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Northern California Pediatric Hospital Medicine Consortium
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Table of Contents
Executive summary
Objectives
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Standardize the care of pediatric patients with viral croup in acute care, ER, and inpatient settings
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Decrease utilization of non-evidence-based evaluation and treatment modalities for croup
Recommendations
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Consider alternative diagnoses in patients with atypical or severe clinical presentation, or those with poor response to standard treatments
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Do not routinely order laboratory testing (including viral testing)
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Do not routinely order x-rays
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Use the consensus croup algorithm (appendix 1) for classifying severity and managing accordingly
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Administer Dexamethasone to all patients with a diagnosis of croup, regardless of symptom severity
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Do not routinely give repeat doses of steroid
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Discharge patients meeting the following criteria:
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No or minimal stridor at rest
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No or minimal work of breathing
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Able to talk and feed without difficulty
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>2 hours from last racemic epinephrine treatment
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No supplemental oxygen requirement
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Methods
This guideline was developed through local consensus based on published evidence and expert opinion as part of the UCSF Northern California Pediatric Hospital Medicine Consortium.
Metrics Plan
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Percentage of patients with discharge diagnosis of croup that receive Dexamethasone
Clinical Consensus Guidelines for Management of Croup: Northern California Pediatric Hospital Medicine Consortium
Introduction
Criteria for Use of Guideline
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Inclusion:
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Previously healthy children
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Common age: 6 months – 6 years
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History & clinical exam consistent with primary diagnosis of croup
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Exclusion:
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Toxic appearance
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Symptoms suggestive of alternative diagnosis (see below)
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Known upper airway abnormality or chronic lung disease
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Recent airway instrumentation
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History of chronic / recurrent aspiration
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Neurologic impairment (hypotonia or neuromuscular disorder)
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Immunocompromise
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Background
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Croup (laryngotracheobronchitis) is a viral illness, most common in late fall to early winter, leading to inflammation of the upper airway
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Most common pathogen: parainfluenza virus
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Others: RSV, influenza A and B, Mycoplasma pneumonia, other respiratory viruses
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Symptoms:
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Sudden onset of barky cough
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Inspiratory stridor
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Hoarse voice
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+/- Antecedent URI symptoms
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+/- Fever
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+/- Respiratory distress
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Natural History:
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Symptoms worse at night
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Typical resolution after 3 days
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Commonly followed by URI symptoms
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Evaluation
Alternative Diagnoses
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Differential Diagnosis:
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Bacterial tracheitis
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Epiglottitis
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Foreign body aspiration
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Allergic reaction
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Trauma
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Paratonsillar or retropharyngeal abscess
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Diphtheria
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Infectious mononucleosis
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Spasmodic croup
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Laryngeal nerve compression
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Subglottic stenosis
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Subglottic hemangioma
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Tumor
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Consider alternative diagnoses IF:
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Age < 6 months or > 6 years
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Duration of stridor > 4 days or cough > 10 days
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History of non-elective intubation in past 6 months
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History of prolonged intubation
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History of recurrent croup
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2nd episode within 30 days
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> 3 episodes within last 12 months
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Toxic appearance
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Drooling, difficulty swallowing, severe anxiety
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Asymmetry of respiratory exam
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Cutaneous hemangiomas present
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Hypoxia / cyanosis
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Poor response to treatment
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Severity Assessment
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Quantitative measurement of severity using a scale such as the Westley Croup Score is impractical for routine use in acute care / inpatient settings
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Qualitative clinical severity assessment is recommended:
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NOTE: use clinical gestalt to determine severity classification; patients may have one or more sign or symptom within a selected severity category
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Mild
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Barky cough, hoarse voice
