CROUP Dr.S. Alyasin Associated professor Pediatric Department Shiraz University of Medical Science

Croup Airway resistance is inversely proportional to 4th power of radius : minor reduction: increase in air flow resistance. Larynx: 4 major cartilage: epiglottic – arytenoid – thyroid – cricoid & the soft tissue souround it Cricoid is just below vocal cord & narrowest in children < 10 yr -0

Supraglottic Infraglottic Epiglotitis – peritonsilar abcess- retropharyngeal abcess Drooling - hot potato voice – positional preference Infraglottic Laryngitis – lanyngotracheitis, laryngotracheobronchitis Croup: Heterogenous group of acute and infectious process Bark like cough , may hoarsness, stridor ,distress (affect larynx,trachea ,bronchus) Stridor:Harsh ,high pitched usually inspiratory or biphasic ,turbulant flow

Croup Croup typically affects larynx, tarchea- bronchi (acute infection - bark cough - hoarsness - stridor)

Croup :Etiolology Viral :Para -influenza 1,2,3 75% Influenza A-B, Adenovirus, RSV, measlse, Inf A: Severe LTB Bacterial: diphtheria- bacterial thracheitis- epiglotitis – mycoplasma (mild)

Croup ;Epidemiology Age: 3 mo – 5yr, peak: 2nd yr of life Boy Late fall & winter (but can throughout the year) Recurrents : 3-6 yr of age, decrease with growth Family hx of croup in 15%

Croup (Laryngotracheobronchitis) Some clinicians use the term laryngotracheitis for the most common & most typical form of croup and laryngotrachobronchitis for more sever form with bacterial super-infection (in 5-7 days course) URI in family URI rhinorrhea- pharyngitis- cough- low grade fever 1-3 days then barking cough Low grade to 39- 40 0c or afebrile

Croup : Clinical manifestation Worse at night Improve in a week Agitation aggravate symptom Prefer sit up Older children are not ill.

Croup : Clinical manifestation PE - hoarse voice Coryza mild to mod infla. Pharynx RR↑ variable respiratory distress (RR- nasal flaring – retraction) - Stridor

Croup :Dx Alveolar gas exchange is nl so hypoxia only in complete airway obstruction (occasionally difficult to differentiate from epiglottitis) X-ray may be helpful in distinguishing between sever LTB & epiglottitis but after airway stabilization.

Diagnosis Croup is a clinical diagnosis and not require X ray. X Ray AP: steeple sign (false +ve & -ve & not correlate with severity) distinghish between epiglotitis & LTB after stabilization of airway “steeple sign” of subglottic narrowing. (b) Laternal neck radiograph showing subglottic narrowing consistent with acute laryngotracheitis

Spasmodic croup 1-3 yr No URI hx in family member & patient No fever Cause?: viral- allergic – psychologic An allergic reaction to viral antigen.

Acute infectious laryngitis Virus – Diphteria URI -sore throat – cough- hoarseness- loss of voice: mild In infant : RD Subglottic inflammation

Croup: Treatment Admission: -progressive stridor severe stridor at rest - RD - hypoxia - cyanosis - depressed mental status – poor oral intake – need for observation.

Croup: Treatment L epinephrinin (5 ml: 1/1000) is as potent as racemic epinephrin (tachycardia – HTN) , every 20 minutes. Indication: -stridor at rest need for intubation - RD - hypoxia (caution: tachycardia- TOF- venticular outlet obstruction)

Croup: treatment: corticosteroid anti inflammatory action: laryngeal edema Oral CS even in mild croup: ↓ admission ↓ duration of admission - ↓need for E – Oral dexametason 0.6 to 0.15 mg/kg single dose = im dexametson or budesonide Single dose of prednisolon is less potent 1 week CS: candidal infection *No during varicella infection

Croup: treatment No Antibiotic – No cough medication in children <4y-0 Heliox

Croup Discharge: after 2-3 hr observation: - no stridor at rest - normal air entry - nl pulse oximetry – nl level of consciousness - received steroid

