Acute obstructive laryngitis [croup], epiglottitis, post-intubation laryngeal edema: clinical guidelines

List of Abbreviations

No abbreviations were used in these clinical guidelines.

Terms and Definitions

New and narrowly focused professional terms are not used in these clinical guidelines.

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

Acute obstructive laryngitis (croup) — inflammation of the larynx and subglottic tissues accompanied by narrowing of the laryngeal lumen. Previously, the terms "stenosing laryngotracheitis" and "pseudocroup" were also used for this condition.

Epiglottitis is an acute bacterial inflammation of the epiglottis and surrounding tissues that can lead to rapid, life-threatening airway obstruction.

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

Acute obstructive laryngitis (croup).

The most common causative agents of acute obstructive laryngitis are respiratory viruses, with up to 80% of croup cases caused by parainfluenza virus [1]. Other pathogens include influenza A and B viruses, adenoviruses, respiratory syncytial virus, rhinoviruses, enteroviruses, bocavirus, coronavirus, and metapneumovirus. In extremely rare cases, croup may be caused by bacterial pathogens, such as Mycoplasma pneumoniae [2]. Several decades ago, the diphtheria bacillus (Corynebacterium diphtheriae) held a significant place in the etiological structure of obstructive laryngitis, but its role has drastically declined since the introduction of mass immunization against diphtheria.

Postintubation (post-extubation) laryngeal edema.

One of the causes of obstructive laryngitis is endotracheal intubation, during which laryngeal injury frequently occurs due to the pressure of the endotracheal tube. This manifests as varying degrees of edema, ulceration, granulation, and restricted vocal cord mobility, leading to luminal narrowing within the first 24 hours after extubation.

Postintubation laryngeal edema requires reintubation in half of patients, which is associated with a high mortality rate. Therefore, predicting and treating postintubation laryngeal edema is a critical component of managing intubated patients.

Epiglottitis.

The etiologic factor of epiglottitis in the vast majority of cases is Haemophilus influenzae type b (>90%). In countries where mass immunization against Haemophilus influenzae infection has been introduced, epiglottitis is rare in vaccinated children and may be caused by other etiologic agents [3]. In rare cases, epiglottitis can be caused by Streptococcus pneumoniae, groups A and C streptococci, Staphylococcus aureus, Moraxella catarrhalis, Haemophilus parainfluenzae, Neisseria meningitidis, etc.

Currently, in countries with mass immunization against Haemophilus influenzae infection, epiglottitis caused by this pathogen is more common in adults [4].

1.3 Epidemiology of the Disease or Condition

Croup is the most common cause of acute upper airway obstruction in children aged 6 months to 6 years. Obstructive laryngitis accounts for up to 6% of annual pediatric and emergency department visits [5]. It is usually a self-limiting acute condition, with symptom resolution occurring within 48 hours of initiating adequate therapy in 60% of cases; however, approximately 5% of children with croup require hospital admission, and 1–3% of those hospitalized may require mechanical ventilation [5, 6].

Epiglottitis is a rare disease predominantly affecting children, but it also occurs in adult patients (more commonly in the elderly). The incidence of epiglottitis has declined significantly in many countries following the introduction of mass immunization against Haemophilus influenzae type b infection. Prior to mass vaccination, the annual incidence ranged from 3 to 5 per 100,000 children under 5 years of age [1, 7].

According to research data, postintubation laryngeal edema occurs in 5% to 54% of the adult population [8, 9]. The direct development of stridor has been noted in 1.5–26.3% of patients [9], and the need for reintubation ranges from 1.8 to 31.4% [10]. This variance is due to differences in definitions, diagnostic criteria, and methods used for detection.

In studies conducted on pediatric patient populations, the incidence of post-extubation stridor ranged from 2% to 42% [11, 12, 13, 14]. According to other authors, the incidence of post-extubation stridor in children varies from 1.6 to 6% [15]. The peak incidence occurs between 1 and 4 years of age [16].

1.4 Features of Coding the Disease or Condition

Acute obstructive laryngitis [croup] and epiglottitis (J05)

J05.0 – Acute obstructive laryngitis [croup]

J05.1 – Acute epiglottitis

J38.4 – Edema of larynx

J38.6 – Stenosis of larynx

1.5 Classification of the disease or condition

In Russia, the classification of acute obstructive laryngitis by the degree of laryngeal stenosis is widely accepted (Table 1)

Table 1 – Degrees of laryngeal stenosis (according to V.F. Undrits, 1969)

In foreign countries, the croup severity classification is also widely used (Table 2) [17].

Table 2.

The degree of laryngeal stenosis – croup severity – can also be assessed using the Westley score (Appendix G1).

Currently, this scale has many modifications.

1.6 Clinical presentation of the disease or condition

Acute obstructive laryngitis (croup) typically begins with nonspecific symptoms of an acute respiratory viral infection:

o rhinorrhea, sore throat, and cough appear.

o It most commonly occurs against the background of a low-grade fever, and rarely with febrile fever.

o As a rule, symptoms of laryngeal stenosis are preceded by signs of laryngitis: hoarseness of voice and/or dry, harsh cough. As the inflammatory process in the larynx progresses, hoarseness may increase, the cough becomes barking, and noisy breathing or noisy inspiration (stridor) appears. With increasing severity of laryngeal stenosis, inspiratory dyspnea develops, which can be identified by the retraction of the jugular notch on inspiration.

o Symptoms of obstructive laryngitis usually develop in the evening, at night, and frequently in the early morning hours.

§ First-degree laryngeal stenosis is accompanied by intermittent harsh, barking cough and hoarseness; stridor is absent at rest and increases only with child agitation or physical exertion. Mild retraction of the supraclavicular fossae and intercostal spaces during breathing may be present.

§ Second-degree laryngeal stenosis is characterized by an increased frequency of barking cough, stridulous breathing persists even at rest, and pronounced retraction of compliant chest areas during breathing at rest is observed.

§ Third-degree laryngeal stenosis presents with symptoms of severe respiratory failure, accompanied by marked anxiety or depressed consciousness. At this stage of the disease, the child requires emergency care.

§ Fourth-degree laryngeal stenosis (terminal stage, asphyxia) – unconsciousness, severe pallor and cyanosis, hypothermia, possible convulsions, mydriasis, rapid, shallow breathing, arterial hypotension, thready pulse. This stage precedes respiratory and cardiac arrest

In clinical practice, more than 2/3 of patients present with signs of first-degree laryngeal stenosis, while severe laryngeal stenosis develops in less than 1% of children [5, 18]. Croup symptoms typically resolve within 48 hours; however, severe infections, though rarely, can cause respiratory impairment up to arrest [17, 19].

