CLINICAL PATHWAY VIRAL CROUP ALGORITHM: Outpatient/ED Management Inclusion Criteria Severity Assessment • Previously healthy • Age 6 months to 6 years Exclusion Criteria • Symptoms suggestive of an alternative diagnosis • Known upper airway abnormality Mild Severity Moderate Severe/Life-Threatening • Hypotonia or neuromuscular • Stridor only with activity/ • Inspiratory stridor at rest, • Biphasic stridor or absent due disorder agitation Biphasic with agitation to poor respiratory effort • Suprasternal retractions only • Intercostal AND suprasternal • Severe retractions • Normoxia, no tachypnea, no retractions (intercostal, nasal flaring) tachycardia • Normal saturation on room air, • Hypoxemia or cyanosis, • Normal mental status mild tachypnea, mild marked tachycardia or • Able to talk or feed tachycardia bradycardia • Agitated OR tired, low tone • Abnormal, confused, drowsy • Difficulty in talking / feeding • Unable to talk or feed ! Give Racemic Epinephrine Give Racemic Epinephrine Give Dexamethasone and and Consider other (if not previously given) Give Dexamethasone Give Dexamethasone diagnoses in children (if not previously given) (if not previously given) who appear toxic, have poor response to racemic ephinephrine, Initiate resuscitation and have high fever, or have Immediate Severity continue racemic every 20 a rapid decompensation Assessment minutes Admit to ICU Improved? ! Signs of Impeding Respiratory Failure No Yes • Poor respiratory effort • Stridor may be present or Observation for 3 hours with Consider repeat racepinephrine decreased • minimum Q1 hour assessment • Can be given Q2 hours Listless or decreased LOC • Cyanosis / Hypoxia Remains mild severity Admit Criteria Criteria for Transport • Patient with continued stridor at rest AND any symptoms listed in Patients being evaluated in an Discharge Criteria Worsens to moderate/severe the severity assessment above outpatient clinic or facility outside severity • Minimal stridor at rest(stridor • Patients receiving multiple CHCO/NOC who meet admission with activity to be expected) doses of racepinephrine criteria should be referred to the • Minimal retractions • Patients not otherwise CHCO ED. • Able to talk or feed without meeting discharge criteria difficulty Consider repeat racepinephrine • Consider ICU admission for poor Consider transporting by • 3 hours since racepinephrine response to racepinephrine or ambulance. toxic appearance Discharge Instructions Transport to Inpatient Return for increased work of breathing Management Page 1 of 12 CLINICAL PATHWAY ALGORITHM: Inpatient Management Not Routinely Recommended (No evidence supporting the use of) Inclusion Criteria Viral PCR •Previously healthy Radiographs Severity Assessment • Age 6 months to 6 years Repeat Dexamethasone Exclusion Criteria Cool Mist • Symptoms suggestive of an alternative diagnosis • Known upper airway abnormality • Hypotonia or neuromuscular Moderate Severe/Life-Threatening disorder • Inspiratory stridor at rest, • Mild Severity Biphasic stridor or absent due • Patient in PICU • Stridor only with activity/ Biphasic with agitation to poor respiratory effort agitation • Intercostal AND suprasternal • Severe retractions • Suprasternal retractions only retractions (intercostal, nasal flaring) • Normoxia, no tachypnea, no • Normal saturation on room air, • Hypoxemia or cyanosis, tachycardia mild tachypnea, mild marked tachycardia or • Normal mental status tachycardia bradycardia ! • Able to talk or feed • Agitated OR tired, low tone • Abnormal, confused, drowsy • Difficulty in talking / feeding • Unable to talk or feed Consider other diagnoses in children Give Racemic Epinephrine who appear toxic, Call code and continue have poor response Give Dexamethasone racemic every 20 minutes to racemic ephinephrine, Give Dexamethasone (if not previously given) have high fever, or have (if not previously given) a rapid decompensation Immediate Severity Assessment ! Signs of Impeding Respiratory Failure Observe Improved? • Poor respiratory effort • Stridor may be present or decreased • Listless or decreased LOC • Cyanosis / Hypoxia Evaluate criteria for No racemic epinephrine Yes Observation Observation Can give racemic ! Complete severity assessment Q4 hr Assess severity Q1 hr x 2 using epinephrine every 1 hour if until patient meets discharge criteria severity assessment MD at bedside and RRT Hypoxia is called uncommon Meets discharge criteria • Consider alternative diagnosis in Croup (see page 5 for differential • Discharge Criteria If patient worsens, consider diagnosis and Indicates severe disease, repeat racepinephrine recommendations) alternate diagnosis or lower • • Can be given Q2 hrs Minimal stridor at rest(stridor • Consider blood gas respiratory tract disease with activity to be