Discharge
Instructions· Return for
increased
work of
breathing
Inclusion Criteria· Previously healthy children
· Age 6 months to 6 years
Exclusion Criteria· Toxic appearance
· Symptoms suggestive of an alternative
diagnosis
· Known upper airway abnormality
· Hypotonia or neuromuscular disorder
Off
Pathway
No
Croup v3.0: ED Management
Explanation of Evidence RatingsSummary of Version Changes
Give Dexamethasone
(if not previously given)· Dosage of 0.6mg/kg Dexamethasone
· Steroids are beneficial for all patients
with croup
Give Racemic Epinephrine · Racepinephrine 2.25% inhalation
solution (0.5 mL nebulized)
diluted in 3 mL NS
AND
Give Dexamethasone
(if not previously given)· Dosage of 0.6mg/kg Dexamethasone
Yes
Observation for 2 hr with minimum
Q1 hour assessments· Racepinephrine effect lasts only 2 hours
· If patient worsens, consider repeat
racepinephrine and admission
Improved
Assess immediate
clinical response
Consider
alternative
diagnosis or
ICU
admission
Not
improved
Meets
discharge
criteria
Evaluate
criteria for
racemic
epinephrine
Discharge Criteria· Minimal stridor at rest (stridor with
activity to be expected)
· Minimal retractions
· Able to talk or feed without
difficulty
· 2 hours since racepinephrine
Admit CriteriaPatients with continued stridor at
rest AND any symptoms listed in
the severity assessment above
Patients receiving 3 or more doses
of racepinephrine
Patients not otherwise meeting
discharge criteria
Severity Assessment
(moderate / severe distress)Stridor at rest AND
one or more of the following:
· Moderate intercostal retractions
(suprasternal retractions are acceptable)
· Tachypnea
· Agitation / restlessness / tired appearing
· Difficulty with talking or feeding
Discharge criteria
not met
Severity Assessment
(moderate / severe distress)Stridor at rest AND
one or more of the following:
Moderate intercostal retractions
(suprasternal retractions are acceptable)
Tachypnea
Agitation / restlessness / tired appearing
Difficulty with talking or feeding
!
Signs of
impending
respiratory failure
· Poor respiratory effort
· Stridor may be present or
decreased
· Listless or decreased LOC
· Cyanosis / Hypoxemia
Meets
discharge
criteria
Discharge criteria
not met
!Consider
BACTERIAL
TRACHEITIS
in children who
appear toxic or have poor
response to racepinephrine
Pathophysiology
Racemic Epinephrine
!For children
that are
not improving
with 3 doses of
racepinephrine,
consider further workup,
OTO consultation,
and/or evaluation for ICU
Last Updated: February 2019
Next Expected Review: August 2020
For questions concerning this pathway,
contact: [email protected]
© 2019 Seattle Children’s Hospital, all rights reserved, Medical Disclaimer
To Inpatient Management
Dexamethasone
Urgent Care Transfer Criteria Poor initial response to 1st
Racepinephrine
If 2nd Racepinephrine given
ALS recommended for all patients.
Can repeat Racepinephrine while
awaiting transportation if necessary.
Citation Information
Not Recommended
(No evidence supporting the use of)
Cool Mist
Viral PCRRadiographsRepeat Dexamethasone
Observation with Respiratory
Assessment Q1 hour· If worsening or not meeting discharge
criteria consider racepinephrine
Recommendations1. Consider OTO consultation/referral for direct
laryngoscopy in patients with 2 or more episodes
of croup and that have a history of intubation and
age less than 36 months or who have prolonged
severe disease requiring inpatient management.
