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Clinical care guideline template

Croup Clinical Care Guideline:
Age 6 Months to 3 Years*
Posted: 8/1/2011
*Always check intranet for latest version Table of Contents
Target Population
Key Treatment Principles
Intended for patients with:
Indicated:
Principal diagnosis: croup
Not intended for patients with:
Suspicion of tracheitis (laryngotracheal- bronchitis or –pneumonitis) or epiglottitis Uncommon or life threatening presentation dysplasia cystic fibrosis, pulmonary artery Not routinely Indicated:
Suspicion of serious bacterial infection 10. Active varicella or tuberculosis (TB) 11. Congenital or acquired heart disease Please Note: Clinical care guidelines are designed to assist clinicians and patients make decisions about appropriate health care for specific clinical circumstances. These guidelines should not be considered inclusive of all proper methods of care or exclusive of other methods of care reasonably directed at obtaining the same results. The ultimate judgment regarding care of a particular patient must be made by the clinician in light of the individual circumstances presented by the patient and the needs and resources particular to the locality or institution. Clinical Management
• Phone contact with primary care provider (PCP): barking cough, acting normally, good fluid intake 1. Prevention
3. Initial Triage
• Droplet precautions for all care settings Obtain brief history of presenting conditions and past medical history \ birth (hospitalization, intubation \ mechanical • Protect high risk patients from exposure Check immunization status: Haemophilus influenza type b 2. Telephone Triage
(HIB), pneumococcal, tetanus. Important when considering • Activate EMS (911): Severe difficulty breathing (struggling for breath, grunting noises with each breath, unable to speak or cry), blue lips or reduced Obtain all pertinent patient history, including onset and duration of symptoms including croup prodrome (rhinorrhea, sore • ED visit (immediate): Underlying heart or lung disease, throat, low grade fever, cough) and timing of evidence of upper breathing heard across room, poor fluid intake, airway obstruction (hoarse voice, barking cough, audible temperature greater than 105°F, excessive drooling, stridor) and subglottic involvement (aphonia) o Age less than 12 months, respiratory rate (RR) Inquire regarding history of congenital or acquired heart greater than 60, unable to suck or sleep disease, congenital or acquired subglottic stenosis, o Age greater than 12 months, RR greater than 40, tracheomalacia, tracheal webs, choanal narrowing or atresia, • Office visit same day: Worsening cough, some difficulty breathing, poor fluid intake, chronic or underlying Check current medications and time and dose of last PAGE 1 of 12
Strength of Evidence:
A = Objective data (OD) and expert opinion (EO) strongly support; B = OD and EO predominantly support; C = EO supports, but OD lacking or inconclusive • Retractions (suprasternal, intercostal, abdominal) 4. Clinical Assessment
Evaluation of presence of noninvasive croup versus a more Evaluate hydration status. Evaluate patient using Croup
Clinical Progress Croup
Score every 30 to 90 minutes based on severity (reference
5. Knowledge Base
Croup is an acute inflammatory process expressed as Day 3 to 7 Onset symptoms of upper airway inflammation laryngotracheitis. Infection begins in the nasopharynx and spreads to the respiratory epithelium of larynx & trachea. Inflammation, erythema and edema of the vocal folds cause Differential Diagnosis
While all medical care providers need to be aware of the potential for extension of the disease process to tracheitis (laryngotracheal-bronchitis or –pneumonitis), it is beyond the Etiology of Croup
Table 1 Etiology of Croup (Laryngotracheitis) Allergic response to viral antigen causing acute non- inflammatory recurrent intermittent swelling of laryngotracheal tissues. Acute nocturnal onset in older child than primary croup, repeat attacks same Clinical Symptoms of Tracheitis
Table 2 Etiology of Tracheitis (laryngotracheal-bronchitis or – Sudden worsening of symptoms airway is indicative of more severe or invasive disease and warrants immediate specialty Increased work of breathing with retractions Parainfluenza type 1, 2, 3
Clinical Symptoms of Croup
Symptoms increase at night and improve during day
Hoarse voice
Barking cough (often described as a “barking seal”)
Stridor (variable, usually inspiratory)
PAGE 2 of 12
Strength of Evidence:
A = Objective data (OD) and expert opinion (EO) strongly support; B = OD and EO predominantly support; C = EO supports, but OD lacking or inconclusive
6. Monitoring:
The croup score is felt to be useful to assess the Figure 1 CROUP SCORE (Modified Westley) [B]
efficacy of interventions, but there is little proof of its Possible Score 0 to 17:
Less than 4=mild croup, 4 to 6=moderate croup,
7. Laboratory and Radiology Studies
Greater than 6=severe croup