expected) • Consider ICU transfer • Minimal retractions • Consider ENT consult • Able to talk or feed without Recommendations difficulty 1. Consider ENT consultation for direct laryngoscopy in • 3 hours since racepinephrine ≥3 doses racemic epinephrine patients with 2 or more episodes of croup AND one of the following: - history of intubation - age less than 36 months - prolonged severe disease requiring Discharge Instructions Consider further workup, inpatient management Return for increased work of and/or RRT evaluation 2. Consider evaluation for GERD and initiation of anti- breathing (see page 5 for differential reflux medications in patients with prolonged or diagnosis) recurrent coup 3. Consider evaluation and treatment for allergies Page 2 of 12 CLINICAL PATHWAY TABLE OF CONTENTS Algorithm: Outpatient/ED Management Algorithm: Inpatient Management Target Population Prevention Outpatient Telephone Triage Clinical Management Laboratory Studies | Imaging Therapeutics Disposition Follow-Up | Discharge Instructions Education Etiology of Croup References Clinical Improvement Team TARGET POPULATION Inclusion Criteria • First or repeat episode • Age 6 months to 6 years • Principle diagnoses: croup (laryngotracheitis) Exclusion Criteria • Suspicion of bacterial tracheitis, epiglottitis, upper-airway abscess (peritonsillar or retropharyngeal), or other serious bacterial infection • Severe or life-threatening disease requiring PICU admission • Chronic lung disease (bronchopulmonary dysplasia, cystic fibrosis, pulmonary artery hypertension) • Known upper airway abnormalities (for example: laryngomalacia, tracheomalacia, subglottic stenosis) • Recent airway instrumentation • Foreign body aspiration or ingestion • Neuromuscular disorder or hypotonia • Allergic reaction • Angioedema • Active varicella or tuberculosis (TB) • Congenital or acquired heart disease Page 3 of 12 CLINICAL PATHWAY PREVENTION • Droplet precautions for all care settings • Good hand washing • Protect high risk patients from exposure • Eliminate exposure to smoke OUTPATIENT TELEPHONE TRIAGE Stridor Has, but not now Has now • Trouble breathing • Struggling for breath • Croupy cough • Lip or face blue during • Passed out/stopped • Fever cough breathing • Post-tussive emesis • Retractions • Lips or face bluish • Had croup before that • Croup started after bee needed decadron sting, new medicine, • Under 1 year of age allergic food • Drooling/trouble swallowing See in office within 24 See in office or ED Call 911 hours now • Activate EMS (911): Severe difficulty breathing (struggling for breath, grunting noises with each breath, unable to speak or cry), blue lips or reduced level of consciousness. • ED visit (immediate): Underlying heart or lung disease, breathing heard across room, poor fluid intake, temperature greater than 105 F, excessive drooling, inability to lie flat without distress o Age less than 12 months, respiratory rate (RR) greater than 60, unable to sleep o Age greater than 12 months, RR greater than 40, difficulty breathing, not interactive • Office visit same day: Worsening cough, some difficulty breathing, poor fluid intake, chronic or underlying illness • Phone contact with primary care provider (PCP): barking cough, acting normally, good fluid intake CLINICAL MANAGEMENT Obtain History and perform physical exam Evaluate hydration status Distinguish croup from a more extensive or progressive process Evaluate patient using Croup severity assessment History: • Obtain past medical history \ birth (hospitalization, intubation/mechanical ventilation), sick contacts • Check immunization status: Haemophilus influenza type b (HIB), pneumococcal, tetanus. Important when considering epiglottitis or diphtherial croup • Obtain all pertinent patient history, including onset and duration of symptoms including croup prodrome (rhinorrhea, sore throat, low grade fever, cough) and timing of evidence of upper airway obstruction (hoarse voice, barking cough, audible stridor) and subglottic involvement (aphonia) Page 4 of 12 CLINICAL PATHWAY • Inquire regarding history of congenital or acquired heart disease, congenital or acquired subglottic stenosis, tracheomalacia, tracheal webs, choanal narrowing or atresia, micrognathia, macroglossia • Check current medications and time and dose of last antipyretic and recent steroid use. Clinical Symptoms of Croup: • Symptoms increase at night and improve during day o Hoarse voice o Barking cough (often described as a “barking seal”) o Stridor (variable, usually inspiratory) • Respiratory distress (variable): o Retractions (suprasternal, intercostal) o Tachypnea o Tachycardia Clinical Progress of Croup: Day 1 to 3 Rhinorrhea Day 3 to 7 Onset symptoms of upper airway inflammation Sore throat Hoarseness Low grade fever