO2 is low
- Dexamethasone 0.6 mg/kg IM/IV/PO, repeat at 24 h if no improvement
- Nebulised adrenaline 0.5 mg/kg (0.5 ml/kg of 1:1000 adrenaline, max 5 ml) repeat PRN - consider intubation if > 3-4 doses, minimal effect, effect lasting < 60 min
Intubation
- Fatigue
- Increasing respiratory distress unresponsive to nebulised adrenaline
- SpO2 < 90% - suggests parenchymal disease or inadequate ventilation
- Airway obstruction
Intubation Technique
- Get help (Intensivist/Anaesthetist/ENT)
- Gas induction with sevoflurane in oxygen - induction is slow (10-15 min), do not hurry
- Uncuffed ETT ½ size smaller than usual. In general do not use a size < ID 3mm ETT
- Intubate orally first, then change to nasal tracheal tube (NTT)
- Secure NTT, place NG in stomach, place arm splints
- Secure IV access
- CXR to check NTT position, parenchymal disease is not an indication for antibiotics
- Allow patient to awaken, sedatives e.g. morphine/benzodiazepine or propofol may be initially required
- CPAP/oxygen may be required for post-obstruction pulmonary oedema or parenchymal disease
Extubation
- Trial extubation on day 3-5.
- Leak around NTT
- Steroid cover - prednisone 1 mg/kg PO 8-12 h, continue 24 h after extubation
- Consider nebulised adrenaline for post-extubation stridor. Some children (10-20%) will require re-intubation.
- Discharge to ward 6 h after extubation if no interventions required
- ENT consult +/- bronchoscopy for those who fail extubation or have recurrent croup
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Document Control
- Date last published: 04 July 2017
- Document type: Clinical Guideline
- Services responsible: Paediatric Intensive Care Unit
- Author(s): Brian Anderson
- Editor: John Beca
- Review frequency: 2 years
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