1. Croup: Not all that barks is viral! Craig Dobson, MD CPT, MC, USAR NCC Pediatrics

2. Definitions Croup- term used to describe the clinical picture of laryngotracheitis. Hoarse voice Barking cough Inspiratory stridor Possible respiratory distress

3. Epidemiology Peak fall & winter. Range primarily 1-6 years Incidence 5/100 of children between age 1-2 years Males > females

4. Etiologies Parainfluenza, types 1,2,3 Contribute 65% of cases. Influenza A & B Adenovirus RSV Rarely mycoplasma.

5. Pathogenesis Subglottic narrowing due to inflammation. Cricoid ring allows fixed area for obstruction. 1mm swelling causes 65% obstruction in infant.

6. Pathogenesis Atelectasis/mucus plugging Ventilation/perfusion mismatch Negative intrapleural pressure may lead to varying degrees of pulmonary edema. Hypoxia/hypercarbia Air hunger Anxiety/Lethargy/Obtundation.

7. Clinical history Parents usually report viral URI symptoms 12-48hrs prior to cough. Fever, “Barking cough,”Stridor Typical course 3-5 days.

8. Worry if Drooling Dyphagia Toxic appearance Stridor without cough or without fever Incomplete immunizations

9. Badness mimicking croup Epiglottis Dysphagia Odynophagia Drooling Tripoding/sword-swallowing Pt resists lying on back Prefers leaning forward Stat to OR for evaluation/intubation

10. Badness Mimicking Croup, cont. Bacterial tracheitis More common in order children to teens Staph aureus/Diphtheria Fever/ resp distress/Dysphagia/Odynophagia Worsening over hours Difficult to distinguish from epiglottis Doesn’t matter, management is same: OR intubation Abx, worry more about Staph coverage if child is older.

11. Badness Mimicking Croup, cont. Bacterial superinfection of Croup Symptoms 5-7 days Worsening quickly over hours Increasingly high fevers Toxic appearance

12. Badness Mimicking Croup, cont. Retropharyngeal/peritonsilar abscess Fever Odynophagia Prodrome of sore throat Often swollen, tender ant. cerv. Nodes. Resistence to neck movement

13. Badness Mimicking Croup, cont. Neoplasm Foreign body Afebrile Toddlers most at risk Often no history of aspiration Trauma History/physical exam.

14. Badness Mimicking Croup, cont. Angioneurotic edema Recurrent Lip swelling Spasmotic croup (well, not really badness) Recurrent Nighttime

15. Laboratory tests No value….. ‘nough said. Agitation for sticking child for ABG will worsen child’s symptoms. You still need IV access, though, sorry.

16. Radiographic findings Steeple sign Lateral neck films if unsure of ruling out retropharyngeal abscess Fluouroscopy if still unsure Still this is a clinical diagnosis If any airway worries, no radiographs Example radiograph…

17. Management of Croup Do I need an artificial airway!!!! Cool mist No literature to support efficacy Multiple studies demonstrating that it may worsen situation Bronchospasm Hypothermia in young infants Tent obscures close observation of pt.

18. Epinephrine Mechanism- constricts arterioles to airway thus reducing further edema. Waiisman, et al. Prospective RCT comparing L-epi and RE in treatment of laryngotracheitis. Pediatrics. 1992. Demonstrated reduced croup score by 30min, lasts usually 2hrs. Dose 0.5cc of 2.25% racemic solution No difference found L- epi using 5cc of 1:1000 conc.

19. Epi, cont. Rebound phenomenon Bunk… It just wears off in 2hours usually. Multiple studies demonstrating safe to d/c pt from ER if: Steroids were given, too. No resting stridor 2-4 hrs after tx.

20. Corticosteroids ‘Roid controversy…. getting clearer. Ausejo, M. Glucocorticoids for croup. Cochrane Database of Systemic Reviews Jan 2000. Repeated with identical results by Moyer in Pediatrics, March 2000. Metanalysis (N=2221 patients) Improved Croup score at 6 and 12 hrs, not 24 after dexamethasone or budesonide neb. Decr. need for epi nebs by 9%. Decr. Emergency Room stay (-11hrs). Decr. Hospital stay (-16hrs).

21. Corticosteroids, cont. Kairys, et al. Steroid treatment of laryngotracheitis. Pediatrics. 1989. First meta-analysis of randomized trials. Demonstrated reduction in intubation from 1.27% (no steroids) to 0.17% steroids. No difference in inhaled budesonide versus IM dex.

22. Corticosteroids, cont Ritticher and Ledwith. Outpatient treatment of moderate croup with dexamethasone: Intramuscular versus oral dosing. Pediatrics. 2000 ER patients sent home. No statistical difference in later interventions. Power to detect at least 10% difference.

23. Corticosteroids, cont. Klassen, et al. Nebulized budesonide and oral dexamethasone treatment for croup. JAMA. 1998 Oral dexamethasone/Inhaled budesonide Both treatments No difference in groups Budesonide much more expensive.

24. Corticosteroids A moment on dosage: Most studies 0.6mg/kg (IM or PO) Malhotra and Krilov. Viral Croup. PIR, 2001 Lower doses of 0.15mg/kg and 0.3mg/kg shown to be equally effective.

25. Heliox Weber, JE. A randomized comparison of Heliox and racemic epinephrine for the treatment of moderate to severe croup. Pediatrics. 2001 N=29 Similar improvement in both groups. No significant difference in croup score, oxygen sat, respiratory rate or heart rate.

26. Where to now? Still unanswered questions: Should you re-dose dexamethasone since the duration is pharmacologically is 48hrs, but benefit was only demonstrated though 12hrs? What about heliox and epi together? Should any patient with croup symptoms be given steroids?