Croup A Review

1. CroupA Review Kimberly A. Dovin, MD PGY3 Swedish Family Medicine April 27, 2004

2. Objectives - Goals • Diagnosis and Management of Croup • Review natural history of viral croup • Distinguish between and review evidence of various treatment options • Determining need for outpatient vs inpatient treatment • Develop a differential diagnosis • Review indications for hospitalization

3. Case #1 • T.T. is a 27mos male who comes in w/ his very worried mother. • Runny nose started 2 days ago • Temp 100.3 yesterday • Barking cough started this AM • Now making a horrible noise when he takes a deep breath in • Refuses to lie down

4. Case # 1 Continued • VS: 99.8F 120 22 O2 sat 96% when quiet • Gen: alert, sitting in mother’s lap quietly when you enter, sees you and starts to cry  you note inspiratory stridor • Ears: nl TMs • Nose: rhinnorhea • Mouth: no exudate, tonsils normal • Neck: cervical LAD • Chest: expiratory wheeze, inspiratory sounds obscured, subcostal retractions worsened w/ crying • CV: RRR no murmur • Ext: 2+ cap refill, wwp

5. Definition • “A generic term” • A heterogenous group of illnesses affecting the larynx, trachea, and bronchi • Viral origin • Characteristic cough, inspiratory stridor, hoarseness

6. Epidemiology • Annual incidence: 6 cases per 100 children younger than 6yoa • Affects children 6mos-12yoa, peak incidence at 2yoa • Boys:Girls 1.5:1 • Fall and winter predominance

7. Cost • Leading cause of hospitalization in children younger than 4yoa • $56 million annually

8. The Usual Suspects • Viral: Parainfluenza, Influenza A & B,Adenovirus, RSV, rhinovirus, enteroviruses, measles • Spasmodic: viral associated, possibly allergic reaction to antigens

9. Symptoms 12-72hr prodrome of fever/coryza Hoarseness “Croupy”/barking cough Stridor Dyspnea/wheeze Signs Hx consistent w/ croup Normal pulse ox Low-grade fever Clinical Course

10. Epiglottitis Bacterial tracheitis Foreign body Subglottic stenosis Peritonisillar abscess Retropharyngeal abscess Diptheria Laryngomalacia Vocal cord paralysis Smoke inhalation Burns/Thermal injury Neoplasm Laryngeal fracture Differential Dx

11. Studies? • Plain neck XR: “Steeple sign” • CT: supected other causes • Larynogoscopy

12. Anatomy

13. Management • Serial observation • Mist therapy • Steroids • Epinephrine

14. Indications to Hospitalize • Actual/expected epiglottitis • Cyanosis • Depressed sensorium • Hypoxemia • Pallor • Progressive stridor • Resp distress • Restlessness • Toxic-appearing

15. Epiglottitis Croup Age Can occur in infants, older children, or adults Six months to six years Onset Sudden Gradual Location Supraglottic Subglottic Temp High fever Low-grade fever Dysphagia Severe Mild or absent Dyspnea Present Present Drooling Present Present Cough Uncommon Chracteristic cough Position Sitting forward with mouth open Comfortable in different positions Radiology Positive thumb sign* Positive steeple sign Adapted with permission from DeSoto H. Epiglottitis and croup in airway obstruction in children. Anesthesiol Clin North Am 1998;16:855. Comparison of the Features of Epiglottitis and Croup

16. Management: Steroids 1 • 1970 – the debate begins! • “With the battle won, what remains are largely minor skirmishes…”1 • Nebulized vs oral vs IM • Inpatient vs outpatient • Dose 1J. Paton, Royal Hospital for Sick Children, Glasgow, Scotland

17. Management: Steroids 2 • BMJ 1999, meta-analysis: Steroids improve sx within 6hrs for up to 12hrs • Nebulized vs Oral: 1999 & 2004 RCTs, equivalent; 2002 oral significantly better. • Oral vs IM: 2000 Randomized, uncontrolled, equivalent • Dose: equivalent outcomes with 0.15/kg, 0.3/kg and 0.6/kg dexamethasone

18. Management: Steroids 3 • Nebulized vs oral vs IM • For children with increased WOB • Might consider oral or IM over nebulized • Inpatient vs Outpatient • Either – depends on VS/PE • Dose • PO: 0.15mg/kg – lowest known effective dose of dexamethasone • IM: 0.15-0.6mg/kg IM

19. Management: Epinephrine • For moderate to severe distress • 5ml 1:1000 Nebulized racemic epinephrine • Decreased stridor/retractions in 30min • Duration 2 hrs • Rebound phenomenon • Observe 3-4hrs after administration • Side effects: tachycardia, HTN

20. Case #1 – Follow-up • You decide to give T.T. a dose of dexamethasone in the clinic at 0.3mg/kg • Advise mother to check in on him during the night and gave warning signs • Suggest taking him out into the air or running a hot shower might help

21. Case #1a • T.T. returns to your clinic in 2 days. His mother says that the cough is tapering and he is sleeping better through the night. However, he has been tugging at his ear all day long and complaining of pain. • PE: notable for a erythematous TM on left w/ decreased mobility and obscured landmarks

22. Complications • Otitis media • Bronchiolitis • Pnemonia (rare) • Bacterial tracheitis (rare)

23. Case #1a Follow-up ANTIBIOTICS? I THINK NOT!

24. Summary • Croup is a common viral illness in children • Treatment options include • Steroids – good evidence to support • Epinephrine – years of experience and trials support its use • Mist – years of use/no data to support • Evidence supports outpatient treatment in mild to moderate croup

25. Bibliography • Behrman, RE, Kliegman, RM, Jenson, HB Nelson Textbook of Pediatrics, 16th Ed. W.B. Saunders Co. 2000. • Cetinkaya F, Tufekei BS, Kutluk GT. A comparison of nebulized budesonide, and intramuscular, and oral dexamethasone for treatment of croup. Int J Pediatric Otorhinolaryngology 2004; 68(4): 453-6 • Knutson, D, Aring, A. Viral Croup. American Family Physician 2004; 69:535-540. • Luria JW, Gonzalez-del-Rey JA DiGiulio GA, et al. Effectiveness of oral or nebulized dexamethasone for children with mild croup. Arch Pediatric and Adolescent Medicine 2001; 155: 1340-5. • Neto GM, Kentab O, Klassen TP, Osmond MH. A randomized controlled trial of mist in the acute treatment of moderate croup. Academy of Emergence Medicine 2002; 9(9): 873-9. • Rittichier KK, Ledwith CA. Outpatient treatment of moderate croup with dexamethasone: intramuscular versus oral dosing. Pediatrics 2000; 106(6): 1344-8.