Diagnostic tests are only indicated if they will change outcome. Indicators of Disease Severity
Croup is a clinical diagnosis and usually no testing needed Inspiratory stridor
If concern for SBI or bacteria super infection Intercostal Retractions
• Classic “Steeple sign” reflects narrowed Patchy infiltrate seen in laryngotracheal- Only if clinical presentation is atypical Air Entry
Epiglottitis: classic “thumb” sign reflects • Retropharyngeal abscess: widened pre- 8. Therapeutics
Cyanosis
Corticosteroids
Mechanism of action: Long lasting anti-inflammatory agent Adverse Effects: Risk of progressive viral infection Level of Consciousness
Figure 2 Severity Classification
Dexamethasone
SEVERITY CLASSIFICATION: Follow croup score classification
Treatment
Severity
Management
Considerations
Peak serum levels: Oral: Within 1 to 2 h Note, the taste of oral dexamethasone liquid may not be well tolerated thus the preferred method of administration may be a crushed dexamethasone • Nebulized Budesonide
Equal efficacy to dexamethasone; expensive Consider in children with emesis or severe respiratory Reassess every 4 hours, consider discharge Moderate: Reassess every 2 hours, consider admission Severe: Reassess every 1 hour, consider ICU admission Prednisolone
Monitoring
Prednisone
Continuous cardiac/pulse oximetry monitoring only recommended for unstable patient or receiving repeat 4 mg/kg/ (equivalent 0.6 mg/kg dexamethasone) 2 mg/kg/ (equivalent 0.3 mg/kg dexamethasone)
1 mg/kg/ (equivalent 0.15 mg/kg dexamethasone)
Follow vital signs to assess response to therapy: temperature, heart rate, respiratory rate PAGE 3 of 12
Strength of Evidence:
A = Objective data (OD) and expert opinion (EO) strongly support; B = OD and EO predominantly support; C = EO supports, but OD lacking or inconclusive Nebulized Epinephrine
For Croup Score greater than 3, stridor Mechanism of Action: Stimulation α-adrenergic receptors Constrict capillary arterioles causing fluid resorption from Ibuprofen
interstitial space and decreases interstitial edema Duration of action: less than or equal to 2 hours Efficacy: Racemic & L-epinephrine are equally efficacious [A]
Oxygen Utilize supplemental oxygen to treat hypoxia
Adverse effects: Myocardial Infarction (rare) Other therapies
Racemic Epinephrine
(1:1 mixture of δ & ϑ-isomers epinephrine) Mist: Humidified air with or without oxygen [C]
Dose: 0.05 mL/kg/dose of 2.25% solution in 2.5mL normal Controversial therapy without supporting evidence saline (NS) via nebulizer over 15 minutes Weight greater than or equal to 5 kg = 0.5mL May decreases viscosity of tracheal mucus secretions Frequency: Repeat every 20 min as indicated enabling patient to remove them by coughing May increase wheezing in laryngotracheitis-bronchitis\ • L-epinephrine
(use if racemic epinephrine unavailable) Anti-tussive or decongestant
Dose: 0.5 mL/kg/dose of 1:1000 L-epinephrine in 2.5 mL Antibiotics
Frequency: Repeat every 15 to 20 minutes as indicated Indicated only for bacterial component (tracheitis) The term ‘rebound phenomenon’ is a misnomer. Epinephrine Helium-Oxygen Mixture
doesn’t change the duration of croup and benefits lasts less Not shown to be more effective than nebulized It is safe to send children home from the ED after receiving May be efficacious in patient with severe croup with racemic epinephrine if they have been observed for a minimum 9. Parent/Caregiver Education (see
Antipyretics
Expected clinical course less than ten days Indicated for temperature greater than 38.3°C Signs of worsening clinical status and when to notify Acetaminophen: Maximum daily dose oral or rectal:
Less than 12 kg = 5 doses/24 hours or 2.6 grams/ 24 Provide parent with patient education materials For neonatal dosing (preterm neonates and term 10. Discharge Criteria
Begin discharge planning at time of initial
ORAL dosing (Maximum single dose = 500 mg)
presentation
Assess caretaker ability to provide home care Assess home resources adequate to support care Confirm follow-up PCP/designee in specified time Provide verbal and written instructions to caretakers Assure family awareness indications return Provide 24-hour contact number for PCP or designee Discharge Home
RECTAL dosing (Maximum single dose = 650 mg)
Patient at baseline level of functioning Presenting condition stabilized or improves PAGE 4 of 12
Strength of Evidence:
A = Objective data (OD) and expert opinion (EO) strongly support; B = OD and EO predominantly support; C = EO supports, but OD lacking or inconclusive o Bradypnea or tachypnea outside normal limits Patients who have received nebulized epinephrine may be
discharged home after a minimum of 3 hours if no stridor
Admit Inpatient/ Observation
Continued stridor at rest despite therapy Condition deteriorates or does not improve Admit ICU
Consider for croup score greater than 6 Escalating stridor at rest despite therapy • Patient benefiting from ICU monitoring, treatment, or • Any patient with impending respiratory failure: o SaO2 less than 90% in 40% FiO2 o Cyanosis with supplemental oxygen
11. Follow-up


