EPIGLOTTITIS, CROUP AND TRACHEITIS

1. EPIGLOTTITIS, CROUP AND TRACHEITIS Robert H. Stroud, M.D. Norman R. Friedman, M.D. 10 March 1999 Acute infections of airway common in pediatric population leading cause of hospital admission of children less than 4 mild, self-limited dz that may never be seen by MD, to potentially life-threatening diagnosis often on PE, radiology for case atypical airway protection always foremost when evaluatingAcute infections of airway common in pediatric population leading cause of hospital admission of children less than 4 mild, self-limited dz that may never be seen by MD, to potentially life-threatening diagnosis often on PE, radiology for case atypical airway protection always foremost when evaluating

2. Basic Science Venturi effect Bernoulli principle turbulence è stridor Stridor is sign not diagnosis (diff dx slide) normally approx laminar flow, inflammation leads to narrowing Venturi effect (Venturi/Bernoulli slide) Bernoulli principle turbulence manifest as stridorStridor is sign not diagnosis (diff dx slide) normally approx laminar flow, inflammation leads to narrowing Venturi effect (Venturi/Bernoulli slide) Bernoulli principle turbulence manifest as stridor

3. Basic Science glottis supraglottic subglottic intrathoracic trachea Glottic obs-inspiratory early, biphasic late - cartilage framework supraglottis - inspiratory, soft tissue collapse with negative pressure distal and subglottic narrowing increased with positive intrathoracic pressure during exhalation - expiratory stridor or wheezing Glottic obs-inspiratory early, biphasic late - cartilage framework supraglottis - inspiratory, soft tissue collapse with negative pressure distal and subglottic narrowing increased with positive intrathoracic pressure during exhalation - expiratory stridor or wheezing

4. Basic Science pedi airway narrowest at subglottis cross-section of airway proportional to square of radius (?r2) Adult and pedi airway different, children more susceptible subglottis narrowest rigid cricoid with loose submucosa pi r squared/ pi r squared = r2/r2 (6mm, 1 mm edema = 44% narrowing) worse with subglottic stenosis Adult and pedi airway different, children more susceptible subglottis narrowest rigid cricoid with loose submucosa pi r squared/ pi r squared = r2/r2 (6mm, 1 mm edema = 44% narrowing) worse with subglottic stenosis

5. Supraglottitis “angina epiglottidea anterior” bacterial cellulitis of supraglottis 2 to 7 years old Haemophilus influenzae type B most common incidence greatly decreased since vaccine Michel 1878 involves all supraglottic structures including epiglottis (lingual surface), AE folds, arytenoids epiglottis pushed post - progressive airway obs 2-7 yo, occ less than 1yo HIB most common, group A beta hemolytic strep, staph, pneumococcus, kleb, pseudomonas, candida, viruses HIB vaccine mid-1980’s - huge decrease in incidence 3.47/100,000 to 0.63 organisms beside HIB more commonMichel 1878 involves all supraglottic structures including epiglottis (lingual surface), AE folds, arytenoids epiglottis pushed post - progressive airway obs 2-7 yo, occ less than 1yo HIB most common, group A beta hemolytic strep, staph, pneumococcus, kleb, pseudomonas, candida, viruses HIB vaccine mid-1980’s - huge decrease in incidence 3.47/100,000 to 0.63 organisms beside HIB more common

6. Supraglottitis odynophagia fever irritability stridor rapidly progressive Acute onset fever, throat pain, irritability, respiratory distress (stridor late) rapidly progressive (hours) toxic, sitting, leaning forward - +/- drooling, muffled voice, limited speech secondary infection in 50% - meningitis, OM, pneumonia Acute onset fever, throat pain, irritability, respiratory distress (stridor late) rapidly progressive (hours) toxic, sitting, leaning forward - +/- drooling, muffled voice, limited speech secondary infection in 50% - meningitis, OM, pneumonia