In post-intubation laryngeal edema the pathological process (edema) begins shortly after intubation, however, symptoms appear only after the removal of the endotracheal tube. Most patients with post-intubation laryngeal edema report mild symptoms such as sore throat, dysphonia, and difficulty swallowing. The onset of stridor indicates clinically significant upper airway obstruction. Stridor and respiratory failure occur when more than half of the airway lumen is obstructed [20]. As mentioned previously, the clinical picture of laryngeal edema may manifest within the first minutes to hours after extubation; however, cases of laryngeal edema requiring re-intubation 48–72 hours after endotracheal tube removal have been described [8, 21]. On average, symptoms resolve within 72 hours.

The symptoms of clinically significant post-extubation laryngeal edema do not differ from those of croup: retraction of compliant areas of the chest wall, inspiratory dyspnea, and noisy stridorous breathing.

There are risk factors for the development of clinically significant post-intubation laryngeal edema [8, 22, 23, 24] (see Appendix A3.3).

According to accumulated data, at least in children, there is no upper safe limit for the duration of intubation [25].

In most patients, symptoms resolve spontaneously within 24–48 hours.

Epiglottitis is a severe bacterial infection,

o The disease typically begins acutely with high fever and impaired general condition.

o Sore throat, trismus, drooling, tripod posture, and an open mouth are characteristic.

o Rapid development of stridor and posterior displacement of the epiglottis in the supine position.

o The barking cough typical of croup is absent.

2. Diagnostics, medical indications and contraindications for diagnostic methods

Diagnostic criteria:

The diagnosis of acute obstructive laryngitis (croup) is clinical and is generally made based on the medical history and symptoms of hoarseness, barking cough, and inspiratory stridor.

Epiglottitis is diagnosed based on characteristic clinical signs:

• The disease typically begins acutely with high fever and impaired general condition.

• Sore throat, trismus, drooling, tripod posture, and an open mouth are characteristic.

• Rapid development of stridor and posterior displacement of the epiglottis in the supine position.

• The barking cough typical of croup is absent.

It should be remembered that examination of the oropharynx in a child with suspected epiglottitis is performed only in an operating room setting with full preparation for tracheal intubation due to the high probability of reflex laryngeal muscle spasm and subsequent asphyxia.

Post-intubation laryngeal edema is diagnosed based on such symptoms as sore throat, dysphonia, and difficulty swallowing. The onset of stridor indicates clinically significant upper airway obstruction. Stridor and respiratory failure occur when more than half of the lumen is obstructed. Symptoms of post-intubation laryngeal edema may appear within the first minutes or hours after extubation, and less commonly – 48–72 hours after endotracheal tube removal.

Diagnosis is primarily clinical, optionally utilizing instrumental methods: laryngeal ultrasound in intubated patients, and in adults, additionally performing a cuff leak test.

2.1 Complaints and Anamnesis

See section 1.6 "Clinical Presentation"

In croup and epiglottitis, it is also necessary to clarify the vaccination history regarding Haemophilus influenzae type b, Streptococcus pneumoniae, and diphtheria.

2.2 Physical Examination

The diagnosis of acute obstructive laryngitis (croup) is clinical and is generally made based on the medical history and symptoms of hoarseness, barking cough, and inspiratory stridor.

• During the examination, attention should be paid to signs of respiratory distress:

  • cyanosis,

  • use of accessory muscles in breathing,

  • retractions of the jugular notch and intercostal spaces during respiration,

  • assessment of the respiratory rate,

  • measurement of oxygen saturation levels.

• Auscultation is used to determine the type of dyspnea (obstructive laryngitis is characterized by inspiratory dyspnea; expiratory or mixed dyspnea may be observed with concomitant bronchial obstruction, and mixed dyspnea may also occur in severe upper airway obstruction secondary to severe croup).

Epiglottitis is diagnosed based on characteristic clinical features (see the "Clinical Presentation" section).

It should be remembered that examination of the oropharynx in a child with suspected epiglottitis is performed only in an operating room setting with full preparation for tracheal intubation due to the high probability of reflex laryngeal muscle spasm and subsequent asphyxia [26].

2.3 Laboratory Diagnostics

• Since acute obstructive laryngitis (croup) is predominantly a viral disease, laboratory tests (complete blood count with differential), and if necessary (in doubtful cases) serum C-reactive protein measurement, are recommended only when the child has a high fever and there is a need to rule out bacterial infection [1, 2, 5, 19, 27, 28].

(Recommendation grade C; level of evidence - 5).

Comment: in an inpatient setting, a complete blood count with differential is performed for all patients; serum C-reactive protein measurement is optional.

• All patients with suspected epiglottitis and high fever are recommended to undergo a complete blood count with differential, and if necessary (in doubtful cases), serum C-reactive protein measurement to assess the inflammatory response [3, 7].

(Recommendation grade C; level of evidence - 5).

Comment: Epiglottitis, unlike croup, is a severe bacterial infection accompanied by pronounced leukocytosis (>15×10⁹/L) and elevated C-reactive protein levels.

At the same time, given the high probability of reflex laryngospasm if the child is agitated, laboratory tests are recommended to be performed only after the physician is certain it is safe for the patient (in some cases, only after tracheal intubation).

(Recommendation grade C; level of evidence - 5).

Comments: blood and epiglottic cultures are obtained after the airway has been secured. Epiglottic swabbing is potentially dangerous and contraindicated in non-intubated patients.

2.4 Instrumental Diagnostics

(Recommendation grade C; level of evidence - 5).

(Recommendation grade C; level of evidence - 5).

(Recommendation grade C; level of evidence - 4).

Comment: in the absence of relevant comorbidities or the need for differential diagnosis, it is not required. It must be remembered that any diagnostic procedure in patients with suspected epiglottitis may lead to airway obstruction.

(Recommendation grade C; level of evidence - 4).

Comment: Laryngeal ultrasound is a fast and non-invasive procedure that allows measuring the air column width (ACW) – the width of the acoustic shadow at the level of the vocal cords before and after cuff deflation in intubated patients. As shown in studies in adult patients [35, 36], a decrease in ACW and ACWD (the difference in air column width before and after deflation of the endotracheal tube cuff) was a predictor of post-extubation stridor in patients. However, there are currently no clinical studies to make a definitive conclusion about the accuracy of this diagnostic method for identifying predictors of laryngeal edema.

Studies on the feasibility of using laryngeal ultrasound by measuring the air column width difference in children have shown that this technique can serve as a simple, reliable, and non-invasive method for predicting post-extubation edema [37].

To assess upper airway patency when resources are available in a medical organization, fiberoptic laryngoscopy may be performed in patients with risk factors for post-extubation stridor to evaluate upper airway patency before extubation [8, 25]. This primarily applies to patients with difficult tracheal intubation or those who developed post-extubation stridor/dysphonia 48–72 hours later.

