(1 of 4)

1 Patient (typically a child) presents w/ signs & symptoms of croup

ASSESS POSSIBLE AIRWAY OBSTRUCTION • Evaluate general appearance • Observe for stridor, tracheal tug, chest wall retractions • Assess the need for immediate supplemental O2

2 3 CLINICAL ASSESSMENT No ALTERNATIVE Determine severity of DIAGNOSIS airway obstruction

Yes

Mild Moderate Severe

A Nonpharmacological A Nonpharmacological therapy • Admit patient therapy • Patient/guardian reassurance • Consider intubation, if • Patient/guardian - Observe for possible necessary reassurance � A B progression of symptoms Nonpharmacological Pharmacological therapy B Pharmacological therapy therapy • • Corticosteroid • Corticosteroids (systemic) O2 (4L/min) - Systemic, single-dose • Heliox inhalation Or B • Budesonide (nebulized) Pharmacological therapy • Epinephrine (nebulized) • Corticosteroids (systemic) DISCHARGE PATIENT ASSESS CLINICAL RESPONSE

Complete Partial No improvement improvement improvement

DISCHARGE • Observe • Admit PATIENT • Repeat corticosteroid • Consider (oral) after 12 hr alternative • Discharge if w/ clinical diagnosis improvement © MIMS• Follow-up

Not all products are available or approved for above use in all countries. Specifi c prescribing information may be found in the latest MIMS.

A1 © MIMS 2019 CROUP • • • ofStridor Causes Other • Tracheitis • • • • • • Diphtheria • • Oximetry TestsLab • • • • • • Moderate • • • • Mild Obstruction ofAirway Severity treatment immediate requiring emergency amedical inCroup children is • • • • • &Symptoms Signs • • • • • • rapidly disease resp byan oftencharacterized acute, Croup progressing is Hereditary angioedema Hereditary abscess Retropharyngeal Foreign body toEpinephrine response Patient poor febrile, toxic &gives appears coughBarking israrely observed Patient insniffi prefers tositforward ng position ofhighfever, appearance sudden &anxious onset by drooling Characterized dysphagia, may occur obstruction W/ insidiouscourse butsudden respiratory when attempted removed tobe membrane adherent gray-white maytothe exam atypical tissuethat show bleeds pharyngeal days, W/in 2-3 &low-grade throat, sore anorexia, malaise, by Characterized - results ismore important than assessment oximetry Clinical oxygen saturationDetermines iswarranted observation tion, careful obstruc- Symptoms airway may tosevere progress littleIrritable, ornodistress rate respiratory Tachycardia, increased breathing, labored fltug &nasal present aring tracheal at retractions are rest wall observed, Chest at persistent Stridor rest even Frequent barking minimalornoneat retractions all wall Chest Intermittent may stridor observed ormay notbe Patient iscomfortable, nocyanosis barking coughOccasional Fever may ormay notoccur &may obstruction herald complete severe may stridor be airway Inspiratory voiceHoarse obstruction rapid toairway progression w/possible Dyspnea, coughBarking &improveOccurrence daytime during isusuallyat ofsymptoms night &w/abruptonset, syncytial Respiratory - Parainfl common) most 1being 1-3(type virus uenza - common ofcroup:Most causes disease concurrent w/coryzal Develops obstruction resp severe cause butmay possibly self-limiting Often Rarely occurs inadults inchildn tractobstruction resp ofupper cause Common

