Croup

1. Croup

2. Objectives • Clarify the definition and epidemiology of croup • List the potential etiologic agents • Know the signs and symptoms • Differentiate croup from other causes of inspiratory stridor and upper respiratory disease • Understand the management of croup

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

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

5. Etiologies • Parainfluenza, types 1,2,3 • Contribute 65%-80% of cases. • Influenza A & B • Adenovirus • RSV • Rarely mycoplasma.

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

7. 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.

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

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

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

11. 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.

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

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

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

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

16. Laboratory tests • Little to no value…... • ABG to assess for respiratory acidosis – could worsen child’s symptoms by stressing them • May need IV access if in moderate to severe distress

17. Radiographic findings • REMEMBER – CROUP IS A CLINICAL DIAGNOSIS!!! • Steeple sign on PA Film • Lateral neck films if unsure of ruling out retropharyngeal abscess • Fluouroscopy if still unsure

18. Anatomy

19. Anatomy on X-ray

20. Red -dilated hypopharynx White - dilatation of the laryngeal ventricle Blue - narrowing of the sub-glottic trachea

21. Steeple Sign

22. What is this? Retropharyngeal Abscess!

23. What is this? Epiglottis

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

25. 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.

26. 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.

27. Corticosteroids • Steroid 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).

28. 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.

29. 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.

30. 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.

31. 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.

32. 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.

33. 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?