7. Supraglottitis if suspected, diagnose by direct laryngoscopy in OR lateral neck film - “thumb sign” 1nasotracheal intubation IV antibiotics extubate when air leak noted - usually within 48 hours If hx and PE consistent - to OR for DL for diagnosis MD capable of airway control with pt at all times no intraoral exam, phlebotomy or other procedures that may upset child sit in parents lap x-rays if ? Dx and no resp distress - lat neck with thumb sign and hypopharyngeal over distention (loss of vallecular air space, thick epiglottis and AE folds) normal subglottis on AP Endoscopy as quickly as possible - always accompany pt communication b/t endoscopist and anesthesiologist spontaneous ventilation - orotracheal intubate (anesthesia or Oto) rigid telescope with ETT threaded over it, brochoscopes (age approppriate and size smaller), trach set-up draw blood after airway secure - CBC and cultures thorough endoscopy with cultures NT intubation, IV abx (Amp/Chlor, Ceftriaxone, Cefuroxime, Unasyn) If hx and PE consistent - to OR for DL for diagnosis MD capable of airway control with pt at all times no intraoral exam, phlebotomy or other procedures that may upset child sit in parents lap x-rays if ? Dx and no resp distress - lat neck with thumb sign and hypopharyngeal over distention (loss of vallecular air space, thick epiglottis and AE folds) normal subglottis on AP Endoscopy as quickly as possible - always accompany pt communication b/t endoscopist and anesthesiologist spontaneous ventilation - orotracheal intubate (anesthesia or Oto) rigid telescope with ETT threaded over it, brochoscopes (age approppriate and size smaller), trach set-up draw blood after airway secure - CBC and cultures thorough endoscopy with cultures NT intubation, IV abx (Amp/Chlor, Ceftriaxone, Cefuroxime, Unasyn)

8. Laryngotracheobronchitis croup - Scottish for barking cough 6 months to 3 years old Parainfluenza viruses types 1 and 2 most common Croup - Scottish, barking cough with many airway congenital and infectious airway lesions LTB most appropriate 6 month to 3 yrs under 1 yr - ? Subglottic stenosis 90% of acute airway obs, 3-5% of all children have one episode, 5% recurrent, hospitalization rare, intubation very rare 1-5% Parainfluenza viruses 1&2, influenza A&B, RSV, HSV I, measles, adenovirus and varicella all reported Croup - Scottish, barking cough with many airway congenital and infectious airway lesions LTB most appropriate 6 month to 3 yrs under 1 yr - ? Subglottic stenosis 90% of acute airway obs, 3-5% of all children have one episode, 5% recurrent, hospitalization rare, intubation very rare 1-5% Parainfluenza viruses 1&2, influenza A&B, RSV, HSV I, measles, adenovirus and varicella all reported

9. Laryngotracheobronchitis URI symptoms barking cough hoarseness inspiratory stridor low-grade fever URI for several days barking cough, low-grade fever, hoarseness, stridor (inspiratory, biphasic severe) Croup scores - several - Westley most commonly used- not practical stridor air entry level of consciousness cyanosis retractions URI for several days barking cough, low-grade fever, hoarseness, stridor (inspiratory, biphasic severe) Croup scores - several - Westley most commonly used- not practical stridor air entry level of consciousness cyanosis retractions

10. Laryngotracheobronchitis laryngoscopy for those with respiratory distress AP neck - “steeple sign” supraglottis normal AP neck - steeple sign, normal supraglottis dynamic obs, increased on inspiration, subglottic stenosis and hemangiaoma fixed with resp cycle Expiratory film useful to differentiate fixed from dynamic obstruction widening of stenosis on expiration: unilat VF paralysis LTB no change: subglottic stenosis bacterial tracheitis normal x-rays in 50% flexible fiberoptic exam OK if pt coop and no distress OR for severe distressAP neck - steeple sign, normal supraglottis dynamic obs, increased on inspiration, subglottic stenosis and hemangiaoma fixed with resp cycle Expiratory film useful to differentiate fixed from dynamic obstruction widening of stenosis on expiration: unilat VF paralysis LTB no change: subglottic stenosis bacterial tracheitis normal x-rays in 50% flexible fiberoptic exam OK if pt coop and no distress OR for severe distress

11. Laryngotracheobronchitis usually self-limited humidified air racemic epinephrine steroids heliox intubation for severe, refractory cases Usu self limited, most do not seek medical attention humidified air - no studies to prove benefit, strong anecdotal evidence - soothe mucosa, moisten secretions for easier expectoration racemic epi - vasoconstrictive - l-rotatory cheaper and same benefit, improve in 10-30 minutes, lasts 2 hours, REBOUND - ? Need for hospitalization - obs 3 hours steroids - ? Action - decrease perm of cap endothelium, stabilize lysosomal membranes - decrease inflammatory cascade and submucosal edema - 3 hours to onset of effect used since 60’s - Klassen and Johnson (decreased hosp rate as compared to placebo), nebulized Budesonide not available in US, no clear benefit and more expensive Dexamethasone 0.6 mg/kg/day po/IM/IV, Prednisolone 2.0 mg/kg/day divided or Dexamethasone 1.0 mg/kg/day divided heliox - promotes laminar flow, deceased work of breathing endoscopy if unresponsive, NT intubation, small tube, extubate in several days after airleak, scope for recurrent, atypical (5-7 day intubation), unresponsive, youngUsu self limited, most do not seek medical attention humidified air - no studies to prove benefit, strong anecdotal evidence - soothe mucosa, moisten secretions for easier expectoration racemic epi - vasoconstrictive - l-rotatory cheaper and same benefit, improve in 10-30 minutes, lasts 2 hours, REBOUND - ? Need for hospitalization - obs 3 hours steroids - ? Action - decrease perm of cap endothelium, stabilize lysosomal membranes - decrease inflammatory cascade and submucosal edema - 3 hours to onset of effect used since 60’s - Klassen and Johnson (decreased hosp rate as compared to placebo), nebulized Budesonide not available in US, no clear benefit and more expensive Dexamethasone 0.6 mg/kg/day po/IM/IV, Prednisolone 2.0 mg/kg/day divided or Dexamethasone 1.0 mg/kg/day divided heliox - promotes laminar flow, deceased work of breathing endoscopy if unresponsive, NT intubation, small tube, extubate in several days after airleak, scope for recurrent, atypical (5-7 day intubation), unresponsive, young