2. Consider evaluation for GERD and initiation of
anti-reflux medications in patients with prolonged
or recurrent croup
3. Consider evaluation and treatment for allergies
Croup v3.0: Inpatient Management
Off
Pathway
No
Give Dexamethasone
(if not previously given)· Dosage of 0.6mg/kg Dexamethasone
· Steroids are beneficial for all patients
with croup
Give Racemic Epinephrine· Racepinephrine 2.25% inhalation
solution (0.5 mL nebulized)
diluted in 3 mL NS
· Can give
more than 1 additional dose on medical
unit requires MD evaluation
· Racepinephrine can be ordered by the
physician more frequently than Q2 hrs if
the patient is worsening and MD bedside
evaluation is in progress
Give Dexamethasone
(if not previously given)· Dosage of 0.6mg/kg Dexamethasone
Yes
Meets
Discharge
Criteria
Improved
Assess immediate
clinical response
Worsening
Discharge Criteria· Minimal stridor at rest (stridor with
activity to be expected)
· Minimal retractions
· Able to talk or feed without difficulty
· 2 hours since racepinephrine
· No supplemental oxygen for more
than 12 hours
Discharge
Instructions· Return for
increased work
of breathing
Severity Assessment
(moderate / severe distressStridor at rest AND
one or more of the following:
· Moderate intercostal retractions
(suprasternal retractions are acceptable)
· Tachypnea
· Agitation / restlessness / tired appearing
· Difficulty with talking or feeding
Observation· RN assess symptoms Q2
hr until patient meets
discharge criteria
· If patient worsens, consider
repeat racepinephrine
Observe
Severity Assessment
(moderate / severe distress)Stridor at rest AND
one or more of the following:
Moderate intercostal retractions
(suprasternal retractions are acceptable)
Tachypnea
Agitation / restlessness / tired appearing
Difficulty with talking or feedingClinical Assessment
IF 2 INPATIENT DOSES OF
RACEPINEPHRINE GIVEN
· Notify MD to evaluate patient
and consider RRT
· Consider alternative
diagnosis
· Consider blood gas
· Consider RRT (ICU
eval)
· Consider OTO
evaluation
ObservationRN assess symptoms
Q1 hr x 2 using severity
assessment
Improved
Evaluate
criteria for
racemic
epinephrine
Not
Improved
Inclusion Criteria· Previously healthy children
· Age 6 months to 6 years
Exclusion Criteria· Toxic appearance
· Symptoms suggestive of an alternative
diagnosis
· Known upper airway abnormality
· Hypotonia or neuromuscular disorder
!Signs of
impending
respiratory failure
· Poor respiratory effort
· Stridor may be present or
decreased
· Listless or decreased LOC
· Cyanosis / Hypoxemia
Racemic Epinephrine
racepinephrine Q2 hrs;
To ED Management
Dexamethasone
Recommendations1. Consider OTO consultation/referral for direct
laryngoscopy in patients with 2 or more episodes
of croup and that have a history of intubation and
age less than 36 months or who have prolonged
severe disease requiring inpatient management.