Fiberoptic laryngoscopy allows for the assessment of structural or functional changes of the larynx, such as edema and laryngospasm, which helps determine the management strategy. The limitation of this method is the inability to visualize the subglottic space. It should be kept in mind that stenoses are usually subglottic and are not visualized during laryngoscopy/fiberoptic laryngoscopy.

2.5 Other Procedures

(Recommendation grade C; level of evidence - 4).

Comment: is a simple test demonstrating air leakage around the endotracheal tube with a deflated cuff, providing insight into upper airway patency. It is widely used to predict the occurrence of post-extubation stridor in adults. A consensus document adopted by the American Thoracic Society recommends performing an air leak test in patients at risk for post-extubation laryngeal edema [38].

However, its positive predictive value in children remains low with contradictory results [39, 40], and therefore it has not yet become widespread in pediatric practice.

Differential diagnosis

• It is recommended to differentiate croup and epiglottitis from each other and from other conditions accompanied by upper airway stenosis or obstruction in order to establish a diagnosis and prescribe adequate therapy [27, 34, 41, 42, 43].

(Recommendation grade C; level of evidence - 5).

Comments: primarily from epiglottitis, which still occurs in the absence of mass vaccination against Haemophilus influenzae type b. Unlike viral croup, epiglottitis is not characterized by catarrhal symptoms, cough, and hoarseness.

Also, during the history taking, attention should be paid to the presence of atopy in the child, a history of bronchial obstruction or laryngeal stenosis episodes, as well as symptoms indicating the possibility of gastroesophageal reflux, since laryngeal stenosis may be associated with allergen exposure or caused by gastroesophageal reflux. Conditions requiring differential diagnosis with acute obstructive laryngitis (croup) are presented in Table 3 [41].

The main differential diagnostic features of croup and epiglottitis are given in Appendix A3.2.

- Laryngospasm

- Angioedema, anaphylaxis

- Airway foreign body

- Postoperative hematomas causing airway compression

- Vocal cord paresis after neck surgery

- Sleep apnea [8].

(Recommendation grade C; level of evidence - 5).

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

3.1 Conservative Treatment

3.1.1 Conservative treatment of acute obstructive laryngitis (croup)

• Antibacterial therapy is not recommended for croup as it is ineffective [28, 44].

(Level of Recommendation A; Level of Evidence - 1).

• For croup of influenza etiology, selective use of neuraminidase inhibitors is recommended (e.g., Oseltamivir** from 1 year of age, Zanamivir from 5 years of age) [45, 46].

(Level of Recommendation A; Level of Evidence - 1).

Comments: etiotropic antiviral agents (J05A Direct-acting antivirals) highly active against most viruses causing croup do not exist. Neuraminidase inhibitors may be used for influenza.

• Steam inhalations previously used are not recommended as controlled studies have shown low efficacy [47, 48, 49].

(Level of Recommendation B; Level of Evidence - 1).

• For the treatment of croup, the use of glucocorticoids (for inhalation use) and/or systemic corticosteroids (#Dexamethasone**, #Prednisolone**) is recommended for all patients [42, 50, 51, 52].

(Level of Recommendation A; Level of Evidence - 1).

Comments: In most cases, a single dose of systemic corticosteroids is sufficient to relieve the symptoms of acute obstructive laryngitis. For children over 3 years of age, oral administration of systemic corticosteroids is preferred. Oral administration is as effective as parenteral administration.

#Dexamethasone^** 0.15–0.6 mg/kg is administered intramuscularly (or intravenously) to all patients regardless of the degree of stenosis. For oral administration, a dose of 0.15 mg/kg is preferred.

If #Dexamethasone** is unavailable, the patient may be prescribed #Prednisolone** at an equivalent dose (1 or 2 mg/kg of #Prednisolone** corresponds to 0.15 and 0.6 mg/kg of #Dexamethasone**) [52], however, with similar efficacy, especially in mild and moderate croup, the risk of recurrence of croup symptoms is higher after #prednisolone** therapy, which may require re-administration of the drug [51]

Re-administration of systemic corticosteroids to children with obstructive laryngitis is not required in most cases [5, 17, 50].

According to some studies, systemic corticosteroid therapy is more effective than inhalation therapy. The inhalation route of administration may be less effective due to patient anxiety during the procedure.

For the relief of croup, inhalation of Budesonide** suspension via a compressor nebulizer or mesh nebulizer – an inhalation device with a medication reservoir and aerosol generator (mesh) (e.g., Velox inhalation device type 055 with accessories) at a dose of 2 mg per day is effective. The dose of the drug can be inhaled at once (single dose) or divided into two inhalations of 1 mg with an interval of 30 minutes. In 85% of cases (usually with grade 1 laryngeal stenosis), a single procedure is sufficient. If necessary, inhalations can be repeated according to the instructions.

(Level of Recommendation A; Level of Evidence - 2).

Comments: for #Dexamethasone** doses, see above

• In severe croup or in the absence of glucocorticoids (ATX group – R03BA) / systemic corticosteroids (ATX group – H02AB) (for inhalation use or systemic), selective use of inhalation with #Epinephrine^** is recommended [6].

(Level of Recommendation A; Level of Evidence - 1).

Comments: #Epinephrine** 1:1000 solution may be used to treat croup syndrome. 5 ml of the 1:1000 solution is used per inhalation, regardless of the child's age and physical parameters [54]. Studies on the necessity of repeated inhalations with #epinephrine** and their efficacy have not been conducted [55]. It should be borne in mind that #epinephrine** has a rapid but short-lived effect (on average, no more than 2 hours), and therefore it should not be used as monotherapy for acute obstructive laryngitis [6]. The use of #epinephrine** in children in the Russian Federation is considered off-label—in accordance with indications (characteristics) not specified in its instructions for use (off-label), and is carried out by decision of a medical commission provided that informed voluntary consent has been signed (pursuant to Federal Law No. 323-FZ of November 21, 2011, as amended). In addition, the efficacy and safety of #epinephrine** manufactured in the Russian Federation for croup in children has not been studied. There is data confirming the efficacy of lower doses (below 0.5 mg/kg) [56].

• If blood oxygen saturation drops to 92% or lower, oxygen therapy is recommended to correct hypoxemia [2, 42].

(Recommendation grade C; level of evidence - 5).

• In grade 4 laryngeal stenosis, emergency intubation is recommended to secure respiratory function [5, 17, 28].

(Recommendation grade C; level of evidence - 4).

Comments: consider intubation in grade 3 laryngeal stenosis

3.1.2 Conservative treatment of epiglottitis

(Recommendation grade C; level of evidence - 5).