© MIMS may oxygen present obstruction resp normal w/nearly Patient saturation of severe symptoms with onoximetry 3 2 ALTERNATIVE DIAGNOSIS CLINICAL ASSESSMENT Croup (2of4) 1 1 CROUP A2 • • • • • • Failure Resp Impending • • • • • Severe Pallor, w/osupplemental O cyanosis Hypotonia consciousness Irrational behavior, of level decreased retractions wall Chest Audible at stridor rest coughBarking prominent) (may notbe rate respiratory increased/decreased markedly present, flaring tugtracheal & nasal retractions, wall chest Marked stridor) expiratory w/orw/o atProminent (inspiratory rest even stridor Persistent tachycardia &agitated restless exhausted, lethargic & Patient irritated, easily tired, appears Frequent barking cough 2 © MIMS 2019 CROUP • • • • (Nebulized) Corticosteroid • Dexamethasone • • • • • • (Systemic) Corticosteroid • • • • (Nebulized) Epinephrine • Oxygen erapy • • Helium-Oxygen (Heliox) Inhalation • • • Reassurance Parent/Guardian • • • Humidifi therapy cation - Budesonide may be mixed w/Epinephrine simultaneously &administered mixed may be Budesonide - onlyinpatients distress resp Indicated w/persistent vomiting&w/severe - length that ofadministration Not routinely cost, &anxiety toachild itcauses given duetoits Administration may more agitation cause tothe child w/croup whoare intolerant tochildn given diagnosed May toDexamethasone be Eg Budesonide fiRecommended rst-line corticosteroid therapy longhalf-life forcroup duetoits immune toachild defi given w/known Should not be orrecentciency varicella exposure additionalbenefi donotprovide Multiple doses asingledose t over Well-absorbed, relatively safe admission ofhospital risk &reduces Improves symptoms w/croup tochildn given diagnosed Should be Prednisolone Eg Dexamethasone, croup formoderate tosevere isindicated Epinephrine w/oralDexamethasone Nebulized patient administration ofEpinephrine 2hrafter Hold discharge forat least &observe noeff w/inmin butexerts symptoms Reduces 1hr beyond ect distress resp topatients given Should w/severe be supplementalProvide O in patients w/croup resistance inreducing ofairfl useful May be &turbulence,ow the thereby respiration work during decreasing the ofheliox toprove Further use inpatients w/croup studiesare needed issecure ofthe until oralcavity) the airway inspection ordirect position lineplacement, placingthe extraction,IV child (eginasupine maneuvers Avoid blood anxiety-provoking held &comforted Child shouldbe Actions are that appropriate issecure anxiety minimize until the airway Has not been proven to be aneff proven tobe notbeen Has treatment ective toreduce croup severity duetocroup forchildrenRecommended hospitalized secretions mist therapy, called Also humidifi uses air to &help thickeninged reduce mucosal of surface dryness © MIMS Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not 2 Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing if necessary ifnecessary A NON-PHARMACOLOGICAL THERAPY A PHARMACOLOGICAL THERAPY Croup (3of4) A3 © MIMS 2019 CROUP Prednisolone 1-2 mg/kg PO/IM as a as 1-2mg/kgPO/IM Prednisolone as 0.15-0.6mg/kgPO/IM Dexamethasone Budesonide (Adrenaline) Epinephrine Drug Drug Drug All dosage recommendations are for children w/ normal renal & hepatic function unless otherwise stated. otherwise unless function &hepatic renal w/ normal children for are recommendations dosage All Products listed above may not be mentioned in the disease management chart but have been been have but chart management disease the in mentioned be not may above listed Products placed here based on indications listed in regional manufacturers’ product information. product manufacturers’ regional in listed indications on based here placed © MIMS 5 mLof1:1,000soln L-Epinephrine water orsterile mL NS in3 0.5 mLof2.25%soln Epinephrine Racemic Nebulization: single dose a singledose apart 30min 1 mgx2doses or asingledose 2 mgas Nebulization: Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing Dosage Dosage Dosage Please see the end of this section for the reference list. reference the for section this of end the see Please CORTICOSTEROIDS (SYSTEMIC) CORTICOSTEROID (INHALED) ADRENERGIC AGONIST Dosage Guidelines Croup (4of4) • Instruction Special • Reactions Adverse • • Instructions Special • Reactions Adverse • • Instructions Special • Reactions Adverse A4 treatment w/Epinephrine 2hrsafter forat least Patient observed shouldbe Others (ocular eff diaphoresis) ects, eff Resp weakness); edema); pulmonary (dyspnea, ects Neuromuscular eff N/V); appetite, (tremor,ects GIeff insomnia); headache, of throat, loss (dry ects effCNS (anxiety, ects cerebral hemorrhage, dizziness, Should discontinue treatment gradually Take w/food eff (adrenal infection) suppression, ects (contactreaction Other anaphylaxis); dermatitis, Hypersensitivity skinirritation); dermatitis, rash, eff Dermatologic edema); (pulmonary (urticaria, ects eff Resp diarrhea); gain, pain,wt abdominal ect effCNS GIeff dizziness); (headache, ects (N/V,ects acuteasthma asthmaticus, treatment ofstatus in primary Contraindicated candidiasis oral treatment mouth after Rinse todecrease Otheranaphylaxis); (adrenal suppression) (contact reaction Hypersensitivity dermatitis, eff skinirritation); dermatitis, rash, (urticaria, ects Dermatologic inoropharynx); infection Candida throat cough, irritation, (rhinitis, hoarseness, eff Resp diarrhea); gain, pain,wt abdominal ects effCNS GIeff dizziness); (headache, ects (N/V,ects Remarks Remarks Remarks © MIMS 2019