Treatment: acute laryngeal swelling on an allergic basis Epinephrine 1/1000 – 0.01 ml/kg im or Racemic E Q .5 ml / with 3 ml nl/s CS 2-4 mg/kg/24 : prednison

Post-extubation croup Racemic E - dexametason 0.5 mg/kg/dose every 6 hrs

Croup: complication 15% Om bronchial , lung parenchyma Bacterial tracheitis (with toxic shock syndrome)

Prognosis Is related to Length of admission and extension o f infection( except in epiglotitis) Death in croup: - laryngeal obstruction – complication of tracheotomy Px is excellent Admitted patient: increased bronchial reactivity

Croup : Df Dx Foreign body 6mo-3 yrs, sudden , No prodrom Retropharngeal abscess (CT) Peritonsilar abscess Extrinsic compression (web- vascular ring) Intraluminal (papiloma- hemangioma) Angioedema Post extubation Hypocalcaemia tetani I.Mono Trauma Tumor Malformation Very hot liquid : epiglottis like drooling – dysphagia – stridor

Foreign Body

Lateral neck radiograph demonstrating widening of the retropharyngeal space and reversal of the normal cervical spine curvature. The epiglottis and subglottic area are normal.

Epiglotitis: Etiology Hl type B ↓80-90% in vaccinated area for epiglottis: st. pyogen- st. pneumonia- st. aureus Age 2-4 (although range of 1 to 7 y-0)

Epiglotitis Potentially lethal High fever- sore throat- dyspnea- resp obstruction within few hours: toxic difficult swallowing Drooling- neck extention Tripod position Air hunger, restless: cyanosis & coma Stridor after complete airway obstruction No barking cough – No illness in family

Epiglotitis Dx lanygoscopy: cherry red epiglottis when dx is certain or probable, lanyngoscopy should be done in OR or in ICU Phlebotomy, IV line, supine or direct inspection of oral cavity after airway is secure If dx is not certain : lat X ray neck “ thumb sign” direct visualization.

Epiglotittis Anxiety provoked intervention (phlebotomy- supine –IV-direct inspection of oral cavity) should be avoided. Most patients have bacteremia: occasionally pneumonia- cervical LAP- OM, rarely: meningitis – arthritis - Occasionally aryepiglottic fold is more involved than epiglottis

Treatment: Epiglotitis Epiglotitis is medical emergency: Artificial airway in OR or ICU : improved immediately culture (B- epi_ sometimes CSF) after airway stabilized All should recieve O2 Ceftriaxone – Cefotoxime- meropenem 7-10 days CS or E are not effective

Treatment: Epiglotitis Indication for rifampin for household members if: - any centact < 48 mo of age incomplete vaccinated - Any contact < 12 mo of age not received the 10 vaccine series - Immuno-compromised child

Bacterial tracheitis Stap au.* - morexella cat.- Non typable HI- anerobic Age: 5-7 y-o 2nd to LT & viral infection is more common than 10 infection Brassy cough- high fever- toxic – RD- not drool- can lie- no dysphagea Need intubation in 50-60 % (younger children) Major pathology: mucosal swelling in cricoid cartilage purulent secretion pseudomembrane

Bacterial tracheitis : diognosiS : Fever- purulent discharge- absence of epiglottitis finding X-Ray is not needed but show classic finding During ET intubation : pus below cord Tx: Artificial airway is strongly suspected Vancomycin + nafcillin O2 suction

   Lateral neck radiograph showing intraluminal membranes and tracheal wall irregularity (arrows) consistent with bacterial tracheitis.

Tracheotomy; Endotracheal Intubation Epiglotitis mortality rate of 6% dropped to zero -In OR or in ICU -Tube 0.5-1 mm smaller than estimation T, ET for most patient of bacterial tracheitis (50-60%) T, ET in LTB in outbreak of influenza A & measlse Extubation :few days T. complication: Mediastinal emphysema / pneumothorax DL in epiglottitis: after 42 hr inflammation ↓, (2-3 days after antibiotic)