What is the management of severe croup in an adult Intensive Care Unit (ICU)?

Management of Severe Croup in an Adult ICU

Severe croup in adults requires immediate airway stabilization with nebulized epinephrine, corticosteroids, and preparation for potential emergency intubation or front-of-neck airway access, as adult croup represents a critical airway emergency with significantly higher risk of complete obstruction than in pediatric cases.

Initial Assessment and Airway Evaluation

• Position the patient upright immediately to optimize respiratory mechanics and reduce work of breathing 1
• Assess for stridor at rest, paradoxical abdominal breathing, and signs of impending respiratory failure 2
• All adult ICU patients with severe croup must be considered at high risk for complicated intubation and should have the most experienced airway operator available 3
• Avoid agitating the patient, as distress increases oxygen consumption and may precipitate complete airway obstruction 4
• Establish reliable intravenous access immediately for rapid drug administration and potential fluid resuscitation 3

Immediate Medical Management

Pharmacological Interventions

• Administer nebulized epinephrine (4-5 mL of 1:1000 solution undiluted) immediately for severe respiratory distress with stridor 4, 5, 2
• The effect of nebulized epinephrine is short-lived (1-2 hours), requiring close monitoring for rebound symptoms 4, 6
• Give dexamethasone 0.6 mg/kg (or equivalent corticosteroid dose) immediately, regardless of severity 4, 7
• Multiple doses of nebulized epinephrine may be required; monitor for need for escalation to definitive airway management 4, 6

Oxygenation and Ventilatory Support

• Administer high-flow humidified oxygen to maintain SpO2 ≥94% 4, 6
• Consider heliox (helium-oxygen mixture) immediately if available, as it can provide rapid relief of stridor and reduce work of breathing 2
• Preoxygenation with CPAP may be beneficial if intubation becomes necessary, as it reduces myocardial depression and maintains left ventricular afterload 3

Preparation for Airway Crisis

Intubation Planning

• Assemble the most experienced airway team immediately, as adult croup represents a predicted difficult airway with high risk of "can't intubate, can't oxygenate" (CICO) scenario 3
• Prepare for potential front-of-neck airway (FONA) access with scalpel cricothyroidotomy equipment at bedside 3
• Consider smaller endotracheal tubes (6.0 mm inner diameter) for initial intubation to facilitate passage through narrowed subglottic space 3
• Have videolaryngoscopy immediately available, as it may improve first-pass success in difficult airways 3

Hemodynamic Optimization

• Assign a dedicated team member to monitor and manage hemodynamic status throughout airway management 3
• Administer 500 mL crystalloid bolus before intubation in absence of cardiac failure to mitigate hypotension risk 3
• Prepare vasopressors before induction, as ICU intubation carries up to 25% risk of severe hemodynamic instability 3
• Consider ketamine (1-2 mg/kg) as induction agent in hemodynamically unstable patients 3

Intubation Strategy

• Awake intubation is generally contraindicated in severe adult croup due to risk of precipitating complete airway obstruction, aspiration, and laryngospasm 3
• If intubation is required, use modified rapid sequence approach with optimal preoxygenation and peroxygenation techniques 3
• Limit laryngoscopy attempts to prevent worsening airway edema and trauma; failure of first-pass success dramatically increases complication rates including cardiac arrest 3
• If two intubation attempts fail, immediately transition to FONA via scalpel cricothyroidotomy rather than persisting with repeated attempts 3

Post-Intubation Care

• Confirm tube placement with waveform capnography immediately after intubation 3
• Obtain chest radiograph to verify tube position and rule out endobronchial intubation 3
• Monitor continuously for tube displacement or obstruction, as over 80% of ICU airway-related critical incidents occur after initial intubation 3
• Ensure multiprofessional team is aware of difficult airway status with bedhead signage and clear documentation 3
• Plan extubation strategy in advance, considering airway exchange catheter use and potential for reintubation difficulty 3

Critical Pitfalls to Avoid

• Do not delay definitive airway management if patient shows signs of fatigue or deteriorating mental status, as this indicates impending respiratory arrest 6
• Never perform blind finger sweeps if foreign body aspiration is in the differential, as this may worsen obstruction 4
• Do not rely on humidification therapy alone, as it has not been proven beneficial in croup management 7
• Avoid multiple intubation attempts by inexperienced operators, as each failed attempt increases risk of cardiac arrest from 2% to 12.5% after four attempts 3
• Do not discharge or downgrade monitoring for at least 2 hours after last epinephrine dose due to risk of rebound airway obstruction 4, 6

Special Considerations for Adults

• Adult croup is exceedingly rare and may indicate underlying pathology requiring investigation after acute stabilization 2
• Respiratory viral testing (including RSV) should be obtained but should not delay treatment 2
• Consider bacterial tracheitis in the differential diagnosis, particularly if patient appears toxic or fails to respond to standard therapy 4
• The subglottic narrowing in adults may be more severe relative to baseline airway diameter than in children, increasing obstruction risk 2