• Evaluate vital signs and oxygen saturation • Evaluate respiratory status
12. Clinical Care Guideline Measures & Targets

Principle diagnosis of Croup (ICD-9 Code: 464.4) Age: less than 18 years Patient classes: ED: Emergency and Urgent Care IP: Inpatient, Observation, and Ambulatory Surgery Location
Children’s
Colorado
PAGE 5 of 12
Strength of Evidence:
A = Objective data (OD) and expert opinion (EO) strongly support; B = OD and EO predominantly support; C = EO supports, but OD lacking or inconclusive 2011 Croup Task Force Members
2011 update approved by Dr. Dan Hyman August 1, 2011 Scheduled for review for invalidating evidence on August 1, 2012 Scheduled for full review on August 1, 2014 PAGE 6 of 12
Strength of Evidence:
A = Objective data (OD) and expert opinion (EO) strongly support; B = OD and EO predominantly support; C = EO supports, but OD lacking or inconclusive Figure 3 Algorithm Croup
Croup Score < 4
Croup Score 4 - 6
Croup Score > 6
Additional Workup as Indicated
Clinical Dehydration: Basic metabolic panel
Concern Pneumonia : Chest xray
CROUP SCORE: Modified Westley
TREATMENT Croup Score ≥ 4
Indicators of Disease Severity Score
Inspiratory stridor
Indications for Specialty Consultation
Any Concern for Invasive Disease, including: Retractions
Dose: 0.05 ml/kg/dose of 2.25% in 2.5mL NS Air Entry
0. 5 mL (wt ≥ 5 kg)
Indications for Admission
Cyanosis
≥ 3 Nebulized Epinephrine treatments in 3 h Dose: 0.5 mL/kg/dose of 1:1000 in 2.5 mL NS Inadequate hydrationModerate – severe retractions Level of Consciousness
Condition deteriorates or does not improve Aphonia – consider alternative diagnosis + Antibiotics Indicated only for bacterial tracheitis PAGE 7 of 12
Strength of Evidence:
A = Objective data (OD) and expert opinion (EO) strongly support; B = OD and EO predominantly support; C = EO supports, but OD lacking or inconclusive PARENT/CAREGIVER EDUCATION MATERIALS
Croup:

Tobacco Smoke:

