5.3. RESPIRATORY DISTRESS SYNDROME IN CHILDREN (CROUP)

(Adapted from evidence-based guideline developed using the National Evidence-Based Guideline Development Process Model).

Related Names

None.

Purpose of assistance

1. Relieve respiratory distress.
2. Prompt detection of respiratory disorders, failure and/or stop, as well as manipulation in patients who need further EMF.
3. Conducting appropriate therapy by differentiating other causes of respiratory disorders in children.

Patient description

Inclusion criteria

Suspicion of croup (history of stridor or barking cough).

Exclusion criteria

It is considered the main cause, which includes one of the following:

1. Anaphylaxis.
2. Asthma.
3. Bronchiolitis (wheezing in children younger than 2 years).
4. Aspiration of a foreign object.
5. Immersion/drowning.
6. Epiglottitis.

Patient Management

Condition assessment

1. History:

a) onset of symptoms (history of dyspnea);
b) the presence of simultaneous symptoms (fever, cough, rhinorrhea, swelling of the lips/tongue, rash, difficulty breathing, aspiration of a foreign object);
c) contact with other patients;
d) treatment;
d) whether there is a history of asthma, croup or bronchiolitis.

2. Examination:

a) a full range of vital signs (Temperature, pulse, ND, AT, saturation);
b) presence of stridor at rest and during excitation;
c) description of cough;
d) other signs of respiratory failure (grunting, swelling of the wings of the nose, retraction);
d) skin color (pale, cyanotic, normal);
e) state of consciousness (conscious, flabby, drowsy, unconscious)

Treatment and intervention

1. Monitoring:

a) pulse oximetry and capnography should always be used as auxiliary means of monitoring breathing;
b) ECG only if there are no signs of clinical improvement after treatment of respiratory distress.

2. Respiratory tract:

a) perform oxygen therapy – start with the use of the nasal cannula and, if necessary, go to the usual mask and non-revertive mask to maintain the normal level of oxygenation;
b) perform nasal and/or oral sanitation (using a sanitation catheter) in the presence of excessive secretion.

3. Aerosol medications:

a) nebulizer epinephrine 5 ml 1 mg/ml (5 mg) in children with severe respiratory distress with signs of stridor in a patient at rest – this dose of the drug can be repeated many times in case of prolonged respiratory distress;
b) humidified oxygen or aerosol therapy is not indicated.

4. Drugs – dexamethasone 0.6 mg/kg orally, IV, IV; max. dose – 16 mg; should be administered for suspected croup.

5. Obtaining IV access and the use of liquids – the use of IV access for children with respiratory distress should occur only under conditions of signs of dehydration or the need for the introduction of drugs.

6. Improvement of oxygenation and/or respiratory distress by non-invasive methods:

a) therapy using an oxygen-helium mixture for croup can be used in the presence of respiratory distress, which is not alleviated after administering 2 doses of epinephrine;
b) in case of severe respiratory distress, it is necessary to use (if any) a PTPD fan;
c) ventilation through the AMBU bag should be used only in case of respiratory failure in a child.

7. Ultra-pharyngeal ducts and intubation should be used only if ventilation with an AMBU bag has not yielded results. Airway control should be provided in the least invasive way.

Patient safety

1. Routine use of light beacons, sirens is not recommended during transportation.
2. Patients receiving epinephrine in aerosol form should be taken to hospital.

Useful information for training

Key points

1. Upper airway obstruction may be accompanied by inspiratory, expiratory, or biphasic stridor.

2. Foreign bodies can create sounds inherent in breathing in the presence of croup, so it is important to find out if the child has previously choked on a foreign object.

3. The increase in respiratory failure is characterized by:

a) a change in mental status: fatigue and apathy;
b) pale skin;
c) tired appearance;
d) a decrease in retraction;
e) attenuation of respiratory noises and stridor.

4. In the absence of stridor or other signs of respiratory distress in the patient, aerosol drugs should not be used

Relevant evaluation results

1. Respiratory distress (chest wall retractions, whistling, stridor).
2. Reduced saturation.
3. Skin color.
4. Assessment of neurological condition.
5. Changes in breathing after treatment.
6. Improved oxygenation due to respiration.

Key elements of documentation

Document the main details of the review to check for changes after each intervention:

1. PD.
2. Saturation.
3. Participation of auxiliary muscles in the act of breathing.
4. Respiratory noises.
5. Laryngeal lumen.
6. State of consciousness.
7. Skin color.

Criteria for the effectiveness of care

1. Time of specific, according to the protocol, interventions.
2. Frequency of specific, per protocol interventions.