(Recommendation grade C; level of evidence - 4).

Comments: extubation is safe after normalization of temperature, clearing of consciousness, and subsiding of symptoms, usually after 24-48 hours. Epiglottitis is often accompanied by bacteremia, which increases the duration of treatment;

In rare cases of mild epiglottitis, endotracheal intubation may not be indicated [27].

• In epiglottitis, it is strongly not recommended to perform inhalations, use hypnotics and sedatives, or provoke anxiety, in order to prevent the development of reflex laryngospasm [7, 26, 42, 43, 61].

(Recommendation grade C; level of evidence - 5).

• Systemic antibacterial therapy is mandatory and recommended for pathogen eradication (dosages are specified in the comments) [7, 26, 42, 43, 58, 60, 62].

(Recommendation grade C; level of evidence - 5).

Comments: for example, intravenous Cefotaxime^** in accordance with the drug instructions or Ceftriaxone^** at the dosage per instructions (children from 15 days to 12 years old) 20-80 mg/kg/day, with the most justified dose considered to be 75 mg/kg/day; for children weighing over 50 kg and older than 12 years, adult dosages are used (according to foreign publications, Ceftriaxone** dosages in children with epiglottitis range from 50-100 mg/kg/day) [7, 26, 42, 43, 60, 63] as monotherapy or in combination with antistaphylococcal drugs (e.g., #Vancomycin** at a dose of 40 mg/kg/day) [64, 65].

If therapy is ineffective (in suspected or confirmed S. aureus infection!), intravenous Clindamycin^** at a dose of 30 mg/kg/day (according to the instructions—for children aged 3 years and older) or Vancomycin^** at a dose of 40 mg/kg/day [65]

For adult patients—the same drugs in accordance with the instructions for use (Vancomycin** at an average dose of 40 mg/kg/day (where possible—dose adjustment based on therapeutic drug monitoring results) [65].

The duration of antibacterial therapy should be 7-10 days. Treatment is usually initiated with parenteral (intravenous) administration of a systemic antibacterial drug, and after fever subsides, the condition normalizes, and oral fluid intake is restored, treatment is continued with oral antibacterial medications. Considering that Haemophilus influenzae is the predominant causative agent of epiglottitis, as well as data on its resistance to antibacterial drugs obtained in the Russian multicenter study "PeGАС 2014-2017" [66, 67], beta-lactam antibacterial drugs remain the drugs of choice for oral administration: Penicillins (J01CR Combinations of penicillins, including beta-lactamase inhibitor combinations)—Amoxicillin + clavulanate** and second- or third-generation cephalosporins—Cefuroxime**, etc.

Evidence of the clinical efficacy of macrolides in respiratory infections caused by Haemophilus influenzae is contradictory, therefore these drugs should not be used for epiglottitis.

• If blood oxygen saturation drops below 92%, oxygen therapy is recommended to correct hypoxemia [42, 61, 68].

(Recommendation grade C; level of evidence - 5).

3.1.3 Conservative treatment of post-extubation edema

(Recommendation grade C; level of evidence - 5).

Comment: systemic glucocorticoids are the drug of choice for treating post-extubation laryngeal edema in both adults and children. Dexamethasone** is most commonly administered (see doses below), less frequently methylprednisolone** or prednisolone**.

The drug is administered intravenously. There is no unified approach to the doses used and the administration regimen in either adult or pediatric practice.

A single dose of dexamethasone** for the treatment of laryngeal edema in adults is 5 mg; methylprednisolone**, 20-40 mg [8, 71].

Dexamethasone** doses in children are still debated; on average, 0.6 mg/kg/day is used, with variations upward or downward. Similarly, #prednisolone**—on average, 1 mg/kg/day, with doses lower than 1 mg/kg/day or, conversely, higher doses up to 2 mg/kg/day being possible [25, 72].

The minimum duration of treatment for post-extubation laryngeal edema is at least 48 hours [69, 71].

• In addition to intravenous administration of systemic glucocorticoids, the selective use of the following drugs is recommended in patients with post-extubation laryngeal edema to relieve this condition:

- #epinephrine* inhalations at a dose of 1000 mcg / 5 ml of 0.9% sodium chloride solution in adults [8, 71, 73].

And #epinephrine** for children—1% solution 0.25 ml in 2 ml of 0.9% sodium chloride** (by inhalation) [73] or 0.5 ml or 2.5 ml, up to a maximum of 5 ml of #epinephrine** [74].

(Recommendation grade C; level of evidence 4).

- Inhalations of nebulized #budesonide: The dose in adults is 1000 mcg every 12 hours [9, 73, 74].

(Recommendation grade A; level of evidence 3).

The dose for children is 1000 mcg x 2 times a day [73].

(Recommendation grade A; level of evidence 3).

Comment: It is important to emphasize the possibility of using lower doses of #epinephrine**, given the fact that extubation eliminates the factors causing edema, which does not occur in acute respiratory infections.

(Recommendation grade C; level of evidence - 5).

(Recommendation grade C; level of evidence - 5).

Comment: There is no unified approach regarding the time interval between prophylactic administration of systemic glucocorticoid and extubation. Thus, the American Thoracic Society consensus document [38] and other researchers [71] recommend administering systemic glucocorticoids to at-risk adult patients with a negative endotracheal tube cuff leak test at least 4 hours (according to other authors, 6-12 hours [22]) prior to extubation.

3.1.4 Conservative treatment of laryngeal stenosis due to edema

Comments: for destenosing therapy, parenteral administration of glucocorticoids (ATC H02AB Glucocorticoids) and "loop" diuretics (ATC C03C) is advisable [77, 78, 79]

3.3 Surgical Treatment

Not required in uncomplicated cases of croup and epiglottitis.

(Recommendation grade C; level of evidence - 5).

4. Medical Rehabilitation and Sanatorium-Resort Treatment

Not required

5. Prevention and Dispensary Observation

5.1 Prevention of acute obstructive laryngitis (croup)

(Level of Recommendation C; Level of Evidence - 2).

Comment: non-specific prophylaxis prevents the spread of respiratory viruses, which may help reduce the incidence of croup.

(Recommendation grade C; level of evidence - 5).

Comments: there are no studies indicating a likely reduction in the frequency of croup in children vaccinated against influenza; however, since croup can develop against the background of influenza, vaccination will have a positive effect in terms of preventing croup caused by influenza viruses.

5.2 Prevention of epiglottitis

(Recommendation grade C; level of evidence - 5).

Dispenser surveillance (clinical observation) for croup and epiglottitis is not required.

5.3 Prevention of post-intubation laryngeal edema

(Level of Recommendation A; Level of Evidence - 1).

