Croup

OVERVIEW

= acute laryngotracheobronchitis

  • parainfluenza, influenza or RSV
  • oedema of larynx, trachea and bronchi

CLINICAL FEATURES

  • autumn & early spring
  • 6 months -> 2 years
  • URTI -> barking cough, hoarseness, stridor secretions +++
  • mild fever
  • dysphagia

Severity assessment

  • Mild: barking cough, inspiratory stridor, hoarse voice
  • Moderate: accessory muscle use at rest, distressed
  • Severe: severe respiratory distress, hypoxia, severe stridor

INVESTIGATIONS

  • clinical diagnosis

MANAGEMENT

  • keep calm
  • O2
  • dexamethasone 0.125-0.6mg/kg PO or prednisone 1mg/kg (decreases LOS and need for nebulised ADR)
  • nebulised adrenaline 0.5mg/kg up to max of 5 mg
  • patient requires admission to ICU: requires more than one adrenaline nebuliser, ongoing stridor at rest, parental concern, presentation at night, important co-morbid conditions (subglottic stenosis, previous neonatal ventilation, Downs)
  • intubation; IV with EMLA, gas induction with sevoflurane, sitting -> supine, scrubbed ENT surgeon, use CPAP, laryngoscopy often OK, use small ETT PO then change to nasal
  • suction
  • check for cuff leak daily

AIRWAY MANAGEMENT

Indications for Intubation in a child with croup

Failure of medical treatment (O2, nebulised adrenaline, dexamethasone) and progression to:

  • exhaustion from increased work of breathing
  • hypercapnic respiratory failure
  • hypoxic respiratory failure (child would usually be obtunded)
  • decreased LOC (and not protecting own airway, responding to pain only)
  • imminent airway obstruction

Upper Airway Obstruction (COMET-Failure)

  • Call for help
  • Optimise treatment
  • Monitoring
  • Equipment and Drugs
  • Technique
  • Failure – plan for failed intubation

Call for help

  • another anaesthetist/ airway specialist to be present
  • an ENT surgeon scrubbed and ready to perform emergency tracheostomy

Optimise Medical Treatment

  • high flow O2 (avoid distressing child – hold mask away, keep on parents lap if appropriate)
  • nebulised adrenaline 5mg (repeated doses)
  • dexamethasone 0.6mg/kg IV
  • oxygen/helium mixture
  • obtain IV access (using EMLA and parents comforting patient) – if this will distress the child too much then delay until under anaesthesia

Monitoring

  • P
  • SpO2
  • NIBP
  • ETCO2
  • end-tidal anaesthetic agent concentration

Equipment

  • range of ET tube sizes 4.0/4.5/5.0
  • two laryngoscopes with a range of blades
    – small bougie
    – cannulae for needle cricothyroidotomy + method of O2 delivery
    – suction

Technique

(1) inhalational induction (preferred)
(2) IV induction with paralysis

Inhalational Induction

Patient will have critical laryngeal oedema and airway obstruction below the level of the vocal cords. If patient is still breathing and is able to be transferred to theatre, the safest way to induce this patient will be using an inhalational induction with maintenance of spontaneous ventilation until airway is secure.

  • slowly turn up sevoflurane concentration to 8% mixed with O2
  • wait until adequate depth of anaesthesia (eyes are mid line and small)
  • gentle laryngoscopy with assessment of laryngeal inlet
  • intubation with a small uncuffed endotracheal tube (probably size 4.0 to 4.5)
    -> preferably using a nasal tube as this patient will need to be transferred to a paediatric intensive care unit and nasal tube provides easier fixation and are easier to care for.

IV Induction with Paralysis

  • if patient obtunded and needs emergency intubation then a rapid sequence induction with cricoid pressure may be used.
  • an LMA or fiberoptic bronchoscope are unlikely to be helpful

Failure

  • LMA
  • facemask
  • needle cricothyroidotomy
  • surgical cricothyroidotomy

CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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