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

2. 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

3. 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

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

5. 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)

6. 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%

7. 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 c or afebrile

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

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

10. 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.

11. 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

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

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

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

15. 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)

16. 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

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

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

20. 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

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

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

23. 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

24. 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

25. Foreign Body

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

28. 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)

29. 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

31. 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.

33. 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

34. 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 days
CS or E are not effective

35. 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

37. 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 % (younger children)
Major pathology: mucosal swelling in cricoid cartilage
purulent secretion
pseudomembrane

38. 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

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

41. Tracheotomy; Endotracheal Intubation
Epiglotitis mortality rate of 6% dropped to zero
-In OR or in ICU
-Tube 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)