General Measures

• Support by stabilizing airway, breathing, circulation (ABCs)
• Maintain airway
• Initiate IV, O₂, and monitor
• Rapid assessment of ABCs is essential with emphasis on airway control.
• Supplemental oxygen is usually needed.
• Anticipate and prepare for emergent endotracheal intubation and tracheostomy.
• Endoscopy with suctioning and debridement is often necessary for diagnosis and therapy.
• Subsequent airway suctioning and monitoring prevents adverse outcomes.
• Increased ventilatory support is often required for children with pre-existing artificial airways.

Diet
NPO until airway stabilized and patient is able to tolerate oral foods.

Nursing

• Suction secretions
• Monitor closely

Medication

Select antibiotic therapy based on gram stain and culture results of tracheal secretions. Also consider known prior colonization and institutional pathogens in children with pre-existing artificial airway and hospital-acquired infections.

• Mild illness:
  • Empiric therapy with amoxicillin–clavulanic acid or a 2nd-generation cephalosporin for 10–14 days (25–45 mg/kg per 24 hours depending on the antibiotic used)
  • Consider a semisynthetic penicillin such as dicloxacillin (15–25 mg/kg per 24 hours) if H. influenzae type B vaccine completed and clindamycin (10–30 mg/kg per 24 hours) if presence of a penicillin allergy
• Moderate to severe illness:
  • Empiric therapy with a 2nd- or 3rd-generation cephalosporin or with ampicillin–sulbactam
  • Consider vancomycin (40 mg/kg per 24 hours) if a hospital-acquired infection is present or if pneumococcal resistance is suspected.
• Anaerobic, pseudomonas, and other Gram-negative coverage should be considered in children not responding to initial therapy or having pre-existing artificial airways.
• In contrast to croup, nebulized racemic epinephrine does not provide significant relief.
• Duration: Based on clinical response; usually 10–14 days