1 / 26

Croup: Not all that barks is viral!

Croup: Not all that barks is viral!. Craig Dobson, MD CPT, MC, USAR NCC Pediatrics. Definitions. Croup - term used to describe the clinical picture of laryngotracheitis. Hoarse voice Barking cough Inspiratory stridor Possible respiratory distress. Epidemiology. Peak fall & winter.

benjamin
Download Presentation

Croup: Not all that barks is viral!

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  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?

More Related