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Upper airway Upper airway obstruction:obstruction:
Croup and its differentialCroup and its differentialPeter LouiePeter Louie
January 2004January 2004
Case: 12 month old male, with 1 day Case: 12 month old male, with 1 day history of coryza, barky cough, and fever. history of coryza, barky cough, and fever.
Presents with 2 hour Hx. Stridor & Presents with 2 hour Hx. Stridor & difficulty breathing difficulty breathing
ObjectivesObjectivesDifferential diagnosis of upper airway obstructionDifferential diagnosis of upper airway obstruction
CroupCroup► Def’n, ethilogy, epidemiology, Def’n, ethilogy, epidemiology,
pathophysiologypathophysiology► History and physical findingsHistory and physical findings► TreatmentTreatment
EpiglottitisEpiglottitisForeign bodyForeign body
DDX upper airway DDX upper airway obstructionobstruction
Airway swellingAirway swellingInfectious: Infectious: viral croupviral croup
Bacterial Bacterial tracheitistracheitis
epiglottisepiglottis diphteriadiphteria
Non-infectious: anaphylaxisNon-infectious: anaphylaxis
Space occupying lesion or Space occupying lesion or structural abnormalitystructural abnormality
Congenital Congenital (choanal atresia, larynogomalacia, (choanal atresia, larynogomalacia, subglottic stenosis, laryngeal subglottic stenosis, laryngeal
web)web)
AcquiredAcquired► Foreign bodyForeign body► Human papilloma virusHuman papilloma virus► Retropharyngeal abscessRetropharyngeal abscess► TumorTumor► HematomaHematoma
Croup: DefinitionCroup: DefinitionClinical syndrome characterized by triad of Clinical syndrome characterized by triad of 1.1. inspiratory stridorinspiratory stridor
2.2. Barking coughBarking cough
3.3. HoarsenessHoarseness
…………and varying degrees of respiratory distress and varying degrees of respiratory distress
Types of CroupTypes of Croup
Viral croup (laryngotracheobronchitis)Viral croup (laryngotracheobronchitis)
Pseudomembranous croup Pseudomembranous croup (bacterial tracheitis) (bacterial tracheitis)
Spasmodic croupSpasmodic croup
Viral Croup: etiologyViral Croup: etiologyParainfluenza 1 (most common), 2, 3Parainfluenza 1 (most common), 2, 3Respiratory syncytial virus (RSV)Respiratory syncytial virus (RSV)AdenovirusAdenovirusInfluenza A, BInfluenza A, Benterovirusesenteroviruses
Viral Croup: pathophysiologyViral Croup: pathophysiology
Viral Croup - PathogenesisViral Croup - Pathogenesis► Subglottic trachea at cricoid Subglottic trachea at cricoid
cartilage is the narrowest part cartilage is the narrowest part of a child’s airway. of a child’s airway.
► This area is surrounded by firm This area is surrounded by firm cartilage. cartilage.
► Any swelling in this area can Any swelling in this area can encroach on the airway.encroach on the airway.
Viral Croup: pathophysiologyViral Croup: pathophysiologyRespiratory droplets Respiratory droplets
Host immune response activatedHost immune response activated
mucous secretionmucous secretion edema & erythema of edema & erythema of vocal vocal cords (hoarseness) cords (hoarseness)
subglottic region (stridor)subglottic region (stridor)
Upper airway obstruction Upper airway obstruction
Steeple SignSteeple Sign
Viral Croup: EpidemiologyViral Croup: Epidemiology►First 3 years of life (6 – 36 First 3 years of life (6 – 36
months)months)
►Peak incidence 2 yrs: 4.7/100Peak incidence 2 yrs: 4.7/100
►Male:female (3:2)Male:female (3:2)
Clinical presentation: historyClinical presentation: history►Onset and duration Onset and duration ►FeverFever►choking choking ►dysphagia, droolingdysphagia, drooling►Trauma, previous airway manipulationTrauma, previous airway manipulation►AllergiesAllergies► immunization immunization
Clinical presentationClinical presentation►onset of fever, barky cough, coryzaonset of fever, barky cough, coryza►Stridor follows 1-2 days afterwardsStridor follows 1-2 days afterwards►Stridor and respiratory distress Stridor and respiratory distress
worsens worsens at night and when child at night and when child
agitatedagitated
Clinical presentation: Clinical presentation: physicalphysical
►A: A: inspect, listeninspect, listen
►B: B: sats, RR, A/Esats, RR, A/E
►C: C: color, pulse, BPcolor, pulse, BP
►D: D: LOCLOC
Nasal flaring
RetractionsInability to lie down
•Appearance: quiet, tired, no drooling•Airway: inspiratory stridor •Breathing: RR 24, SaO2 96%, harsh breath sounds
•Circulation: HR 170, cool extremities, cap refill 3 sec•Disability: awake, tired•Exposure: Wt 9 kg
Viral croup: Investigations?Viral croup: Investigations?► Not necessary, clinical diagnosisNot necessary, clinical diagnosis► Uncertainty of diagnosisUncertainty of diagnosis CBC: ?bacterial infectionCBC: ?bacterial infection
Xrays: Xrays: Anterior posterior: viral croup(steeple sign)Anterior posterior: viral croup(steeple sign) lateral neck: epiglottitis (thumb sign)lateral neck: epiglottitis (thumb sign)
retropharyngeal abscessretropharyngeal abscess Radio-opaque foreign bodyRadio-opaque foreign body
Viral croup: treatmentViral croup: treatment► Do not agitate child: Do not agitate child: crying increases oxygen demand and crying increases oxygen demand and
worsens laryngeal obstructionworsens laryngeal obstruction
► Ensure adequate fluid intakeEnsure adequate fluid intake
► Analgesia : paracetemolAnalgesia : paracetemol
► Illness self limited: 3-5 daysIllness self limited: 3-5 days
Viral croup: treatmentViral croup: treatment►Cool MistCool Mist
►SteroidsSteroids
►EpinephrineEpinephrine
Cool MistCool Mist Previous beliefs that:Previous beliefs that:
► mist moistens airway secretions & soothes inflammed mucosa.mist moistens airway secretions & soothes inflammed mucosa.► Mist can activate mechanoreceptors in larynx and lead to reflex slowing of respiratory Mist can activate mechanoreceptors in larynx and lead to reflex slowing of respiratory
rate.rate.