2. Consider evaluation for GERD and initiation of
anti-reflux medications in patients with prolonged
or recurrent croup
3. Consider evaluation and treatment for allergies
!Consider
BACTERIAL
TRACHEITIS
in children who
appear toxic or have poor
response to racepinephrine
!For children
that are
not improving
with 3 doses of
racepinephrine,
consider further workup,
OTO consultation,
and/or evaluation for ICU
Discharge CriteriaMinimal stridor at rest (stridor with
activity to be expected)
Minimal retractions
Able to talk or feed without difficulty
2 hours since racepinephrine
No supplemental oxygen for more
than 12 hours
Not Recommended
(No evidence supporting the use of)
Cool Mist
Viral PCRRadiographsRepeat Dexamethasone
Last Updated: February 2019
Next Expected Review: August 2020
For questions concerning this pathway,
contact: [email protected]
© 2019 Seattle Children’s Hospital, all rights reserved, Medical Disclaimer
Explanation of Evidence RatingsSummary of Version ChangesCitation Information
To ED ManagementTo Inpatient
Management
To ED ManagementTo Inpatient
Management
To ED ManagementTo Inpatient
Management
To ED ManagementTo Inpatient
Management
To ED ManagementTo Inpatient
Management
To ED ManagementTo Inpatient
Management
Dexamethasone
a
To ED ManagementTo Inpatient
Management
To Pg 2To Inpatient
Management
To Inpatient
ManagementPg 3
To Inpatient
Management
To Inpatient
Management
To Inpatient
Management
To ED ManagementTo Pg 2To Inpatient
Management
Back To ED ManagementTo Inpatient
Management
To ED ManagementTo Inpatient
Management
To ED ManagementTo Inpatient
Management
To ED Management
To Inpatient
Management
To ED ManagementTo Inpatient
Management
To ED ManagementTo Inpatient
Management
To ED ManagementTo Inpatient
Management
To ED ManagementTo Inpatient
Management
Return to Home
Croup Citation
Title: Croup Pathway
Date: August, 2015
Retrieval Website: http://www.seattlechildrens.org/pdf/croup-pathway.pdf
Example:
Seattle Children’s Hospital, Bishop J, Enriquez B, Allard, A, Beardsley E, Fenstermacher S, Klee K,
Leu MG, Ohare P, Popalisky, J, Tade A, 2015 August, Croup Pathway. Available from: http://
www.seattlechildrens.org/pdf/croup-pathway.pdf
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CSW Croup Team:
Pathway Owner, Inpatient Medicine Julianne Bishop, MDPathway Owner, ED/UC Pathway Owner Brianna Enriquez, MDED CNS Elaine Beardsley, MN
UC CNS Sara M. Fenstermacher, RN, MSN, CPNMedical Unit CNS Anjanette Allard, MN, RNPIT Pharmacist Rebecca Ford, Pharm DPharmacist Tracy Chen, Pharm D
Clinical Effectiveness Team:
Consultant: Jean Popalisky, DNPProject Leader: Pauline Ohare, MBA, RNCE Analyst: James Johnson CIS Informatician: Carlos Villavicencio, MDCIS Analyst: Yalda NettlesLibrarian: Jackie MortonProgram Coordinator: Ashlea Tade
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Medical Disclaimer
Medicine is an ever-changing science. As new research and clinical experience broaden our
knowledge, changes in treatment and drug therapy are required.
The authors have checked with sources believed to be reliable in their efforts to provide
information that is complete and generally in accord with the standards accepted at the time of
publication.
However, in view of the possibility of human error or changes in medical sciences, neither the
authors nor Seattle Children’s Healthcare System nor any other party who has been involved in
the preparation or publication of this work warrants that the information contained herein is in
every respect accurate or complete, and they are not responsible for any errors or omissions or
for the results obtained from the use of such information.
Readers should confirm the information contained herein with other sources and are
encouraged to consult with their health care provider before making any health care decision.
Return to Home
Summary of Version Changes
· Version 1.0 (12/19/2011): Go live
· Version 1.1 (05/31/2012): Updated Viral FA to Viral PCR. Correction to Alternative Diagnosis
slide: upset changed to onset
· Version 2.0 (08/19/2015): Scheduled review update (see executive summary for significant
changes)
· Version 3.0 (02/04/2019): Removed “ Patients receiving 2 doses of racepinephrine” from
admission criteria
Evidence RatingsEvidence Ratings
To Bibliography
This pathway was developed through local consensus based on published evidence and expert
opinion as part of Clinical Standard Work at Seattle Children’s. Pathway teams include
representatives from Medical, Subspecialty, and/or Surgical Services, Nursing, Pharmacy, Clinical
Effectiveness, and other services as appropriate.
