Pediatric Respiratory Distress (Croup)

Table of Contents

(Adapted from an evidence-based guideline created using the National Prehospital Evidence-Based Guideline Model Process)

Aliases

None noted

Patient Care Goals

  1. Alleviate respiratory distress
  2. Promptly identify respiratory distress, respiratory failure, and respiratory arrest, and intervene for patients who require escalation of therapy
  3. Deliver appropriate therapy by differentiating other causes of pediatric respiratory distress

Patient Presentation

Inclusion Criteria

Suspected croup (history of stridor or history of barky cough)

Exclusion Criteria            

  1. Presumed underlying cause that includes one of the following:
    1. Anaphylaxis
    2. Asthma
    3. Bronchiolitis (wheezing 2 yo)
    4. Foreign body aspiration
    5. Submersion/drowning
    6. Epiglottitis

Patient Management

Assessment

  1. History
    1. Onset of symptoms (history of choking)
    2. Concurrent symptoms (fever, cough, rhinorrhea, tongue/lip swelling, rash, labored breathing, foreign body aspiration)
    3. Sick contacts
    4. Treatments given
    5. Personal history of asthma, wheezing, or croup in past
  2. Exam
    1. Full set of vital signs (T, BP, RR, P, O2 sat)
    2. Presence of stridor at rest or when agitated
    3. Description of cough
    4. Other signs of distress (grunting, nasal flaring, retracting)
    5. Color (pallor, cyanosis, normal)
    6. Mental status (alert, tired, lethargic, unresponsive)

Treatment and Interventions

  1. Monitoring
    1. Pulse oximetry and end-tidal CO2(ETCO2) should be routinely used as an adjunct to other forms of respiratory monitoring
    2. Perform EKG only if there are no signs of clinical improvement after treating respiratory distress
  2. Airway
    1. Give supplemental oxygen. Escalate from a nasal cannula to a non-breather mask as needed, in order to maintain normal oxygenation
    2. Suction the nose and/or mouth (via bulb, Yankauer®, or suction catheter) if excessive secretions are present
  3. Inhaled Epinephrine should be administered to all children with croup in respiratory distress with signs of stridor at rest – this medication should be repeated at this dose with unlimited frequency for ongoing distress. Choose one of the following:
    1. Racemic Epinephrine: Nebulize 0.5 ml (11.25 mg) & 3 mL of Normal Saline together
    2. Cardiac Arrest Epinephrine: Nebulize 5 mL of 0.1 mg/mL (0.5 mg)
  4. Medications – dexamethasone 0.6 mg/kg oral, IV, or IM to maximum dose of 10 mg should be administered to patients with suspected croup
  5. Utility of IV placement and fluids – IVs should only be placed in children with respiratory distress for clinical concerns of dehydration, or when administering IV medications
  6. Improvement of oxygenation and/or respiratory distress with non-invasive airway adjuncts
    1. Bag-valve-mask ventilation should be utilized in children with respiratory failure
  7. Extraglottic devices and intubation – extraglottic devices and intubation should be utilized only if bag-valve-mask ventilation fails. The airway should be managed in the least invasive way possible

Notes – Pediatric Respiratory Distress (Croup)