What are the intensive care unit (ICU) management strategies for croup in pediatric patients (Pediatric Intensive Care Unit, PICU)?

From the Guidelines

Severe croup requiring PICU care should be managed with immediate respiratory support, including humidified oxygen to maintain saturation above 92% and consideration for intubation in cases of impending respiratory failure, as supported by the most recent guidelines and evidence 1.

Key Considerations

• Administer dexamethasone 0.6 mg/kg (maximum 16 mg) orally or intravenously as the first-line corticosteroid, with effects lasting 24-48 hours.
• For acute symptoms, nebulized epinephrine (racemic 2.25% solution 0.5 mL in 3 mL saline or L-epinephrine 1:1000 solution 5 mL) should be given, which provides temporary relief for 1-2 hours but may require repeated doses.
• Continuous cardiorespiratory monitoring is essential due to the risk of rebound symptoms after epinephrine wears off.
• Heliox (helium-oxygen mixture) may be considered for stridor not responding to standard treatments.
• Maintain the child in a calm environment with the parent present when possible, as agitation can worsen airway obstruction.
• Fluid management is important, with IV fluids often necessary if respiratory distress prevents adequate oral intake.

Evidence-Based Recommendations

The use of a clinical guideline and orderset to reduce hospital admissions for croup has been shown to be effective in reducing admissions and improving patient outcomes 1.

• The study period was divided into a 24 month baseline and a 12 month intervention period, with the primary outcome measures being percentage of patients admitted after an ED encounter for croup and percentage of patients with neck radiographs.
• The secondary outcome measure was average encounter hospital charges, and the process measure was admission rate among patients who received 2 or fewer RE doses before or during ED encounter.

Quality of Care

The guidelines and levels of care for pediatric intensive care units, as outlined in the study by Rosenberg et al. 1, emphasize the importance of providing high-quality care to critically ill children.

• The concept of level I and level II PICUs is continued, with level II PICUs being necessary to provide stabilization of critically ill children before transfer to another center or to avoid long-distance transfers for disorders of less complexity or lower acuity.
• The same standards of quality care should be applied to patients managed in level II PICUs and level I PICUs.

From the Research

Croup PICU Care

• Croup is a common childhood disease characterized by sudden onset of a distinctive barking cough, stridor, hoarse voice, and respiratory distress resulting from upper airway obstruction 2.
• The introduction of steroids in the treatment of croup has seen a significant reduction in hospital admissions and improved outcomes for children 2.
• In moderate to severe croup, treatment with corticosteroids and nebulised epinephrine (adrenaline) is required, but corticosteroids take time to achieve full effect and nebulised epinephrine may have dose-related adverse effects 3, 4.

Heliox for Croup

• Heliox, a mixture of helium and oxygen, may prevent morbidity and mortality in ventilated neonates by reducing the viscosity of the inhaled air 3, 5.
• There is some evidence to suggest a short-term benefit of heliox inhalation in children with moderate to severe croup who have been administered oral or intramuscular dexamethasone 3, 5.
• However, the effectiveness and safety of heliox remain uncertain due to limited evidence, and adequately powered RCTs comparing heliox with standard treatments are needed to further assess its role in the treatment of children with moderate to severe croup 3, 5.

Treatment Strategies

• A single dose of corticosteroids is the first-line treatment for croup, resulting in fewer return visits and hospital admissions, shorter lengths of stay in the emergency department (ED) or hospital, and less need for supplemental medication 4.
• Nebulized racemic or L-epinephrine reduces severity of symptoms in moderate-to-severe croup, but the role of heliox in moderate to severe croup remains uncertain 4.
• Humidified air provides no demonstrable benefit in the acute setting 4.

PICU Care

• In severe or life-threatening croup, treatment with adrenaline and immediate hospitalization via ambulance is required 2.
• The assessment of airway, breathing, and circulation, focusing on airway, is paramount in treating croup, and it is essential to take care not to cause the child undue distress 2.