No evidence supports the effectiveness of mist therapy. No evidence supports the effectiveness of mist therapy. Klassen T, Klassen T, Pediatr Clin North Am, Pediatr Clin North Am, 1999; 46(6).1999; 46(6).
SteroidsSteroids reduced length of time spent in ER and reduced length of time spent in ER and
admissionsadmissions
decrease laryngeal mucosa edemadecrease laryngeal mucosa edema
Clinical improvement, but not immediateClinical improvement, but not immediate►Single dose IM/oral dexamethasone (0.6mg/kg) Single dose IM/oral dexamethasone (0.6mg/kg)
effective in 6 hours. effective in 6 hours. ►Single dose Inhaled budesonide as effective Single dose Inhaled budesonide as effective
(effective in 2-4 hours).(effective in 2-4 hours).
SteroidsSteroids Dexamethasone 0.15 mg/kg/dose as effective Dexamethasone 0.15 mg/kg/dose as effective
as 0.6 mg/kg/dose; oral and IM as effective as 0.6 mg/kg/dose; oral and IM as effective Geelhoed & Macdonald. Pediatr Pulmonol. 20. 1995Geelhoed & Macdonald. Pediatr Pulmonol. 20. 1995
Poor evidence supporting combined Poor evidence supporting combined budenoside and dexamethasone Rx.budenoside and dexamethasone Rx.
Klassen et al. Pediatrics 97 (4). 1996Klassen et al. Pediatrics 97 (4). 1996 Dexamethasone preferred over budenoside Dexamethasone preferred over budenoside
because of ease of administration, lower cost, because of ease of administration, lower cost, and more widespread availabilityand more widespread availability. . Klassen et al. JAMA 279 (20). 1998Klassen et al. JAMA 279 (20). 1998
Epinephrine/adrenalineEpinephrine/adrenaline►Potent alpha and beta adrenergic stimulatorPotent alpha and beta adrenergic stimulator►Alpha adrenergic mediated vasocontriction of Alpha adrenergic mediated vasocontriction of
edematous laryngeal mucosaedematous laryngeal mucosa► Indications: respiratory distress, stridor at restIndications: respiratory distress, stridor at rest►Onset of action: 30-60 min, duration: 2 hrs Onset of action: 30-60 min, duration: 2 hrs ►Rebound effect: does not alter course of illnessRebound effect: does not alter course of illness►Monitor for signs of worsening respiratory Monitor for signs of worsening respiratory
distress and impending respiratory failure distress and impending respiratory failure
Bacterial tracheitis Bacterial tracheitis ►Potentially life threatening infection of Potentially life threatening infection of
the tracheal mucosathe tracheal mucosa► Important complication of measlesImportant complication of measles►Proceeding viral infectionProceeding viral infection►Organisms:Organisms:
Staphylococcus aureus(most common)Staphylococcus aureus(most common)Streptococcus pneumoniaStreptococcus pneumoniaHemophilus influenza BHemophilus influenza BTBTB
Bacterial tracheitisBacterial tracheitisInfectionInfection
purulent secretions and mucosal necrosispurulent secretions and mucosal necrosis (sloughing mucosa)(sloughing mucosa)
Airway obstructionAirway obstruction
Bacterial tracheitis Bacterial tracheitis ►Acute: over 8-10 hoursAcute: over 8-10 hours►Toxic appearanceToxic appearance
high feverhigh feverlethargylethargymarked signs of respiratory marked signs of respiratory
obstructionobstruction►Absence of droolingAbsence of drooling
Bacterial tracheitisBacterial tracheitis►Monitor airway closelyMonitor airway closely
►Prepare for emergent intubationPrepare for emergent intubation
►Abx: Cefuroxime or CephalexinAbx: Cefuroxime or Cephalexin chloramphenicol and penicillinchloramphenicol and penicillin
►Complication: tracheal stenosisComplication: tracheal stenosis
Spasmodic CroupSpasmodic Croup►Sudden onset of dyspnea, inspiratory Sudden onset of dyspnea, inspiratory
stridor, croupy cough w/out fever or stridor, croupy cough w/out fever or URTI prodrome; often wakes child from URTI prodrome; often wakes child from sleepsleep
►Sxs a result of non-inflammatory Sxs a result of non-inflammatory subglottic edema (pale, boggy)subglottic edema (pale, boggy)
