Croup
1/12/10
FANZCA Part II Notes
OHOA page 810
CK Notes
= acute laryngotracheobronchitis
- parainfluenza, influenza or RSV
- oedema of larynx, trachea and bronchi
CLINICAL FEATURES
-
autum & 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
MANAGEMENT
- keep calm
- O2
- dexamenthasone 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
Jeremy Fernando (2010)
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 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
Jeremy Fernando (2010)
- 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 cricothyroidomy
surgical cricothyroidomy
Jeremy Fernando (2010)