PAGE 8 of 12
Strength of Evidence:
A = Objective data (OD) and expert opinion (EO) strongly support; B = OD and EO predominantly support; C = EO supports, but OD lacking or inconclusive REFERENCES

General
1.
Argent, A.C., C.J. Newth, and M. Klein, The mechanics of breathing in children with acute severe croup. Intensive
Care Med, 2008. 34(2): p. 324-332.
Briassoulis, G., et al., Unexpected combination of acute croup and myocarditis: case report. BMC Clin Pathol,
2005. 5: p. 5.
Brown, J.C., The management of croup. Br Med Bull, 2002. 61: p. 189-202.
Chan, P.W., Risk factors associated with severe viral croup in hospitalised Malaysian children. Singapore Med J,
2002. 43(3): p. 124-7.
Cherry, J.D., State of the evidence for standard-of-care treatments for croup: are we where we need to be?
Pediatr Infect Dis J, 2005. 24(11 Suppl): p. S198-202, discussion S201.
Cherry, J.D., Clinical practice. Croup. N Engl J Med, 2008. 358(4): p. 384-91.
Ewig, J.M., Croup. Pediatr Ann, 2002. 31(2): p. 125-30.
Fisher, J.D., Out-of-hospital cardiopulmonary arrest in children with croup. Pediatr Emerg Care, 2004. 20(1): p.
35-6.
Garyfallou, G.T., S.K. Costalas, and C.J. Murphy, Acute pulmonary edema in a child with spasmodic croup. Am J
Emerg Med, 1997. 15(2): p. 211-3.
Greenberg, R.A., N.C. Dudley, and K.K. Rittichier, A reduction in hospitalization, length of stay, and hospital
charges for croup with the institution of a pediatric observation unit.
Am J Emerg Med, 2006. 24(7): p. 818-21.
Johnson, D., Croup. Clin Evid, 2005(14): p. 310-27. Kwong, K., M. Hoa, and J.M. Coticchia, Recurrent croup presentation, diagnosis, and management. Am J
Otolaryngol, 2007. 28(6): p. 401-7.
Leung, A.K., J.D. Kellner, and D.W. Johnson, Viral croup: a current perspective. J Pediatr Health Care, 2004.
18(6): p. 297-301.
Li, S.F., The Westley croup score. Acad Emerg Med, 2003. 10(3): p. 289; author reply 289.
Magomedov, M.K., [A fatal outcome of false croup in lacunar angina complicated by peritonsillar abscess]. Arkh
Patol, 2001. 63(1): p. 36-7.
Marx, A., et al., Pediatric hospitalizations for croup (laryngotracheobronchitis): biennial increases associated with
human parainfluenza virus 1 epidemics.
J Infect Dis, 1997. 176(6): p. 1423-7.
Myers, C., et al., Multiple pulmonary abscesses caused by Legionella pneumophila infection in an infant with
croup.
Pediatr Infect Dis J, 2006. 25(8): p. 753-4.
Peltola, V., T. Heikkinen, and O. Ruuskanen, Clinical courses of croup caused by influenza and parainfluenza
viruses.
Pediatr Infect Dis J, 2002. 21(1): p. 76-8.
Savenkova, M.S., et al., [Causes of lethal outcomes in croup syndrome in children]. Vestn Otorinolaringol, 2001(3): p. 50-1. Sturludottir, M., et al., [Case report: prolonged croup due to herpes simplex infection]. Laeknabladid, 2006.
92(12): p. 855-7.
Szenborn, L., et al., [Croup in children--results of prospective, multicenter observation]. Przegl Lek, 2004. 61(5):
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TJ, O.L. and A. Messner, Subglottic hemangioma. Otolaryngol Clin North Am, 2008. 41(5): p. 903-11, viii-ix.
van der Hoek, L., et al., Croup is associated with the novel coronavirus NL63. PLoS Med, 2005. 2(8): p. e240.
Westley, C.R., E.K. Cotton, and J.G. Brooks, Nebulized racemic epinephrine by IPPB for the treatment of croup: a
double-blind study.
Am J Dis Child, 1978. 132(5): p. 484-7.

