EPIGLOTTITIS and CROUP

Basic Science l Venturi effect l Bernoulli principle turbulence  stridor

Bernoulli's Principle l as the speed of moving air increases, the pressure within the air decreases. When airflow is forced through a narrowed tube, a local area of low pressure creates a vacuum effect distal to the narrowing. The focal area of low pressure distal to a narrowed airway causes the airway walls to collapse and vibrate, generating the squeak characteristic of stridor

Basic Science l glottis l supraglottic l subglottic l intrathoracic trachea

Basic Science l pedi airway narrowest at subglottis cross-section of airway proportional to square of radius (  r 2 )

Supraglottitis- Epiglottitis l “angina epiglottidea anterior” l bacterial cellulitis of supraglottis l 2 to 7 years old l Haemophilus influenzae type B most common l incidence greatly decreased since vaccine

Supraglottitis l odynophagia l fever l irritability l stridor l rapidly progressive

Supraglottitis l if suspected, diagnose by direct laryngoscopy in OR l lateral neck film - “thumb sign” l 1nasotracheal intubation l IV antibiotics l extubate when air leak noted - usually within 48 hours

Laryngotracheobronchitis l croup - Scottish for barking cough l 6 months to 3 years old l Parainfluenza viruses types 1 and 2 most common

Laryngotracheobronchitis l URI symptoms l barking cough l hoarseness l inspiratory stridor l low-grade fever

Laryngotracheobronchitis l laryngoscopy for those with respiratory distress l AP neck - “steeple sign” l supraglottis normal

Laryngotracheobronchitis l usually self-limited l humidified air l racemic epinephrine l steroids l heliox l intubation for severe, refractory cases

Spasmodic Croup l presentation similar to LTB l sudden onset stridor l afebrile l recurrent episodes that resolve spontaneously l unknown cause

Case Study 1 l1l14 month old male lblbreathing difficulties l2l2-3 days of URI symptoms ltlthis morning, cough and loud breathing sound

l afebrile, respirations 26/min, pulse 124 beats/min l reclining in mother’s lap, NAD l soft, biphasic stridor l lungs clear to auscultation

Case Study 1 l laryngotracheobronchitis l differential: epiglottitis, bacterial tracheitis, foreign body, subglottic stenosis

Case Study 1 l lateral airway film - neck extended, inspiratory l racemic epinephrine l oral dexamethasone

Case Study 1 l observe for 3 hours l vastly improved at 4 hours post- treatment l consider direct laryngoscopy and bronchoscopy in 3-4 weeks

Case Study 2 l6l6 year old lrlrhinorrhea, cough, low grade fever lalacute onset high fever and stridor

ltlto OR for endoscopy leledematous larynx lululceration and sloughing of tracheal mucosa lplpurulent secretions in right lower lobe

lnlnasotracheal intubation lIlIV Cefuroxime lSlS. aureus lClCXR with right lower lobe pneumonia lelextubated 4 th day post intubation

Controversies and Future l drastic decrease in supraglottitis as a result of vaccine l nasotracheal intubation for supraglottitis l disposition of children treated for LTB with epinephrine l steroids in LTB

Conclusion l cause of much morbidity in pediatric population l potentially life-threatening l prompt diagnosis l assure adequate airway