12. Spasmodic Croup presentation similar to LTB sudden onset stridor afebrile recurrent episodes that resolve spontaneously unknown cause barking cough, stridor, sudden onset usually at night afebrile without URI sx’s often recurrent and reslove spontaneously unknown pathogenesisbarking cough, stridor, sudden onset usually at night afebrile without URI sx’s often recurrent and reslove spontaneously unknown pathogenesis

13. Bacterial Tracheitis Jackson - 1945, Jones - 1979 6 months to 8 years old bacterial infection complicating viral LTB Staph aureus most common described as early as 1945 by Jackson but Jones in 1979 detailed description bacterial LTB, membranous LTB, pseudomembranous croup rare but should be included in diff dx of resp distress as may be life-threatening 6 months to 8 yesrs complication of LTB, bacterial superinfection Staph most common, Moraxella in recent study by Bernstein et al, HIB, Strep described as early as 1945 by Jackson but Jones in 1979 detailed description bacterial LTB, membranous LTB, pseudomembranous croup rare but should be included in diff dx of resp distress as may be life-threatening 6 months to 8 yesrs complication of LTB, bacterial superinfection Staph most common, Moraxella in recent study by Bernstein et al, HIB, Strep

14. Bacterial Tracheitis URI symptoms acute onset high fever and respiratory distress no odynophagia similar to LTB with URI sx, then acute onset high fever, resp distress, toxic no drooling or odynophagia increased WBC count, may have secondary infection, pneumonia common similar to LTB with URI sx, then acute onset high fever, resp distress, toxic no drooling or odynophagia increased WBC count, may have secondary infection, pneumonia common

15. Bacterial Tracheitis “steeple sign” on AP neck intraluminal soft tissue irregularities endoscopy best diagnostic method to OR for those in resp distress “steeple sign” hazy tracheal air column with scalloping due to pseudomembrane detachment endoscopy diagnostic method of choice to OR for those in resp distress “steeple sign” hazy tracheal air column with scalloping due to pseudomembrane detachment endoscopy diagnostic method of choice

16. Bacterial Tracheitis subglottic edema ulceration pseudomembrane formation suction and debride nasotracheal intubation IV antibiotics extubate after 3-7 days endoscopy with spontaneous ventilatin glottic and subglottic edema, ulceration and pseudomembrane formation in trachea purulent materail and sloughed mucosa suction and debride with FB forceps Gram stain, culture and sensitivites decision for intubation made case-by-case, 57% in study by Bernstien but 80% historically 3-7 days, extubate when fever down and secretion s down anitbiotics for Staph - nafcillin + Ceftriaxone, Cefuroxime, Unasyn OK 14 day of abx (IV and oral)endoscopy with spontaneous ventilatin glottic and subglottic edema, ulceration and pseudomembrane formation in trachea purulent materail and sloughed mucosa suction and debride with FB forceps Gram stain, culture and sensitivites decision for intubation made case-by-case, 57% in study by Bernstien but 80% historically 3-7 days, extubate when fever down and secretion s down anitbiotics for Staph - nafcillin + Ceftriaxone, Cefuroxime, Unasyn OK 14 day of abx (IV and oral)

17. Case Study 1 14 month old male breathing difficulties 2-3 days of URI symptoms this morning, cough and loud breathing sound Is this stridor? Age at onset - today Duration - hours Position - no association Assoc sx - feeding - OK cyanosis - none agitation - none Cough description - any choking episode? Dry or productive? More in AM or at night? Any prior episodes? 2 - 4 & 8 months of age, took one week to improve Social - Daycare, Home, Immunizations Is this stridor? Age at onset - today Duration - hours Position - no association Assoc sx - feeding - OK cyanosis - none agitation - none Cough description - any choking episode? Dry or productive? More in AM or at night? Any prior episodes? 2 - 4 & 8 months of age, took one week to improve Social - Daycare, Home, Immunizations