When possible, we used the GRADE method of rating evidence quality. Evidence is first assessed
as to whether it is from randomized trial or cohort studies. The rating is then adjusted in the
following manner (from: Guyatt G et al. J Clin Epidemiol. 2011;4:383-94.):
Quality ratings are downgraded if studies:
· Have serious limitations
· Have inconsistent results
· If evidence does not directly address clinical questions
· If estimates are imprecise OR
· If it is felt that there is substantial publication bias
Quality ratings are upgraded if it is felt that:
· The effect size is large
· If studies are designed in a way that confounding would likely underreport the magnitude
of the effect OR
· If a dose-response gradient is evident
Guideline – Recommendation is from a published guideline that used methodology deemed
acceptable by the team.
Expert Opinion – Our expert opinion is based on available evidence that does not meet GRADE
criteria (for example, case-control studies).
Return to Home
Bibliography
Return to Home
Literature Search Strategy
Search Methods, Croup, Clinical Standard Work
Studies were identified by searching electronic databases using search strategies
developed and executed by a medical librarian, Jackie Morton. The searches for
croup and recurrent stridor were performed in February 2015 and the search for
tracheitis was performed in March 2015. The following databases were searched –
on the Ovid platform: Medline, Cochrane Database of Systematic Reviews;
elsewhere – Embase, Clinical Evidence, National Guideline Clearinghouse, TRIP and
Cincinnati Children’s Evidence-Based Care Guidelines. Clinical questions regarding
croup were searched from March 2012 to date or the closest date range available in
the respective databases. Clinical questions regarding recurrent stridor and tracheitis
were searched from 2005 to date.
Retrieval was limited to humans ages 0 – 12 and English language. In Medline and
Embase, appropriate Medical Subject Headings (MeSH) and Emtree headings were
used respectively, along with text words, and the search strategy was adapted for
other databases using their controlled vocabularies, where available, along with text
words. Concepts searched were croup, recurrent stridor or tracheitis. All retrieval
was further limited to certain evidence categories, such as relevant publication types,
Clinical Queries filters for diagnosis and therapy, index terms for study types and
other similar limits.
Jackie Morton, MLS
June 26, 2015Identification
Screening
Eligibility
Included
Flow diagram adapted from Moher D et al. BMJ
2009;339:bmj.b2535
93 records identified
through database searching
1 additional records identified
through other sources
94 records after duplicates removed
94 records screened 68 records excluded
26 records assessed for eligibility
17 studies included in pathway
9 full-text articles excluded,
4 did not answer clinical question
5 did not meet quality threshold
Bibliography
1. Bjornson C, Russell K, Vandermeer B, Klassen TP, Johnson DW. Nebulized epinephrine
for croup in children. Cochrane Database of Systematic Reviews. 2013; 10; CD006619
2. Chun R, Preciado DA, Zalzal GH, Shah RK. Utility of Bronchoscopy for Recurrent Croup.
Annals of Otology, Rhinology and Laryngology. 2009: 118(7): 495-9.
3. Cooper T, Kuruvilla G, Persad R, El-Hakim H. Atypical Croup: Association with Airway
Lesions, Atopy and Esophagitis. Otolaryngology—Head and Neck Surgery. 2012. 147(2): 209-
14.
4. Delany DR, Johnston DR. Role of Direct Laryngoscopy and Bronchoscopy in Recurrent
Croup. Otolaryngology—Head and Neck Surgery. 2015: 152(1) 159-64.
5. Dobrovoljac M, Geelhoed G. How fast does oral dexamethasone work in mild to
moderately severe croup? A randomized double-blinded clinical trial. Emergency Medicine
Australasia. 2012; 24; 79-85.
6. Garbutt J, Conlon, B, Sterkel R, Baty J, Schechtman K, Mandrell K, Leege E, Gentry S,
Stunk R. The comparative effectiveness of prednisolone and dexamethasone for children with
croup: A community-based randomized trial. Clinical Pediatrics 2013;52;11: 1014-21.
7. Hoa M, Kingsley EL, Coticchia JM. Correlating the Clinical Course of Recurrent Croup with
Endoscopic Findings: A Retrospective Observational Study. Annuals of Otolology , Rhinology
and Laryngology. 2008; 117 (6):464-9.