►Associated with atopic disease Associated with atopic disease (asthma, eczema, hay fever)(asthma, eczema, hay fever)►Treatment: moist-air and reassuranceTreatment: moist-air and reassurance
EpiglottitisEpiglottitisDefinitionDefinition► Life threatening Life threatening
bacterial infectionbacterial infection► Cellulitis and edema Cellulitis and edema
of epiglottis, of epiglottis, aryepiglottic folds, aryepiglottic folds, arytenoids, and arytenoids, and hypopharynx hypopharynx narrowed glottic narrowed glottic openingopening
EpiglottitisEpiglottitisEtiologic agentsEtiologic agents►Hemophilus influenza B (>90% cases)Hemophilus influenza B (>90% cases)►Staphylococcus aureusStaphylococcus aureus►Streptococcus pneumoniaStreptococcus pneumonia►Streptococcus pyogenesStreptococcus pyogenes►Candida (immunocompromised)Candida (immunocompromised)
Epiglottitis: clinical Epiglottitis: clinical presentationpresentation
►Age of onset: 2-7 yrs, peak 2-3 yearsAge of onset: 2-7 yrs, peak 2-3 years►Abrupt onset, minimal or no prodromeAbrupt onset, minimal or no prodrome►Stridor is softStridor is soft►High fever(39-40 ), tripod positionHigh fever(39-40 ), tripod position►DDysphagia, ysphagia, DDrooling, rooling, DDysarthyriaysarthyria►Rapid onset of respiratory distress and Rapid onset of respiratory distress and
obstructionobstruction
Epiglottitis: managementEpiglottitis: managementDo NotDo Not► Examine throatExamine throat► lie child supinelie child supine► Xray neckXray neck► Perform invasive Perform invasive
proceduresprocedures► Nasopharyngeal tube Nasopharyngeal tube
for oxygenfor oxygen
DoDo► Calm childCalm child► Attach pulse oximeterAttach pulse oximeter► Arrange for controlled Arrange for controlled
intubation under intubation under general anaesthetic general anaesthetic
► IV, blood and throat IV, blood and throat culturescultures
► Abx: Abx: 1.1. Cefuroxime, cefotaxime, Cefuroxime, cefotaxime,
or ceftriaxone or ceftriaxone2.2. Chloramphenical and Chloramphenical and
penicillinpenicillin
Croup Vs. EpiglottitisCroup Vs. EpiglottitisCroup Croup epiglottitisepiglottitis
Age Age 6 months-3 6 months-3 yearsyears
2-7 years2-7 years
onsetonset daysdays HoursHoursPreceeding Preceeding coryzacoryza
yesyes nono
coughcough Severe, barkySevere, barky Absent or mildAbsent or mildAppearance Appearance unwellunwell toxictoxicfeverfever <38.5<38.5 >38.5>38.5Dysphagia,drooliDysphagia,droolingng
nono yesyes
voicevoice hoarsehoarse softsoftintubationintubation 1%1% 80%80%
Inhaled foreign BodyInhaled foreign Body►Sudden onset cough, stridorSudden onset cough, stridor►Previously wellPreviously well►Asymmetrical breath soundsAsymmetrical breath sounds►X-raysX-rays
Lateral neckLateral neckinspiratory and expiratory filmsinspiratory and expiratory films
(air trapping)(air trapping)80% objects non radiopaque80% objects non radiopaque
DDX upper airway DDX upper airway obstructionobstruction
Airway swellingAirway swellingInfectious: Infectious: viral croupviral croup
Bacterial Bacterial tracheitistracheitis
epiglottisepiglottisdiphteriadiphteria
Non-infectious: anaphylaxisNon-infectious: anaphylaxis adenoid adenoid
hypertrophyhypertrophy
Space occupying lesion Space occupying lesion or structural or structural abnormalityabnormality
Congenital (choanal atresia, Congenital (choanal atresia, larynogomalacia, subglottic larynogomalacia, subglottic stenosis, laryngeal web)stenosis, laryngeal web)
AcquiredAcquired► Foreign bodyForeign body► Human papilloma virusHuman papilloma virus► Retropharyngeal abscessRetropharyngeal abscess► TumorTumor► HematomaHematoma
Take home messageTake home messagePatient with stridor/upper airway obstructionPatient with stridor/upper airway obstruction►Newborn: congenital anatomical anomalyNewborn: congenital anatomical anomaly►6 months-3 yrs nontoxic6 months-3 yrs nontoxic viral croup viral croup
toxic toxic bacterial tracheitis bacterial tracheitis epiglottitisepiglottitis
►Older child, persistent stridor Older child, persistent stridor Human Human papillomapapilloma virusvirus