Comments: administration of systemic glucocorticoids 12–24 hours before extubation is considered most effective [72], followed by the administration of these drugs as indicated for 24–48 hours after extubation.

(Level of Recommendation A; Level of Evidence - 1), - in premature newborns – 0.25 mg/kg – 4 doses at 6-hour intervals [87]

(Level of Recommendation A; Level of Evidence - 2).

Comments: a meta-analysis conducted by Iyer NP et al. [88] showed that early (12 hours before extubation) administration of high-dose #dexamethasone** (0.5 mg/kg/dose) is the most effective strategy for preventing both post-extubation laryngeal edema and reintubation; in addition, early administration of #dexamethasone** (at least 6-12 hours before extubation) may be more important than the dose administered.

Given the individual characteristics of patients, the decision to use a specific #dexamethasone** administration strategy must be personalized, taking into account the risk of post-extubation laryngeal edema, risk factors for extubation failure (including respiratory muscle weakness), potential side effects (including gastrointestinal bleeding and arterial hypertension), and the time available before planned extubation [88].

6. Organization of Medical Care

6.1 Organization of medical care for acute obstructive laryngitis [croup]

Patients with obstructive laryngitis [croup] may receive medical care of any type, conditions, and forms provided for by the legislation of the Russian Federation, as needed. Children with obstructive laryngitis [croup] and a Westly score of 1–2 generally do not require hospitalization [89].

Achieving an effect from inhalation of Budesonide** or injection of #Dexamethasone** (#Prednisolone**) at home or in an outpatient setting makes it possible to avoid hospitalization, as repeated intensification of stenosis occurs extremely rarely [43].

Hospitalization is carried out in an infectious diseases hospital or a boxed ward. Inpatient care for a patient with croup is provided by a pediatrician or an infectious disease physician, if necessary – by an otolaryngologist, and in the case of indications for emergency medical care – by an anesthesiologist-resuscitologist

Hospitalization is indicated in the following cases:

- grade 2-3 laryngeal stenosis;

- inability to provide adequate therapy at home;

- progressive deterioration of the condition.

The organization of clinical nutrition for patients during inpatient treatment in medical organizations is carried out in accordance with Appendix 3 of the Order of the Russian Ministry of Health dated September 23, 2020, No. 1008n "On Approval of the Procedure for Providing Patients with Therapeutic Nutrition".

Discharge criteria:

If hospitalized, the patient may be discharged after resolution of stenosis, normalization of body temperature and saturation [43]. The average length of hospital stay for a child with croup is 1 to 2 days.

Comments: Parents of children with recurrent croup should be educated and provided with an individual action plan. If symptoms suspicious of a new episode of laryngeal stenosis appear, inhalation of budesonide** or intramuscular administration of #dexamethasone** (#prednisolone**) is indicated.

6.2 Organization of medical care for epiglottitis

A patient with epiglottitis must be urgently hospitalized (as a rule, by an ambulance team) to a medical organization with an intensive care unit and the capability for tracheal intubation (an intensive care room or intensive care unit, followed by possible transfer to an infectious disease ward or a boxed ward). Inpatient care for a patient with epiglottitis is provided by a pediatrician/general practitioner or an infectious disease specialist, if necessary by an otolaryngologist, and in the presence of indications for emergency medical care, by an anesthesiologist-intensivist

Comments: It is important to remember that any painful manipulations or those perceived negatively by a patient with epiglottitis (injections, infusions, sometimes even inhalations) can lead to asphyxia.

The average length of stay in the hospital for a patient with epiglottitis is 3–5 days.

Discharge criteria:

relief of stenosis, normalization of body temperature and saturation, ability to independently take food and liquids, restoration of appetite.

7. Additional Information

7.1 Outcomes and prognosis

The prognosis of croup with timely diagnosis and adequate treatment is always favorable. In case of late diagnosis with grade 3–4 laryngeal stenosis when intubation or tracheostomy is impossible, death from asphyxia is possible.

The prognosis of epiglottitis is always serious, although timely treatment ensures recovery.

• It is important to rule out epiglottitis as quickly as possible in a patient with laryngeal stenosis.

• Acute obstructive laryngitis (croup) in most cases responds well to treatment with glucocorticoids (for inhalation use) and/or systemic corticosteroids.

Criteria for Evaluating the Quality of Medical Care

Criteria for assessing the quality of specialized medical care for children and adults with acute obstructive laryngitis [croup] and epiglottitis (ICD-10 codes: J05.0, J05.1)

2.10.5.2. Criteria for assessing the quality of specialized medical care for children and adults with acute obstructive laryngitis [croup] and epiglottitis (ICD-10 codes: J05.0, J05.1)

References

Appendix A1. Working Group Composition

Baranov A.A. Academician of the Russian Academy of Sciences, MD, Honorary President of the Union of Pediatricians of Russia, Advisor to the Head of the Research Institute of Pediatrics and Child Health of the Petrovsky National Research Centre of Surgery, Chief freelance pediatric specialist of the Russian Ministry of Health, Professor of the Department of Pediatrics and Pediatric Rheumatology of the Filatov Clinical Institute of Children's Health of the Sechenov First Moscow State Medical University of the Russian Ministry of Health (Sechenov University),

Daikhes N.A., MD, Professor, Corresponding Member of the Russian Academy of Sciences, Director of the National Medical Research Center of Otorhinolaryngology of the Federal Medical-Biological Agency of Russia, Chief freelance otolaryngologist of the Russian Ministry of Health, Vice-President of the National Medical Association of Otorhinolaryngologists, Head of the Department of Otorhinolaryngology of the Faculty of Postgraduate Medical Education of the Pirogov Russian National Research Medical University of the Russian Ministry of Health

Kozlov R.S., Corresponding Member of the RAS, Professor, Doctor of Medical Sciences, Rector of the Smolensk State Medical University of the Russian Ministry of Health, Chief Freelance Specialist of the Russian Ministry of Health in Clinical Microbiology and Antimicrobial Resistance, President of MACMAH

Namazova-Baranova L.S., Academician of the RAS, Professor, Doctor of Medical Sciences, President of the Union of Pediatricians of Russia; Past President of EPA/UNEPSA; Head of the Research Institute of Pediatrics and Child Health of the Petrovsky National Research Centre of Surgery, Head of the Department of Faculty Pediatrics, Pediatric Faculty, Pirogov Russian National Research Medical University of the Russian Ministry of Health, Chief Freelance Pediatric Specialist in Preventive Medicine of the Russian Ministry of Health

Andreeva I.V., Senior Research Fellow, Associate Professor, Institute of Antimicrobial Chemotherapy, Smolensk State Medical University of the Ministry of Health of Russia, Member of MACMA