Epinephrine
1.
Argent, A.C., et al., The effect of epinephrine by nebulization on measures of airway obstruction in patients with
acute severe croup.
Intensive Care Med, 2008. 34(1): p. 138-147.
Rizos, J.D., et al., The disposition of children with croup treated with racemic epinephrine and dexamethasone in
the emergency department.
J Emerg Med, 1998. 16(4): p. 535-9.
Taussig, L.M., et al., Treatment of laryngotracheobronchitis (croup). Use of intermittent positive-pressure
breathing and racemic epinephrine.
American Journal of Diseases of Children, 1975. 129(7): p. 790-3.
PAGE 9 of 12
Strength of Evidence:
A = Objective data (OD) and expert opinion (EO) strongly support; B = OD and EO predominantly support; C = EO supports, but OD lacking or inconclusive Thomas, L.P. and L.R. Friedland, The cost-effective use of nebulized racemic epinephrine in the treatment of
croup.
Am J Emerg Med, 1998. 16(1): p. 87-9.
Waisman, Y., et al., Prospective randomized double-blind study comparing L-epinephrine and racemic
epinephrine aerosols in the treatment of laryngotracheitis (croup).
Pediatrics, 1992. 89(2): p. 302-6.
PAGE 10 of 12
Strength of Evidence:
A = Objective data (OD) and expert opinion (EO) strongly support; B = OD and EO predominantly support; C = EO supports, but OD lacking or inconclusive

Heliox
1.
Beckmann, K.R. and W.M. Brueggemann, Jr., Heliox treatment of severe croup. Am J Emerg Med, 2000. 18(6): p.
735-6.
Vorwerk, C. and T.J. Coats, Use of helium-oxygen mixtures in the treatment of croup: a systematic review. Emerg
Med J, 2008. 25(9): p. 547-50.
Weber, J.E., et al., A randomized comparison of helium-oxygen mixture (Heliox) and racemic epinephrine for the
treatment of moderate to severe croup.
Pediatrics, 2001. 107(6): p. E96.

Humidified Air
1.
Bird, E., Humidified air appears to be of no benefit in treating moderate croup. J Pediatr, 2006. 149(1): p. 141.
Colletti, J.E., Myth: Cool mist is an effective therapy in the management of croup. CJEM, 2004. 6(5): p. 357-8.
Lavine, E. and D. Scolnik, Lack of efficacy of humidification in the treatment of croup: Why do physicians persist
in using an unproven modality?
CJEM, 2001. 3(3): p. 209-12.
Moore, M. and P. Little, Humidified air inhalation for treating croup. Cochrane Database Syst Rev, 2006. 3: p.
CD002870.
Neto, G.M., et al., A randomized controlled trial of mist in the acute treatment of moderate croup. Acad Emerg
Med, 2002. 9(9): p. 873-9.
Scolnik, D., et al., Controlled delivery of high vs low humidity vs mist therapy for croup in emergency departments:
a randomized controlled trial.
JAMA, 2006. 295(11): p. 1274-80.
Wyer, P.C., Delivery of 100%, 40%, and blow-by humidity did not differ for change in croup scores in children with
moderate croup.
Evid Based Med, 2006. 11(5): p. 142.

