Croup - management in the intensive care setting

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(Laryngotracheobronchitis)

PICU review considerations

1. Diagnostic doubt e.g. foreign body, tracheitis, epiglottitis
2. SpO₂ < 90% on air
3. Sternal or suprasternal retraction at rest
4. Restlessness or pallor
5. Decreased level of consciousness/exhaustion
6. Known pre-existing airway pathology or admission to PICU with croup
7. 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

1. Minimise distress/ adequate fluids/ observation
2. Do not routinely give oxygen (a SpO₂ < 90% is a possible indication for intubation)
3. Do not give antibiotics
4. No investigations - CXR if SpO₂ is low
5. Dexamethasone 0.6 mg/kg IM/IV/PO, repeat at 24 h if no improvement
6. 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

1. Fatigue
2. Increasing respiratory distress unresponsive to nebulised adrenaline
3. SpO₂ < 90% - suggests parenchymal disease or inadequate ventilation
4. Airway obstruction

Intubation Technique

1. Get help (Intensivist/Anaesthetist/ENT)
2. Gas induction with sevoflurane in oxygen - induction is slow (10-15 min), do not hurry
3. Uncuffed ETT ½ size smaller than usual. In general do not use a size < ID 3mm ETT
4. Intubate orally first, then change to nasal tracheal tube (NTT)
5. Secure NTT, place NG in stomach, place arm splints
6. Secure IV access
7. CXR to check NTT position, parenchymal disease is not an indication for antibiotics
8. Allow patient to awaken, sedatives e.g. morphine/benzodiazepine or propofol may be initially required
9. CPAP/oxygen may be required for post-obstruction pulmonary oedema or parenchymal disease

Extubation

1. Trial extubation on day 3-5.
2. Leak around NTT
3. Steroid cover - prednisone 1 mg/kg PO 8-12 h, continue 24 h after extubation
4. Consider nebulised adrenaline for post-extubation stridor. Some children (10-20%) will require re-intubation.
5. Discharge to ward 6 h after extubation if no interventions required
6. ENT consult +/- bronchoscopy for those who fail extubation or have recurrent croup