Artemova I.V. Member of the Union of Pediatricians of Russia

Bakradze M.D., Doctor of Medical Sciences, Head of the Department of Diagnostics and Rehabilitative Treatment, National Medical Research Center for Children's Health of the Russian Ministry of Health, Member of the Union of Pediatricians of Russia

Vishneva E.A., Doctor of Medical Sciences, Professor of the RAS, Deputy Head for Science at the Research Institute of Pediatrics and Child Health of the Petrovsky National Research Centre of Surgery, Professor at the Department of Faculty Pediatrics, Pediatric Faculty, Pirogov Russian National Research Medical University of the Russian Ministry of Health

Girina A.A. – Candidate of Medical Sciences, Associate Professor at the Department of Pharmacology, Pediatrics and Infectious Diseases, Khanty-Mansiysk State Medical Academy, President of the Regional Branch of the Union of Pediatricians of Russia

Karaseva M.S. – Pediatrician, Researcher at the Department of Standardization and Study of Evidence-Based Medicine Foundations, Research Institute of Pediatrics and Child Health of the Petrovsky National Research Centre of Surgery

Karneeva O.V., Doctor of Medical Sciences, Deputy Director for Academic and Research Work, National Medical Research Center for Otorhinolaryngology of the Federal Medical-Biological Agency of Russia, Professor at the Department of Otorhinolaryngology, Faculty of Postgraduate Education, Pirogov Russian National Research Medical University of the Russian Ministry of Health, Member of the National Medical Association of Otorhinolaryngologists

Kim I.A., Doctor of Medical Sciences, Head of the Department of Science and Education, National Medical Research Center for Otorhinolaryngology of the Federal Medical-Biological Agency of Russia, Professor at the Department of Otorhinolaryngology, Faculty of Postgraduate Education, Pirogov Russian National Research Medical University of the Russian Ministry of Health

Kovtun O.P., Academician of the RAS, Doctor of Medical Sciences, Professor, Rector of the Ural State Medical University of the Russian Ministry of Health, Vice President of the Union of Pediatricians of Russia, Chief Freelance Pediatric Specialist of the Ural Federal District

Kulichenko T.V., Doctor of Medical Sciences, Professor of the RAS, Pirogov Russian National Research Medical University of the Russian Ministry of Health, World Health Organization Expert, Member of the Union of Pediatricians of Russia

Lashkova Yu.S., Candidate of Medical Sciences, Expert Analyst at Pirogov Russian National Research Medical University of the Russian Ministry of Health, Physician at the Department of Emergency Pediatrics, National Medical Research Center for Children's Health of the Russian Ministry of Health, Member of the Union of Pediatricians of Russia.

Zelenkova I.V., Candidate of Medical Sciences, Head of the Day Hospital of Otorhinolaryngology and Audiology, Senior Researcher, Otorhinolaryngologist, Research Institute of Pediatrics and Child Health of the Petrovsky National Research Centre of Surgery, Member of the Union of Pediatricians of Russia

Novik G.A., Doctor of Medical Sciences, Professor, Head of the Vorontsov Department of Children's Diseases, Faculty of Postgraduate and Additional Professional Education, Saint Petersburg State Pediatric Medical University of the Ministry of Health of the Russian Federation, Vice President of the Union of Pediatricians of Russia, Chief Pediatric Allergist-Immunologist of the Russian Ministry of Health in the Northwestern Federal District of the Russian Federation

Polyakova A.S. Candidate of Medical Sciences, Associate Professor at the Department of Pediatrics and Public Health, National Medical Research Center for Children's Health of the Russian Ministry of Health, Head of the Consultative Department, Consultative and Diagnostic Center of the National Medical Research Center for Children's Health of the Russian Ministry of Health, Member of the Union of Pediatricians of Russia

Selimzyanova L.R., Candidate of Medical Sciences, Member of the Union of Pediatricians of Russia, Head of the Department of Standardization and Study of Evidence-Based Medicine Foundations, Research Institute of Pediatrics and Child Health of the Petrovsky National Research Centre of Surgery, Associate Professor at the Department of Pediatrics and Pediatric Rheumatology, Filatov Clinical Institute of Children's Health, Sechenov First Moscow State Medical University of the Russian Ministry of Health (Sechenov University), Associate Professor at the Department of Faculty Pediatrics, Pediatric Faculty, Pirogov Russian National Research Medical University of the Russian Ministry of Health

Stetsyuk O.U., Senior Researcher, Research Institute of Antimicrobial Chemotherapy of the Smolensk State Medical University of the Russian Ministry of Health, Member of MACMAH

Tatochenko V.K., Doctor of Medical Sciences, Professor, Advisor to the Director of the National Medical Research Center for Children's Health of the Russian Ministry of Health, Member of the Union of Pediatricians of Russia

Tepaev R.F., Doctor of Medical Sciences, Head of the Anesthesiology and Intensive Care Service, Bashlyeva Children's City Clinical Hospital, Professor at the Department of Pediatrics and Pediatric Rheumatology, Sechenov First Moscow State Medical University of the Russian Ministry of Health (Sechenov University)

Fedoseenko M.V. Candidate of Medical Sciences, Member of the Union of Pediatricians of Russia, Leading Researcher at the Research Institute of Pediatrics and Child Health of the Petrovsky National Research Centre of Surgery, Associate Professor at the Department of Faculty Pediatrics, Pediatric Faculty, Pirogov Russian National Research Medical University of the Russian Ministry of Health

Yakushin S.B. Assistant at the Department of Outpatient Pediatrics, Smolensk State Medical University of the Russian Ministry of Health, Smolensk, Member of MACMAH

The authors declare no financial support or conflicts of interest that need to be disclosed.

Appendix A2. Methodology for Developing Clinical Guidelines

Target audience for these clinical guidelines:

1. Pediatricians;

2. General practitioners (family physicians);

3. Medical students;

4. Residents in training.

Methods used for evidence collection/selection: electronic database search.

Description of methods used to assess the quality and strength of evidence: the evidence base for the guidelines includes publications included in the Cochrane Library, EMBASE, MEDLINE, and PubMed databases. Search depth – 10 years.

Methods used to assess the quality and strength of evidence:

• expert consensus;

• assessment of significance in accordance with the rating scheme.

Methods used for evidence analysis:

• reviews of published meta-analyses;

• systematic reviews with evidence tables.

Description of methods used for evidence analysis

When selecting publications as potential sources of evidence, the methodology used in each study is examined to ensure its validity. The result of this examination affects the level of evidence assigned to the publication, which in turn affects the strength of the recommendations.