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No stridor at rest
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Mild coarse stridor only during agitation / activity
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No or mild work of breathing
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Moderate
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Stridor at rest
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Tachypnea
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Moderate work of breathing
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Anxiety / agitation / restlessness
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Difficulty talking or feeding
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Severe
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Stridor at rest
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Severe work of breathing or respiratory fatigue
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Self-positioning (example: tripoding, neck extension)
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Decreased LOC
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Inability to talk or feed
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Impending Respiratory Failure
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Stridor may be present or decreased
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Severe work of breathing
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Bradypnea or poor respiratory effort
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Cyanosis / hypoxemia despite supplemental oxygen
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Hypercarbia
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Listless / decreased LOC
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Lab Testing & Imaging
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Labs: Routine lab testing (including respiratory viral testing) NOT recommended
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Consider arterial blood gas if suspected / impending respiratory failure
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Imaging: Routine imaging (CXR or lateral neck x-ray) NOT recommended
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Consider imaging if atypical presentation or suspected alternative diagnosis
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Management
Acute Management Algorithm
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See APPENDIX 1 for croup algorithm
Admission & Discharge Criteria
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ER Discharge criteria
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Croup symptoms mild or improved from presentation
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No or minimal stridor at rest
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No or minimal work of breathing
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Able to talk and feed without difficulty
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>2 hours since last racemic epinephrine treatment
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Received dexamethasone
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Admission criteria
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Pediatric Ward
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Persistent moderate symptoms after Dexamethasone & racemic epinephrine
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Continued stridor at rest despite therapy
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Inadequate hydration
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Moderate work of breathing
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Need for supplemental oxygen
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Atypical presentation / concern for alternative diagnosis
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PICU / Transfer to higher level of care
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Persistent severe croup symptoms despite therapy
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Escalating stridor at rest despite therapy
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Need for intubation in ER
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Impending respiratory failure
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Bradypnea or poor respiratory effort
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Severe work of breathing
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Stridor may be present or decreased
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Cyanosis / hypoxemia despite supplemental oxygen
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Hypercarbia
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Listlessness / decreased LOC
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Hospital discharge criteria
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Croup symptoms mild or improved
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No or minimal stridor at rest
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No or minimal work of breathing
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Able to talk and feed without difficulty
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Able to maintain adequate hydration
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>2 hours since last racemic epinephrine treatment
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>12 hours since supplemental oxygen requirement
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Consider postponing discharge until after an event-free/symptom-free NIGHT, unless respiratory exam is completely normal
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Follow-up
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Consider phone or in person follow-up with PMD in 1-2 days depending on reliability of patient/family and access to care
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Therapies
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Medications:
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See APPENDIX 2 for medication dosing
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Steroids
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NOTE: no conclusive studies recommend one drug, dose, or route over another. Oral route may be preferred due to non-invasiveness causing less stress for the child. However, IM, IV, or neb routes may be useful in children who cannot tolerate oral medications.
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Dexamethasone: single PO dose
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Administer for all patients with croup (regardless of severity)
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Alternative routes: IV, IM
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No evidence supports repeated doses of dexamethasone
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NOTE: For severe or atypical cases, repeat steroid doses may be considered; consultation with pediatric subspecialists (PICU, ENT) is recommended
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Budesonide: single nebulized dose
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Evidence demonstrates equal efficacy to Dexamethasone but more expensive medication
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Consider as alternative to Dexamethasone in children with emesis, severe respiratory distress, or parental refusal of systemic steroid
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Prednisone / Prednisolone are NOT recommended
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Nebulized Epinephrine: racemic or L-epinephrine doses PRN