18. Case Study 1 afebrile, respirations 26/min, pulse 124 beats/min reclining in mother’s lap, NAD soft, biphasic stridor lungs clear to auscultation VS normal for age, sitting quietly in mother’s lap soft, musical biphasic stridor volume - loud more severe obstruction sudden decrease may indicate near complete obs Pitch - low: nose, NP, supraglottis high: glottis intermediate: subglottis Phase - inspiratory: supraglottic expiratory: intrathoracic biphasic: glottic or subglotticVS normal for age, sitting quietly in mother’s lap soft, musical biphasic stridor volume - loud more severe obstruction sudden decrease may indicate near complete obs Pitch - low: nose, NP, supraglottis high: glottis intermediate: subglottis Phase - inspiratory: supraglottic expiratory: intrathoracic biphasic: glottic or subglottic

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

20. Case Study 1 lateral airway film - neck extended, inspiratory racemic epinephrine oral dexamethasone Lateral airway film all that is needed - inspiratory with neck extended - hypopharynx filled with air Expiratory film useful to differentiate fixed from dynamic obstruction widening of stenosis on expiration: unilat VF paralysis LTB no change: subglottic stenosis bacterial tracheitis Labs: CBC and cultures racemic epinephrine dexamethasoneLateral airway film all that is needed - inspiratory with neck extended - hypopharynx filled with air Expiratory film useful to differentiate fixed from dynamic obstruction widening of stenosis on expiration: unilat VF paralysis LTB no change: subglottic stenosis bacterial tracheitis Labs: CBC and cultures racemic epinephrine dexamethasone

21. Case Study 1 observe for 3 hours vastly improved at 4 hours post-treatment consider direct laryngoscopy and bronchoscopy in 3-4 weeks discharge or admission - obs 3 hours, vastly improved at 4 hours ?mitigating circimstances follow-up - repeat airway films DL and B for early onset and recurrence (3-4 weeks) discharge or admission - obs 3 hours, vastly improved at 4 hours ?mitigating circimstances follow-up - repeat airway films DL and B for early onset and recurrence (3-4 weeks)

22. Case Study 2 6 year old rhinorrhea, cough, low grade fever acute onset high fever and stridor several days URI, rhinorrhea, low grade temp ED with acute onset high fever and resp distress (102.7) o2 sat 95-97% on RA retraction and harsh barking cough several days URI, rhinorrhea, low grade temp ED with acute onset high fever and resp distress (102.7) o2 sat 95-97% on RA retraction and harsh barking cough

23. Case Study 2 to OR for endoscopy edematous larynx ulceration and sloughing of tracheal mucosa purulent secretions in right lower lobe 5.0 mm tube by anesthesia CBC with WBC 19000 glottic edema, ulceration with purulent material in trachea - cleaned 5.0 mm tube by anesthesia CBC with WBC 19000 glottic edema, ulceration with purulent material in trachea - cleaned

24. Case Study 2 nasotracheal intubation IV Cefuroxime S. aureus CXR with right lower lobe pneumonia extubated 4th day post intubation NT intubation IV Cefuronxime RLL pneumonia by CXR cx S. aureua sens to Cefuroxime clinically imporved and extubated in 4th day after intubation after leak with positive pressure d/c’d 7 days after admission on po abx for total of 14 days therapyNT intubation IV Cefuronxime RLL pneumonia by CXR cx S. aureua sens to Cefuroxime clinically imporved and extubated in 4th day after intubation after leak with positive pressure d/c’d 7 days after admission on po abx for total of 14 days therapy

25. Controversies and Future drastic decrease in supraglottitis as a result of vaccine nasotracheal intubation for supraglottitis disposition of children treated for LTB with epinephrine steroids in LTB HIB vaccine - incidence deceased (Bailey 3.47 cases per 100,000 in1980to 0.63 in 1990 incidence in adults stable other organisms besides HIB more common airway in supraglottitis - now NT intubation, past trach - ? obs in ICU LTB - disposition in pts treated with epi - admit or home after obs for a few hours steroids - Dexamethasone - dose and route of administration nebulized Budesonide - ? any benefit who should receive it? nedd clear cut indicators HIB vaccine - incidence deceased (Bailey 3.47 cases per 100,000 in1980to 0.63 in 1990 incidence in adults stable other organisms besides HIB more common airway in supraglottitis - now NT intubation, past trach - ? obs in ICU LTB - disposition in pts treated with epi - admit or home after obs for a few hours steroids - Dexamethasone - dose and route of administration nebulized Budesonide - ? any benefit who should receive it? nedd clear cut indicators

26. Conclusion cause of much morbidity in pediatric population potentially life-threatening prompt diagnosis assure adequate airway common and may be life-threatening must make quick diagnosis on PE airway first prioritycommon and may be life-threatening must make quick diagnosis on PE airway first priority