To minimize potential bias, each study was evaluated independently. Any discrepancies in evaluations were discussed by the full panel of authors. If a consensus could not be reached, an independent expert was involved.

Evidence tables: compiled by the authors of the clinical guidelines.

Methods used to formulate the recommendations: expert consensus.

Good Practice Points (GPPs)

Recommended good clinical practice is based on the clinical experience of the authors of these guidelines.

Economic analysis

Cost analysis was not performed, and pharmacoeconomic publications were not analyzed.

Recommendation validation method

• External expert review.

• Internal expert review.

Description of the recommendation validation method

The draft of these recommendations was reviewed by independent experts who were primarily asked to comment on how comprehensible the interpretation of the evidence underlying the recommendations is.

Feedback was obtained from primary care physicians regarding the readability of these guidelines and their assessment of the importance of the proposed recommendations as a tool for daily practice.

All comments received from the experts were thoroughly systematized and discussed by the members of the working group (authors of the recommendations). Each item was discussed individually.

Consultation and peer review

The draft recommendations were reviewed by independent experts who were primarily asked to comment on the clarity and accuracy of the interpretation of the evidence base underlying the recommendations.

Working Group

For the final revision and quality control, the recommendations were re-evaluated by the members of the working group, who concluded that all comments and feedback from the experts had been taken into account and the risk of bias in the development of the recommendations was minimized.

Table 1. Levels of Evidence (LoE) grading scale for diagnostic methods (diagnostic interventions)

Table 2. Scale for grading levels of evidence certainty (LEC) for prevention, treatment, and rehabilitation methods (preventive, therapeutic, and rehabilitative interventions)

Table 3. Scale for grading grades of recommendation (GR) for prevention, diagnostic, treatment, and rehabilitation methods (preventive, diagnostic, therapeutic, and rehabilitative interventions)

Procedure for updating clinical guidelines.

The mechanism for updating clinical guidelines provides for their systematic revision — at least once every three years, as well as upon the emergence of new evidence-based medicine data regarding the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.

Appendix A3. Reference Materials

Care delivery pathways:

1. Order of the Ministry of Health and Social Development of the Russian Federation No. 366n of April 16, 2012, "On Approval of the Procedure for Providing Pediatric Care";

2. Order of the Ministry of Health and Social Development of the Russian Federation dated May 5, 2012, No. 521n "On approval of the Procedure for providing medical care to children with infectious diseases"

Criteria for assessing the quality of medical care:

1. Order of the Russian Ministry of Health No. 203n dated May 10, 2017 'On Approval of Criteria for Assessing the Quality of Medical Care'

2. Order of the Ministry of Health of the Russian Federation No. 205n dated May 2, 2023, On Approval of the Nomenclature of Positions of Medical and Pharmaceutical Workers.

3. Order of the Ministry of Health of the Russian Federation No. 541n dated July 23, 2010 (as amended on April 9, 2018) 'On Approval of the Unified Qualification Reference Book of Positions of Managers, Specialists and Employees, Section "Qualification Characteristics of Employee Positions in Healthcare".

4. Federal Law No. 489-FZ dated December 25, 2018, "On Amendments to Article 40 of the Federal Law 'On Compulsory Medical Insurance in the Russian Federation' and the Federal Law 'On the Basics of Protecting the Health of Citizens in the Russian Federation' regarding Clinical Guidelines."

5. Order of the Ministry of Health of the Russian Federation No. 103n dated February 28, 2019, "On Approval of the Procedure and Deadlines for the Development and Revision of Clinical Guidelines, Their Standard Form, and Requirements for Their Structure, Composition, and Scientific Validity of Information Included in Clinical Guidelines."

6. Order of the Ministry of Health of the Russian Federation No. 804n dated October 13, 2017 "On approval of the nomenclature of medical services".

7. 5. Order of the Ministry of Health of the Russian Federation (Russian Ministry of Health) No. 1094n dated November 24, 2021, 'On Approval of the Procedure for Prescribing Medicinal Products, Prescription Form Templates for Medicinal Products, the Procedure for Issuing Said Forms, Their Accounting and Storage, Templates of Prescription Forms Containing Prescriptions for Narcotic Drugs or Psychotropic Substances, the Procedure for Their Manufacture, Distribution, Registration, Accounting and Storage, as Well as the Rules for Issuing Prescription Forms, Including in the Form of Electronic Documents' State Register of Medicinal Products: https://grls.rosminzdrav.ru

8. Order of the Russian Ministry of Health No. 1008n dated September 23, 2020, "On approval of the procedure for providing patients with therapeutic nutrition"

Diagnosis examples

1. Acute obstructive laryngitis, grade 1 laryngeal stenosis;

2. Acute obstructive laryngitis, grade 2 laryngeal stenosis;

3. Epiglottitis. Grade 3 respiratory failure.

Appendix A3.1 Explanation of Notes

** – a medicinal product included in the Order of the Government of the Russian Federation No. 2406-r dated October 12, 2019 (as amended on June 9, 2023) "On Approval of the List of Vital and Essential Drugs, as well as Lists of Medicinal Products for Medical Use and the Minimum Assortment of Medicinal Products Required for the Provision of Medical Care"

# – The use of a medicinal product in accordance with indications (characteristics) not specified in the instructions for its use (off-label) is carried out by the decision of the medical commission subject to a signed informed voluntary consent (in accordance with Federal Law No. 323-FZ dated November 21, 2011, as amended).

Appendix A3.2 Differential diagnosis of croup and epiglottitis

Table 1. Differential diagnosis of acute obstructive laryngitis (croup) with other clinically similar conditions

* Upper airway anomalies: tracheomalacia, laryngomalacia, laryngeal cleft, subglottic stenosis.

It should be remembered that in certain laryngeal diseases (congenital stridor, subglottic hemangioma/neoplasia, paresis, laryngomalacia), inspiratory difficulty increases during an acute respiratory infection, creating the illusion of acute stenosis.

Table 2. Clinical differences between croup and epiglottitis

Appendix A3.3 Risk factors for the development of post-intubation laryngeal edema.

[8, 22, 23, 24, 37, 90, 91, 92].

A. Intubation-related risk factors:

- History of difficult intubation (prolonged intubation attempt)

- Large endotracheal tube size (smaller height-to-diameter ratio)

- Increased mobility of the endotracheal tube

- Intubation (children) for more than a week

- Mechanical ventilation for 48 hours in children under 12 months of age

- Emergency out-of-hospital intubation

B. Post-intubation factors:

- Prolonged endotracheal intubation

- High cuff pressure

- Patient agitation during intubation

- Self-extubation and reintubation

- Excessively aggressive tracheal suctioning

C. Patient- and surgery-related factors:

- Type of surgery (e.g., head and neck surgery)

- Prone positioning during neurosurgical procedures

- Pregnancy

- Fluid therapy

- Neck and airway injuries (including infectious processes)

- Inhalation injuries and burns

- Low Glasgow Coma Scale score

- Treatment without sedation

- Female sex

- Body mass index (>26.5)

- Gastroesophageal reflux.