Steroids
1.
Amir, L., et al., Oral betamethasone versus intramuscular dexamethasone for the treatment of mild to moderate
viral croup: a prospective, randomized trial.
Pediatr Emerg Care, 2006. 22(8): p. 541-4.
Ausejo, M., et al., Glucocorticoids for croup. Cochrane Database Syst Rev, 2000(2): p. CD001955. Bjornson, C.L., et al., A randomized trial of a single dose of oral dexamethasone for mild croup. N Engl J Med,
2004. 351(13): p. 1306-13.
Cetinkaya, F., B.S. Tufekci, and G. Kutluk, A comparison of nebulized budesonide, and intramuscular, and oral
dexamethasone for treatment of croup.
Int J Pediatr Otorhinolaryngol, 2004. 68(4): p. 453-6.
Chub-Uppakarn, S. and P. Sangsupawanich, A randomized comparison of dexamethasone 0.15 mg/kg versus
0.6 mg/kg for the treatment of moderate to severe croup.
Int J Pediatr Otorhinolaryngol, 2007. 71(3): p. 473-7.
Donaldson, D., et al., Intramuscular versus oral dexamethasone for the treatment of moderate-to-severe croup: a
randomized, double-blind trial.
Acad Emerg Med, 2003. 10(1): p. 16-21.
Fifoot, A.A. and J.Y. Ting, Comparison between single-dose oral prednisolone and oral dexamethasone in the
treatment of croup: a randomized, double-blinded clinical trial.
Emerg Med Australas, 2007. 19(1): p. 51-8.
Geelhoed, G.C., Budesonide offers no advantage when added to oral dexamethasone in the treatment of croup.
Pediatr Emerg Care, 2005. 21(6): p. 359-62.
Godden, C.W., et al., Double blind placebo controlled trial of nebulised budesonide for croup. Arch Dis Child,
1997. 76(2): p. 155-8.
Griffin, S., et al., Nebulised steroid in the treatment of croup: a systematic review of randomised controlled trials.
Br J Gen Pract, 2000. 50(451): p. 135-41.
Johnson, D.W., et al., A comparison of nebulized budesonide, intramuscular dexamethasone, and placebo for
moderately severe croup.
N Engl J Med, 1998. 339(8): p. 498-503.
Klassen, T.P., et al., Nebulized budesonide and oral dexamethasone for treatment of croup: a randomized
controlled trial.
JAMA, 1998. 279(20): p. 1629-32.
Luria, J.W., et al., Effectiveness of oral or nebulized dexamethasone for children with mild croup. Arch Pediatr
Adolesc Med, 2001. 155(12): p. 1340-5.
O'Mara, L., Dexamethasone reduced the incidence of children with mild croup who returned for medical care. Evid
Based Nurs, 2005. 8(2): p. 41.
Parker, R., C.V. Powell, and A.M. Kelly, How long does stridor at rest persist in croup after the administration of
oral prednisolone?
Emerg Med Australas, 2004. 16(2): p. 135-8.
Paton, J.Y., Oral dexamethasone led to fewer treatment failures than did nebulized dexamethasone or placebo in
children with mild croup.
ACP J Club, 2002. 137(1): p. 31.
PAGE 11 of 12
Strength of Evidence:
A = Objective data (OD) and expert opinion (EO) strongly support; B = OD and EO predominantly support; C = EO supports, but OD lacking or inconclusive Rittichier, K.K. and C.A. Ledwith, Outpatient treatment of moderate croup with dexamethasone: intramuscular
versus oral dosing.
Pediatrics, 2000. 106(6): p. 1344-8.
Roberts, G.W., et al., Repeated dose inhaled budesonide versus placebo in the treatment of croup. J Paediatr
Child Health, 1999. 35(2): p. 170-4.
Rowe, B.H., Corticosteroid treatment for acute croup. Ann Emerg Med, 2002. 40(3): p. 353-5.
Russell, K., et al., Glucocorticoids for croup. Cochrane Database Syst Rev, 2004(1): p. CD001955. Sparrow, A. and G. Geelhoed, Prednisolone versus dexamethasone in croup: a randomised equivalence trial.
Arch Dis Child, 2006. 91(7): p. 580-3.
Sumboonnanonda, A., S. Suwanjutha, and S. Sirinavin, Randomized controlled trial of dexamethasone in
infectious croup.
J Med Assoc Thai, 1997. 80(4): p. 262-5.
Worster, A., P.H. Tang, and G. Hall, Dexamethasone for mild croup. CJEM, 2006. 8(4): p. 282-3.
PAGE 12 of 12
Strength of Evidence:
A = Objective data (OD) and expert opinion (EO) strongly support; B = OD and EO predominantly support; C = EO supports, but OD lacking or inconclusive

Source: http://www.childrenscolorado.org/File%20Library/Conditions-Programs/Breathing/Croup-Clincal-Care-Guidelines.pdf

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