1. Croup and Bronchiolitis Karen D. Sawitz, MD St. Barnabas Hospital Department of Pediatrics

2. The Pediatric Airway

3. Croup - Epidemiology 15% of respiratory visits in children Most common cause of stridor in children Primarily 1 to 6 years, mean 18 months Boys > girls (1.5 to 1) Peak incidence in US 5 per 100 in 2nd yr Predominates during fall and winter

4. Croup - Etiology Viral-mediated inflammatory condition AKA laryngotracheitis, laryngotracheobronchitis Affects vocal cords and subglottic airway 65% due to parainfluenza types 1, 2, 3 Most hospitalized cases are type 1 Others: adenovirus, RSV, varicella, measles, HSV, enteroviruses, Mycoplasma pneumoniae, and influenza A and B Transmitted by inhalation via nasopharynx

5. Croup – Clinical Presentation Prodrome: rhinorrhea, pharyngitis, low-grade fever, +/- cough over 12-48 hours Gradual development of barking cough, hoarseness, varying inspiratory stridor +/- fever May develop more severe obstruction with inspiratory stridor at rest, increased HR/RR, nasal flaring, retractions, progressive hypoxia and cyanosis Symptoms may worsen at night/with crying Mild course 3-7 days, more severe 7-14 days

6. Westley Croup Score Inspiratory Stridor None (0 points) When agitated (1 points) On/off at rest (2 points) Continuous at rest (3 points) Retractions None (0 points) Mild (1 points) Moderate (2 points) Severe (3 points) Air Movement/Entry Normal (0 points) Decreased (1 points) Moderately decreased (2 points) Severely decreased (3 points) Cyanosis (Color) None (0 points) Dusky (1 point) Cyanotic on room air (2 points) Cyanotic with supplemental oxygen (3 points) Level of Alertness (Mentation) Alert (0 points) Restless or anxious (1 points) Lethargic/Obtunded (2 points) <4 Mild 5-6 Mild-Moderate 7-8 Moderate 9-10 Severe

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8. Croup – Differential Diagnosis Infectious –Acute epiglottitis –Bacterial Tracheitis –Retropharyngeal or peritonsillar abscess Noninfectious –Angioneurotic edema –Foreign body aspiration

9. Pediatrics in Review January 2001

10. Croup - Treatment Home Management –Cool mist or night air –Steam (vaporizer or from shower) –Keep child calm Primary Care/ER Setting –Cool mist (may precipitate bronchospasm) –Steroids: oral or IM dexamethasone 0.6 mg/kg single dose (half-life 36-52 hours) –Racemic epinephrine in severe cases: 0.25-0.5 ml in 2.5 ml saline by nebulizer

11. Croup - Treatment Criteria for discharge after Racemic Epi –Observation for 3-4 hours –No stridor at rest –Normal air entry –Normal color –Normal level of consciousness –Have received a dose of dexamethasone

12. Croup – Indications for Admission Suspected or actual epiglottitis Cyanosis/hypoxemia/pallor Stridor at rest or progressive stridor Respiratory distress Depressed sensorium Restlessness Toxic appearance Nelson Textbook of Pediatrics 16 th Edition 2000

13. Bronchiolitis - Epidemiology Most common lower respiratory tract infection in infants Most common etiology is RSV, most cases between December and March (75% of cases under 2) More common in crowded living conditions and smoke exposure Breastfeeding appears to confer a protective advantage Most severe symptoms in those under 2 >50% affected by age 1, 80-90% by age 2, 40% have LRTI No permanent RSV immunity, reinfections common 1-2% require hospitalization 90,000 hospitalizations annually (80% under 1 year) Deaths 4500 (1985)  510 (1997)  390 (1999) Cost of hospitalization infants under 1 year: $700 mil/yr More likely to have respiratory problems when older

14. RSV Spread Humans only source of infection Direct or close contact with secretions Large-particle droplets <3 ft or fomites May persist hours on surfaces or 30 minutes on hands Viral shedding 3-8 days or longer Incubation period 2-8 days (4-6)

15. Bronchiolitis – Clinical Features Pathophysiology –Marked inflammation, edema, necrosis of smaller airway epithelial cells –Increased mucus production –Bronchospasm Clinical Features –Rhinitis, tachypnea, wheezing, cough, crackles –Accessory muscle use and nasal flaring –Apnea, grunting, cyanosis –Poor feeding, difficulty sleeping, fussiness –Tachycardia and dehydration may occur –Natural course 7-10 days, peak on day 4

16. Bronchiolitis – Diagnosis & Testing Clinical diagnosis on basis of H & P Laboratory and radiologic studies should not routinely be ordered per AAP NP swab for RSV ELISA may be used eg for cohorting CXR to exclude other Dx, or if not improving as expected Concurrent SBI is rare, may need to be ruled out in febrile young infants (UTI)

17. Bronchiolitis – Risk Factors for Severe Disease Age under 6-12 weeks History of prematurity esp < 28 weeks GA Underlying cardiopulmonary disease –Chronic lung disease (BPD, CF) –Complex congenital heart disease –Congenital airway abnormalities Immunodeficiency Severe neuromuscular disease

18. Bronchiolitis - Management Mainstay: supportive care (hydration, oxygenation, nasal suction, respiratory support if needed) No routine bronchodilator use – may improve symptoms short-term but no effect on length of illness or LOS; potential for harm (SE, cost) No routine corticosteroid use – no benefit in RR, O2 sat, LOS though given to 60% of inpatients No routine use of ribavirin – variable results, may be appropriate for severely ill infants Antibiotics only if indication of concurrent bacterial infection

19. Bronchiolitis – Criteria for Admission Persistent hypoxia Respiratory distress Inability to tolerate fluids Inability to ensure close follow-up Infants under 2 months of age - consider Premature infants - consider

20. RSV Bronchiolitis - Prevention Palivizumab (Synagis®) prophylaxis for selected infants under 24 months –15 mg/kg IM monthly November-March Hand washing Avoiding passive smoke exposure Promotion of breastfeeding

21. Criteria for Passive Immunization ≤24 mos old with –CLD on therapy in 6 mos before start of RSV season –Hemodynamically significant congenital heart disease ≤32 weeks GA even without CLD –<28 wks GA during first season/≤12 mos at start –29-32 wks GA up to 6 mos of age at start of season 32-35 wks GA up to 3 mos with ≥1 risk factor: –Day care attendance or –Sibling under 5 years of age <34 wks GA with airway abn or neuromuscular dz Source: AAP Red Book 2009