- Narrow larynx

- Low gestational age, low birth weight

- Pediatric age

Appendix B. Physician Action Algorithms

Algorithm 1.

Management of a patient with acute obstructive laryngitis [croup].

Algorithm 2.

Management of a patient with acute epiglottitis.

Appendix C. Patient Information

Acute obstructive laryngitis [croup] is an inflammation of the larynx and adjacent areas leading to narrowing of the laryngeal lumen. It carries the risk of severe respiratory failure and death (in extremely rare cases, without prompt and proper treatment).

It develops secondary to an acute respiratory viral infection (ARVI).

Etiology – various viruses. The disease occurs most frequently in autumn, winter, and early spring.

How the viral infection that causes croup is transmitted: most commonly via transfer to the nasal mucosa or conjunctiva from hands contaminated through contact with an infected person (e.g., shaking hands) or virus-contaminated surfaces.

Another transmission route is airborne droplets: inhaling saliva droplets produced during sneezing, coughing, or close contact with an infected person.

Incubation period: in most cases, from 2 to 7 days. Viral shedding by a patient (contagiousness to others) peaks on the 3rd day after infection and drops sharply by the 5th day; low-level viral shedding may persist for up to 2 weeks.

Signs of croup: it typically begins with symptoms of an acute respiratory viral infection: rhinorrhea, scratchy throat, and cough. The fever is usually low-grade. Laryngitis typically precedes inspiratory dyspnea: hoarseness and/or a dry, harsh cough appear. The condition may then worsen: hoarseness may increase, the cough takes on a barking character, and noisy breathing or inspiratory stridor develops. As the narrowing of the laryngeal lumen progresses, inspiratory dyspnea worsens, which can be identified by suprasternal notch retractions on inspiration.

Croup symptoms typically develop in the evening, at night, or often in the early morning hours. Mild croup presents with an occasional harsh, barking cough and hoarseness; at rest, inspiratory stridor is absent and appears only with agitation or exertion. Mild suprasternal and intercostal retractions may be present during breathing. In moderate croup, the barking cough becomes more frequent, inspiratory stridor persists at rest, and pronounced suprasternal and intercostal retractions are visible at rest. Severe croup manifests as pronounced respiratory failure: "labored breathing", marked pallor and cyanosis, potential altered mental status, and seizures. At this stage of the disease, the child requires emergency medical care.

If you suspect croup in your child at any stage: call an emergency medical service immediately!!

Investigations: in most cases, additional investigations are not required for a child with croup

Treatment: croup is self-limiting in most cases; the physician will most commonly prescribe corticosteroid hormones. Currently, this is the most effective and safe method to treat croup. Corticosteroid hormones do not cause any adverse effects in a child with croup, as they are administered in moderate doses for a short duration!

If signs of croup are pronounced, the physician may hospitalize the child.

Fever management: a febrile child should be undressed and sponged with water at 25–30°C. Only two medications are permitted for reducing fever in children: paracetamol** or ibuprofen**. Antipyretic medications in healthy children aged ≥3 months are warranted at temperatures above 39–39.5°C. With lower fever (38–38.5°C), antipyretics are indicated in infants under 3 months, in patients with chronic conditions, or if the fever causes discomfort. Regular (scheduled) administration of antipyretics is not recommended; a repeat dose is administered only upon a recurrent temperature rise.

Alternating these two medications or using them in combination does not increase the antipyretic effect.

Acetylsalicylic acid** and nimesulide are not used as antipyretics in children. The use of metamizole sodium in children is strongly discouraged due to the high risk of agranulocytosis. In many countries worldwide, metamizole sodium was banned more than 50 years ago.

Antibiotics (J01 Antibacterials for systemic use) are ineffective against viruses (the primary cause of croup). Antibiotic therapy is considered only if a bacterial infection is suspected. Antibiotics (J01 Antibacterials for systemic use) must be prescribed by a physician. Uncontrolled use of antibiotics (J01 Antibacterials for systemic use) can lead to the development of antimicrobial resistance and cause complications.

How to prevent the respiratory viral infections that lead to croup:

A sick child should be kept at home (not sent to kindergarten or school).

Measures that prevent the spread of viruses are of paramount importance: thorough handwashing after contact with an infected person.

Wearing masks, sanitizing surfaces around the sick person, and regular room ventilation are also important.

Annual influenza vaccination starting at 6 months of age reduces the risk of this infection. It has also been proven that vaccinating children against influenza and pneumococcal infection reduces the incidence of acute otitis media in children and complicated courses of ARVI.

There is no reliable evidence that various immunostimulants reduce respiratory morbidity. The prophylactic efficacy of herbal products, vitamin C, and homeopathic remedies is also unproven.

The outcome of croup with prompt diagnosis and adequate treatment is consistently favorable. In cases of delayed diagnosis with severe laryngeal narrowing when resuscitation is unavailable, death from asphyxia may occur.

Epiglottitis is an acute bacterial inflammation of the epiglottis and surrounding tissues that can lead to rapid, life-threatening airway obstruction.

Epiglottitis is rare, occurring predominantly in children, but it can also occur in adults.

Epiglottitis is caused by Haemophilus influenzae (Haemophilus influenzae type b) (>90%). In countries with universal immunization against Hib, epiglottitis is less frequent, and vaccinated children may develop epiglottitis caused by other pathogens. Vaccination of children against Hib is also available in Russia.

Epiglottitis is a severe bacterial infection; the disease usually has an acute onset with high fever and deterioration of general condition. It is characterized by sore throat, the child may clench their teeth tightly, drooling may be observed, along with a "tripod" posture, an open mouth, rapid development of inspiratory stridor, and epiglottic collapse in the supine position. The barking cough typical of croup is absent.

If you suspect acute epiglottitis in your child: call an emergency medical service immediately!!

A child with epiglottitis must be admitted to the hospital.

In epiglottitis, it is prohibited to administer inhalations, sedatives, or hypnotics, or to induce agitation; antibacterial therapy is mandatory:

Antibiotics are prescribed by a physician. When antibiotics are prescribed, strict adherence to the dosage regimen and treatment duration is required as directed by the physician.

Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools

Appendix G1 Westly croup severity score

Name in Russian: Westley Croup Severity Scale

Original name (if any): Westley croup score

Source (developer official website, validation publication): 93, 94, 95, 96

Type (underline): assessment scale

Purpose: assessment of croup severity

Content (template):