8. Hopkins A, Lahiri T, Salerno R, Heath B. Changing epidemiology of life-threatening upper
airway infections: The reemergence of bacterial tracheitis. Pediatrics 2006; 118;1418
9. Huang Y, Peng C, Chiu N, Lee K, Hung H, Kao H, Hsu C, Chang J, Huang F. Bacterial
tracheitis in pediatrics: 12 year experience at a medical center in Taiwan. Pediatrics International
2009;51; 110-113
10. Jabbour NP, Parker N, Finkelstein M, Lander TA, Sidman JD. Incidence of Operative
Endoscopy Findings in Recurrent Croup. Otolaryngology—Head and Neck Surgery. 2011 April;
144(4) 596-601.
Return to HomeTo Bibliography
11. Johnson DW. Croup. BMJ Clin Evid. 2014 Sep 29;2014
12. Kwong K, Hoa M, Coticchia JM. Recurrent Croup Presentation, Diagnosis and Management.
American Journal of Otolaryngology –Head and Neck Surgery. 2007; 28: 401-7.
13. Najada A, Dahabreh M. Bronchoscopy Findings in Children with Recurrent and Chronic
Stridor. Journal of Bronchology and Interventional Pulmonology. 2011; 18:42-7.
14. Miranda A, Valdez T, Pereira K. Bacterial tracheitis - a varied entity. Pediatric Emergency
Care 2011;27: 950-953.
15. Rankin I, Wang SM, Waters A, Clement WA, Kubba H. The Management of Recurrent Croup
in Children. The Journal of Laryngology and Otology. 2013; 127: 494-500.
16. Seattle Children’s Hospital, Bishop J, Beardsley E, Klee K, Leininger R, Leu MG, Tieder J.
2011 December. Croup Pathway.
17. Shargorodsky, Josef; “Bacterial Tracheitis: A Therapeutic Approach” Laryngoscope; 120;
December 2010; 2498-2501
18. Tebruegge, M. et al. “Bacterial Tracheitis: a Multi-Centre Perspective,” Scandinavian Journal
of Infectious Diseases, 2009; 41: 548-557
19. Tewary, K. et all “Bacterial tracheitis: When croup is not what it seems,” Emirates Medical
Journal; (2007); 25(1): 69-71
Bibliography
Return to HomeTo Bibliography
Guidelines and Reviews
Croup.(2008). CKS (Formerly PRODIGY)
Diagnosis and management of croup.(2008). Toward Optimized Practice
Bjornson, C., Russell, K.F., Vandermeer, B., Durec, T. Klassen, T.P., & Johnson, D.W. (2011). Nebulized
epinephrine for croup in Children. Cochrane Database of Systemic Reviews, 2, 006619.
Bjornson, CL et al. “Croup” Lancet. 2008. 371(9609) 329-339.
Johnson, et al. “Croup” Clinical Evidence. 2004; 12 401-426.
Mazza, D., Wilkinson, F., Turner, T., Harris, C., & Health for Kids Guideline Development Group. (2008). Evidence
based guideline for the management of croup. Australian Family Physician, 37(6 Spec No), 14-20.
Moore M, Little P. (2006) Humidified Air Inhalation for Treatment of Croup. Cochrane Database of Systematic
Reviews.
Russell KF, Liang Y, O’Gorman K, Johnson DW, Klassen TP. (2011) Glucocorticoids for croup. Cochrane
Database of Systematic Reviews, 1, 001955.
Wagner et al (1986) “Management of Children Hospitalized for laryngotracheobronchitis.” Pediatric Pulmonology
2(3), 159-162.
Westley CR, Cotton EK, Brooks JG. Nebulized racemic epinephrine by IPPB for the treatment of croup: a double
blind study. American Journal of Diseases of Children. 1978; 132: 484-87.
Bibliography
References from Pathway Version v.1.1:
Return to HomeTo Bibliography