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Nebulized L-epinephrine may be used as an alternative to racemic epinephrine in settings where racemic epinephrine is unavailable (e.g. EMS vehicles)
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The clinical effect of nebulized epinephrine is apparent at 30 minutes post-treatment and the clinical benefit of racemic epinephrine has dissipated at 120 minutes (NOTE: L-epinephrine may have longer half-life)
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There is no evidence to suggest that croup symptoms, on average, worsen after the treatment effect of nebulized epinephrine dissipates
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Supportive Care & monitoring
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Oxygen
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Initiate supplemental oxygen for saturations <90% in room air
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NOTE: hypoxia in croup is uncommon; consider alternative diagnoses in patients with significant hypoxia
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Continuous pulse oximetry NOT routinely recommended
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Consider continuous monitoring for unstable patients or those receiving numerous repeated doses of racemic epinephrine
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Cool mist in ER / hospital settings NOT supported by evidence
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There is no supporting evidence for added benefit of cool mist over other evidence-based therapies in hospital setting
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Cool mist therapy / moist night air is still recommended + has potential benefit in home setting; recommend to families at ER/hospital discharge
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Antipyretics PRN
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Avoid painful procedures and maintain calm atmosphere (example: child in parent’s arms for exam and therapies) since agitation may worsen clinical status
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Therapies NOT Recommended:
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Antibiotics
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Decongestant or antitussive medications
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Heliox
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Subspecialty consultation (ENT, anesthesia, pulmonology, ID, surgery, etc) indications:
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Severe / impending respiratory failure
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Intubation / need to secure critical airway
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Atypical or complicated presentation (rule-out alternative diagnoses)
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Recurrent croup
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Critical airway stabilization
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Intubation:
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Personnel:
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Recognize clinical deterioration quickly and activate expert providers with greatest airway skills immediately when respiratory failure + potential need for intubation is identified (consider anesthesia or PICU if available)
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Most experienced provider should intubate
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Equipment:
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Cuffed ET tube (if available): cuff deflated; use high volume, low pressure cuff if available
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ETT size: 4 + ¼ x age, minus 0.5 for cuffed tube; 0.5 size lower ETT also available for back-up
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Sedation:
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Use RSI (or protocol most familiar to providers) for intubation
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NOTE: If aspiration is a likely alternative diagnosis, use caution when considering intubation. Paralysis is relatively contraindicated as it is important to maintain spontaneous respirations so potential partial obstruction doesn’t become complete
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Supportive resources:
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For non-invasive PPV, choose a flow-dependent bag over self-inflating bag for option of delivering CPAP (providing PEEP) while awaiting intubation
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Consider placing salem sump/NG tube to decompress stomach from non-invasive PPV, once patient is appropriately sedated
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References
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Beigelman A, Chipps BE, Bacharier LB. Update on the utility of corticosteroids in acute pediatric respiratory disorders. Allergy Asthma Proc, 2015;36:332-338.
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Bjornson C, et al. 2011. Nebulized epinephrine for croup in children. Cochrane Database of Systematic Reviews, 2, 006619.
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Cetinkaya F, Tufekci BS, Kutluk G. A comparison of nebulized budesonide, and intramuscular, and oral dexamethasone for treatment of croup. . Int J Pediatr Otorhinolaryngol, 2004;68(4) : 453-456.
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Johnson DW, Jacobson S, Edney PC, et al. A comparison of nebulized budesonide, intramuscular dexamethasone, and placebo for moderately severe croup. N Engl J Med, 1998;339:498-503.
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Mandal A, Kabra SK, Lodha R. Upper Airway Obstruction in Children. Indian J Pediatr, 2015;82 8 :737-744.
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Petrocheilou A, Tanou K, Kalampouka E, et al. Viral Croup: Diagnosis and a Treatment Algorithm. Pediatr Pulmonol, 2014;49:421-429.
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Russel KF, et al. 2011. Glucocorticoids for croup. Cochrane Database of Systematic Reviews, 1, 001955.
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Taketomo CK, Hodding JH, Kraus DM. Pediatric & Neonatal Dosage Handbook: A Universal Resource for Clinicians Treating Pediatric and Neonatal Patients, 21st ed. Hudson, OH: Lexi-Comp, 2014.
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Zoorob, R, Sidani M, Murray J. Croup: An Overview. Am Fam Physician, 2011;83(9):1067-1073.
Published U.S. Children’s Hospital Croup Guidelines / Pathways:
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Children’s Hospital of Philadelphia Pathways (links):
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Emergency Department Pathway: http://www.chop.edu/clinical-pathway/croup-emergent-evaluation-and-treatment-clinical-pathway#
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Inpatient Pathway: http://www.chop.edu/clinical-pathway/croup-clinical-pathway
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Seattle Children’s Hospital Pathway (PDF):
http://www.seattlechildrens.org/healthcare-professionals/gateway/pathways -
University of Cincinnati Best Evidence Statement (PDF):
http://www.cincinnatichildrens.org/service/j/anderson-center/evidence-based-care/recommendations/topic -
Colorado Children’s Hospital Guideline (PDF):
http://www.childrenscolorado.org/health-professionals/referral-tools/referral-guidelines
APPENDIX 1: Croup Algorithm
APPENDIX 2: Medications for Croup
Northern California Pediatric Hospital Medicine Consortium. Originated 1/2016. Updated: 06/2016, 10/2017.
Approved by UCSF P&T: 1.10.18
Approved by UCSF QIEC: 12.19.17